Podcast December 16, 2025
In this Behind the Manuscript episode, we speak with Dr. Margaret Sibley, Professor of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine and clinical psychologist at Seattle Children’s Hospital. Dr. Sibley, recipient of the 2024 Paul Wender Best Paper Award, joins The JCP Podcast to discuss how our understanding of ADHD has evolved across the lifespan. She also reflects on her path from political science to clinical psychology and offers a behind-the-scenes perspective on the landmark Multimodal Treatment of ADHD (MTA) study.
Challenging the traditional binary view of ADHD persistence versus remission, Dr. Sibley details the findings of her award-winning paper, revealing that for the majority of subjects studied from childhood to adulthood, ADHD follows a fluctuating course into adulthood rather than a static one. The conversation explores the critical role of “environmental fit,” the complex interplay between anxiety and symptom management, and the distinct clinical profiles of those with persistent versus fluctuating ADHD. Today’s episode offers vital nuances on how patient environments and comorbidities shape long-term outcomes beyond childhood diagnosis.
Dr. Sibley has authored more than 120 scholarly publications on ADHD, with research supported by the National Institute of Mental Health and the Institute of Education Sciences. She is author of Parent-Teen Therapy for Executive Function Deficits in ADHD: Building Skills and Motivation and currently serves as Secretary of the American Professional Society for ADHD and Related Disorders (APSARD), Professional Advisory Board Member for CHADD, and Associate Editor of the Journal of Attention Disorders. Her work focuses on how ADHD trajectories and functional outcomes are shaped by environmental factors and comorbidities throughout development.
Featured Article
Read the full article discussed in this episode. This study demonstrates that ADHD fluctuations are common and substantive and that, when remitted, individuals with fluctuating ADHD can successfully manage increased responsibilities.
Read MoreJournal of Clinical Psychiatry: Psychiatrist.com/jcp/
Margaret Sibley: https://www.margaretsibley.com/
Parent-Teen Therapy for Executive Function Deficits in ADHD: Building Skills and Motivation: Dr. Sibley’s clinical guide for working with adolescents with ADHD and their families.
CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder): National advocacy organization providing resources and support for individuals with ADHD; Dr. Sibley serves on the Professional Advisory Board.
The Multimodal Treatment Study of Children with ADHD (MTA): Landmark NIMH-funded study examining treatment approaches for childhood ADHD with 16-year longitudinal follow-up into adulthood.
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Ben Everett, PhD, is the Senior Scientific Director for The Journal of Clinical Psychiatry and Psychiatrist.com, where he oversees editorial strategy, content development, and multimedia education initiatives. He is the creator and host of The JCP Podcast, a series that brings together leading voices in psychiatry to explore the latest research and its clinical implications. Dr. Everett earned his PhD in Biochemistry with an emphasis in Neuroscience from the University of Tennessee Health Science Center. Over a two-decade career spanning academia, publishing, and the pharmaceutical industry, he has helped launch more than a dozen new treatments across psychiatry, neurology, and cardiometabolic medicine. His current work focuses on translating complex scientific advances into accessible, evidence-based insights that inform clinical practice and foster meaningful dialogue among mental health professionals.
This transcript has been auto-generated and may contain errors. Please refer to the original recording for full accuracy.
Dr Ben Everett (0:08)
Welcome to the JCP podcast, where we explore the science and stories shaping mental health care today. I’m your host, Dr. Ben Everett, Senior Scientific Director with Physicians Postgraduate Press, publisher of the journal Clinical Psychiatry. On this podcast, we speak with clinicians, researchers, and thought leaders advancing the field of psychiatry with a focus not just on what’s new, but what’s meaningful for our listeners in their clinical practice.
Today’s podcast is in our Behind the Manuscript feature, where we invite the corresponding author of a recent JCP paper on the show. My guest today is Dr. Margaret Sibley, a leading expert in the field of ADHD across the lifespan. Dr. Sibley is Professor of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine and a clinical psychologist at Seattle Children’s Hospital. Dr. Sibley completed her master’s in psychology at James Madison University. Her doctorate in psychology at the State University of New York in Buffalo, and her residency in clinical psychology at Florida International University in Miami. She has authored more than 120 scholarly publications on ADHD in adolescence and adulthood, with her research supported by the National Institute of Mental Health and the Institute of Education Sciences, as well as the book Parent-Teen Therapy for Executive Function Deficits in ADHD, Building Skills and Motivation.
