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William Curb

Welcome to Hacking youg 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 your ADHD brain. Today I'm joined by Sky Waterson for our Research Recap series. In this series we take a look at a single research paper or in today's case, multiple papers and dive into what the papers say, how it was conducted and try and find any practical takeaways. In this episode. The first paper we're discussing is called the MTA at eight 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 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 requires sustained management rather than just something cure. Dive in and talk about what's going on in this eight year follow up study.

Sky Waterson

Yeah, yeah, 100%. Yeah. It was really interesting because obviously they're doing 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, 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?

William Curb

Yeah, I think so. And it was definitely, I mean as I said it was. This is a huge study.

Sky Waterson

Yeah,

William Curb

almost 580 children. The time span of looking at things at eight years is incredible.

Sky Waterson

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

William Curb

Yeah, and yeah, and then it's also, we're looking at kids that are, were ages like 7 to 9. And so this is really getting a full spectrum of 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, what interventions did 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?

Sky Waterson

Yeah, exactly, exactly. So they were reassessed at the 14 month treatment phase, at the 24 and 36 month. And then again at 6 and 8 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.

William Curb

It is really interesting. And so 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.

Sky Waterson

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, 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 fact.

William Curb

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 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.

Sky Waterson

Yeah. And also I, I imagine again, this is a big study. They're not just looking at, they're looking at so many different factors that they want to take into account.

William Curb

Yeah, absolutely. I think, I mean, one of the big things was so like, yeah, absolutely. Their initial intervention had great effects on reducing ADHD symptoms, although they were still behind the localized group. Uh, but when we go out toward the eight year mark, the intervention disappears.

Sky Waterson

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

William Curb

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.

Sky Waterson

Yeah.

William Curb

But it is also something that is. Oh, that's going to have. What I thought was more interesting though was that even the medicated group still did not have the same intervention level

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as

William Curb

the, the initial 14 months did.

Sky Waterson

Well, that was the thing. And I think, you know, obviously I'm, and I want to say this upfront, 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 stop taking medication because they were teenagers. And sure, that is true. But if you look at the people who did take the medication, they were not experienced 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.

William Curb

Yeah. It's really interesting to further data on because we don't have any information from them on why they stopped taking the medication, which they're. In previous studies that we've looked at that have discussed why people stopped using medication. There are a lot of reasons that people might stop taking medication with social pressure and, you know, side effects. Not feeling like it's working well enough.

Sky Waterson

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

William Curb

Yeah. Or the cost is a big one too, as. And I was just thinking I need to look up the. When some of our more modern medications came out, like Adderall and all that, and what was available to them in 1999 versus the last 15 or 20 years.

Sky Waterson

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

William Curb

Yeah. So I think one of the big takeaways that we want. I want people to hear from this because there 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 I 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.

Sky Waterson

Yeah, yeah, 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 would you say that's because of the. Would you say I'm not. I don't want to put you on the spot here, but what does this mean about the type of treatment that you decide to take?

William Curb

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. Yeah, actually how do we bring that other paper in? I think that actually brings in a lot of those points because.

Sky Waterson

Come on out. Second paper.

William Curb

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. Symptomatology is a great word. That's so long. But yeah, so this is talking. So this is papers looking at the same MTA data. It runs an algorithm to try and talk about kids going into middle school because they didn't have this specific data in the MTA study. But 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?

Sky Waterson

Yeah.

William Curb

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.

Sky Waterson

Yeah, 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 take a minute to describe that this for me? Because from an international perspective, middle school is not as much of a thing. We have. We have primary, intermediate and college. And yeah, intermediate school is a transition, but I feel like American middle school is its own thing.

William Curb

I can actually, I got my emails this week on what to expect for transferring my elementary school age daughter into middle school next year because we're gearing up for that. And so I'm like, oh, this is very on note for what I'm know about right now. And a big change for middle school for kids in the US is that you go from having a single teacher that has other teachers come in to do things. So in elementary school they'll have their homeroom teacher and then they might go to PE or music or they have social, emotional or stem stuff. They'll have 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. And so 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.

Sky Waterson

Yeah. Okay, this makes sense. This 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 losing my paper all the time. Because that's what we were doing.

William Curb

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 doing 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 whole wife. You also have just. 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.

Sky Waterson

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

William Curb

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's. Which I was. 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.

Sky Waterson

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

William Curb

Yep. And I was just like, oh, yeah, of course they wouldn't have anything about that because.

Sky Waterson

Yeah. Yeah. I was reading the latest copy of the DSM this week, as I do, and. 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.

William Curb

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

Sky Waterson

Okay. Do you want to take us through what they found?

William Curb

Yeah. So they. They found the middle school was associated with a significant disruption with. Am I reading my note right? It says decline of inattention, hyperactivity, impulsivity. But yes, this is why. So this was an. 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 letting loose once they get home.

Sky Waterson

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

William Curb

Yeah, yeah, yeah, it was because. Yeah, that was my note. Like, they did not, I think, because they're like, oh, yeah, this is probably because 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 going to be an increased level of needing to keep up your defenses while you're at school and not let your try and over compensate for your ADHD symptoms.

Sky Waterson

Yeah, yeah, and we see that. We talk about that. You know, people talk about masking and people having, you know, sort of falling apart once they get home when they're in those environments. Um, 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?

William Curb

What I really saw was, for the original MTA research, it really, it showed like, this, you know, the level of impairment, you know, staying the same when. Or 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 passed. Yeah, 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 my life demand changes, and my. 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 going. It's not going to be as effective.

Sky Waterson

Yeah, no, exactly. Exactly. And I think that's the. That's the reality. Otherwise you could say, you know, oh, 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.

William Curb

Yeah. I am, 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.

Sky Waterson

Yeah, yeah, there is.

William Curb

There's something happened and we know what happened. And pretending like that didn't happen does not help answer the question.

Sky Waterson

Yeah, 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.

William Curb

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

Sky Waterson

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

William Curb

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

Sky Waterson

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 multiple, 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.

William Curb

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

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Sky Waterson

If you have enjoyed listening to this episode, then you might like to listen to my podcast, the ADHD Skills Lab, where we go and deep dive into more of the research. And also we focus on ADHD support for business owners. Whether you're aspiring or you have your own company, and if you have your own company and you wish that you had somebody who would just build these systems for you so you could stop figuring out what to do all the time, well, that's what we do. We are mentor and operator together. So if you want to learn a little bit more about that, you can find me at Unconventional Organization. Thanks for listening.

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William Curb

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