Cited by 240Attention Deficit Hyperactivity DisorderBehavioral and Psychological StudiesChild and Adolescent Psychosocial and Emotional Development

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National Institute of Mental Health Collaborative Multimodal Treatment Study of Children With ADHD (the MTA): Design Challenges and Choices

Arnold, L. Eugene·1997·Archives of General Psychiatry

DOI 10.1001/archpsyc.1997.01830210113015

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Abstract

The Collaborative Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (ADHD), the MTA, is the first child multisite cooperative agreement treatment study of children conducted by the National Institute of Mental Health, Rockville, Md. It examines the long-term effectiveness of medication vs behavioral treatment vs both for treatment of ADHD and compares state-of-the-art treatment with routine community care. In a parallel-groups design, 576 children (age, 7-9 years) with ADHD (96 at each site) are thoroughly assessed and randomized to 4 conditions: (1) medication alone, (2) psychosocial treatment alone, (3) the combination of both, (4) or community comparison. The first 3 groups are treated for 14 months and all are reassessed periodically for 24 months. Designers met the following challenges: framing clinically relevant primary questions; defining the target population; choice, intensity, and integration and combination of treatments for fair comparisons; combining scientific controls and standardization with clinical flexibility; and implementing a controlled clinical trial in a nonclinical setting (school) controlled by others. Innovative solutions included extensive decision algorithms and manualized adaptations of treatments to specific needs.