Dr. Sibley currently serves as Secretary of the American Professional Society for ADHD and Related Disorders, is a Professional Advisory Board Member for CHADD, and is Associate Editor of the Journal of Attention Disorders. Her recent paper, Characteristics and Predictors of Fluctuating ADHD and the Multimodal Treatment of ADHD Study, was published in the December issue of the Journal of Clinical Psychiatry and was awarded the 2024 Paul Wender Best Paper Award by the American Society of Clinical Psychopharmacology, for which the Journal of Clinical Psychiatry is the official journal. This award honors the legacy of Dr. Paul Wender, widely regarded as the Dean of ADHD, whose pioneering work helped define the modern understanding and treatment of ADHD, including its persistence into adulthood. It’s a privilege to welcome Dr. Sibley to the podcast today as we discuss her research, what it means for clinicians and where the field of ADHD is heading next. I would be remiss if I did not add a congratulations on being named the Wender Award winner for 2024. All right.
Well, let’s get started. We like to start every episode with a couple of kind of icebreaker questions to orient everybody to who you are kind of as a person. So let’s start at the beginning.
What drew you into the field of psychology?
Dr. Margaret Sibley (2:41)
Well, I actually studied political science in undergraduate, and I’ve always been interested in public health. But after I graduated, I was not actually sure what profession I wanted that to translate into. So I was trying to look back on what meaningful experiences I had had in my life as a 21-year-old.
And the first job I ever had was a camp counselor for a sleepaway camp. The most meaningful thing out of that experience for me was getting to know and sort of counsel teenagers that were under my care. And that really led me to be interested in potentially like a help-seeking job in like counseling or psychology.
But since I had the political science background, I decided I’d go back to school and get a master’s in psychology to sort of explore that interest a little bit more. The thing is, I’ve always been a science and math person. So when I got into that graduate program, what I really was connecting with the most was the research aspects of it.
So I ended up changing my coursework to be less about the counseling applied aspect and more about the research quantitative aspect. Got really interested in ADHD. I sort of stumbled upon it because my graduate school mentor at the time was studying it.
That was my first introduction to really the fact that ADHD doesn’t end in childhood. And so I really sort of latched on to that really frontier at that point, because this was about 20 years ago. So there really was not a lot of clear information about the developmental course of ADHD.
And I got very interested in just anywhere where there was a frontier that could potentially lead to helping people and had some really interesting public health questions. So that was my entry into sort of everything. And from there on, I’ve never found a reason to stop investigating that topic because every little breadcrumb leads to a new important question.
And the feedback that I get from families and the ADHD community in general is that this work is meaningful to them. And so it’s been a very rewarding profession for me so far.
Dr Ben Everett (4:47)
So you’ve worn a lot of hats, you know, researcher, clinician, author, editor. So what role has surprised you most or taught you something that you didn’t expect?
Dr. Margaret Sibley (4:56)
Well, I really like the work I do at CHADD. That’s the advocacy organization for ADHD. It was never like a conference I was socialized to going to when I was in my training, but I got a Young Scientist Award from them, like, I think it’s a just out of graduate school and started going to that conference and became a member of the professional advisory board.
And I think the most meaningful thing is just staying out of spaces that are only meant for professionals in the ADHD world and getting into spaces that are meant for everyone. You really get the most important ideas, I think, from just listening to people who interface with that particular aspect of psychiatry in different ways than you do. And so for me, the energy that you get from going to a conference like that and then connecting in different ways through that community and then being able to enrich what you’re doing from a science side with that two-way conversation has probably been one of the most rewarding aspects of what I do without it necessarily being the prescribed path for a person to be a successful researcher.
