Research Recap with Skye: Multitreatment of ADHD
Welcome to Hacking Your ADHD. I’m your host, William Curb, and I have ADHD. On this podcast, I dig into the tools, tactics, and best practices to help you work with your ADHD brain. Today, I’m joined by Skye Waterson for our Research Recap series. In this series, we look at a single research paper—or, in today’s case, multiple papers—and dive into what they say, how they were conducted, and try to find practical takeaways.
The first paper we’re discussing is called "The MTA at Eight Years: Prospective Follow-Up of Children Treated for Combined-Type ADHD in a Multisite Study." This is about the MTA, the Multitreatment Study of Children with ADHD, which was the largest, most expensive, and most influential study conducted on ADHD treatment, originally published in 1999. It had a huge impact on how we view ADHD, especially in highlighting the shift toward thinking of ADHD as a chronic condition that requires sustained management rather than just something you "cure." Let’s dive in and talk about what’s going on in this eight-year follow-up study.
If you'd life to follow along on the show notes page you can find that at https://HackingYourADHD.com/304
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William Curb: Welcome to Hacking Your ADHD. I’m your host, William Curb, and I have ADHD. On this podcast, I dig into the tools, tactics, and best practices to help you work with your ADHD brain. Today, I’m joined by Skye Waterson for our Research Recap series. In this series, we look at a single research paper—or, in today’s case, multiple papers—and dive into what they say, how they were conducted, and try to find practical takeaways.
The first paper we’re discussing is called "The MTA at Eight Years: Prospective Follow-Up of Children Treated for Combined-Type ADHD in a Multisite Study." This is about the MTA, the Multitreatment Study of Children with ADHD, which was the largest, most expensive, and most influential study conducted on ADHD treatment, originally published in 1999. It had a huge impact on how we view ADHD, especially in highlighting the shift toward thinking of ADHD as a chronic condition that requires sustained management rather than just something you "cure." Let’s dive in and talk about what’s going on in this eight-year follow-up study.
Skye Waterson: Yeah, 100%. It was really interesting because they were using multiple methods of treatment, which was the thing that made this study so fascinating. They had different groups: systematic medication management, multi-component behavioral therapy, a combination of both, and then usual community care. They were looking at these four different methods to see the effect they had on these children over time. Was that the first time that had ever happened?
William Curb: I think so. As I said, this was a huge study. It involved almost 580 children, and looking at things over an eight-year time span is incredible.
Skye Waterson: It’s a longitudinal study where they divided the participants into different groups, which was pretty awesome. Also, shout out to the parents for letting them do this!
William Curb: Yeah, and we’re looking at kids who were between the ages of seven and nine at the start. This covers a full spectrum of childhood; if you’re nine at the beginning, you’re 17 at the end. That is such a huge life change, which we’re going to get into as well. What they really wanted to look at in this study was how well treatment worked over time—what interventions did on a longer timescale rather than just a six-week study. They wanted to know how the kids were doing way in the future.
Skye Waterson: Exactly. They were reassessed at the 14-month treatment phase, at 24 and 36 months, and then again at six and eight years post-randomization. They actually had very high participation rates, which you always have to check in a study like this. They had 97%, 93%, 84%, 78%, and 75% retention, which is really good. It’s also important to mention that the initial portion of the study was fairly well-regulated for the first 14 months, but it became more of a "natural experiment" as it went on toward the eight-year mark.
They also had a comparison group—a local normative group recruited at 24 months to reflect the local populations. Interestingly, they said children were not excluded from that group due to ADHD, which is a bit of a factor.
William Curb: I can see why they did that. If you’re a randomly selected person from the population, that group is going to include people with ADHD, and they didn’t want to skew the data. But one of the big findings was that while the initial intervention had great effects on reducing ADHD symptoms, by the eight-year mark, that intervention effect disappeared.
Skye Waterson: That was crazy. I have a big exclamation point next to that in my notes because I think it was the most interesting thing to me. The medication use over time was also really interesting.
William Curb: Right, because by year eight, only a third of the group was still on any form of medication, which is a huge drop-off. It’s understandable when you realize we’re talking about teenagers, but what I thought was even more interesting was that even the medicated group didn’t have the same symptom reduction as they did during the initial 14 months.