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“…the data reported here were collected at baseline (i.e., before any of the treatments began), we do not describe the treatments or outcome findings here (instead, see the following reports: Arnold et al., 1997; Greenhill et al., 1996; MTA Cooperative Group, 1999a, 1999b; Wells et al., 2000).”
ResultSelf-citation
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“The National Institute of Mental Health has conducted a multi-site cooperative agreement study of 576 children with ADHD (aged from 7 to 9 years) in parallel groups randomised according to 4 conditions: (i) pharmacotherapy alone; (ii) psychosocial treatment alone; (iii) a treatment combination; and (iv) community comp…”
Method
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Self-citation
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“However, at three time points, the MTA (for a description, see Arnold et al., 1997) collected sociometrics on a subgroup of their sample.”
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Owens, E. B., Hinshaw, S. P., KRAEMER, H. C., Arnold, L. E., Abikoff, H., Cantwell, D. P., Conners, C. K., Elliott, G. R., Greenhill, L. L., Hechtman, L. T., et al. (2003) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.71.3.540 · Cited by 285
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Self-citation
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“The MTA recruitment strategy, procedures for diagnosing ADHD, treatment specifics, and sample demographics have been described elsewhere (Arnold et al., 1997; Greenhill et al., 1996, 2001; Hinshaw et al., 1997; The MTA Cooperative Group, 1999a,b, 2004a,b; Wells et al., 2000).”
Method
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Method
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Result
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BackgroundResult
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Self-citation
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“…screening, diagnostic instruments, outcome measures, randomization, methods, informed consent, institutional board review at the performance sites, and the basic characteristics of the full MTA sample have been described previously (Arnold et al. 1997a, 1997b, MTA Cooperative Group 1999a).”
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Background
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Rieppi, R., Greenhill, L. L., Ford, R. E., Chuang, S. Z., WU, M., Davies, M., Abikoff, H., Arnold, L. E., Conners, C. K., Elliott, G. R., et al. (2002) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1097/00004583-200203000-00006 · Cited by 129
The NIMH Multimodal Treatment Study for Attention-Deficit Hyperactivity Disorder: Just Say Yes to Drugs Alone?
Pelham, W. E. (1999) · The Canadian Journal of Psychiatry · doi:10.1177/070674379904401004 · Cited by 129
Psychiatric Comorbidities in Children with Attention Deficit Hyperactivity Disorder
Pliszka, S. R. (2003) · Pediatric Drugs · doi:10.2165/00148581-200305110-00003 · Cited by 129
Attention deficit hyperactivity disorder and sensory modulation disorder: A comparison of behavior and physiology
Miller, L. J., Nielsen, D. M., & Schoen, S. A. (2012) · Research in Developmental Disabilities · doi:10.1016/j.ridd.2011.12.005 · Cited by 125
Attention Deficit Hyperactivity Disorder in Preschool Children
Greenhill, L. L., Posner, K., Vaughan, B. S., & Kratochvil, C. J. (2008) · Child and Adolescent Psychiatric Clinics of North America · doi:10.1016/j.chc.2007.11.004 · Cited by 126
Randomised controlled trials of selective serotonin reuptake inhibitors in treating depression in children and adolescents: A systematic review and meta-analysis
Usala, T., Clavenna, A., Zuddas, A., & Bonati, M. R. (2007) · European Neuropsychopharmacology · doi:10.1016/j.euroneuro.2007.06.001 · Cited by 119
Treatment of Children With Attention-Deficit/Hyperactivity Disorder (ADHD) and Irritability: Results From the Multimodal Treatment Study of Children With ADHD (MTA)
de la Cruz, L. F., Simonoff, E. A., McGough, J. J., Halperin, J. M., Arnold, L. E., & Stringaris, A. K. (2014) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2014.10.006 · Cited by 124
“Additional details about the sampling and the procedures in the MTA have been widely described elsewhere.(2,26,27)”
Method
Revisiting the latent structure of ADHD: is there a ‘g’ factor?
Martel, M. M., von Eye, A., & Nigg, J. T. (2010) · Journal of Child Psychology and Psychiatry · doi:10.1111/j.1469-7610.2010.02232.x · Cited by 122
“Recruitment and identification—A broad community-based recruitment strategy was used, with mass mailings to parents in local school districts, public advertisements, as well as flyers at local clinics, to mimic the recruitment strategy of the MTA study (Arnold et al., 1997), while including all ADHD subtypes and addin…”
Method
Maternal Depressive Symptomatology and Parenting Behavior: Exploration of Possible Mediators
Gerdes, A. C., Hoza, B., Arnold, L. E., Pelham, W. E., Swanson, J. M., Wigal, T. L., & Jensen, P. S. (2007) · Research on Child and Adolescent Psychopathology · doi:10.1007/s10802-007-9134-3 · Cited by 115
Mental Health Care for Latinos: Mental Health Services for Latino Adolescents With Psychiatric Disorders
Hough, R. L., Hazen, A. L., Soriano, F. I., Wood, P., McCabe, K. M., & Yeh, M. (2002) · Psychiatric Services · doi:10.1176/appi.ps.53.12.1556 · Cited by 114
Multimethod Psychoeducational Intervention for Preschool Children with Disruptive Behavior: Two-Year Post-Treatment Follow-up
Shelton, T. L., Barkley, R. A., Crosswait, C., Moorehouse, M., Fletcher, K. E., Barrett, S., Jenkins, L., & Metevia, L. (2000) · Research on Child and Adolescent Psychopathology · doi:10.1023/a:1005144304071 · Cited by 110
“These programs typically focus on peer relations, classroom conduct, and school achievement (Arnold et al., 1997; Bierman, Miller, & Stabb, 1987; Cunningham & Cunningham, 1998; Pfiffner & Barkley, 1998).”
Background
Considering Usual Medical Care in Clinical Trial Design