So I would encourage everyone to make sure that you engage in those spaces. And those spaces are increasingly existing online, too, and not just in person. And so really making sure that you read the Reddit threads about what people are saying that have a condition that you’re working with, or just really make sure that you go out there and try to be nonjudgmental about the lenses people see aspects of mental health through, even if it’s different than what you were trained in or even what the science says.
Dr Ben Everett (6:38)
I tell you, that really resonates with me. And your passion is really coming through for what you do in that answer. And it definitely fits back with your kind of public policy and political science background.
So I think it’s awesome when someone can end up in a field where all these different aspects of their life come together. It really makes it more meaningful. And I think it probably helps you wake up every morning with sort of a renewed sense of purpose about, OK, this is what I’m doing when I go to work today.
Dr. Margaret Sibley (7:07)
Yeah, I feel very blessed to have a profession that I like because it’s interesting and it happens to also help people. That’s like, I think, all we could all ever hope for.
Dr Ben Everett (7:17)
Yeah, absolutely. All right, look, let’s transition over to the multimodal treatment of ADHD study. So this is a study.
I’m 50. I’m a basic scientist by training. I have ADHD.
And reading this paper and then getting into the history of this study, which really goes back to the early and mid 90s, explained so much about myself. I wish I’d have known about this study 30 years ago, and it would have helped me as a parent with my own children. So I was hoping you could kind of give us a little bit of a background on the MTA study and how it started.
I know it was an NIMH funded study. So if you can give us some historical context before we really get into your paper, I think that’ll be helpful for everybody. You know, what was the initial rationale or hypothesis that National Institute of Mental Health was trying to achieve with the funding for this study?
Dr. Margaret Sibley (8:07)
So just for some context, I’m 43 years old, which means I’m the same age as the kids in the study, you know, could have been because this was recruited in the early 90s. So I was not involved in the early phases of this study, but I’m very well aware of, you know, the lore of the MTA and how it was founded. So, and I’ve been invited to be a part of the follow-up phase of this study and been involved in that for over 10 years
So in the 90s, the NIMH was interested in understanding the comparative efficacy of various strategies for the treatment of childhood ADHD. And at the time, obviously, medication and specifically stimulant medications were short acting stimulant medications were the main, most common treatments for childhood ADHD. But there was also sort of folks who were investigating and applying behavioral interventions for ADHD as well.
The early research questions that drove this study were really just about a randomized controlled trial comparing stimulant medication treatment to behavioral intervention, to their combination, and then also having a community control group that didn’t get any intervention from the research team. And there was a 14-month acute treatment phase of this trial where they did a classic RCT with these four groups and compared these children with ADHD who are on average eight years old to each other to see what their outcomes were in primary symptom domains, some comorbidities, some areas of impairment, just really understand the outcomes there. The findings of that initial phase supported the idea that combined treatment was sort of the most efficacious treatment.
There is a little bit of debate about how to interpret the MTA findings because they’re complex in certain ways. Stimulant medication, by some people’s account, was just as effective as the combined treatment, but we won’t go down that debate path today. So after the 14-month phase was over, they began to follow the kids for a long time, 16 years actually from baseline.
So at three years in the study, there was an important finding that all of the groups reconverged back to basically where there was no separation between the groups. And so the conclusion was that although there was some short-term differential efficacy of the treatment strategies, by three years, everyone was back in the same place. So there wasn’t necessarily a long-term differential comparative effect of these treatment strategies, which pivoted the MTA’s focus for the next 13 years to just understanding what happens to people with ADHD as they grow up and transition to adulthood.
Every time we write an MTA paper, we check to make sure that childhood treatment effect doesn’t come back, but it never has. And so we sort of accept that the childhood treatments aren’t necessarily having an impact on these outcomes, but we can learn a lot just in general about the development of folks with ADHD and what the lifespan trajectory of ADHD can be within the MTA data.
Dr Ben Everett (11:10)
Awesome. Very thorough. I think the only thing I’ll add is the target enrollment was about 600 subjects, so a decent power for the study, about 150 per arm, which they achieved really, really close to that. So I’m curious, so they’re treated for 14 months, and then they return to their community care, essentially their pediatrician at home.
And after three years, the gains had come back together, as you put. So was that because, you’ll have to think through or conjecture or whatever, but what do you think that is? Is it because, OK, maybe they’re still getting their medication, but they’re not getting counseling anymore.
