NIMH Multimodal Treatment Study of Children with ADHD

Get details on the largest clinical study of ADHD in children and major findings regarding the most effective ADHD treatments for children with ADHD.

1. What is the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (ADHD)? The Multimodal Treatment Study of Children with ADHD (MTA) is an ongoing, multi-site, cooperative agreement treatment study of children conducted by the National Institute of Mental Health. The first major clinical trial in history to focus on a childhood mental disorder, and the largest clinical trial ever conducted by the NIMH, the MTA has examined the leading treatments for ADHD, including various forms of behavior therapy and medications. Te study has included nearly 600 elementary school children, ages 7-9, randomly assigned to one of four treatment modes: (1) medication alone; (2) psychosocial/behavioral treatment alone; (3) a combination of both; or (4) routine community care.

2. Why is this study important? ADHD is a major public health problem of great interest to many parents, teachers, and health care providers. Up-to-date information concerning the long-term safety and comparative effectiveness of its treatments is urgently needed. While previous studies have examined the safety and compared the effectiveness of the two major forms of treatment, medication and behavior therapy, these studies generally have been limited to periods up to 4 months. The MTA study for the first time demonstrates the safety and relative effectiveness of these two treatments (including a behavioral therapy-only group), alone and in combination, for a time period up to 14 months, and compares these treatments to routine community care.

3. What are the major findings of this study? The MTA results indicate that long-term combination treatments as well as ADHD medication-management alone are both significantly superior to intensive behavioral treatments for ADHD and routine community treatments in reducing ADHD symptoms. The longest clinical treatment trial of its kind to date, the study also shows that these differential benefits extend as long as 14 months. In other areas of functioning (specifically anxiety symptoms, academic performance, oppositionality, parent-child relations, and socials skills), the combined treatment approach was consistently superior to routine community care, whereas the single treatments (medication-only or behavioral treatment only) were not. In addition to the advantages proved by the combined treatment for several outcomes, this form of treatment allowed children to be successfully treated over the course of the study with somewhat lower doses of medication, compared to the medication-only group. These same findings were replicated across all six research sites, despite substantial differences among sites in their samples' socio-demographic characteristics. Therefore, the study's overall results appear to be applicable and generalizable to a wide range of children and families in need of treatment services for ADHD.

4. Given the effectiveness of ADHD medication management, what is the role and need for behavioral therapy? As noted in the NIH ADHD Consensus Conference in November 1998, several decades of research have amply demonstrated that behavioral therapies for ADHD in children are quite effective. What the MTA study has demonstrated is that on average, carefully monitored medication management with monthly follow-up is more effective than intensive behavioral treatment for ADHD symptoms, for periods lasting as long as 14 months. All children tended to improve over the course of the study, but they differed in the relative amount of improvement, with the carefully done medication management approaches generally showing the greatest improvement. Nonetheless, children's responses varied enormously, and some children clearly did very well in each of the treatment groups. For some outcomes that are important in the daily functioning of these children (e.g., academic performance, familial relations), the combination of behavioral therapy and ADHD medication was necessary to produce improvements better than community care. Of note, families and teachers reported somewhat higher levels of consumer satisfaction for those treatments that included the behavioral therapy components. Therefore, medication alone is not necessarily the best treatment for every child, and families often need to pursue other treatments, either alone or in combination with medication.

5. Which treatment is right for my ADHD child? This is a critical question that must be answered by each family in consultation with their health care professional. For children with ADHD, no single treatment is the answer for every child; a number of factors appear to be involved in which treatments are best for which children. For example, even if a particular treatment might be effective in a given instance, the child may have unacceptable side effects or other life circumstances that might prevent that particular treatment from being used. Furthermore, findings indicate that children with other accompanying problems, such as co-occurring anxiety or high levels of family stressors, may do best with approaches that combine both treatment components, i.e., medication management and intensive behavioral therapy. In developing suitable treatments for ADHD, each child's needs, personal and medical history, research findings, and other relevant factors need to be carefully considered.

6. Why do many social skills improve with ADHD medication? This question highlights one of the surprise findings of the study: Although it has long been generally assumed that the development of new abilities in children with ADHD (e.g., social skills, enhanced cooperation with parents) often requires the explicit teaching of such skills, the MTA study findings suggest that many children can often acquire these abilities when given the opportunity. Children treated with effective medication management (either alone or in combination with intensive behavioral therapy) manifested substantially greater improvements in social skills and peer relations 14 months later than children in the community comparison group. This important finding indicates that symptoms of ADHD may interfere with their learning of specific social skills. It appears that medication management may benefit many children in areas not previously well known to be salient medication targets, in part by diminishing symptoms that had previously interfered with the child's social development.

7. Why were the MTA medication treatments more effective than community treatments that also usually included medication? There were substantial differences between the study-provided ADHD medication treatments and those provided in the community, differences mostly related to the quality and intensity of the medication management treatment. During the first month of treatment, special care was taken to find an optimal dose of medication for each child receiving the MTA medication treatment. After this period, these children were seen monthly for one-half hour at each visit. During the treatment visits, the MTA prescribing therapist spoke with the parent, met with the child, and sought to determine any concerns that the family might have regarding the medication or the child's ADHD-related difficulties. If the child was experiencing any difficulties, the MTA physician was encouraged to consider adjustments in the child's medication (rather than taking a "wait and see" approach). The goal was always to obtain such substantial benefit that there was "no room for improvement" compared with the functioning of children not suffering from ADHD. Close supervision also fostered early detection and response to any problematic side effects from medication, a process that may have facilitated efforts to help children remain on effective treatment. In addition, the MTA physicians sought input from the teacher on a monthly basis, and used this information to make any necessary adjustments in the child's treatment. While the physicians in the MTA medication-only group did not provide behavioral therapy, they did advise the parents when necessary concerning any problems the child may have been experiencing, and provided reading materials and additional information as requested. Physicians delivering the MTA medication treatments generally used 3 doses per day and somewhat higher doses of stimulant medications. In comparison, the community-treatment physician generally saw the children face-to-face only 1-2 times per year, and for shorter periods of time each visit. Furthermore, they did not have any interaction with the teachers, and prescribed lower doses and twice-daily stimulant medication.

