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     

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.     

Attachment to the Missing Object: Infidelity and Obsessive Love

In an object relations study on infidelity and obsessive love, the author observes that in relationships marked by chronic, repetitive infidelity and obsession, the lover is enamored with that which they can not have and that the psychological development of such individuals may have been traumatized by early attachment disturbances in the primary dyad. Tenacious, unsatisfying love-attachments as seen in sexual addictions and obsessional love may result from the internalization of an absent or intermittent object relationship—a morbid attachment to the missing object of infancy. Such patients often demonstrate depressive/addictive traits and schizoid defenses and typically have difficulty forming an attachment bond with the analyst, perceiving the analyst as a dangerous, rejecting agent who will recapitulate the original trauma. In the clinical case of Gretchen, the author uses Winnicott's (1960) concept of holding to create a progressive therapeutic bond, as toxic resistant forces are gradually resolved.     

Postural stability and hand preference as constraints on one-handed catching performance in children

Effects of postural state and hand preference as constraints on 1-handed catching performance were investigated in different ability groups of children aged 9-10 years. On the basis of pretest data, the authors classified 48 participants into groups of good, intermediate, and poor catchers (n = 16 in each) and asked them to perform 1-handed catches with their preferred and nonpreferred hands while standing and sitting. The good catchers' performance was not affected by the imposed postural constraints but did improve when they used the preferred hand. A similar effect of hand preference was evident in the intermediate and poor catchers, but there was also an effect of postural constraint. Independent of hand preference, intermediate catchers' performance while seated improved significantly compared with that during standing. For poor catchers, there was an interaction between hand preference and posture; significant improvement was evident only when they used the preferred hand in the sitting condition. The finding that manipulation of posture and hand preference affected performance outcomes indicates that perceptual skill is not the only influence on catching performance in children. Manipulation of those key constraints may facilitate the acquisition of catching skill, but more research is needed to determine the permanence of those effects.