Parental Report of Remission in ADHD: Results From a Community-Based,Nationally Representative Sample

Abstract

Objective:

Various studies have examined rates of remission in ADHD with mixed results.

Method:

Survival curve analyses were performed on a community-based sample.

Results:

The results of the current study appear to support the contemporary literature that rates of remission in ADHD are lower than have been found in many earlier studies. The current study also reports a mean age of remission in ADHD of around 14 years old, which has not been previously reported via survival curve analyses. Additionally, the results of the current study found several variables to be significantly associated with remission in ADHD which included: the presence of comorbid disorder; lower symptoms of ADHD; sex of the child (being female); and the receipt of behavioral treatment.

Conclusion:

Implications and limitations are discussed as related to these findings.

Keywords

symptoms parent-child agreement parenting

ADHD is generally considered a lifelong disorder with a prevalence rate of 1 in 20 school-aged children (American Psychiatric Association, 2022). For an ADHD diagnosis, the age of onset must be in childhood by the age of 12 years per the fifth edition of the Diagnostic and Statistical Manual (APA, 2022). The lifelong developmental course of the disorder and its symptoms has been subject to continued debate (Leffa et al., 2022; Sonuga-Barke et al., 2023). There has been some evidence that symptoms of ADHD may remit (e.g., Biederman et al., 2011; Caye et al., 2016; Cheung et al., 2016; Sibley et al., 2016). This remission may even develop to the point of full remission of ADHD such that symptoms of ADHD would only meet a subclinical threshold of the disorder. However, in reviewing the literature that examines the rates of remission in ADHD, it has been indicated to be quite mixed with varying rates of remission depending upon the methodology and sample utilized. As a result, rates of persistence (as opposed to remission) have been found to range considerably, anywhere from 4% to 76% (e.g., Caye et al., 2016; Sibley et al., 2016, 2022; Van Meter et al., 2023). The literature suggests that higher rates of remission (or lower rates of persistence) in ADHD appear to be more prevalent such that Kim et al. (2019) indicated that the majority of children experience remission in their ADHD as they age.

However, more recently, Sibley et al. (2022) found that sustained remission of ADHD was found in only approximately 9% of the sample from childhood to adulthood with ADHD symptoms fluctuating over time. Indeed, Shaw (2022) remarked from Sibley et al. (2022) that, “the most common trajectory was of ADHD diagnosis that waxes and wanes, moving fluidly between syndromic, symptomatic, and asymptomatic states,” (p. 88). Sonuga-Barke et al. (2022) also concurred with Sibley et al. (2022) that the trajectory of ADHD would indicate repeated periods of remission and persistence of ADHD. Another contemporary study of Grevet et al. (2022) indicated even lower rates of remission in ADHD at 5.7% of the sample with 25.5% of the sample being considered unstable or fluctuating and 68.8% being considered stable or persistent in their symptoms. Additionally, Karam et al. (2015) examined the remission of ADHD symptoms into adulthood across a seven-year period. In this study, Karam et al. (2015) indicated that 12.4% of the sample achieved full remission of symptoms of ADHD. In the view of this more contemporary and recent literature, estimates of ADHD remission rates tend to be lower.

Furthermore, Thomson et al. (2020) found that performance on a sustained attention task did not differ between individuals with ADHD considered in remission and those individuals with ADHD not in remission. These results from Thomson et al. (2020) would indicate the relative permanence of the core impairment in sustained attention among individuals with ADHD despite the symptoms remitting for some individuals. However, this literature measuring neurological functioning between those individuals with ADHD in remission versus those individuals with ADHD who are not in remission has continued to be mixed (e.g., Agnew-Blais et al., 2020; James et al., 2020; Luo et al., 2020; Zhao et al., 2020). Additionally, it has been noted that the presence and degree of impairment related to ADHD is one of the variables that appears to influence the rates of remission (or persistence) in ADHD (Sibley et al., 2022; Weiss & Stein, 2022). As a result, Leffa et al. (2022) summarized the contemporary literature well regarding remission in ADHD well stating that, “ADHD is known to persist into adulthood, even though there is no consensus on the exact rate,” (p. 10).

Several variables have been found to be associated with rates of remission in ADHD across time. In a meta-analysis of studies examining persistence rates in ADHD, Caye et al. (2016) found that the severity of ADHD and the presence of comorbid disorders as being significantly associated with higher persistence or lower rates of remission in ADHD. In their meta-analysis, individuals with ADHD who also had comorbid or coexisting disorders as well as more severe symptoms of ADHD tended to have lower rates of remission (and higher rates of persistence; Caye et al., 2016). Additionally, Grevet et al. (2022) found that males appeared to be more unstable or fluctuating in their rates of remission of ADHD than females. In their study, Grevet et al. (2022) found that 42% of males had unstable or fluctuating symptoms of ADHD as compared to 22% of females with ADHD. However, future research is warranted to examine those variables as significantly associated with rates of remission in ADHD as Sonuga-Barke et al. (2022) notes that, “the determinants of ADHD persistence have been definitively established,” (p. 507).

