Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): Implications and Applications for Primary Care Providers
Abstract
In 1992, the National Institute of Mental Health and 6 teams of investigators began a multisite clinical trial, the Multimodal Treatment of Attention-Deficit Hyperactivity Disorder (MTA) study. Five hundred seventy-nine children were randomly assigned to either routine community care (CC) or one of three study-delivered treatments, all lasting 14 months. The three MTA treatments-monthly medication management (usually methylphenidate) following weekly titration (MedMgt), intensive behavioral treatment (Beh), and the combination (Comb)-were designed to reflect known best practices within each treatment approach. Children were assessed at four time points in multiple outcome. Results indicated that Comb and MedMgt interventions were substantially superior to Beh and CC interventions for attention-deficit hyperactivity disorder symptoms. For other functioning domains (social skills, academics, parent-child relations, oppositional behavior, anxiety/depression), results suggested slight advantages of Comb over single treatments (MedMgt, Beh) and community care. High quality medication treatment characterized by careful yet adequate dosing, three times daily methylphenidate administration, monthly follow-up visits, and communication with schools conveyed substantial benefits to those children that received it. In contrast to the overall study findings that showed the largest benefits for high quality medication management (regardless of whether given in the MedMgt or Comb group), se…
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Stimulant medications can be effectively titrated on a 7-day basis, but in urgent situations, they may be effectively titrated in as few as 3 days.
“Stimulant medications can be effectively titrated on a 7-day basis, but in urgent situations, they may be effectively titrated in as few as 3 days.140”
From Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents (2019) · cites this paper as [140]
A secondary analysis of a combined measure of parent and teacher ratings of ADHD symptoms in the MTA study found a significant advantage for the combination, with a small effect of d = 0.28.
“a secondary analysis of a combined measure of parent and teacher ratings of ADHD symptoms did find a significant advantage for the combination, with a small effect of d = 0.28.140”
From Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents (2019) · cites this paper as [140]
When a full range of doses of methylphenidate is administered, more than 70% of children and adolescents with ADHD are methylphenidate responders.
“Children in the optimal medication management and combined medication and behavioral management groups underwent a systematic trial with 4 different doses of methylphenidate, with results suggesting that when this full range of doses is administered, more than 70% of children and adolescents with ADHD are methylphenidate responders.140”
From Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents (2019) · cites this paper as [140]
MPH reduces ADHD symptoms and has been found to increase inhibition abilities in children with ADHD.
“MPH reduces ADHD symptoms (Jensen et al., 2001) and has been found to increase inhibition abilities in children with ADHD (Bedard et al., 2003).”
From Implementation Intentions Facilitate Response Inhibition in Children with ADHD (2008) · cites this paper as Jensen et al., 2001
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MethodPharmacogenetics predictors of methylphenidate efficacy in childhood ADHD
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“In the ensuing decade, studies examined the cost-effectiveness of medication management and behavioral intervention as prescribed in the Multimodal Treatment Study for ADHD (Foster et al., 2007; Jensen et al., 2001).”
BackgroundApproaching ADHD as a chronic condition: implications for long-term adherence.
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“a. Additional Moderator Analyses Jensen et al. (2001a, 2001b) reported that children with ADHD plus anxiety comorbidities (but not disruptive comorbidities) did relatively well with Beh, but children with ADHD plus both anxiety and disruptive comorbidities had poor outcomes unless they received Comb.”
BackgroundSelf-citationJuvenile Administration of Methylphenidate Attenuates Adult Hippocampal Neurogenesis
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“Treatment with MPH is generally well tolerated and effective in reducing symptoms associated with ADHD: inattentiveness, impulsivity, and hyperactivity (Abikoff et al 2004; Jensen et al 2001; Wilens and Dodson 2004).”
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BackgroundUse of an Internet Portal to Improve Community-Based Pediatric ADHD Care: A Cluster Randomized Trial
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“…there are increasing numbers of evidenced based treatments for the cooccurring conditions commonly presenting in youth with CTDs (Allen et al. 2005; Jensen et al. 2001; Kurlan 2002; Pediatric OCD Treatment Study [POTS] Team 2004; Scahill et al. 2001; Treatment for Adolescents with Depression Study…”
BackgroundChang, C. J., Putukian, M., Aerni, G. A., Diamond, A. B., Hong, E. S., Ingram, Y. M., Reardon, C. L., & Wolanin, A. T. (2020) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0000000000000817 · Cited by 108 · see citing works
Racial and Ethnic Differences in ADHD Treatment Quality Among Medicaid-Enrolled Youth
Cummings, J. R., Ji, X., Allen, L., Lally, C., & Druss, B. (2017) · Pediatrics · doi:10.1542/peds.2016-2444 · Cited by 79 · see citing works
Langberg, J. M., Arnold, L., Flowers, A. M., Epstein, J. N., Altaye, M., Hinshaw, S., Swanson, J., Kotkin, R., Simpson, S., Molina, B., et al. (2010) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374410903532700 · Cited by 78 · see citing works
“Specifically, following active treatment, MTA participants received medication through community providers and medication was not monitored and titrated as frequently or consistently (Jensen et al., 2001).”