Dawson, L., Zarin, D. A., Emanuel, E. J., Friedman, L. M., Chaudhari, B., & Goodman, S. N. (2009) · PLoS Medicine · doi:10.1371/journal.pmed.1000111 · Cited by 93
ASSESSMENT AND INTERVENTION FOR ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN THE SCHOOLS
Swanson, J. M., Lerner, M., March, J. S., & Gresham, F. M. (1999) · Pediatric Clinics of North America · doi:10.1016/s0031-3955(05)70168-1 · Cited by 106
Blood Pressure and Heart Rate Over 10 Years in the Multimodal Treatment Study of Children With ADHD
Vitiello, B., Elliott, G. R., Swanson, J. M., Arnold, L. E., Hechtman, L. T., Abikoff, H., Molina, B. S. G., Wells, K., Wigal, T. L., Jensen, P. S., et al. (2011) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2011.10111705 · Cited by 106
The Texas Children's Medication Algorithm Project: Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. Part II: Tactics
Pliszka, S. R., GREENHILL, L. L., Crismon, M. L., Sedillo, A., Carlson, C. L., Conners, C. K., McCracken, J. T., Swanson, J. M., Hughes, C. W., LLANA, M. E., et al. (2000) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1097/00004583-200007000-00022 · Cited by 104
Evidence, Interpretation, and Qualification From Multiple Reports of Long-Term Outcomes in the Multimodal Treatment Study of Children With ADHD (MTA)
Swanson, J. M., Arnold, L. E., KRAEMER, H. C., Hechtman, L. T., Molina, B. S. G., Hinshaw, S. P., Vitiello, B., Jensen, P. S., Steinhoff, K., Lerner, M., et al. (2008) · Journal of Attention Disorders · doi:10.1177/1087054708319525 · Cited by 97
“…in the initial publications by the MTA Cooperative Group in the late 1990s about the medication algorithm (Greenhill et al., 1996), the design (Arnold et al., 1997a, 1997b), and the assessment battery (Hinshaw et al., 1997), and later about the psychosocial treatments (Wells et al., 2000a,…”
BackgroundInfluential
Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)
Storebø, O. J., Storm, M. R. O., Ribeiro, J. P., Skoog, M., Groth, C., Edemann-Callesen, H., Schaug, J. P., Rasmussen, P. D., Huus, C.-M. L., Zwi, M., et al. (2023) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd009885.pub3 · Cited by 118
NIMH collaborative multimodal treatment study of children with ADHD (MTA): Design, methodology, and protocol evolution
Arnold, L. E., Abikoff, H., Cantwell, D. P., Conners, C. K., Elliott, G. R., Greenhill, L. L., Hechtman, L. T., Hinshaw, S. P., Hoza, B., Jensen, P. S., et al. (1997) · Journal of Attention Disorders · doi:10.1177/108705479700200301 · Cited by 84
A person-centered personality approach to heterogeneity in attention-deficit/hyperactivity disorder (ADHD).
Martel, M. M., Goth-Owens, T. L., Martinez‐Torteya, C., & Nigg, J. T. (2010) · Journal of Abnormal Psychology · doi:10.1037/a0017511 · Cited by 81
“A broad community-based recruitment strategy was used, with mass mailings to parents in local school districts, public advertisements, and fliers at local clinics, in an effort to mimic the recruitment strategy of the MTA study (Arnold et al., 1997).”
Method
Reviews : Pharmacotherapy of adolescent attention deficit hyperactivity disorder: challenges, choices and caveats
Garland, E. J. (1998) · Journal of Psychopharmacology · doi:10.1177/026988119801200410 · Cited by 77
PREDICTORS OF LONG-TERM OUTCOME IN CHILDREN WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
Hechtman, L. T. (1999) · Pediatric Clinics of North America · doi:10.1016/s0031-3955(05)70171-1 · Cited by 76
Long-Term Effects of Stimulant Medications on the Brain: Possible Relevance to the Treatment of Attention Deficit Hyperactivity Disorder
Vitiello, B. (2001) · Journal of Child and Adolescent Psychopharmacology · doi:10.1089/104454601750143384 · Cited by 76
“In this study, 579 children 7–9 years of age were randomly assigned to receive one of four treatment strategies (medication treatment, behavioral therapy, combined medication plus behavioral therapy, and treatment as usual in the community) for 14 months (Arnold et al. 1997).”
Stimulant drugs
Santosh, P. J., & Taylor, E. (2000) · European Child & Adolescent Psychiatry · doi:10.1007/s007870070017 · Cited by 94
Early Onset Bipolar Disorder: Clinical and Research Considerations
Carlson, G. A. (2005) · Journal of Clinical Child & Adolescent Psychology · doi:10.1207/s15374424jccp3402_13 · Cited by 74
“For instance, using the sample from the Multimodal Treatment Study of Children with ADHD (Arnold et al., 1997), a large population of well-diagnosed children with ADHD, Galanter et al.”
BackgroundMethodInfluential
Nature, Nurture, and Attention Deficit Hyperactivity Disorder
Faraone, S. V., & Biederman, J. (2000) · Developmental Review · doi:10.1006/drev.2000.0515 · Cited by 76
Reliability of the Services for Children and Adolescents–Parent Interview
Hoagwood, K., Jensen, P. S., Arnold, L. E., Roper, M., Severe, J. B., Odbert, C., & Molina, B. S. G. (2004) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1097/01.chi.0000139558.54948.1f · Cited by 73
Making assessment relevant to treatment planning: the STS Clinician Rating Form. Systemic Treatment Selection.
Fisher, D., Beutler, L., & Williams, O. B. (1999) · Journal of Clinical Psychology · doi:10.1002/(sici)1097-4679(199907)55:7 · Cited by 57
Trajectories of Growth Associated With Long-Term Stimulant Medication in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder
Greenhill, L. L., Swanson, J. M., Hechtman, L. T., Waxmonsky, J. G., Arnold, L. E., Molina, B. S. G., Hinshaw, S. P., Jensen, P. S., Abikoff, H., Wigal, T. L., et al. (2019) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2019.06.019 · Cited by 69
Self-Perception in Children with Attention Deficit/Hyperactivity Disorder
Barber, S., Grubbs, L. M., & Cottrell, B. H. (2005) · Journal of Pediatric Nursing · doi:10.1016/j.pedn.2005.02.012 · Cited by 68
Probabilistic Epigenesis of Psychopathology
Gottlieb, G., & Willoughby, M. T. (2015) · Wiley eBooks · doi:10.1002/9780470939383.ch17 · Cited by 65
Interventions in ADHD: A comparative review of stimulant medications and behavioral therapies
