ADHD Treatment: The Shocking Results After 8 Years

You start medication or therapy, things get better, and then a few years later the old struggles creep back in. You wonder if you did something wrong.

This week, Skye Waterson is joined by Will Curb from Hacking Your ADHD for a Research Recap on the MTA study, the largest and most influential ADHD treatment trial ever conducted. Nearly 580 children were followed for 8 years to understand what happened after the initial treatment period.

Together, Skye and Will unpack why the early differences between medication, behavioral therapy, combined treatment, and community care had largely disappeared by year 8. This is not a conversation about whether medication works. It is about what happens when ADHD is treated as a one time solution instead of an ongoing condition that changes as life becomes more demanding.

What You'll Learn:

• Why the MTA study followed nearly 580 children across four treatment approaches
• Why medication use dropped to about one third of participants by year 8
• Why even participants who remained on medication lost their early advantage
• Why ADHD is better understood as a condition that requires sustained management
• What "pills don't teach skills" really means for long term ADHD management

Learn more about Will and Hacking Your ADHD:

https://hackingyouradhd.com

https://www.youtube.com/@HackingYourADHD

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Transcript

SPEAKER_01 0:00

In this episode, the first paper we're discussing is called Uh The MTA at Eight Years, a prospective follow-up of children treated for combined type ADHD in a multi-site study. And so this is about the MTA, the multi-treatment study of children with ADHD, which was the largest, most expensive, and most influential study conducted on ADHD treatment that was published in 1999. And so we'll get into a few more details about what that paper is in a bit, but it had a huge impact on how we view ADHD, especially in highlighting how to think of this shift into thinking of ADHD as a chronic condition that requires, you know, a sustained management rather than just something that you cure.

SPEAKER_00 0:39

Yeah, yeah, 100%. Yeah, it was really interesting because obviously they're doing like multiple methods of treatment, which I think was the most the obviously the thing that made this study the most interesting. So they had different kinds. They had, you know, they had systematic medication management, they had multi-component behavioral therapy, then they had a combination, and then they had the usual community care. So they were looking at these four different methods to see the effect that they had on these children over time, which was that the first time that that's ever happened?

SPEAKER_01 1:16

Yeah, I think so. And it was definitely, I mean, as I said, the interest it was this is a huge study that they did. It was with what? Almost 580 children, and the time span of looking at things at eight years is incredible.

SPEAKER_00 1:29

Yeah, it's a longitudinal study where they actually, I don't know if it was randomized, but they definitely, you know, divided them into different groups and and and did things like that, which was pretty awesome. And also shout out to the parents for letting them do this.

SPEAKER_01 1:42

And yeah, and then it's also we're looking at kids that are were ages like seven to nine. And so this is really getting a like full spectrum of uh childhood. Because if you're nine at the start of the study, you're 17 at the end, and that's such a huge change in life, which we are going to get into as well. Because what they were really wanting to look at this study is how well treatment worked over time, like what interventions did uh on a longer timescale rather than just being like, hey, we did a you know six-week study and the people did great. But they're like, okay, but how do they do way in the future?

SPEAKER_00 2:18

Yeah, exactly, exactly. So they were you know reassessed at the 14-month treatment phase, at the 24 and 36 month, and then again at six and eight years post-randomization with the treatment phase. They actually did have very, very high participation rates as well, which you always got to check when you have a study like this. So they had 97, 93, 84, 78, and 75, which is which is really good.

SPEAKER_01 2:43

Yeah, it's great results for like keep peep keeping people in the study. And it is really interesting. And so I I think this is also important to mention so that the study, the initial portion of the study was fairly well regulated at 14 months with all these check-ins, and then it was kind of like more of a natural experiment as it went on out to the eight-year mark.

SPEAKER_00 3:05

Yeah, yeah, it's pretty hard to do that. But they also had a comparison group. So they had a local normative comparison group that was recruited at 24 months that was made specifically to reflect the local populations from which the sample was drawn. So when we talk about comparisons, which we'll get to in a second, like that's where they were coming. But weirdly, they said children were not excluded due to ADHD. And so that is a little bit of a factor.

