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The Multimodal Treatment Study of Children with Attention Deficit
Hyperactivity Disorder

In December 1999, the Archives of General Psychiatry published the initial results of the most comprehensive study of treatment strategies for ADHD ever undertaken. (Archives of General Psychiatry, vol. 56, pp. 1073-1086. December 1999).

This was the first study to systematically compare treatment with medication to other forms of treatment. Almost 600 children between the ages of 7 and 9 years old who had been diagnosed with ADHD, combined-type, were divided into four groups. Over 14 months, one group received medication alone, overseen by the study operators who monitored the dosage and performed monthly visits. A second group received intensive behavioral therapy over the same period. A third received medication combined with behavioral therapy, and the fourth was given standard community treatment, which may have included treatment with medication.

The study found unequivocally that medication, when given under a "carefully crafted" treatment program, was significantly more effective at treating the ADHD symptoms than treatments which did not include medication. Although all four groups showed substantial improvement, those in the supervised medication group and the combined treatment group showed substantially more improvements than those who received behavioral therapy alone, or community care.

Interestingly, although the combined treatment group and the medication management group did not differ significantly in their improvement of core ADHD symptoms, in other areas of functioning (specifically anxiety symptoms, academic performance, oppositionality, parent-child relations, and teacher-rated social skills), the combined treatment approach was consistently superior to routine community care, whereas the single treatments (medication only or behavioral treatment only) were not.

The authors concluded:

For ADHD symptoms, our carefully crafted medication management program was superior to behavioral treatment and to routine community care that included medication. Our combined treatment did not yield significantly greater benefits than medication management for core ADHD symptoms, but may have provided modest advantages for non-ADHD symptom and positive functioning outcomes.
Some fear that the MTA results, showing that medication is such an effective treatment, will lead practitioners, and the public, to disregard behavioral therapy for children with ADHD. Although medication alone proved very effective, the study also found that children in the combined group, which received behavioral therapy in addition to medication management, showed similar levels of improvement on lower doses of medication. Also, as noted above, behavioral therapy in combination with medication may be superior to medication alone in treating non-ADHD symptoms which often accompany ADHD, such as anxiety, undeveloped social skills, and compromised academic achievement. In their FAQ on the MTA, the NIMH notes that "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)."

It is also important to note that the medication management program run through the study did significantly better than routine community care. Since routine care often involves medication, the implication is that not all courses of medication treatment will have similar outcomes. According to the NIMH FAQ, "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 children involved in the MTA study will be tracked into adolescence to document and evaluate long-term outcomes, as well as to examine issues raised by the data in the initial report. For example, according to Howard Abikoff, director of research for the NYU Child Study Center, almost 40 percent of the ADHD children in the MTA study also had Oppositional Defiant Disorder (ODD). More research is required into the connections between ADHD and ODD, anxiety and other co-morbid disorders, as well as approaches to treating children with co-morbid disorders. Ongoing MTA follow-up reports continue to be published.

The National Institute of Mental Health's (NIMH) FAQ on the MTA
Answers Lead to Questions: Commentary on the MTA from About.com
NIMH's Announcement of a New Study (starting Spring 2000) on Co-Morbidity and ADHD

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