BackgroundSelf-citationEpstein, J. N., Langberg, J. M., Lichtenstein, P. K., Altaye, M., Brinkman, W. B., House, K., & Stark, L. J. (2010) · Archives of Pediatrics & Adolescent Medicine · doi:10.1001/archpediatrics.2009.263 · Cited by 78 · see citing works
“gested that study-delivered rigorous medication management produced better ADHD symptom improvement than medication management delivered in the community.(4) Further, Epstein et al(21) demonstrated that children treated by pediatricians who successfully adopted a consultation service had much better outcomes than chil…”
BackgroundMethodResultInfluentialGau, S. S., Shen, H.-Y., Soong, W., & Gau, C. (2006) · Journal of Child and Adolescent Psychopharmacology · doi:10.1089/cap.2006.16.441 · Cited by 77 · see citing works
Differentiating between ADHD sub‐types on CCPT measures of sustained attention and vigilance
EGELAND, J., JOHANSEN, S. N., & UELAND, T. (2009) · Scandinavian Journal of Psychology · doi:10.1111/j.1467-9450.2009.00717.x · Cited by 74 · see citing works
Frazier, T., Youngstrom, E., Haycook, T., Sinoff, A., Dimitriou, F., Knapp, J. A., & Sinclair, L. (2010) · Journal of child and adolescent psychopharmacology · doi:10.1089/cap.2009.0048 · Cited by 72 · see citing works
“In other cases, psychosocial interventions have not provided incremental effects in acute treatment when an appropriately structured medication regimen is already in place (e.g., Jensen et al. 2001).”
Attention-Deficit/Hyperactivity Disorder and Early-Onset Substance Use Disorders
Wilson, J. J., & Levin, F. R. (2005) · Journal of Child and Adolescent Psychopharmacology · doi:10.1089/cap.2005.15.751 · Cited by 71 · see citing works
Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions
Marangoni, C., Chiara, L. D., & Faedda, G. L. (2015) · Current Psychiatry Reports · doi:10.1007/s11920-015-0604-y · Cited by 79 · see citing works
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 · see citing works
“Findings of the MTA suggest that pharmacotherapy and behavioral and social skill programs may have a considerable impact on restoring children with ADHD to normal or near-normal functioning not only at home but also at school (Jensen et al., 2001; MTA Cooperative Group, 1999).”
BackgroundLoo, S. K., Hopfer, C. J., Teale, P. D., & Reite, M. L. (2004) · Journal of Clinical Neurophysiology · doi:10.1097/01.wnp.0000150890.14421.9a · Cited by 73 · see citing works
“…treatment of ADHD is psychostimulant medication, which has been shown to affect the core behavioral symptoms of inattention, impulsivity, motor hyperactivity (Jensen et al., 2001), and cognitive performance in several different areas (Aron et al., 2003; Bedard et al., 2002; Giancola et al., 1996).”
BackgroundSo, C. Y. C., Leung, P., & Hung, S. F. (2008) · Behaviour Research and Therapy · doi:10.1016/j.brat.2008.06.007 · Cited by 69 · see citing works
“Thus, ADHD children attending community clinics might receive a dosage that provided some symptom reduction, but they had never tried higher dosages that provided optimization (Jensen et al., 2001).”
BackgroundEvolution of Child Mental Health Services in Primary Care
Kelleher, K. J., & Stevens, J. H. (2009) · Academic Pediatrics · doi:10.1016/j.acap.2008.11.008 · Cited by 64 · see citing works
“The few studies that have followed routine community care suggest modest benefit at best for those treated in typical primary care settings.(17) In fact, children and adolescents treated with psychotropic drugs in primary care settings often do not remain on their drugs long enough to obtain therapeutic benefit.”