SPEAKER_01 3:32

Well, I can definitely see why they would do that in that they're like, hey, we just want if you were a randomly selected person from this group, it's going to include people that have ADHD. And so that they didn't want to like skew either way. I could see the argument for excluding them, but I can also be like, oh yeah, it makes sense to have them as a part of the larger whole of what's going on.

SPEAKER_00 3:51

Yeah. And also I, you know, I imagine again, this is a big study. You know, they're looking at so many different factors that they want to take into account.

SPEAKER_01 3:58

Absolutely. I think, I mean, one of the big things was their initial intervention had great effects on reducing ADHD symptoms, although they were still behind the localized group. But when we go out toward the eight-year mark, the intervention disappears.

SPEAKER_00 4:16

That was crazy. I have a big exclamation point next to it on my on my notes because I think that was the most interesting thing to me. And then the medication use over time was also really interesting.

SPEAKER_01 4:29

Yeah, because by year eight, they only had a third of the group still on any form of medication, which is a huge drop-off. And it is very understandable when you realize we're talking about teenagers. What I thought was more interesting though was that even the medicated group still did not have the same intervention level as the initial 14 months did.

SPEAKER_00 4:52

Well, that was the thing. And I think uh, you know, obviously I'm and I want to say this up front, I'm always very supportive of everyone using whatever method works for them to support their ADHD. But it did make me wonder a little bit of what the causation crossover was there, because like you described it as like the medication group stopped taking medication because, you know, they were teenagers, and and sure that is true, but if you look at the people who did take their medication, they were not experiencing like they initially were experiencing those really positive results compared to their peers, but then they didn't over time. Like the treatment was about the same. And so, you know, obviously we wouldn't usually be saying these things, but this is a really big study. There's a possibility that they kind of knew that, and that was part of the reason why they decided not to take the medication over a long period of time.

SPEAKER_01 5:40

Yeah, it's without further data on because we we don't have any information from them on why they stopped taking the medication, which in previous studies that we've looked at that have just discussed why people stopped using medication, there are a lot of reasons that people might stop taking medication with, you know, a social pressure and side effects, not feeling like it's working well enough.

SPEAKER_00 6:03

The doctor says you should stop taking it on the holiday periods and then you don't pick it up again.

SPEAKER_01 6:08

Yeah, or the cost is a big one too. When some of our more modern medications came out, like Adderall and all that, and what was available to them in 1999 versus, you know, the last 15 or 20 years.

SPEAKER_00 6:22

Yeah, that's a good point. It did remind me though, this paper did remind me of that paper about medication adherence, and where they did go into all the reasons why people didn't take it. And yeah, it felt like this was a really big bird's eye view of that conversation.

SPEAKER_01 6:37

So I think one of the big takeaways that we want I want people to hear from this, it sounds a lot like, oh, the intervention didn't work. Nobody everybody went off and stopped taking medication and it was everything was the same. And it was like, well, the big thing that we're taking should be taking away is that you need to keep treating your ADHD if you want to keep seeing symptom reduction. If you just simply stop treating it, you're not going to keep the benefits.

SPEAKER_00 7:01

Yeah. So in terms of that though, it is interesting because they did find that, yeah, all of the different methods were kind of the same. So what does this mean about the type of treatment that you decide to take?

SPEAKER_01 7:13

Well, I think one thing that you can take is that if a certain treatment isn't working for you, there are other options for you to try. You don't have to be like, this is I only have this one lane I can go to. I do think when we bring in the other paper, we can also talk a lot a little bit about the concept of pills don't teach skills and how that applies here. And I think that actually, how about we bring that other paper in? I think that actually brings in a lot of those points. All right. So second paper: the transition to middle school is associated with changes in the developmental trajectory of ADHD symptomatology in young adolescents with ADHD. Oh, that is well done. I uh I'm like, symptomatology is a great word. That's so long. This is papers looking at the same MTA data. It runs an algorithm to try and see talk about kids going into middle school because they didn't have like the specific data in the MTA study. It's having this argument that it's not just getting older that's going on, it's a change in life and change in demands. And I think that is one of those things that we have to look at when we're considering this treatment option is yeah, what are our life demands and how is it changing what we're doing? And with this, yeah, this idea of pills don't teach skills, you need to learn how to manage your ADHD beyond what just currently exists for you.