And at that point in time, as you mentioned, the medication was essentially just stimulant and the prescribed medication regimen was TID. So they were taking the stimulant medication three times a day as prescribed, not necessarily just like, well, I only took it in the morning because I only need the first dose.
Dr. Margaret Sibley (12:00)
This is complicated, and there’s probably lots of different reasons why that might be happening, ranging from some of my colleagues who are hot on the idea of tolerance to stimulant medication to other of my colleagues who believe that people just aren’t taking the medication as they’re prescribed to people who just think that people change and grow. And what you learn at one phase in your life, it may not be relevant to another phase in your life, and you need to learn new things. So the idea that 14 months of treatment when you were eight, it should have this long-term effect on your life when you hadn’t possibly continued that treatment for the next 10 years.
That was just a little drop in the bucket in terms of what a person with ADHD might need. So there’s a lot there to unpack. But yes, I mean, some people are thinking some of the ideas that you’re thinking.
Dr Ben Everett (12:48)
Yeah, it’s interesting. And yeah, a lot to think through. And well, you can only, yeah, the data are what the data are.
And so we can’t over-editorialize, right? So interesting findings anyway. So in terms of safety or side effects, anything major that came out of the study that people need to be aware of or should think through.
And of course, now we’ve got so many different medications. We’ve got extended release. We’ve got non-stimulants.
We’ve got all sorts of different things.
Dr. Margaret Sibley (13:12)
I mean, everything, all four arms did not demonstrate any significant safety concerns, including behavior therapy, right? We should always be thinking about safety with that too. The main finding that maybe one might consider an adverse effect would be on growth.
So there was a finding that there are very small changes in growth trajectories based on stimulant medication usage across the MTA. It’s a very negligible impact on height. And whether that’s meaningful to people or not is an open question.
But that was one of the findings of the MTA study.
Dr Ben Everett (13:49)
It was, yeah, about a 4% difference between the groups. But so much happens with kids that age. I mean, the data, again, the data are what the data are, but you kind of never know what’s going to happen with that.
So, all right. And then you mentioned follow-up. So before we get to your study, there’s been a lot of research done on, you know, on this cohort of children that are now, you know, full-on adults, you know, any other kind of major findings that have come out that you want to highlight before we really get into your paper?
Dr. Margaret Sibley (14:16)
As far as it goes in the adolescent phase, a lot of it was just showing that adolescents with ADHD are at higher risk for things like substance use and things like behavior that’s rule-breaking and understanding the homework problems that they go through and just really characterizing the different impairments of that age group. When we move into the adult follow-up phase, a lot of the work has focused on persistence. I think that the paper that we’ll be talking about today is sort of just one of the tentacles of that sort of body of work on persistence of ADHD, late-onset ADHD, whether that’s a possibility or not, given that we have a non-ADHD comparison group that was recruited in this sample.
I think that was another one of the kind of hotter papers out of the adult follow-up phase. And just understanding that people whose ADHD seems to persist experience many more continued impairments than those who have ADHD that seems to remit. But I think as I start to describe those findings, we’re still a little bit segueing into the paper, so maybe I’ll just stop there.
Dr Ben Everett (15:15)
And one other thing I wanted to highlight before we really get into that is when we get to the combined therapy, you know, from the initial cohort did seem to do a little bit better, but also it seemed to be maybe a little bit stimulant dose sparing. So the children that got the combined therapy of behavioral therapy with pharmacotherapy actually got by with a little bit lower dose of stimulant medication, which could make a lot of parents feel better. So I thought that was an interesting finding as well.
But of course, you have to continue to do, I would imagine, the behavioral therapy with the stimulant therapy to probably see more enduring or durable results. But we don’t really know because it’s been tested in that way. But I thought it was an interesting finding.
Dr. Margaret Sibley (15:57)
That’s right. And that’s not the only study that’s found that as well.
