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     

Do Coping Styles Differ Across Sociocultural Groups? The Role of Measurement Equivalence in Making This Judgment

Cross-sociocultural group measurement equivalency is an important issue that generally has not been studied in the coping literature. Measurement equivalency of the COPE (Carver, Scheier, & Weintraub, 1989) was assessed across two sociocultural groups, a sample of 100 Anglo middle-class divorced mothers and a sample of 122 low-income Mexican American/Mexican immigrant mothers. A series of restrictive confirmatory factor analyses revealed that seven of the COPE's subscales may be measuring the same underlying construct across populations. However, scores derived from the subscales may not represent the same magnitude of the construct in these two groups. This study makes an important first step in furthering the understanding of coping strategies in low-income Mexican American/Mexican immigrant mothers. This study also illustrates the importance of testing for measurement equivalency before conducting comparative research in disparate populations.     

Do Executive Function Deficits Differentiate Between Adolescents with ADHD and Oppositional Defiant/Conduct Disorder? A Neuropsychological Study Using the Six Elements Test and Hayling Sentence Completion Test

Two neuropsychological measures of executive functions—Six Elements Tests (SET) and Hayling Sentence Completion Test (HSCT)—were administered to 110 adolescents, aged 12–15 years. Participants comprised four groups: Attention Deficit Hyperactivity Disorder (ADHD) only (n = 35), ADHD and Oppositional Defiant Disorder/Conduct Disorder (ODD/CD) (n = 38), ODD/CD only (n = 11), and a normal community control group (n = 26). Results indicated that adolescents with ADHD performed significantly worse on both the SET and HSCT than those without ADHD, whether or not they also had ODD/CD. The adolescents with ADHD and with comorbid ADHD and ODD/CD were significantly more impaired in their ability to generate strategies and to monitor their ongoing behavior compared with age-matched controls and adolescents with ODD/CD only. It is argued that among adolescents with clinically significant levels of externalizing behavior problems, executive function deficits are specific to those with ADHD. The findings support the sensitivity of these two relatively new tests of executive functions and their ecological validity in tapping into everyday situations, which are potentially problematic for individuals with ADHD.     

Testing the ability of children with attention deficit hyperactivity disorder to accurately report the effects of medication on their behavior

Children with attention deficit hyperactivity disorder (ADHD) are often treated with central nervous system stimulants, making the evaluation of medication effects an important topic for applied behavior analysts. Because assessment protocols emphasize informant reports and direct observations of child behavior, little is known about the extent to which children themselves can accurately report medication effects. Double-blind placebo-controlled procedures were used to examine whether 6 children with ADHD could recognize the effects of their medication. The children were given math worksheets to complete for 15 min during each of 14 sessions while on medication and placebo. Children completed a self-evaluation form at the end of each session, and ratings were compared to observed behavior and academic performance. Results indicated that 3 children were able to accurately report their medication status at levels greater than chance, whereas the accuracy of reports by all children was related to dosage level, differences in behavior, and the presence of adverse effects. The implications of these results for placebo-controlled research, self-monitoring of dosage levels, and accuracy training are discussed.     

Effects of methylphenidate on sensitivity to reinforcement in children diagnosed with attention deficit hyperactivity disorder: an application of the matching law

The behavior of children diagnosed with attention deficit hyperactivity disorder (ADHD) has been hypothesized to be the result of decreased sensitivity to consequences compared to typical children. The present study examined sensitivity to reinforcement in 2 boys diagnosed with ADHD using the matching law to provide more precise and quantitative measurement of this construct. This experiment also evaluated the effects of methylphenidate (MPH) on sensitivity to reinforcement of children with ADHD. Subjects completed math problems to earn tokens under four different variable-interval (VI) schedules of reinforcement presented in random order under both medicated and nonmedicated conditions. Results showed that, in the medicated condition, the matching functions for both subjects resulted in higher asymptotic values, indicating an overall elevation of behavior rate under these conditions. The variance accounted for by the matching law was also higher under the medicated conditions, suggesting that their behavior more closely tracked the changing rates of reinforcement while taking MPH compared to placebo. Under medicated conditions, the reinforcing efficacy of response-contingent tokens decreased. Results are discussed with respect to quantifying behavioral changes and the extent to which the drug interacts with prevailing contingencies (i.e., schedule values) to influence behavioral variability.     

Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms

The purpose of the present study was to examine the potential efficacy, patient acceptability, and feasibility of a novel, cognitive-behavioral therapy (CBT) for adults with attention-deficit hyperactivity disorder (ADHD) who have been stabilized on medications but still show clinically significant symptoms. Thirty-one adults with ADHD and stable psychopharmacology for ADHD were randomized to CBT plus continued psychopharmacology or continued psychopharmacology alone. Assessments included ADHD severity and associated anxiety and depression rated by an independent evaluator (IE) and by self-report. At the outcome assessment, those who were randomized to CBT had lower IE-rated ADHD symptoms (p < .01) and global severity (p < .002), as well as self-reported ADHD symptoms (p < .0001) than those randomized to continued psychopharmacology alone. Those in the CBT group also had lower IE-rated and self-report anxiety (p's < .04), lower IE-rated depression (p < .01), and a trend to have lower self-reported depression (p = .06). CBT continued to show superiority over continued psychopharmacology alone when statistically controlling levels of depression in analyses of core ADHD symptoms. There were significantly more treatment responders among patients who received CBT (56%) compared to those who did not (13%) (p < .02). These data support the hypothesis that CBT for adults with ADHD with residual symptoms is a feasible, acceptable, and potentially efficacious next-step treatment approach, worthy of further testing.     

Is inhibition of return a reflexive effect?

The inhibition of return (IOR) phenomenon is routinely considered an effect of reflexive attention because the paradigm used to generate IOR employs peripheral cues that are uninformative as to where a target will appear. Because the cues are spatially unreliable it is thought that there is no reason for attention to be committed volitionally to them, and hence, the IOR effect is considered reflexive. What has been generally overlooked, however, is that the cues provide reliable temporal information as to when a target will occur. This predictive information is used by participants to prepare volitionally for when a target is likely to appear. We investigated whether the IOR effect is a product of the volitional application of attention to peripheral cues for the use of their temporal information. To test this idea we rendered the temporal information provided by peripheral cues unreliable. While this eliminated participants using the cues volitionally, it did not abolish the IOR phenomenon. These data demonstrate two new findings. First, the IOR effect is fundamentally a reflexive phenomenon. Second, when peripheral cues are not used volitionally, the IOR effect is attenuated. Together, the present findings indicate that the IOR effect can be modulated by volitional (top-down) processes but it is not the product of them. We argue that an intimate link between fronto-parietal regions and the superior colliculus provide a functional neural mechanism for this volitional effect to impact IOR.     

Selection and inhibition in infancy: evidence from the spatial negative priming paradigm

We used a spatial negative priming (SNP) paradigm to examine visual selective attention in infants and adults using eye movements as the motor selection measure. In SNP, when a previously ignored location becomes the target to be selected, responses to it are impaired, providing a measure of inhibitory selection. Each trial consisted of a prime and a probe, separated by 67, 200, or 550 ms interstimulus intervals (ISIs). In the prime, a target was accompanied by a distractor. In the probe, the target appeared either in the location formerly occupied by the distractor (ignored repetition) or in another location (control). Adults exhibited the SNP effect in all three ISI conditions, producing slower saccade latencies on ignored repetition versus control trials. The SNP effect obtained for infants only under 550 and 200 ms ISI conditions. These results suggest that important developments in visual selection are rooted in emerging inhibitory mechanisms.     

Audio-visual speech perception is special

In face-to-face conversation speech is perceived by ear and eye. We studied the prerequisites of audio-visual speech perception by using perceptually ambiguous sine wave replicas of natural speech as auditory stimuli. When the subjects were not aware that the auditory stimuli were speech, they showed only negligible integration of auditory and visual stimuli. When the same subjects learned to perceive the same auditory stimuli as speech, they integrated the auditory and visual stimuli in a similar manner as natural speech. These results demonstrate the existence of a multisensory speech-specific mode of perception.     

On the effects of signaling reinforcer probability and magnitude in delayed matching to sample

Two experiments examined whether postsample signals of reinforcer probability or magnitude affected the accuracy of delayed matching to sample in pigeons. On each trial, red or green choice responses that matched red or green stimuli seen shortly before a variable retention interval were reinforced with wheat access. In Experiment 1, the reinforcer probability was either 0.2 or 1.0 for both red and green responses. Reinforcer probability was signaled by line or cross symbols that appeared after the sample had been presented. In Experiment 2, all correct responses were reinforced, and the signaled reinforcer durations were 1.0 s and 4.5 s. Matching was more accurate when larger or more probable reinforcers were signaled, independently of retention interval duration. Because signals were presented postsample, the effects were not the result of differential attention to the sample.