Skye Waterson: I’m always supportive of people using whatever method works for them to support their ADHD, but it made me wonder about the causation there. You mentioned that people might stop taking medication because they were teenagers, but if you look at the people who did continue taking it, they weren’t experiencing those same positive results compared to their peers over time. The treatment effect leveled out. There’s a possibility that they realized this, and that played a part in why they decided not to take medication long-term.
William Curb: It’s interesting data because we don’t have information on why they stopped. Previous studies show many reasons: social pressure, side effects, or feeling like it isn’t working well enough. Or even the cost. I’d also need to look up which medications were available in 1999 versus the last 20 years.
Skye Waterson: This paper reminded me of a study on medication adherence that went into all those reasons. It felt like a big bird’s-eye view of that conversation.
William Curb: I think the big takeaway I want people to hear is this: it sounds like the intervention didn’t work because everything leveled out, but the reality is that you need to keep treating your ADHD if you want to keep seeing symptom reduction. If you simply stop treating it, you aren't going to keep the benefits.
Skye Waterson: Exactly. Since they found that all the different methods ended up about the same, what does that mean for the type of treatment someone should choose?
William Curb: It means that if a certain treatment isn't working for you, there are other options. You aren't stuck in one lane. This brings us to the concept that "pills don't teach skills," which leads perfectly into the second paper.
The second paper is called "The Transition to Middle School is Associated With Changes in the Developmental Trajectory of ADHD Symptomatology in Young Adolescents With ADHD." This paper looks at the same MTA data. It uses an algorithm to look at kids going into middle school, arguing that symptom changes aren't just about getting older—they are about a change in life and demands.
Skye Waterson: Can you describe the transition to middle school? From an international perspective, middle school isn't as much of a thing. We have primary, intermediate, and college. Intermediate is a transition, but I feel like American middle school is its own unique thing.
William Curb: I actually just got emails this week about what to expect for my daughter transferring to middle school next year. The big change in the US is that you go from having a single teacher in elementary school to having different teachers for every class. Instead of one adult who knows you well, you’re working with a bunch of specialists, and you have to do a lot more mental organization. You don’t have the same schedule or the same friends with you all day.
Skye Waterson: That makes sense. That was when my ADHD started to become very obvious. I remember having different books for different classes, writing an essay in one notebook but then not having the right notebook for the right class. I was always in trouble for losing my papers.
William Curb: Exactly. You have to make sure you have the right books and keep track of different homework for different classes. It’s a major mental transition. Plus, though not mentioned in this paper, this is when puberty hits, so you have all these emotional and social changes happening at once.
Skye Waterson: Research indicates that for women especially, going through puberty is a major factor with ADHD.
William Curb: This paper specifically focused on the shift to multiple teachers, harder assignments, and more independence. One thing they found was that while teacher ratings of symptoms didn't change much, parent surveys showed increased ADHD symptoms. To me, that sounds like masking. They are holding it together at school and then letting loose once they get home.
Skye Waterson: 100%. I had the exact same thought.
William Curb: The researchers suggested it might be because different teachers rate students differently, but I think it’s because you aren't as comfortable with five different teachers as you are with one. There’s an increased need to keep up your defenses at school and overcompensate for your symptoms.
Skye Waterson: We talk about that a lot—people "falling apart" once they get home to a safe environment. So, why are we looking at these two papers together?
William Curb: Because the original MTA research showed that treatment effectiveness seemed to fade after eight years, but there is so much more to it than just the passage of time. You’re going through puberty and middle school. The demands on an elementary student versus a high school student are vastly different.
Saying the initial treatment didn't "hold up" doesn't account for how life changes. When life demands change, the effectiveness of your strategies and medication changes. If you aren't learning new strategies to meet those new demands, your treatment won't be as effective.
Skye Waterson: Exactly. Otherwise, you’d just say that between 2020 and 2024, everyone’s ADHD randomly got worse, without acknowledging the pandemic!
William Curb: It amazes me how many people ignore the pandemic when talking about why kids are struggling in school now. We know what happened, and pretending it didn't doesn't help us answer the question. Middle school is a similar life-altering event. You have a different workload and a different relationship with your teachers.
Skye Waterson: It was an interesting conversation because the researchers were essentially asking if environment has an effect. They found that while teachers might not notice the shift, the parents definitely do.
William Curb: These studies are from 2008 and 2009, which feels recent but is actually "old" in research terms. They built the foundation for how we think about ADHD today.