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.     

Modification of verbal behavior through variable interval reinforcement in a quasi-therapy situation

Principles from the operant conditioning laboratory were applied to the verbal behavior of female college students. An experimental setting was designed to replicate a psychotherapist's office, and subjects were seen daily in a study using a functional research design. Variable interval reinforcement was employed to modify the rate of emission of positive self-reference statements. Results demonstrated that the verbal, scheduled reinforcement exerted a definite, marked effect on the verbal behavior of the subjects. All subjects conditioned to the schedules. Sequence of scheduling did not appear to be a significant variable. The feasibility of employing such techniques in actual psychotherapy is discussed.     

A different recruitment of the lateral and basolateral amygdala promotes contextual or elemental conditioned association in Pavlovian fear conditioning

Convergent data suggest dissociated roles for the lateral (LA) and basolateral (BLA) amygdaloid nuclei in fear conditioning, depending on whether a discrete conditioned stimulus (CS)-unconditional stimulus (US) or context-US association is considered. Here, we show that pretraining inactivation of the BLA selectively impaired conditioning to context. In contrast, inactivation of the LA disrupted conditioning to the discrete tone CS, but also either impaired or enhanced contextual conditioning, depending on whether the context was in the foreground or in the background. Hence, these findings refine the current model of the amygdala function in emotional learning by showing that the BLA and the LA not only differentially contribute to elemental and context-US association, but also promote, through their interaction, the most relevant of these two associations.     

Shape-from-shading depends on visual, gravitational, and body-orientation cues

The perception of shading-defined form results from an interaction between shading cues and the frames of reference within which those cues are interpreted. In the absence of a clear source of illumination, the definition of 'up' becomes critical to deducing the perceived shape from a particular pattern of shading. In our experiments, twelve subjects adjusted the orientation of a planar disc painted with a linear luminance gradient from one side to the other, until the disc appeared maximally convex-that is, until the luminance gradient induced the maximum perception of a three-dimensional shape. The vision, gravity, and body-orientation cues were altered relative to each other. Visual cues were manipulated by the York Tilted Room facility, and body cues were altered by simply lying on one side. The orientation of the disc that appeared maximally convex varied in a systematic fashion with these manipulations. We present a model in which the direction of perceptual 'up' is determined from the sum of three weighted vectors corresponding to the vision, gravity, and body-orientation cues. The model predicts the perceived direction of 'up', contributes to our understanding of how shape-from-shading is deduced, and also predicts the confidence with which the 'up' direction is perceived.     

Suffering and the Dialectical Self in Buddhism and Relational Psychoanalysis

The American Journal of Psychoanalysis -