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 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.     

Assessment of the Use and Feasibility of Video to Supplement the Genetic Counseling Process: A Cancer Genetic Counseling Perspective

Cancer genetic counselors use a variety of teaching modalities for patient education. This survey of cancer genetic counselors assessed their use of educational videos and their recommendations for content of future videos. Thirty percent of respondents use videos for patient education. Cited benefits included reinforcement of information for clients and increased counselor efficiency. Of the 70% who do not use videos, predominant barriers included the perceived lack of an appropriate video, lack of space and/or equipment, and concern that videos are impersonal. Most respondents desired a video that is representative of the genetic counseling session, but emphasized the importance of using broad information. Content considered critical included the pros and cons of genetic testing, associated psychosocial implications, and genetic discrimination. The results of this exploratory study provide data relevant for the development of a cancer genetics video for patient education, and suggestions are made based on aspects of information processing and communication theories.     

Category specificity in normal episodic learning: applications to object recognition and category-specific agnosia

Studies of patients with category-specific agnosia (CSA) have given rise to multiple theories of object recognition, most of which assume the existence of a stable, abstract semantic memory system. We applied an episodic view of memory to questions raised by CSA in a series of studies examining normal observers' recall of newly learned attributes of familiar objects. Subjects first learned to associate arbitrarily assigned colors or textures to objects in a training phase, and then attempted to report the newly learned attribute of each object in a recall task. Our subjects' pattern of recall errors was similar both quantitatively and qualitatively to the identification deficits among patients with CSA for biological objects. Furthermore, errors tended to reflect conceptually and structurally based confusions. We suggest that object identification involves recruitment and integration of information across distributed episodic memories and that this process is susceptible to interference from objects that are structurally similar and conceptually related.     

Using video modeling and reinforcement to teach perspective-taking skills to children with autism

We evaluated video modeling and reinforcement for teaching perspective-taking skills to 3 children with autism using a multiple baseline design. Video modeling and reinforcement were effective; however, only 2 children were able to pass an untrained task, indicating limited generalization. The findings suggest that video modeling may be an effective technology for teaching perspective taking if researchers can continue to develop strategies for enhancing the generalization of these new skills.