SPEAKER_00 8:32

Yeah, exactly. Exactly. And it was interesting to see, you know, with this conversation, having a look at at that transitional period of life. Can you give me a m take a minute to describe that this for me? Because from our international perspective, middle school is not as much of a thing. You know, we have um we have primary, intermediate, and college. And yeah, intermediate school is a transition, but I feel like American middle school is its own thing.

SPEAKER_01 9:00

I got my emails this week on what to expect for transferring my elementary school daughter into middle school next year, because we're like gearing up for that. And so I'm like, oh, this is very on note for what I know about right now. And a big change for middle school for kids in the US is that you go from having like a single teacher that has like other teachers come in to do things. So, like in elementary school, they'll have like their homeroom teacher, and then they might go to PE or music or art or have like social emotional or STEM stuff. They'll they'll have like specialist teachers that come in and help the primary teacher. But the primary teacher is your main teacher that you get throughout the day. When you go into middle school, you have different classes, and each class will have a different teacher. So you have go to your English teacher, your math teacher, your history teacher, and all of that. Instead of having a single adult that you're working with, you're working with a bunch and you're doing a lot more mental organization of like, okay, now I have to go to because you you don't have the same schedule with all your same friends the entire day.

SPEAKER_00 9:59

Yeah, okay. This makes sense. This is remind this is sort of the transition to intermediate school. And it is true. I that was when my ADHD started to become very obvious looking back because I had different books and different classes, and I remember writing an essay in one notebook, putting, you know, printing it out, putting it in the wrong notebook, not having it in the right class, and getting in trouble for like losing my paper all the time, um, because that's what we were doing.

SPEAKER_01 10:27

Yeah, and like having to make sure you have all the right books with you, having to, yeah, being like, oh, I have this homework doing this class and this homework do in this class, and like it's a lot more of a mental transition. And then while not mentioned specifically in this paper, I was discussing this with my little wife. This is when you're getting hit bit with puberty and you have a lot of emotional changes and social changes going along as well.

SPEAKER_00 10:51

Yeah. And as I remember, there is research to indicate that, you know, for for a woman, especially going through puberty is a factor. It can be a, you know, a a factor with ADHD as well.

SPEAKER_01 11:03

Yeah. So, yeah, so just to mention though, for this paper specifically, they're just looking at having multiple teachers, harder assignments, and more independence. That felt like a kind of a problem to me, but I also was like, oh, well, if they're grabbing this from the MTA, there's a reason that there's no social emotional stuff in here, too.

SPEAKER_00 11:22

Yeah, yeah. It wasn't even considered as part of ADHD at the time.

SPEAKER_01 11:27

Yep.

SPEAKER_00 11:27

And I was just like, oh, yeah, of course they wouldn't have anything about that because I was reading the latest copy of the DSM this week, as I do, and it it was funny to even see in that it's like it's an addendum. It's kind of put in the corner. Like also side note, emotional regulation is a thing with ADHD. Yeah.

SPEAKER_01 11:46

It's like it's hard to measure, so we don't really want to.

SPEAKER_00 11:51

It's not hard, it's hard to measure, but it's easy to you know, ex when you experience it, you're like, oh yeah, no, that feels right. Okay, do you want to take us through what they found?

SPEAKER_01 12:00

Yeah, so they, you know, they found the middle school was associated with a significant disruption. So this was an in what I thought was really interesting, is that teacher results did not show vastly different results for their ADHD symptoms, but parent surveys showed increased ADHD symptoms, which for me I read that as this is a lot of masking going on at school now, and they're just leading loose once they get home.

SPEAKER_00 12:24

Yeah, 100%. It didn't necessarily feel like that's what they were getting from it, but it was it was interesting. Like I I had the exact same thought.

