Psychosocial Treatment Strategies in the MTA Study: Rationale, Methods, and Critical Issues in Design and Implementation

The Collaborative Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (ADHD), the MTA, is the first multisite, cooperative agreement treatment study of children, and the largest psychiatric/psychological treatment trial ever conducted by the National Institute of Mental Health. It examines the effectiveness of Medication vs. Psychosocial treatment vs. their combination for treatment of ADHD and compares these experimental arms to each other and to routine community care. In a parallel group design, 579 (male and female) ADHD children, aged 7–9 years, 11 months, were randomly assigned to one of the four experimental arms, and then received 14 months of prescribed treatment (or community care) with periodic reassessments. After delineating the theoretical and empirical rationales for Psychosocial treatment of ADHD, we describe the MTA's Psychosocial Treatment strategy applied to all children in two of the four experimental arms (Psychosocial treatment alone; Combined treatment). Psychosocial treatment consisted of three major components: a Parent Training component, a two-part School Intervention component, and a child treatment component anchored in an intensive Summer Treatment Program. Components were selected based on evidence of treatment efficacy and because they address comprehensive symptom targets, settings, comorbidities, and functional domains. We delineate key conceptual and logistical issues faced by clinical researchers in design and implementation of Psychosocial research with examples of how these issues were addressed in the MTA study.Deceased     

Sexual disorders not otherwise specified: compulsive, addictive, or impulsive?

Paraphilias are recurrent and intense sexually arousing fantasies, sexual urges, or behaviors generally involving nonhuman objects. These paraphilias cause the suffering or humiliation of the patient or patient's partner, or children, or other nonconsenting persons. However, in many patients symptoms involve more culturally acceptable patterns (eg, repetitive masturbation, Internet pornography); such hypersexual symptoms have been labeled as compulsive, addictive, or impulsive. Growing evidence supports the existence of a discrete syndrome characterized by recurrent and intense sexually arousing fantasies, sexual urges, or behaviors involving patterns that fall outside the definition of paraphilia. There is, however, high comorbidity with paraphilia. While such symptoms have been labeled as sexual compulsion or addiction, these terms are problematic in this context. Modern nosology has neglected this entity, although the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), category of sexual disorders not otherwise specified includes hypersexual behaviors as an example. We suggest that the DSM-IV category of sexual disorders be modified to include explicitly diagnostic criteria for a disorder characterized by hypersexual symptoms involving patterns that fall outside of the current definition of paraphilia. The disorder might be classified as one of the paraphilias, or as paraphilia-related. In the absence of a comprehensive understanding of the pathogenesis of this disorder, we suggest that it simply be termed hypersexual disorder.     

An abbreviated PTSD checklist for use as a screening instrument in primary care

Although the importance of recognizing posttraumatic stress disorder (PTSD) in primary care has been well-established, routine screening for PTSD remains unfeasible for many primary care clinics because of the length of the available screening instruments. Thus, the purpose of this work was to develop and validate a brief screening tool for PTSD. In Study 1, four short forms of the PTSD Checklist-civilian version were identified that captured a majority of the variance in the measure. In Study 2, the performance of these short forms was evaluated in a separate sample of primary care patients. We found that both two-item and six-item versions have adequate psychometric properties for screening purposes and suggest that the selection of one version over the other depends on the specific needs of each primary care clinic.     

Representation and working memory in early arithmetic

Working memory has been implicated in the early acquisition of arithmetic skill, but the relations among different components of working memory, performance on different types of arithmetic problems, and development have not been explored. Preschool and Grade 1 children completed measures of phonological, visual-spatial, and central executive working memory, as well as nonverbal and verbal arithmetic problems, some of which included irrelevant information. For preschool children, accuracy was higher on nonverbal problems than on verbal problems, and the best and only unique predictor of performance on the standard nonverbal problems was visual-spatial working memory. This finding is consistent with the view that most preschoolers use a mental model for arithmetic that requires visual-spatial working memory. For Grade 1 children, performance was equivalent on nonverbal and verbal problems, and phonological working memory was the best predictor of performance on standard verbal problems. For both age groups, problems with added irrelevant information were substantially more difficult than standard problems, and in some cases measures of the central executive predicted performance. Assessing performance on different components of working memory in conjunction with different types of arithmetic problems provided new insights into the developing relations between working memory and how children do arithmetic.     