Dr Ben Everett (16:00)
Again, and I’ll just say, you know, from a parental standpoint, like if someone had told me, if our pediatrician had said, hey, look, it’s really important that you look into some behavioral therapy to go along with this, I just can’t help but wonder, you know, if it would have had a broader impact on my children’s ability to just function with everything that they do, everything that we ask of kids today with all their different schedules and sports and, other activities, schoolwork and everything else.
When the study was done, we really just had the stimulant medication. It was TID, no extended release. So, we have all these different medications now, stimulant, non-stimulant.
There are genetic tests that can help guide this decision making, which was very helpful for me as a parent. Are there any findings that really hold up in terms of clinical guidance today and the way people think about pharmacotherapy, you know, stimulant versus non-stimulant? Or is that not really a finding that can be extrapolated from that study?
Dr. Margaret Sibley (16:58)
I don’t think the MTA has, at least on a simple level, I don’t think the MTA has a ton of guidance for selecting modern medication formulations just because it was done in a very different time. And I don’t think we see a lot of kids taking three doses of short-acting medication a day anymore. My colleagues who have really dug into the weeds of that medication data may have some nuanced thoughts on the matter.
But I think that mostly what we’re learning is sort of the big picture question of like, how do you combine potentially and maybe even sequence medication generally versus behavior therapies generally? And the behavior therapies have also changed a ton since the 90s as well. So we’re not doing the same kinds of treatments they did back then.
It’s the same, you know, compounds in the medication, but the formulations are very different that people are taking today. So we can learn big picture things from the MTA, but I think there’s a lot of new nuances to it in terms of everyday practice.
Dr Ben Everett (18:00)
Yeah, I think that’s clinical medicine and science in general, right? We’re always learning new stuff. And so sometimes the historical data can be very helpful in sort of understanding how we got to where we are today.
But in terms of trying to get clinical guidance on how we treat patients today is probably asking too much of data that’s getting close to 40 years old. All right, well, look, I want to transition to your current research on the MTA study. Anything else you want to highlight on MTA before we really get into your current paper?
Dr. Margaret Sibley (18:29)
Oh, you know, the MTA is alive and well. We still meet fairly regularly to talk about new paper ideas. It’s a great group of investigators.
It’s been some of the best mentors I’ve ever had just working with those folks. And yeah, we just lost one of our leaders, Gene Arnold, this year. So we’re all pretty sad about that.
But so many of the MTA investigators have officially retired, but they still come on and are contributing to the study because, you know, I think it’s just so important to our field and continues to yield really important messages. So it’s a group effort and no one’s really funded to do it, but we all believe in it and keep it going. So, you know, we’re thankful to have the work continue to be recognized in platforms like this.
Dr Ben Everett (19:10)
That is awesome. And I think it just shows, again, passion and how this work is really important to individuals that they’re going to continue to essentially volunteer their time after they’ve retired, find a way to get things done even if you don’t have funding.
That, again, that just, to me, that just demonstrates their passion for what they’re doing. And it’s been so helpful for clinicians treating kids and young adults and even full-on adults with ADHD now. All right.
Well, let’s transition to your paper, Characteristics and Predictors of Fluctuating ADHD and the Multimodal Treatment of ADHD Study. We’ll put a link in the show notes to where people can go look at that at JCP. So ADHD has historically been characterized as a chronic childhood neurodevelopmental disorder, approximately 50% persistence into adulthood.
You know, that said, several recent studies detected a fluctuating course of ADHD, which I think was sort of the genesis for your paper. And that challenges the notion that, you know, childhood ADHD either permanently remits or persists into adulthood. So can you tell us a little bit about sort of some of these studies and how that set up the current study?
Dr. Margaret Sibley (20:18)
Yeah. So all of this started, at least for our group, when we were interested in this initial question about full remission from ADHD. So the DSM has these specifiers, a person’s partially remitted, a person’s fully remitted, without a definition of what they really are or how to decide if somebody would get one of those specifiers.
So I think on the MTA side, we’re really interested in this question of like, are there people who seem to 100% completely overcome their ADHD permanently in our sample that we really confidently say, it’s not just a technicality that they no longer meet DSM criteria, but this person is functioning as if they never had ADHD. And so we kind of went looking for those folks in an earlier paper, and we found about 50 of them in the MTA sample. That’s about 9% of the sample, which was interesting.
