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Cited by 652Attention Deficit Hyperactivity DisorderBehavioral and Psychological StudiesChild and Adolescent Psychosocial and Emotional Development

Moderators and Mediators of Treatment Response for Children With Attention-Deficit/Hyperactivity Disorder: The Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder

The MTA Cooperative Group·1999·Archives of General Psychiatry
DOI 10.1001/archpsyc.56.12.1088
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Abstract

BACKGROUND: Intent-to-treat analyses of the study revealed that medication management, alone or combined with intensive behavioral treatment, was superior to behavioral treatment and community care in reducing attention-deficit/hyperactivity disorder (ADHD) symptoms; but only combined treatment showed consistently greater benefit than community care across other outcome domains (disruptive and internalizing symptoms, achievement, parent-child relations, and social skills). We examine response patterns in subgroups defined by baseline variables (moderators) or variables related to treatment implementation (mediators). METHODS: We reconducted random-effects regression (RR) analyses, adding factors defined by moderators (sex, prior medication use, comorbid disruptive or anxiety disorder, and public assistance) and a mediator (treatment acceptance/attendance). RESULTS: Study outcomes (N = 579) were upheld in most moderator subgroups (boys and girls, children with and without prior medication, children with and without comorbid disruptive disorders). Comorbid anxiety disorder did moderate outcome; in participants without anxiety, results paralleled intent-to-treat findings. For those with anxiety disorders, however, behavioral treatment yielded significantly better outcomes than community care (and was no longer statistically different from medication management and combined treatment) regarding ADHD-related and internalizing symptoms. In families receiving public assistance, medication management yielded decreased closeness in parent-child interactions, and combined treatment yielded relatively greater benefits for teacher-reported social skills. In families with high treatment acceptance/attendance, intent-to-treat results were upheld. Acceptance/attendance was particularly important for medication treatments. Finally, two thirds of children given community care received stimulants. Behavioral treatment did not significantly differ from, but medication management was superior to, this subgroup. CONCLUSIONS: Exploratory analyses revealed that our study (the Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder [MTA]) results were confirmed across most baseline variables and treatment acceptance/attendance. In children with ADHD plus anxiety, behavioral treatment surpassed community care and approached medication-based treatments regarding parent-reported ADHD symptoms.

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  • Several studies indicate that combining medication with psychosocial treatment works especially well for managing ADHD symptoms.

    “Multiple studies have demonstrated that combination pharmacological and psychosocial treatments are particularly effective for ADHD symptom management [26,62].”

    From Treatment for Co-Occurring Attention Deficit/Hyperactivity Disorder and Autism Spectrum Disorder (2012) · cites this paper as [62]

  • In the MTA, 579 children with ADHD combined type aged 7-9.9 years were randomly assigned to medication management, behavior treatment, combined treatment, or community care.

    “579 children with ADHD combined type (aged 7Y9.9 years) were randomly assigned to medication management consisting of titration with t.i.d.administration of 5 to 20 mg of immediate-release MPH followed by monthly visits (MedMgt); behavior treatment consisting of intensive parent, school, and child components, with therapist involvement gradually reduced over time (Beh); the two combined (Comb); or”

    From Medication Adherence in the MTA: Saliva Methylphenidate Samples Versus Parent Report and Mediating Effect of Concomitant Behavioral Treatment (2009) · cites this paper as [5]

  • In the MTA, medication use mediated changes in ADHD symptom ratings from baseline to 14 months and from 14 to 24 months, supporting the initial 14-month randomized trial finding that carefully monitored t.i.d. stimulant medication, with or without behavioral therapy, produced better outcomes than community care or behavioral therapy alone.

    “In the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA), medication use mediated the degree of baseline to 14-month, and 14-to 24-month changes in ADHD symptom ratings, buttressing the initial 14-month randomized clinical trial findings 4,5,15 that the use of a carefully monitored t.i.d.schedule of stimulant medication (with or”

    From Medication Adherence in the MTA: Saliva Methylphenidate Samples Versus Parent Report and Mediating Effect of Concomitant Behavioral Treatment (2009) · cites this paper as [5]

  • In MTA, medication management and combination subjects began with a 28-day, double-blind, daily-switch titration of MPH hydrochloride using five randomly ordered repeats each of placebo, 5, 10, and 15 or 20 mg, with the higher dose determined by weight.

    “subjects in the medication management and combination groups started with a 28-day, double-blind, daily-switch titration of MPH hydrochloride, using 5 randomly ordered repeats each of placebo, 5, 10, and 15 or 20 mg, with the higher dose, 15 mg versus 20 mg, being determined on the basis of the child's weight (threshold Q26 kg).”

    From Medication Adherence in the MTA: Saliva Methylphenidate Samples Versus Parent Report and Mediating Effect of Concomitant Behavioral Treatment (2009) · cites this paper as [5]

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Authors
The MTA Cooperative Group
Corresponding author
The MTA Cooperative Group
Venue
Archives of General Psychiatry
Publisher
American Medical Association (AMA)
Published
1999-12-01
Volume
56
Issue
12
Pages
1088
ISSN
0003-990X (ISSN-L)
DOI
10.1001/archpsyc.56.12.1088
OpenAlex
W4247130871
Cited by
652
References
0
Citations by year
2026: 3 · 2025: 4 · 2024: 7 · 2023: 12 · 2022: 20 · 2021: 10 · 2020: 21 · 2019: 9 · 2018: 18 · 2017: 23 · 2016: 17 · 2015: 23 · 2014: 24 · 2013: 18 · 2012: 27
FWCI
25.18
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, treatment moderators, stimulant medication, behavior therapy, community-based care, comorbid anxiety disorders, disruptive behavior disorders, social assistance, parent-child relationship, social skills, internalizing problems
MeSH terms
Central Nervous System Stimulants, Attention Deficit Disorder with Hyperactivity, Behavior Therapy, Child, Combined Modality Therapy, Community Mental Health Services, Double-Blind Method, Drug Administration Schedule, Female, Humans, Male, Methylphenidate, Treatment Outcome

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