From sensory processes to conscious perception

In recent years, cognitive neuroscientists have began to explore the process of how sensory information gains access to awareness. To further probe this process, event-related functional magnetic resonance imaging (fMRI) was used while testing subjects with a paradigm known as the "attentional blink." In this paradigm, visually presented information sporadically fails to reach awareness. It was found that the magnitude and time course of activation within the anterior cingulate (BA 32), medial prefrontal cortex (BA 9), and frontopolar cortex (BA 10) predicted whether or not information was consciously perceived during the critical period for the attentional blink. These results are discussed in light of a neural framework for conscious processing.     

Spatial learning in rats is impaired by microinfusions of protein kinase C-gamma antisense oligodeoxynucleotide within the nucleus accumbens

The nucleus accumbens (NAcc) has been shown to play a role in motor and spatial learning. Protein kinase C (PKC) has been implicated in the mechanisms of initiation and maintenance of long-term potentiation that is thought to be involved in the storage of long-term memory. In the present study, the importance of de novo synthesis of PKC-gamma within the NAcc in the acquisition and retention of spatial discrimination learning was assessed using an antisense knockdown approach. Separate groups of Long-Evans rats were exposed to acute microinfusions (6microg/microl) of PKC-gamma antisense oligodeoxynucleotide (AS-ODN), control oligodeoxynucleotide (C-ODN) or vehicle into the NAcc at 24 and 3h before each training session. Behavioral findings showed that the blockade of NAcc-PKC-gamma translation caused impairments in the early phase of learning and retention of spatial information. Biochemical experiments showed that PKC-gamma expression was reduced and Ca(2+)/phospholipid-dependent protein kinase C (PKC) activity was blocked significantly in the AS-ODN-treated rats in comparison with control rats. The present findings suggest that NAcc-PKC-gamma plays a role during the early acquisition of spatial learning. Also, retention test results suggest that NAcc-PKC-gamma may be working as an intermediate factor involved in the onset of molecular mechanisms necessary for spatial memory consolidation within the NAcc.     

A facilitative role for corticosterone in the acquisition of a spatial task under moderate stress

Emotionally charged experiences alter memory storage via the activation of hormonal systems. Previously, we have shown that compared with rats trained for a massed spatial learning task in the water maze in warm water (25°C), animals that were trained in cold water (19°C) performed better and showed higher levels of the stress hormone corticosterone. Here, we examined whether manipulating the levels of corticosterone can determine the strength of spatial information acquisition and retention. Rats were injected with metyrapone (25, 50, and 75 mg/kg, i.p.) or with corticosterone (10 and 25 mg/kg, i.p.) and trained in a massed spatial task in either cold (19°C) or warm (25°C) water. We found that whereas animals injected with vehicle performed well in the spatial task in cold water (moderate stress), rats injected with the intermediate metyrapone dose showed impairment in performance. Moreover, whereas animals injected with vehicle on average did not perform well in warm water (mild stress), rats injected with the lower corticosterone dose showed improvement in performance in warm water. These two mirror experiments of corticosterone blockade and enhancement strongly suggest that corticosterone is instrumental in the acquisition and retention of the spatial learning task.     

The language-specific nature of grammatical development: evidence from bilingual language learners

The fact that early lexical and grammatical acquisition are strongly correlated has been cited as evidence against the view that the language faculty is composed of dissociable and autonomous modules (Bates & Goodman, 1997). However, previous studies have not yet eliminated the possibility that lexical-grammar associations may be attributable to language-general individual differences (e.g. children who are good at learning words are good at learning grammar). Parent report assessments of toddlers who are simultaneously learning English and Spanish (n = 113) allow an examination of the specificity of lexical-grammar relationships while holding child factors constant. Within-language vocabulary-grammar associations were stronger than cross-language relationships, even after controlling for age, proportion of language exposure, general language skill and reporter bias. Similar patterns were found based on naturalistic language samples (n = 22), ruling out a methodological artifact. These results are consistent with the view that grammar learning is specifically tied to lexical progress in a given language and provide further support for strong lexical-grammatical continuity early in acquisition.