But what we stumbled upon while doing that research was that actually the majority of the folks in the sample, if you look over the 16 years that they were enrolled and every two years, they got these comprehensive ADHD evaluations once again and once again, parents, teachers, self-report, interviews, rating scales, everything. If you look, you see that the most common presentation in the group was people who would meet ADHD criteria some years, and then other years they would either appear partially or even fully remitted. And then they meet the ADHD again a few years later.
And that was such an obvious thing to go looking at. But for some reason, within the limitations of the existing studies, no one had really been able to string all that together before. Most people were looking at persistence as a finality, a single outcome.
Once someone’s an adult, do they have it anymore? Do they not? Assuming that’s a permanent status.
But it seems very dynamic. Like some people would have ADHD for a few years, according to clinical criterion, and then they would be doing a lot better and they would not meet that threshold anymore. So in the current paper, we really wanted to understand what exactly is the nature of this fluctuating ADHD with a little bit more precision, which took us to research questions related to what are the current clinical profiles?
What were the childhood clinical profiles of folks who would be considered a fully remitted case long term, a fluctuating ADHD case, a case that partially remits so they get a little bit better, but they’re still somewhat symptomatic, or a case that’s persistent ADHD and just meets criteria for ADHD every single year of the study. And we’re trying to understand differences between those groups. And then sort of the main analysis that caps off the paper is looking, using some complex statistical models at relationships between fluctuations and symptoms and environmental demands and whether there might be any aspect of how demanding your environment is that has an impact on your symptom level.
So that was sort of how we set up the paper, the reason why we set up the paper the way we did and what we were looking for.
Dr Ben Everett (23:17)
Yeah. And I want to highlight, I think this is just an amazing statistic, is the amount of the initial subjects that have continued in the study and that you’ve followed up. So here you’ve got 83.4%. So of the 579, I mentioned the initial N was 600, you got 579 children in the initial data set. You’ve got 483 of those subjects that you’re still following now into adulthood. I think that’s just amazing, like from a clinical trial standpoint that I find a little staggering. So are there any strategies or techniques you all have done to keep the subjects active or do people just believe in it and they know they’ve been studied this way their whole life and they enjoy continuing in the study?
Dr. Margaret Sibley (24:03)
I was not involved in any of the data collection, but I know about what people say. And I think it really was like the personal relationships developed between the research participants and the staff at the site. Since this was a six site study in North America, each site had its own local group of participants and they were responsible for that local group.
And so they were able to sort of develop doing things like birthday cards and just really making people feel like they’re a part of something, I think was the main strategy that was used.
Dr Ben Everett (24:31)
That’s awesome. Yeah. Birthday cards, handwritten notes.
Yeah. And just rapport and developing that therapeutic alliance is so important. I think for any, patient who’s seeing, you know, whether it’s a prescribing clinician or behavioral health clinician, somebody in mental health, that is so important.
So let’s get to the results. So what did you find?
Dr. Margaret Sibley (24:53)
So recall that I mentioned a second ago, over 60% of the folks were in this fluctuating group. And just to orient you, the persistent ADHD group where people had ADHD every single year of the study for 16 years, that was only about 10% of the sample. As I mentioned, the full remission group is about 10% of the sample too.
And then there’s partial remission group. These folks that sort of like have ADHD for a while and slowly get a little bit better and drop underneath that threshold as they become adults. That’s about 15% of our sample.
So we’ve got these four groups set up. And as far as they look in adulthood, what we see is that the folks in the persistent ADHD group really are the group that looks different, the most different from the other groups. The fluctuators are really kind of like your bread and butter people with ADHD, believe it or not.
The persistent ADHD group have many more comorbidities. They have vulnerabilities to substance use that they’re reporting. They’re having trouble and are much more impaired in their daily lives.
And so this is sort of our severe ADHD profile. The folks in the partial remission group, they’re pretty interesting. They’re not experiencing remission for the first time until like average age of 18.
So these folks look like they have ADHD, just like that full ADHD group until they look similar until they’re like about to transition to adulthood. And then these folks, you know, they do a little bit better. They’re still not fully remitted.
