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     

Family Processes and Treatment Outcome in the MTA: Negative/Ineffective Parenting Practices in Relation to Multimodal Treatment

To elucidate processes underlying therapeutic change in a large-scale randomized clinical trial, we examined whether alterations in self-reported parenting practices were associated with the effects of behavioral, medication, or combination treatments on teacher-reported outcomes (disruptive behavior, social skills, internalizing symptoms) in children with attention-deficit hyperactivity disorder (ADHD). Participants were 579 children with Combined-type ADHD, aged 7–9.9 years, in the Multimodal Treatment Study of Children with ADHD (MTA). We uncovered 2 second-order factors of parenting practices, entitled Positive Involvement and Negative/Ineffective Discipline. Although Positive Involvement was not associated with amelioration of the school-based outcome measures, reductions in Negative/Ineffective Discipline mediated improvement in children's social skills at school. For families showing the greatest reductions in Negative/Ineffective Discipline, effects of combined medication plus behavioral treatment were pronounced in relation to regular community care. Furthermore, only in combination treatment (and not in behavioral treatment alone) was decreased Negative/Ineffective Discipline associated with reduction in children's disruptive behavior at school. Here, children in families receiving combination treatment who showed the greatest reductions in Negative/Ineffective Discipline had teacher-reported disruptive behavior that was essentially normalized. Overall, the success of combination treatment for important school-related outcomes appears related to reductions in negative and ineffective parenting practices at home; we discuss problems in interpreting the temporal sequencing of such process-outcome linkages and the means by which multimodal treatment may be mediated by psychosocial processes related to parenting.     

Parenting and Family Stress Treatment Outcomes in Attention Deficit Hyperactivity Disorder (ADHD): An Empirical Analysis in the MTA Study

Parenting and family stress treatment outcomes in the MTA study were examined. Male and female (579), 7–9-year-old children with combined type Attention Deficit Hyperactivity Disorder (ADHD), were recruited at six sites around the United States and Canada, and randomly assigned to one of four groups: intensive, multi-faceted behavior therapy program alone (Beh); carefully titrated and monitored medication management strategy alone (MedMgt); a well-integrated combination of the two (Comb); or a community comparison group (CC). Treatment occurred over 14 months, and assessments were taken at baseline, 3, 9, and 14 months. Parenting behavior and family stress were assessed using parent-report and child-report inventories. Results showed that Beh alone, MedMgt alone, and Comb produced significantly greater decreases in a parent-rated measure of negative parenting, Negative/Ineffective Discipline, than did standard community treatment. The three MTA treatments did not differ significantly from each other on this domain. No differences were noted among the four groups on positive parenting or on family stress variables. Results are discussed in terms of the theoretical and empirically documented importance of negative parenting in the symptoms, comorbidities and long-term outcomes of ADHD.     

The national institutes of health attention-deficit/hyperactivity disorder consensus statement: implications for practitioners and scientists

Although the concept of pharmacotherapy for attention-deficit/hyperactivity disorder (ADHD) was first introduced more than 60 years ago, treatment of this disorder remains more controversial than ever. It is hoped, however, that the recent Consensus Development Conference (CDC) Statement on the diagnosis and treatment of ADHD will not only help answer some of the questions surrounding management of this disorder, but also lend needed scientific weight to debate in this area. While more research in ADHD is needed, the CDC participants pointed to a solid body of evidence showing that careful medication management can result in noticeable improvement in several measures, with little risk of adverse events.     

On the relation between maternal state of mind and sensitivity in the prediction of infant attachment security

Attachment theorists assume that maternal mental representations influence responsivity, which influences infant attachment security. However, primary studies do not support this mediation model. The authors tested mediation using 2 mother-infant samples and found no evidence of mediation. Therefore, the authors explored sensitivity as a moderator, studying the (a) interaction of mental representation and sensitivity as it predicts infant attachment security and (b) level of sensitivity in mothers whose infants' attachment security is either concordant or discordant with their own. The interactional analyses were not significant. But the match-mismatch data showed that when mother-infant attachment strategies were discordant, maternal sensitivity was more consistent with infant than maternal attachment strategy. These findings are congruent with an interpretation of sensitivity as a moderator that can block transmission of attachment strategy.     