SPEAKER_01 12:34

Yeah, it was definitely yeah, it was because yeah, that was my like note, like they did not, because they're like, oh yeah, this is probably because uh they have different teachers and the different teachers are rating them differently. And I'm like, I think it's just because when you I mean, you're probably not as comfortable with five different teachers as you are with one teacher, and so there's gonna be an increased level of like needing to keep up your defenses while you're at school and not let you're trying like overcompensate for your ADHD symptoms.

SPEAKER_00 13:00

Yeah, yeah. And we see that we we talk about that, you know, people talk about masking and and people having, you know, sort of falling apart once they get home when they're in those environments. But yeah, it was it was an interesting, you know. I guess if if you were to say, well, why we're talking about this paper as well as the other paper, what would you kind of say is the reason?

SPEAKER_01 13:20

What I really saw was for the original MTA research, it really showed like this level of impairment increasing after the eight years because the treatment is no longer effective. But I really like there is so much it's saying, like, hey, look, there is so much more than just saying eight years past, you are going through puberty, you're going through middle school, you're going through big life changes and changes in how the demands on you, like the demands on an elementary school student versus the demands on a middle school student or a high school student are vastly different. And so just saying the initial treatment didn't hold up, I feel doesn't do service for looking at how our life changes. Because it's, you know, my life demand changes and the effectiveness of my medication vastly changes. And different demands in your life demand different strategies. And so when you're not learning new strategies, it's not going to be as effective.

SPEAKER_00 14:15

Exactly. And I think that's the that's the reality. Otherwise, you could say, you know, ooh, somewhere between 2020, you know, and 2024, like everybody just randomly got worse. Their ADHD didn't do as well. And it's like, no, there was something else that happened to all of those people.

SPEAKER_01 14:34

I am so amazed how many people completely ignore stuff with the pandemic when talking about they're like, man, kids just are having more trouble in school nowadays. Who knows why? And I'm like, there is data. There is there's something happened, and we know what happened. And pretending like that didn't happen does not help answer the question.

SPEAKER_00 14:55

Yeah, I get that question a lot in interviews, which is why it comes up a lot. It's like, what happened? And I'm like, well, everyone had to suddenly change everything about their life. And middle school is a similar thing.

SPEAKER_01 15:04

Yeah, absolutely. It's you might not have the same friends, you're gonna have a different workload, you're gonna have a bunch of teachers. I I feel like middle school teachers are a little bit tougher than elementary school. You know what? I'm gonna take that back. I'm gonna I'm gonna 100% take that back because I've met some under low entry school teachers that are just as tough. But I feel like there is you're gonna have a different relationship with your teachers in middle school versus elementary school. And sometimes that's gonna be for the better, and sometimes you're gonna be like, Man, my smith history teacher is just out to get me, and I can't do anything about it.

SPEAKER_00 15:35

Gosh, that takes me back. Although I for me, yeah, I primary school teacher. There was a really scary primary school teacher. Nobody wanted to be in our class.

SPEAKER_01 15:43

Yeah, I I think with my kids and like how much they love their teachers, and I'm like, I wonder if that's gonna continue as they get to like get into these, like, you know, where you can choose your teachers more based on classes and stuff.

SPEAKER_00 15:55

Yeah, yeah, definitely. And I think that was an interesting conversation because they they came into it saying, I wonder if environment has an effect, basically. This was the conversation was like, okay, we've talked about multi you know, multi multiple different kinds of treatments, you know, we've talked about age and and how that can have an effect on ADHD. What about environment? Environment has a big effect. And then they found they were like, well, the teachers didn't really notice it, but the parents definitely did.

SPEAKER_01 16:23

And I think there's again, I think it's worth mentioning, you know, these are while these studies came out in 2008, 2009, and I'd like to think that wasn't that long ago. In terms of research, that's that's old research now. So while these were like very influential in how we think about ADHD now, at the time it was just like, oh yeah, like this is really building that foundation of what we know about ADHD.