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 rhetoric and reality of gap closing: when the "have-nots" gain but the "haves" gain even more

Many forms of intervention, across different domains, have the surprising effect of widening preexisting gaps between disadvantaged youth and their advantaged counterparts--if such interventions are made available to all students, not just to the disadvantaged. Whether this widening of gaps is incongruent with American interests and values requires an awareness of this gap-widening potential when interventions are universalized and a national policy that addresses the psychological, political, economic, and moral dimensions of elevating the top students--tomorrow's business and science leaders--and/or elevating the bottom students to redress past inequalities and reduce the future costs associated with them. This article is a first step in bringing this dilemma to the attention of scholars and policymakers and prodding a national discussion.     

A confirmatory approach to the factor structure of the Boredom Proneness Scale: evidence for a two-factor short form

We analyzed previous exploratory factor analytic structures on the Boredom Proneness Scale (BPS; Farmer & Sundberg, 1986) using confirmatory factor analysis in structural equation modeling in LISREL 8 (J?reskog & S?rbom, 1993). These analyses indicated that 2 factors were generally consistent across 6 exploratory models. Items that had significant loadings on these two factors (N = 12; 6 for each factor) indicated a lack of Internal Stimulation and External Stimulation. In further analysis on these 12 items using LISREL, we found a much improved fit and provided support for a short form version of the original BPS. We also found the shortened version to be invariant across gender. We discuss implications for the more precise measurement of boredom proneness and the use of the scale in applied settings.     

The multidimensional nature of ageism: construct validity and group differences

The authors investigated the factor structure and construct validity of the Fraboni Scale of Ageism and the age and gender differences in ageism scores. Confirmatory factor analyses supported the multidimensional nature of FSA scores and generally corroborated the initial factor structure reported by M. Fraboni, with some notable exceptions. Essentially, the present findings were aligned with theoretical models of ageism that emphasize both cognitive facets and affective facets. That is, on the basis of their factor analytic findings, the authors redefined Fraboni's original factors of Antilocution, Avoidance, and Discrimination as Stereotypes, Separation, and Affective Attitudes, respectively, because of the clustering of items within factors. The revised 3-factor structure accounted for 36.4% of the variance in FSA scores. FSA factor scores significantly related to other scores from other measures of age-related attitudes, with higher correlations among factors that were similar in terms of their cognitive nature versus their affective nature. Finally, younger individuals and men had significantly higher ageism scores on the FSA than older individuals and women. The authors discussed the importance of adequately assessing ageism, with particular emphasis devoted to the understanding of age bias.     

Is political conservatism synonymous with authoritarianism?

The authors performed 2 studies that tested the distinction between conservative political ideology and right-wing authoritarianism (RWA). Across these studies, moderate relationships emerged between RWA and our measures of cognitive rigidity, whereas the relationship between rigidity and mainstream conservative ideology was not as strong. The authors used partial-correlation and path analyses to assess the possibility that RWA mediates the relationship between (a) cognitive rigidity and (b) mainstream conservative attitudes and self-identified conservatism. The results indicated that conservatism is not synonymous with RWA. Additionally, RWA appeared to partially mediate the relationship between cognitive rigidity and mainstream conservatism.     

Differential acquisition of lever pressing in inbred and outbred mice: comparison of one-lever and two-lever procedures and correlation with differences in locomotor activity

Recent progress in mouse genetics has led to an increased interest in developing procedures for assessing mouse behavior, but relatively few of the behavioral procedures developed involve positively reinforced operant behavior. When operant methods are used, nose poking, not lever pressing, is the target response. In the current study differential acquisition of milk-reinforced lever pressing was observed in five inbred strains (C57BL/6J, DBA/2J, 129X1/SvJ, C3H/HeJ, and BALB/cJ) and one outbred stock (CD-1) of mice. Regardless of whether one or two levers (an "operative" and "inoperative" lever) were in the operant chamber, a concomitant variable-time fixed-ratio schedule of milk reinforcement established lever pressing in the majority of mice within two 120-min sessions. Substantial differences in lever pressing were observed across mice and between procedures. Adding an inoperative lever retarded acquisition in C57BL/6J, DBA/2J, 129X1/SvJ, and C3H/HeJ mice, but not in CD-1 and BALB/cJ mice. Locomotor activity was positively correlated with number of lever presses in both procedures. Analyses of durations of the subcomponents (e.g., time to move from hopper to lever) of operant behavior revealed further differences among the six types of mice. Together, the data suggest that appetitively reinforced lever pressing can be acquired rapidly in mice and that a combination of procedural, behavioral, and genetic variables contributes to this acquisition.