Given that permanent remission of ADHD appears to be unlikely (Sonuga-Barke et al., 2022), a continued examination of the developmental pattern of symptoms of ADHD is warranted. The purpose of the current study was to examine the rates of remission in ADHD according to parental report. Parental report of ADHD symptoms tends to lend more evidence of validity than self-report alone (Sibley et al., 2017). In the current study, we examined the variables associated with remission in ADHD in addition to age at remission in years. To achieve the purpose of the current study, specifically two research questions were examined using data from the National Survey of Children’s Health (NSCH; United States Census Bureau, 2021). The NSCH may be considered a large, community-based sample that is nationally-representative. The first research question that we examined was what was the age (in years) at which remission was most likely to be reported by parents of children with ADHD? The second research question that we examined was what variables may be associated with remission in ADHD as reported by parents. In the current study, we examined the following variables as being associated with remission in ADHD that emerged in the review of the current literature: the presence of comorbid disorders; degree of symptoms of ADHD; sex of the child; whether the child had a special education plan; whether the child received behavior treatment; whether the child received medication treatment; or the combination of both behavior and medication treatment.

Method

Sample

The sample consisted of 4,580 parents who reported children who ever had ADHD from the NSCH. The average age of the sample was 8.15 years (SD = 5.26). Approximately 33% (n = 1,550) were female and 67% (n = 3.136) were male. Approximately 5% (n = 216) of the sample had diagnoses of intellectual disability, 22% (n = 1,011) had a speech disorder, 15% (n = 678) had diagnoses of Autism Spectrum Disorder, and 38% (n = 1,779) had a specific learning disability. With regard to race, approximately 8% (n = 360) reported to be African American, 0.8% (n = 39) were American Indian or Alaska Native, 2% (n = 91) reported to Asian American, 0.4% (n = 21) reported to be Native Hawaiian or Pacific Islander, 9% (n = 442) reported to be two or more races, and 80% (n = 3,733) reported to be White. With regard to ethnicity, approximately 12% (n = 539) identified as Hispanic. Approximately 7.45% (n = 341) of the sample had ADHD but then did not currently have ADHD as reported by parents, whereas parents were asked whether their child currently had or had not ADHD with a dichotomous “yes” versus “no” response.

Measures

The variable of ADHD symptoms was created as a composite of several variables of parent ratings of behaviors. This composite consisted of the sum of four items with 5-point response format for each item with a value of 1 indicating “always” with a value of 5 indicating “never.” Thus, higher scores indicate lower symptoms of ADHD. The mean score was 21.16 (SD = 4.35). The items were as follows: how often easily distracted; works to finish tasks started; how often follow instructions for simple task; and how often able to sit still. The number of comorbid or coexisting conditions, which ranged from 40 to 90 with a mean of 58.75 (SD = 14.98). Approximately 42% (n = 1,973) received behavioral treatment for ADHD while 58% (n = 2,691) did not. As for medication, approximately 55% (n = 2,545) took medication for their ADHD and 45% (n = 2,118) did not. Approximately 40% (n = 1,839) had a special education plan or IEP while 60% (n = 2,822) did not.

Analyses

A Cox’s proportional hazard model was utilized for the dependent, censored variable of experiencing remission in ADHD (Cox, 1972, Therneau & Grambsch, 2000) via MedCalc (v. 20.009; MedCalc, 2021). Survival curve methodology was utilized as the event of remission would be censored or missing at any point in time as individuals with ADHD could subsequently go into remission. The independent variables were: the number of comorbid disorders; ADHD symptoms; the presence of a special education plan; age at which they received a special education plan; behavior treatment; medication treatment; and combined behavior and medication treatment. Chi-square (χ²) statistic values were reported to reflect model fit versus the null model. Regression coefficients along with standard errors and odds or hazard ratio values (i.e., e ^^B) have been reported. An odds ratio value further away from 1 indicate a stronger direct or inverse likelihood of ADHD remission occurring.

Results

Results indicate acceptable model fit, χ²(7) = 138.38, p < .001. Table 1 provides the model estimates along with odds or hazard ratio values. Survival curve results indicates an overall mean time to event (i.e., experiencing remission in ADHD) of 13.84 years (CI₉₅: 13.50; 14.19) when ADHD remission did occur. Figure 1 provides a display of the cumulative survival function across sessions. The number of comorbid disorders was associated with increased rates of remission in ADHD, b = 0.03 (SE = 0.01), p < .001, e^b = 1.03. Lower symptoms of ADHD was associated with increased rates of remission in ADHD, b = 0.03 (SE = 0.01), p < .001, e^b = 1.03. Being male was significantly associated with decreased rates of remission in ADHD, b = −0.09 (SE = 0.03), p = .007, e^b = 0.92. Behavioral treatment was also significantly associated with increased likelihood of remission in ADHD, b = 0.19 (SE = 0.05), p < .001, e^b = 1.21.