8. How were children selected for this study? In all instances, the child's parents contacted the investigators to learn more about the study, after first hearing about it through local pediatricians, other health care providers, elementary school teachers, or radio/newspaper announcements. Children and parents were then carefully interviewed to learn more about the nature of the child's symptoms, and rule out the presence of other conditions or factors that may have given rise to the child's difficulties. In addition, extensive historical information was gathered and diagnostic interviews were conducted, in order to establish whether or not the child exhibited the long-standing pattern of symptoms characteristic of ADHD across home, school, and peer settings. If children met full criteria for ADHD and study entry (and many did not), informed parental consent with child assent and school permission were received, the children and families were eligible for study entry and randomization. Children who had behavior problems but not ADHD were not eligible for study participation.

9. Where is this study taking place? Research sites include the New York State Psychiatric Institute at Columbia University, New York, N.Y.; Mount Sinai Medical Center, New York, N.Y.; Duke University Medical Center, Durham, N.C.; University of Pittsburgh; Pittsburgh, PA.; Long Island Jewish Medical Center, New Hyde Park, N.Y.; Montreal Children's Hospital, Montreal, Canada; University of California at Berkeley; and University of California at Irvine, CA.

10. How much money has been spent on this study? The study was jointly funded by the NIMH and the Department of Education, with costs totaling just over $11 million dollars.

11. What is Attention Deficit Hyperactivity Disorder (ADHD)? ADHD refers to a family of related chronic neurobiological disorders that interfere with an individual's capacity to regulate activity level (hyperactivity), inhibit behavior (impulsivity), and attend to tasks (inattention) in developmentally appropriate ways. The core symptoms of ADHD include an inability to sustain attention and concentration, developmentally inappropriate levels of activity, distractibility, and impulsivity. Children with ADHD have functional impairment across multiple settings including home, school, and peer relationships. ADHD has also been shown to have long-term adverse effects on academic performance, vocational success, and social-emotional development. Children with ADHD experience an inability to sit still and pay attention in class and the negative consequences of such behavior. They experience peer rejection and engage in a broad array of disruptive behaviors. Their academic and social difficulties have far-reaching and long-term consequences. These children have higher injury rates. As they grow older, children with untreated ADHD, in combination with conduct disorders experience drug abuse, antisocial behavior, and injuries of all sorts. For many individuals, the impact of ADHD continues into adulthood.

12. What are the symptoms of ADHD? (a) Inattention. People who are inattentive have a hard time keeping their mind on one thing and may get bored with a task after only a few minutes. Focusing conscious, deliberate attention to organizing and completing routine tasks may be difficult. (b) Hyperactivity. People who are hyperactive always seem to be in motion. They can't sit still; they may dash around or talk incessantly. Sitting still through a lesson can be an impossible task. They may roam around the room, squirm in their seats, wiggle their feet, touch everything, or noisily tap a pencil. They may also feel intensely restless. (c) Impulsivity. People who are overly impulsive seem unable to curb their immediate reactions or think before they act. As a result, they may blurt out answers to questions or inappropriate comments, or run into the street without looking. Their impulsivity may make it hard for them to wait for things they want or to take their turn in games. They may grab a toy from another child or hit when they are upset.

13. How is ADHD related to ADD? In the early 1980s, DSM-III dubbed the syndrome Attention Deficit Disorder, or ADD, which could be diagnosed with or without hyperactivity. This definition was created to underline the importance of the inattentiveness or attention deficit that is often, but not always, accompanied by hyperactivity. The revised 3^rd edition of DSM-III-R, published in 1987, returned the emphasis back to the inclusion of hyperactivity within the diagnosis, with the official name of ADHD. With the publication of DSM-IV, the name ADHD still stands, but there are different subject types within this classification, to include symptoms of both inattention and hyperactivity-impulsivity, signifying that there are some individuals in whom one or another pattern is predominant (for at least the past 6 months). Thus, the term "ADD" (though no longer current) should be understood to be subsumed under the general family of conditions now called ADHD.

14. How is ADHD diagnosed? The diagnosis of ADHD can be made reliably using well-tested diagnostic interview methods. Diagnosis is based on history and observable behaviors in the child's usual settings. Ideally, a health care practitioner making a diagnosis should include input from parents and teachers. The key elements include a thorough history covering the presenting symptoms, differential diagnosis, possible comorbid conditions, as well as medical, developmental, school, psychosocial, and family histories. It is helpful to determine what precipitated the request for evaluation and what approaches had been used in the past. As of yet, there is no independent test for ADHD. This is not unique to ADHD, but applies as well to most psychiatric disorders, including other disabling disorders such as schizophrenia and autism.

15. How many children are diagnosed with ADHD? ADHD is the most commonly diagnosed disorder of childhood, estimated to affect 3 to 5 percent of school-age children, and occurring three times more often in boys than in girls. On average, about one child in every classroom in the United States needs help for this disorder.

next: Can Other Disorders Accompany ADHD?
~ adhd library articles
~ all add/adhd articles