One interesting feature of that group is that they seem to have the highest comorbid anxiety, which has led to us sort of wondering if that anxiety has actually been a little protective for them. So they’re folks with severe ADHD, but because their anxiety may be a motivating factor for them to manage that ADHD and try to function as well as possible, that they sort of get themselves a little bit better, which is interesting. Our fully remitted group, you know, they are really doing great.
And our fluctuating ADHD group is right in the middle. They have moderate amounts of psychopathology. They have moderate amounts of impairment.
We validated that their fluctuations are not just tiny blips up and down below that threshold. On average, their low points are very low. On average, their low points are having like one symptom of inattention or one symptom of hyperactivity.
And their high points are pretty high, having, you know, seven, eight symptoms of inattention or hyperactivity. All these kids, they were combined type all at baseline, just to clarify that. So these are not small little, we’re not capitalizing on small little changes below or above the threshold.
These are big swings, which is interesting.
Dr Ben Everett (27:33)
That is interesting. So I’m curious, a couple of things, a couple of follow-up questions there. So you mentioned the interplay with anxiety.
That’s something with one of my children was very big. And that’s something that we were counseled about from our pediatrician and did get some behavioral health therapy there because they’re like, you know, if we don’t treat the anxiety, it’s just going to continue to exacerbate the ADHD and they really go together. We hear so much about how kids today are so much more anxious than really any generation that came before them.
And this seems to be multimodal as best we can tell. Any thoughts about, you know, this combination of anxiety and ADHD? Does it seem to be exacerbating ADHD or making ADHD more prevalent in kids these days or anything like that?
Dr. Margaret Sibley (28:16)
Well, we’ve long found this relationship, even in the very early of the MTA, that people do better in behavior therapy for ADHD if they have comorbid anxiety. And one nice analogy is thinking about it like the gas and the brakes in the car. So if you have ADHD and you have anxiety, your ADHD might be activating you to go, go, go, be kind of impulsive.
It may be leading to inattentive symptoms like your mind wandering. But that anxiety that wants you to be able to meet other people’s expectations and do well is like pulling back the reins a little bit and putting on the brakes and saying, like, oh, hold on, don’t be impulsive. Something bad could happen.
It actually may make the consequences feel more salient to people, which can help kind of like counterbalance their ADHD. So it’s not an advocacy for, you know, it’s good to have both because obviously we don’t want anyone to have any psychopathology. But I mean, just observationally, we do see that.
So I think obviously anxiety also causes concentration difficulties and inattentive symptoms. That’s a differential diagnosis, obviously. But certainly there’s a very interesting kind of bidirectional and complex relationship between anxiety and ADHD.
Dr Ben Everett (29:24)
Interesting. And then you mentioned that this group had a much higher level of comorbidities. I just wonder if you can unpack that a little bit more.
Were there any comorbidities in particular that jumped out or, you know, higher prevalence for substance use later in life? Anything else you can highlight from comorbidities? Or is it like kind of lead to thinking about this as a phenotype or something else that people should be looking for clinically?
Dr. Margaret Sibley (29:49)
Yeah. So within the baseline analyses that we also did in this paper, we sort of saw that that 10% that has the persistent ADHD that are very severe, they had a lot of comorbid mood problems across the lifespan. So including in childhood, there was a high mood comorbidity.
And then once they got to, starting when they got to adolescence, there was a high substance use comorbidity there. So it does seem that there may be this like more intractable form of ADHD that may almost be like nonspecific psychopathology that includes a mood aspect to it as well. There’s obviously a lot more to unpack there, but at the surface level, that’s what the profile sort of looks like.
We saw that the people with the remitting, fully remitting ADHD, they actually had some protective factors with respect to mood. So they had particularly low levels of mood problems and almost sort of like positive temperamental profile that was protective against mood problems in that group, which was really interesting. But our fluctuating folks, they were just sort of the average person with ADHD once again.
So that seems like the average profile there. We also found that parental psychopathology was a strong predictor of being in that 10% stable ADHD group, which is interesting because there’s obviously an environmental component to that as well as a genetic component to that. It does sort of lend credence to that possibility that there is sort of like a biologically intractable psychopathology profile that runs in families that is just really hard to mitigate in any way.
