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.     

Effects of noncontingent reinforcement on problem behavior and stimulus engagement: the role of satiation, extinction, and alternative reinforcement

This study examined the effects of noncontingent reinforcement (NCR) with and without extinction on problem behavior and stimulus engagement (consumption of reinforcement) of 4 participants. Reductions in problem behavior using NCR have frequently been attributed to both satiation of the reinforcer and extinction. In the current study, aspects of the NCR treatment effects were difficult to explain based solely on either a satiation or an extinction account. Specifically, it was found that stimulus engagement remained high throughout the NCR treatment analysis, and that problem behavior was reduced to near-zero levels during NCR without extinction. The implications of these findings are discussed with respect to the satiation and extinction hypotheses frequently described in the applied literature. Findings from basic studies examining the effects of response-independent schedules are presented, and are used as the basis for a matching theory account of NCR-related effects. It is proposed that reductions in problem behavior observed during NCR interventions may be a function of the availability of alternative sources of reinforcement.     

Resolving the debate over birth order, family size, and intelligence

Hundreds of research articles have addressed the relationship between birth order and intelligence. Virtually all have used cross-sectional data, which are fundamentally flawed in the assessment of within-family (including birth order) processes. Although within-family models have been based on patterns in cross-sectional data, a number of equally plausible between-family explanations also exist. Within-family (preferably intact-family) data are prerequisite for separating within- and between-family causal processes. This observation reframes an old issue in a way that can be easily addressed by studying graphical patterns. Sibling data from the National Longitudinal Survey of Youth are evaluated, and the results are compared with those from other studies using within-family data. It appears that although low-IQ parents have been making large families, large families do not make low-IQ children in modern U.S. society. The apparent relation between birth order and intelligence has been a methodological illusion.     

Counterconditioning in the treatment of spider phobia: effects on disgust, fear and valence

From the perspective that disgust is a core feature of spider phobia, we investigated whether the treatment efficacy could be improved by adding a counterconditioning procedure. Women with a clinically diagnosed spider phobia (N = 34) were randomly assigned to the regular one-session exposure condition (EXP) or to the exposure with counterconditioning condition (CC). In the CC-condition tasty food-items were used during the regular exposure exercises and the participants' favourite music was played. Both treatment conditions appeared very effective in reducing avoidance behaviour and self-reported fear of spiders, strongly attenuated the disgusting properties of spiders and altered the affective evaluations in a positive direction. CC was not more effective in altering the affective valence of spiders than EXP and was not superior with respect to the long term treatment efficacy at 1 year follow up. Apparently, regular exposure treatment is already quite effective in altering the affective-evaluative component of spider phobia and it remains to be seen whether it is possible to further improve treatment outcome by means of procedures which are specifically designed to reduce the spiders' negative affective valence.     

From image segmentation to anti-textons

We apply the 'patchwork engine' (PE; van Tonder and Ejima, 2000 Neural Networks forthcoming) to encode spaces between textons in an attempt to find a suitable feature representation of anti-textons [Williams and Julesz, 1991, in Neural Networks for Perception volume 1: Human and Machine Perception Ed. H Wechsler (San Diego, CA: Academic Press); 1992, Proceedings of the National Academy of Sciences of the USA 89 6531-6534]. With computed anti-textons it is possible to show that tessellation and distribution of anti-textons can differ from that of textons depending on the ratio of texton size to anti-texton size. From this we hypothesise that variability of anti-textons can enhance texture segregation, and test our hypothesis in two psychophysical experiments. Texture segregation asymmetry is the topic of the first test. We found that targets on backgrounds with regular anti-textons segregate more strongly than on backgrounds with highly variable anti-textons. This neatly complements other explanations for texture segregation asymmetry (e.g. Rubenstein and Sagi, 1990 Journal of the Optical Society of America A 7 1632-1643). Second the relative significance of textons and anti-textons in human texture segregation is investigated for a limited set of texture patterns. Subjects consistently judged a combination of texton and anti-texton gradients as more conspicuous than texton-only gradients, and judged texton-only gradients as being more conspicuous than anti-texton-only gradients. In the absence of strong texton gradients the regularity versus irregularity of anti-textons agrees with perceived texture segregation. Using PE outputs as anti-texton features thus enabled the conception of various useful tests on texture segregation. The PE is originally intended as a general image segmentation method based on symmetry axes. With this paper we therefore hope to relate anti-textons with visual processing in a wider sense.     

The Therapeutic Factors Inventory: Development of a Scale

Although Yalom's (1995) framework of the therapeutic factors facilitating outcome in group has been accepted by group specialists, no empirically based instrument assesses all of these factors. The Therapeutic Factors Inventory (TFI), with 11 scales based on the therapeutic factors, has been designed to fill this gap. This article summarizes the development and preliminary reliability testing of the TFI. Each scale of the instrument demonstrated high internal consistency; however, one scale obtained unacceptably low test-retest reliability. Further validity testing is needed. Implications of these findings are discussed.     

Differential recall of central and peripheral details of emotional slides is not a stable phenomenon

A number of studies have reported that central information of an emotional scene is well retained, whereas peripheral details of such a scene are poorly recalled. Experiment 1 tested the hypothesis that attentional narrowing is responsible for this phenomenon. In addition, an attempt was made to increase the ecological validity of the experiment by giving extensive self-relevant instructions. Results showed that, although an emotional slide elicited eye-movements consistent with attentional narrowing, the corresponding recall patterns were absent. Experiments 2 and 3 explored some of the variables that might be responsible for the latter result. Experiment 2, relying on the original design of Christianson and E.F. Loftus (1991), found enhanced recall of central information of an emotional scene. Experiment 3 systematically varied stimulus exposure and interstimulus interval durations. However, the results of this experiment were rather complex and did not fully support the predicted differential recall patterns. Possible explanations for these findings are discussed. It is suggested that other methods (e.g. increasing levels of emotion rather than involvement) may be more suitable for testing the attentional narrowing hypothesis of emotional memory.