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.     

Evolution of the Clonal Man: Inventing Science Unfiction

From carrots to frogs to sheep and finally to humans, the history of cloning is a fascinating study of the interplay between science and popular culture. Imagination and discovery provide mutual impetus in the evolving science and cultural phenomenon of cloning. Its history is a paradigm of science unfiction: What once belonged unequivocally on the pages of science fiction is now emerging in flesh and blood. Writers, movie producers, ethicists, and all manner of social commentators, no less than scientists, have all participated in the creation of the human clone as an idea and as a biological entity. While the clone stands apart as having only one genetic parent, it truly is a brainchild of multifarious origins.     

Meaning resolution processes for words: A parallel independent model

Lexical ambiguity research over the last two decades is reviewed, with a focus on how that literature applies to understanding the resolution of meaning for words. Early models of ambiguity processing dealt almost exclusively with the time course of the effects of context on lexical access, in order to address the issue of modularity of lexical access. Newer models of ambiguity processing accommodate recent findings of early context effects that are contingent on both strength of context and meaning frequency. The most important contribution of these newer models of ambiguity processing is not to the modularity debate, but to investigation of the range of parameters affecting the entire meaning resolution process, including meaning access as well as the integration of meanings into context. As an example of this approach, we describe a simple quantitative model of meaning resolution that subsumes many other models as parametric variations.     

Modelling therapy for test anxiety: The role of model affect and consequences

This study assessed the effectiveness of modelling therapy as a treatment for test anxiety and investigated the role of model affect and consequences in determining that effectiveness. Twenty-four test anxious subjects were shown one of four one-hour modelling displays of intelligence testing sessions. The displays represented combinations of calm or anxious model affect and positive or negative consequences. Two self report and two performance measures of test anxiety were analyzed by means of a 2 × 2 vs. control group factorial design. The results indicated an overall significant improvement on modelled intelligence tests for the experimental groups vs. the control group. Differential effects were also found depending upon the characteristics of the modelling display. Viewing anxious models lead to a significant increase in introductory psychology grades and viewing negative consequences lead to a decrease in self-reported test anxiety. The present results question the notion that the most effective modelling scenes are ones displaying calm models and positive consequences (Bandura, 1969). Parallels were drawn between the results of the research and the recent success of implosively-oriented behaviour therapies.     

The therapist's self in dialogical family therapy: some ideas about not-knowing and the therapist's inner conversation

In this article, the focus is on the therapist's self, which will be in line with Bakhtin's thinking, viewed as a dialogical self. First, the dialogical view of the self is situated in the context of psychology's traditional focus on the individual self. Then, leaning on Bakhtin and Volosinov, the self is described as a dialogue of multiple inner voices. Some of the implications of this concept for family therapy practice are examined, focusing especially on the therapist's participation in the therapeutic process and on the therapist's inner conversation. The author argues that not-knowing does not only refer to the therapist's receptivity and respect but also implies that the therapist is aware of his or her experience and reflects on how his or her inner conversation might inform and enrich the therapeutic conversation. Finally, these ideas are illustrated with a brief clinical vignette.