Dr Ben Everett (31:22)
That’s very interesting. So I know we’re kind of drawing to the end of our time here. So any clinical pearls from this study that you think, you know, if I’m a pediatrician or a general practitioner or now I’m seeing an adult that had diagnosed ADHD as a child but thought it had gone away, any clinical pearls that you think that our listeners can take away from what you found now?
Dr. Margaret Sibley (31:45)
Well, I think that the final analysis we did is really where the clinical pearls come from. So looking at that relationship between environmental demands and ADHD fluctuations, we found the opposite of what we expected. So we actually found that when environmental demands were higher, people were more likely to be experiencing remission.
Most people thought that if you turn up the demands, you increase the executive function burden and people sort of have more chaos and experience worsening ADHD. But on the contrary, although these relationships cannot be assigned like causal directions, you know, you can either say that, well, when people have lower ADHD, they tend to seek out more demands in their life because they think they can handle more. But you also might say that when the stakes are higher, a person with ADHD rises to the occasion and seems to do their best.
And within the ADHD community, there’s a lot of endorsement of that interpretation of our finding, which is very interesting. So my group’s doing some qualitative interviews right now trying to understand that a little bit. But for your clinicians out there, I think really we have to understand that this is just the first signal that there seems to be relationships between the environment and a person’s ADHD severity in any given period of time, and that we should be thinking about environmental fit as a potential way to help people manage their ADHD better.
Self-selecting into environments that have features or characteristics that seem to help a person keep their ADHD at bay as best as possible, whether that’s a higher interest environment because the environmental consequences in that environment are more salient to the person, whether that has to do with avoiding stressful situations that sort of exacerbate ADHD or just helping people find environments that are a fit for their skill set to boost their self-efficacy and the psychological aspects of what a person with ADHD experiences.
That’s all possible directions for that, right? So I think the environment deserves a lot of attention here.
Dr Ben Everett (33:48)
That’s really amazing. And I tell you, so much of what you said resonates with me as an individual with ADHD. And a lot of this stuff I’ve kind of figured out on my own.
If I could have read a paper like this 20 years ago, it really would have helped me. But that’s great. So final question.
So what’s next for the MTA? Or what’s the next question that y’all are trying to get an answer to?
Dr. Margaret Sibley (34:09 – 34:44)
You know, there’s some work being done on medication and the long-term aspects of medication and why people stay on it. Most people did not stay on it long-term. Spoiler, that’s in the published data already.
Most people desist it, 90% by the time they’re adults. So why? And for those who stay on versus don’t stay on, what benefits are there?
Those are very complicated relationships to disentangle. But my colleague, Jim Swanson, is leading some work in that area. So we hope to have better answers for everyone about how medication might be impacting the ups and downs of ADHD for folks, as well as their long-term functioning.
Dr Ben Everett (34:45)
All right. Well, in closing, I want to thank Dr. Sibley for joining us today on the JCP Podcast and for sharing her passion and enthusiasm for treating ADHD in her recent research. It’s been great speaking with you today.
Dr. Margaret Sibley (34:56)
Thanks for having me.
Dr Ben Everett (34:57)
Next time on the JCP Podcast, I’ll be joined by Dr. Michael Asbach, a doctorate-level physician assistant. Dr. Asbach is a nationally recognized PA and Associate Director of Interventional Psychiatry at the Dent Neurological Institute. Known for his engaging presentations on the CME circuit, Mike brings a unique perspective as an advanced practitioner on treatment-resistant depression, bipolar disorder, and emerging psychiatric treatments.
We’ll also talk about his work empowering clinicians through the white coats of the which is a new venture he’s started. It’s a conversation you won’t want to miss. This has been the JCP Podcast.
Insightful, evidence-based, human-centered. Thanks for joining us. Until next time, stay curious, stay informed, and take care.
Vol 86 • 2025 • Number 3
Original Research
Academic Highlights
Academic Highlights
In Memoriam
Narrative Review
Original Research
September 8, 2025
February 19, 2025