Table 1.

Summary of Covariates.

Covariate	b	SE	Wald	p	e ^B	95% CI of e^B
Comorbid disorders	0.03	0.01	26.03	<.001	1.03	[1.02, 1.05]
ADHD symptoms	0.03	0.003	71.25	<.001	1.03	[1.02, 1.04]
Male	−0.09	0.03	7.26	.007	0.92	[0.86, 0.98]
Special education plan	−0.02	0.03	0.30	.58	0.98	[0.92, 1.05]
Behavior treatment	0.19	0.05	13.78	<.001	1.21	[1.09, 1.33]
Medication treatment	<0.001	0.04	<0.001	.99	0.99	[0.92, 1.08]
Combined treatment	0.05	0.06	0.67	.41	1.05	[0.93, 1.20]

Bolded text indicates statistical significance.

Figure 1.

Cumulative survival curve across sessions.

Discussion

The current study found that approximately 7% of the sample had ADHD in remission as reported by parents. The sample derived from the NSCH consists of a large, community-based study that may be considered nationally representative (United States Census Bureau, 2021). The mean age at which remission in ADHD was reported by parents was 13.84 years. We could not locate a study that examined rates of remission that reported the mean age of remission in ADHD. We next examined the relationship of covariates of interest in being associated with a higher likelihood of remission. In the current study, the variables of the presence of comorbid disorders, symptoms of ADHD, sex, and behavior treatment were found to be statistically significant as related to remission in ADHD. As the number of comorbid disorders increased, the likelihood of ADHD remission increased as well, which could indicate the presence of other disorders as being more predominant as compared to ADHD. Less symptoms of ADHD was associated with increased rates of remission in ADHD, which indicates more severe symptoms would indicate decreased rates of remission. Being female was associated with a greater likelihood of subsequently being reported to have ADHD remission.

Additionally, the receipt of behavioral treatment was significantly associated with remission in ADHD. The more likely that students were reported to receive behavioral treatment for ADHD, then then more likely that students would experience an increase likelihood of remission. These results would indicate some effectiveness of behavioral treatment being significantly associated with increased remission in ADHD and would indicate that services provide may lead to remission. The finding that medication as treatment was not significantly associated with remission in ADHD is not surprising given the phenomenon of paradoxical decompensation that can occur over time (Yanofski, 2011) or simply tolerance to the medication. It would appear that medication may offer more shorter term benefits not significantly associated with ADHD remission while behavior treatment may be associated with more longer term benefits, thus more likely to have remission in ADHD occur.

Several implications emerged in conducting the current study. First, given past reported high rates of remission in ADHD, parents and their students may consider prematurely discontinuing medication. However, Tsujii et al. (2020) found that discontinuing medication was associated with more negative quality of life outcomes. Yet, intermittent medication non-adherence, also known as medication vacations has been found to be associated with some positive outcomes for students with ADHD (Barnard-Brak et al., 2020, 2023).

Some limitations which emerged in the current study should be noted. Parental report may be considered somewhat less valid than a parent completing an instrument in tandem with clinician interpretation and evaluation. However, parents serve as a cornerstone in the diagnostic process given their continual contact with their child. Interestingly, the rates of remission from parental report appear to be well aligned with the contemporary literature indicating rates of remission ranging from approximately 6% (Grevet et al., 2022) to 9% (Sibley et al., 2022). Another limitation is the community-based and nationally-representative nature of the NSCH sample, which precludes the in-depth clinical histories that a clinic-based sample would typically have. Conversely, the current study is not limited by the presence of Berkson’s bias (or clinic-based bias), whereas clinic-based samples tend to represent those individuals with more severe symptomologies. Finally, the variable of sex of the child was not collected beyond the binary of male or female as part of the NSCH, which precludes the examination of the ADHD within populations outside of the binary.

In conclusion, the results of the current study appear to support the contemporary literature that rates of remission in ADHD are lower than have been found in many earlier studies (e.g., Caye et al., 2016; Sibley et al., 2016, 2022; Van Meter et al., 2023). Sibley et al. (2022) notes that these lower rates of remission in ADHD appear to be a function of methodological choices in their terms of measurement. The current study also reports out a mean age of remission in ADHD of around 14 years old, which has not been previously reported via a survival curve study. Additionally, the results of the current study found several variables to be significantly associated with remission in ADHD which included: the presence of comorbid disorder; symptoms of ADHD; sex of the child; and the receipt of behavioral treatment.

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Lucy Barnard-Brak

Author Biography

Lucy Barnard-Brak is a Professor of Special Education at the University of Alabama. She earned her Ph.D. in Educational Psychology from Texas Tech University.

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