Rajeh, A., Amanullah, S., Shivakumar, K., & Cole, J. (2016) · Asian Journal of Psychiatry · doi:10.1016/j.ajp.2016.09.005 · Cited by 64
Bulimia nervosa symptoms in the Multimodal Treatment Study of Children with ADHD
Mikami, A. Y., Hinshaw, S. P., Arnold, L. E., Hoza, B., Hechtman, L. T., Newcorn, J. H., & Abikoff, H. (2009) · International Journal of Eating Disorders · doi:10.1002/eat.20692 · Cited by 62
Noninvasive Brain Stimulation in Pediatric Attention-Deficit Hyperactivity Disorder (ADHD)
Rubio, B., Boes, A. D., Laganiere, S. E., Rotenberg, A., Jeurissen, D., & Pascual‐Leone, Á. (2015) · Journal of Child Neurology · doi:10.1177/0883073815615672 · Cited by 64
Catechol-O-Methyltransferase (COMT) Val 108/158 Metpolymorphism does not modulate executive function in children with ADHD
Taerk, E., Grizenko, N., Amor, L. B., Lageix, P., Mbékou, V., Deguzman, R., Torkamanzehi, A., Ter-Stepanian, M., Baron, C., & Joober, R. (2004) · BMC Medical Genetics · doi:10.1186/1471-2350-5-30 · Cited by 60
“Theories of dysregulated dopamine (DA) pathways in ADHD have been supported by the efficacy of dopamine agonists in reducing the core symptoms of the disorder [12].”
Which polyunsaturated fatty acids are active in children with attention-deficit hyperactivity disorder receiving PUFA supplementation? A fatty acid validated meta-regression analysis of randomized controlled trials
Puri, B. K., & Martins, J. G. (2014) · Prostaglandins, Leukotrienes and Essential Fatty Acids · doi:10.1016/j.plefa.2014.01.004 · Cited by 56
Psychopathology in Children
Frick, P. J., & Silverthorn, P. (2002) · Springer eBooks · doi:10.1007/0-306-47377-1_31 · Cited by 57
Maternal ADHD Symptoms, Personality, and Parenting Stress: Differences Between Mothers of Children With ADHD and Mothers of Comparison Children
Algorta, G. P., Kragh, C. A., Arnold, L. E., Molina, B. S. G., Hinshaw, S. P., Swanson, J. M., Hechtman, L. T., Copley, L. M., Lowe, M., & Jensen, P. S. (2014) · Journal of Attention Disorders · doi:10.1177/1087054714561290 · Cited by 62
“We utilized data from the MTA (Arnold et al., 1997; MTA Cooperative Group, 1999, 2004), including the auxiliary LNCG.”
MethodInfluential
The Multidimensional Anxiety Scale for Children (MASC): Confirmatory factor analysis in a pediatric ADHD sample
March, J. S., Conners, C. K., Arnold, G., Epstein, J. N., Parker, J. D. A., Hinshaw, S., Abikoff, H., Molina, B. S. G., Wells, K. C., Newcorn, J. H., et al. (1999) · Journal of Attention Disorders · doi:10.1177/108705479900300202 · Cited by 54
“The rationale and design of the MTA have been reported elsewhere (Arnold et al., 1997; Hinshaw et al., 1997).”
BackgroundInfluential
What Does the MTA Study Tell Us About Effective Psychosocial Treatment for ADHD?
Greene, R. W., & Ablon, J. S. (2001) · Journal of Clinical Child & Adolescent Psychology · doi:10.1207/s15374424jccp3001_13 · Cited by 55
“In discussing early findings from the MTA study, it is very important to be explicit about the research questions the study was designed to answer (see Arnold et al., 1997a): (a) How do excellent long-term medication and psychosocial treatments compare with one another?”
BackgroundInfluential
Progression of impairment in adolescents with attention-deficit/hyperactivity disorder through the transition out of high school: Contributions of parent involvement and college attendance.
Howard, A. L., Strickland, N. J., Murray, D. W., Tamm, L., Swanson, J. M., Hinshaw, S. P., Arnold, L. E., & Molina, B. S. G. (2016) · Journal of Abnormal Psychology · doi:10.1037/abn0000100 · Cited by 58
“Recruitment strategy, detailed exclusion criteria, diagnostic procedures, treatment, and sample demographic characteristics appear in other reports (Arnold et al., 1997; MTA Cooperative Group, 1999; 2004).”
Clinically significant symptom change in children with attention‐deficit/hyperactivity disorder: does it correspond with reliable improvement in functioning?
Karpenko, V., Owens, J. S., Evangelista, N. M., & Dodds, C. M. (2008) · Journal of Clinical Psychology · doi:10.1002/jclp.20549 · Cited by 50
Nine Months of Multicomponent Behavioral Treatment for ADHD and Effectiveness of MTA Fading Procedures
Arnold, L. E., Chuang, S. Z., Davies, M., Abikoff, H., Conners, C. K., Elliott, G. R., Greenhill, L. L., Hechtman, L. T., Hinshaw, S. P., Hoza, B., et al. (2003) · Research on Child and Adolescent Psychopathology · doi:10.1023/b:jacp.0000007579.61289.31 · Cited by 49
“The NIMH Cooperative Multimodal Treatment Study of Children with ADHD (the MTA) was a landmark comparison of the these two treatment strategies and their combination (Arnold et al., 1997a, 1997b; MTA Cooperative Group, 1999a, 1999b).”
Method
Relation Between Outcomes on a Continuous Performance Test and ADHD Symptoms Over Time
Vaughn, A. J., Epstein, J. N., Rausch, J. R., Altaye, M., Langberg, J. M., Newcorn, J. H., Hinshaw, S. P., Hechtman, L. T., Arnold, L. E., Swanson, J. M., et al. (2011) · Research on Child and Adolescent Psychopathology · doi:10.1007/s10802-011-9501-y · Cited by 50
“Greater detail regarding the rationale, design, and results of the MTA study may be found elsewhere (Arnold et al., 1997; MTA Cooperative Group, 1999).”
Background
Child Psychiatric Disorder
Rutter, M. L. (1997) · Archives of General Psychiatry · doi:10.1001/archpsyc.1997.01830210021002 · Cited by 48
The structure of childhood disruptive behaviors.
Martel, M. M., Gremillion, M. L., Roberts, B., von Eye, A., & Nigg, J. T. (2010) · Psychological Assessment · doi:10.1037/a0020975 · Cited by 45
“Recruitment and identification—A broad community-based recruitment strategy was used, with mass mailings to parents in local school districts, public advertisements, and fliers at local clinics, in an effort to mimic the recruitment strategy of the MTA study (Arnold et al., 1997).”
Method
Moderators and Mediators of Treatment Outcome for Youth With ADHD: Understanding for Whom and How Interventions Work
Hinshaw, S. P. (2007) · Ambulatory Pediatrics · doi:10.1016/j.ambp.2006.04.012 · Cited by 44

