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Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): Implications and Applications for Primary Care Providers

JENSEN, PETER S. M.D.*; HINSHAW, STEPHEN P. Ph.D.; SWANSON, JAMES M. Ph.D.§; GREENHILL, LAURENCE L. M.D.; CONNERS, C. KEITH Ph.D.; ARNOLD, L. EUGENE M.D.*; ABIKOFF, HOWARD B. Ph.D.; ELLIOTT, GLEN Ph.D., M.D.; HECHTMAN, LILY M.D.; HOZA, BETSY Ph.D.**; MARCH, JOHN S. M.D.; NEWCORN, JEFFREY H. M.D.; SEVERE, JOANNE B. M.S.*; VITIELLO, BENEDETTO M.D.*; WELLS, KAREN Ph.D.; WIGAL, TIMOTHY Ph.D.§

Journal of Developmental & Behavioral Pediatrics: February 2001 - Volume 22 - Issue 1 - p 60-73
Special Article

In 1992, the National Institute of Mental Health and 6 teams of investigators began a multisite clinical trial, the Multimodal Treatment of Attention-Deficit Hyperactivity Disorder (MTA) study. Five hundred seventy-nine children were randomly assigned to either routine community care (CC) or one of three study-delivered treatments, all lasting 14 months. The three MTA treatments-monthly medication management (usually methylphenidate) following weekly titration (MedMgt), intensive behavioral treatment (Beh), and the combination (Comb)-were designed to reflect known best practices within each treatment approach. Children were assessed at four time points in multiple outcome. Results indicated that Comb and MedMgt interventions were substantially superior to Beh and CC interventions for attention-deficit hyperactivity disorder symptoms. For other functioning domains (social skills, academics, parent-child relations, oppositional behavior, anxiety/depression), results suggested slight advantages of Comb over single treatments (MedMgt, Beh) and community care. High quality medication treatment characterized by careful yet adequate dosing, three times daily methylphenidate administration, monthly follow-up visits, and communication with schools conveyed substantial benefits to those children that received it. In contrast to the overall study findings that showed the largest benefits for high quality medication management (regardless of whether given in the MedMgt or Comb group), secondary analyses revealed that Comb had a significant incremental effect over MedMgt (with a small effect size for this comparison) when categorical indicators of excellent response and when composite outcome measures were used. In addition, children with parent-defined comorbid anxiety disorders, particularly those with overlapping disruptive disorder comorbidities, showed preferential benefits to the Beh and Comb interventions. Parental attitudes and disciplinary practices appeared to mediate improved response to the Beh and Comb interventions.

Address for reprints: Peter S. Jensen, M.D., Center for the Advancement of Children's Mental Health, Department of Child Psychiatry, NYSPI/Columbia University, 1051 Riverside Drive, #78, New York, New York 10032; e-mail: pj131@columbia.edu; fax: 212-543-5260.

The MTA is a cooperative treatment study performed by six independent research teams in collaboration with the staff of the Division of Clinical and Treatment Research of the National Institute of Mental Health (NIMH),* Rockville, Maryland, and the Office of Special Education Programs (OSEP) of the U.S. Department of Education (DOE). The NIMH Principal Collaborators are Peter S. Jensen, M.D., L. Eugene Arnold, M.Ed., M.D., John E. Richters, Ph.D., Joarme B. Severe, M.S., Donald Vereen, M.D., and Benedetto Vitiello, M.D. Principal Investigators and Coinvestigators from the six sites are as follows: University of California at Berkeley/San Francisco† (UO1 MH50461): Stephen P. Hinshaw, Ph.D., Glen R. Elliott, M.D., Ph.D.; Duke University‡ (UO1 MH50447): C. Keith Conners, Ph.D., Karen C. Wells, Ph.D., John S. March, M.D., M.P.H.; University of California at Irvine/Los Angeles§ (UO1 MH50440): James M. Swanson, Ph.D.; Dennis P. Cantwell, M.D.; Timothy Wigal, Ph.D.; Long Island Jewish Medical Center/Montreal Children's Hospital∥ (UO1 MH50453): Howard B. Abikoff, Ph.D., Lily Hechtman, M.D.; New York State Psychiatric Institute/Columbia University/Mount Sinai Medical Center¶ (UO1 MH50454): Laurence L. Greenhill, M.D., Jeffrey H. Newcorn, M.D.; University of Pittsburgh** (UO1 MH50467): William E. Pelham, Ph.D., Betsy Hoza, Ph.D. Helena C. Kraemer, Ph.D. (Stanford University) is statistical and design consultant. The OSEP/DOE Principal Collaborator is Ellen Schiller, Ph.D.

© 2001 Lippincott Williams & Wilkins, Inc.