Validity and reliability of the audit and CAGE-AID in Northern Plains American Indians

According to the Indian Health Service, substance abuse and Type 2 diabetes are serious problems among Native Americans. To assess substance use in a medical setting, valid screening tests are needed so the Alcohol Use Disorders Identification Test (AUDIT), a simple brief screen for excessive drinking, and the CAGE-adapted to Include Drugs (CAGE-AID) for identifying primary care patients with alcohol and drug disorders were given 50 Northern Plains American Indians with diabetes. Both are short, easy to administer, have good sensitivity and specificity, and can be easily incorporated into a medical history protocol or intake procedure. Reliability coefficients were above .90 and appeared to have sufficient concurrent and divergent validity indicated by moderate correlations with the General Well-being Schedule (rs=-.39 and -.36), the Family-Adaptation, Partnership, Growth, Affection, & Resolve (r =-.47 and -.36), and the Beck Depression Inventory-IT (r = .36 and .29).     

Index of suspicion: feeling not believing

Throughout the U.S., state laws require professionals who work with children to report cases of suspected child abuse to child protection services. Both practically and conceptually, however, significant problems arise from a lack of clarity regarding the threshold that has been set for reporting. Specifically, there is no consensus as to what constitutes reasonable suspicion, and little direction for how mandated reporters should gauge their legal and professional responsibilities when they harbor suspicion. In this paper we outline the context of the problem, discuss the nature and scope of its conceptual underpinnings, and offer recommendations for moving towards a concrete, practical solution.     

The effects of yoga on the attention and behavior of boys with Attention-Deficit/ hyperactivity Disorder (ADHD)

Boys diagnosed with ADHD by specialist pediatricians and stabilized on medication were randomly assigned to a 20-session yoga group (n = 11) or a control group (cooperative activities; n = 8). Boys were assessed pre- and post-intervention on the Conners' Parent and Teacher Rating Scales-Revised: Long (CPRS-R:L & CTRS-R:L; Conners, 1997), the Test of Variables of Attention (TOVA; Greenberg, Cormna, & Kindschi, 1997), and the Motion Logger Actigraph. Data were analyzed using one-way repeated measures analysis of variance (ANOVA). Significant improvements from pre-test to post-test were found for the yoga, but not for the control group on five subscales of the Conners' Parents Rating Scales (CPRS): Oppositional, Global Index Emotional Lability, Global Index Total, Global Index Restless/Impulsive and ADHD Index. Significant improvements from pre-test to post-test were found for the control group, but not the yoga group on three CPRS subscales: Hyperactivity, Anxious/Shy, and Social Problems. Both groups improved significantly on CPRS Perfectionism, DSM-IV Hyperactive/ Impulsive, and DSM-IV Total. For the yoga group, positive change from pre- to post-test on the Conners' Teacher Rating Scales (CTRS) was associated with the number of sessions attended on the DSM-IV Hyperactive-Impulsive subscale and with a trend on DSM-IV Inattentive subscale. Those in the yoga group who engaged in more home practice showed a significant improvement on TOVA Response Time Variability with a trend on the ADHD score, and greater improvements on the CTRS Global Emotional Lability subscale. Results from the Motion Logger Actigraph were inconclusive. Although these data do not provide strong support for the use of yoga for ADHD, partly because the study was under-powered, they do suggest that yoga may have merit as a complementary treatment for boys with ADHD already stabilized on medication, particularly for its evening effect when medication effects are absent. Yoga remains an investigational treatment, but this study supports further research into its possible uses for this population. These findings need to be replicated on larger groups with a more intensive supervised practice program.     

Test-retest reliability of the Holyoake Codependency Index with Australian students

The Holyoake Codependency Index is a 13-item self-report measure of three aspects of codependency: External Focus, Self-sacrifice, and a sense of being overwhelmed by another person's problematic behavior (termed Reactivity). Previous studies have supported internal validity and the internal consistency and construct validity of the subscales. The present scores for 59 students indicate full scale test-retest reliability of .88 and for subscales (.76 to .82) over a 3-wk. interval.     

An emerging postural response: is control of the hip possible in the newly walking child?

Previous researchers have proposed that because of their slow muscle-response latencies, 1- to 2-year-old children are unable to control hip-dominant postural responses when responding to balance threats (G. McCollum & T. Leen, 1989). To test that proposition, the authors exposed 41 children to backward support-surface translations and recorded muscle activations and movement kinematics. Children between 10 months and 10 years of age stood on a platform that was unexpectedly moved. Passive hip-dominant responses were observed among the least experienced walkers. In contrast, older children produced an active response, signified by higher levels of abdominal and quadriceps muscle activity and accompanied by larger hip flexor torques. Greater success in withstanding large magnitudes of perturbations were associated with actively generated hip responses.