Authors: Arnold, L. E.
Affiliations: National Institute of Mental Health (US)
Corresponding author: Arnold, L. Eugene
ORCID: Arnold, L. Eugene
Venue: Archives of General Psychiatry
Publisher: American Medical Association (AMA)
Published: 1997-09-01
Volume: 54
Issue: 9
Pages: 865
ISSN: 0003-990X (ISSN-L)
DOI: 10.1001/archpsyc.1997.01830210113015
OpenAlex: W2157719972
Cited by: 240
References: 20
Citations by year: 2026: 2 · 2025: 1 · 2024: 1 · 2023: 4 · 2022: 2 · 2021: 2 · 2020: 2 · 2019: 8 · 2018: 3 · 2017: 6 · 2016: 4 · 2015: 10 · 2014: 7 · 2013: 3 · 2012: 3
FWCI: 14.40
Type: journal article
Language: en
Open access: closed
Locations: Archives of General Psychiatry (publishedVersion)
PubMed (publishedVersion)
Funders: National Institute of Mental Health (UO1 MH50461, UO1 MH50440, U01MH050447, U01MH050440, UO1 MH50447, U01MH050461)
Topics: Health Sciences › Medicine › Psychiatry and Mental health › Attention Deficit Hyperactivity Disorder
Social Sciences › Psychology › Developmental and Educational Psychology › Behavioral and Psychological Studies
Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
Keywords: attention deficit hyperactivity disorder, children, multimodal therapy, stimulant medication, behavior therapy, psychosocial interventions, combination therapy, community-based care, long-term treatment effectiveness, decision-making algorithm, target population definition
MeSH terms: Attention Deficit Disorder with Hyperactivity, Behavior Therapy, Child, Clinical Protocols, Combined Modality Therapy, Decision Making, Dextroamphetamine, Female, Health Policy, Health Services Research, Humans, Imipramine, Male, Methylphenidate, National Institute of Mental Health (U.S.), Pemoline, Research Design, United States, Patient Selection

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National Institute of Mental Health Collaborative Multimodal Treatment Study of Children With ADHD (the MTA): Design Challenges and Choices

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