Fluctuating course of attention-deficit/hyperactivity disorder across development: Multifactorial influences

Abstract

Attention-deficit/hyperactivity disorder (ADHD) is increasingly conceptualized as a dynamic neurodevelopmental condition, marked by fluctuating symptom trajectories across development rather than the traditional static patterns of persistence or remission. This review synthesizes empirical evidence on the varied trajectories of ADHD symptoms-including late-onset, partial remission, and recurrent fluctuation patterns-and underscores their clinical significance in long-term functioning. We adopt a multifactorial framework to explore how genetic, environmental, and gene–environment interactions contribute to the emergence and evolution of ADHD symptoms over time. In addition, we consider how medication-related variables-particularly tolerance and adherence-may influence symptom fluctuation. Characterizing these developmental dynamics offers critical guidance for designing flexible, personalized interventions that align with individual trajectories and transitional vulnerabilities.

Keywords: Attention-deficit/hyperactivity disorder; Symptom fluctuation; Developmental trajectories; Longitudinal studies; Gene-environment interaction

Core Tip: This review shifts the focus from static views of attention-deficit/hyperactivity disorder (ADHD) persistence to the developmental fluctuation of symptoms over time. Instead of focusing on prevalence or average trajectories, it emphasizes individual-level variability and synthesizes longitudinal evidence on late onset, partial remission, and recurrent fluctuation patterns. Through a multifactorial perspective, the review discusses the independent and interactive roles of genetic and environmental factors in shaping these trajectories. This lens offers a refined understanding of ADHD heterogeneity and informs developmentally tailored clinical approaches.