BackgroundBaweja, R., Soutullo, C., & Waxmonsky, J. G. (2021) · World Journal of Psychiatry · doi:10.5498/wjp.v11.i12.1206 · Cited by 68 · see citing works
Heidbreder, R. (2015) · ADHD Attention Deficit and Hyperactivity Disorders · doi:10.1007/s12402-015-0171-4 · Cited by 74 · see citing works
Epstein, J. N., Rabiner, D., Johnson, D. E., Fitzgerald, D., Chrisman, A., Erkanli, A., Sullivan, K. K., March, J. S., Margolis, P., Norton, E. C., et al. (2007) · Archives of Pediatrics & Adolescent Medicine · doi:10.1001/archpedi.161.9.835 · Cited by 65 · see citing works
Self-citationHammond, D. (2010) · Applied Psychophysiology and Biofeedback · doi:10.1007/s10484-009-9106-1 · Cited by 64 · see citing works
“In addition to the fact that diagnostic criteria for conditions such as ADD/ADHD are broad, it is well known that only rarely are pure cases of a diagnosis found in which comorbidities are not present (Barkley 1998; Jensen et al. 2001).”
BackgroundGardner, W., Kelleher, K., Pajer, K., & Campo, J. (2004) · Jornal de Pediatria · doi:10.1016/j.jpeds.2004.08.028 · Cited by 62 · see citing works
“Our findings about the rates of follow-up visits are similar to those found by Olfson et al(6) and somewhat higher than those reported by the MTA group.(14) Because children in the MTA usual care group received five study assessments, parents may have felt less need for physician visits than if they had not been in th…”
BackgroundResultPharmacotherapy for Child and Adolescent Attention-deficit Hyperactivity Disorder
Kaplan, G., & Newcorn, J. H. (2011) · Pediatric Clinics of North America · doi:10.1016/j.pcl.2010.10.009 · Cited by 63 · see citing works
Self-citationDo Low-Effort Learning Strategies Mediate Impaired Memory in ADHD?
Egeland, J., Johansen, S. N., & Ueland, T. (2010) · Journal of Learning Disabilities · doi:10.1177/0022219409355473 · Cited by 56 · see citing works
“Children with ADHD frequently have comorbid psychiatric disorders (Jensen et al., 2001).”
BackgroundMucci, A., Volpe, U., Merlotti, E., Bucci, P., & Galderisi, S. (2006) · Clinical EEG and Neuroscience · doi:10.1177/155005940603700206 · Cited by 59 · see citing works
Keulers, E. H. H., Hendriksen, J. G. M., FERON, F. J. M., Wassenberg, R., Wuisman-Frerker, M. G. F., Jolles, J., & Vles, J. S. H. (2006) · European Journal of Paediatric Neurology · doi:10.1016/j.ejpn.2006.10.002 · Cited by 54 · see citing works
“studies showed that the positive effects of MPH continued during longer-term treatment.(22) However, it is still unclear whether short-term gains of MPH can be translated into longterm improvements in academic achievement.”
BackgroundResultLian, W., Ying, S. H. K., Tean, S. C. H., Lin, D. C. K., Lian, Y., & Yun, H.-L. (2008) · Journal of Paediatrics and Child Health · doi:10.1111/j.1440-1754.2007.01231.x · Cited by 55 · see citing works
Cornacchio, D., Furr, J. M., Sanchez, A. L., Hong, N., Feinberg, L. K., Tenenbaum, R. B., del Busto, C. T., Bry, L. J., Poznanski, B., Miguel, E. M., et al. (2019) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000422 · Cited by 67 · see citing works
“These findings are consistent with the growing body of literature documenting high satisfaction with intensive treatment formats for a range of child mental health problems, including anxiety (e.g., Jensen et al., 2001; Ollendick et al., 2009, 2015; Santucci et al., 2009).”
ResultPediatric Behavioral Health in Primary Care: A Collaborative Approach
Campo, J., Shafer, S., Strohm, J., Lucas, A., Cassesse, C., Shaeffer, D., & Altman, H. (2005) · Journal of the American Psychiatric Nurses Association · doi:10.1177/1078390305282404 · Cited by 52 · see citing works
“In the model described, child and adolescent psychiatric input is mediated by the APN, who regularly discusses and reviews cases with the PCCs (Katon et al., 1999; Katon et al., 2001).”
BackgroundThe Multidimensional Anxiety Scale for Children
Houghton, S., Hunter, S. C., Trewin, T., Glasgow, K., & Carroll, A. (2014) · Journal of Attention Disorders · doi:10.1177/1087054712439100 · Cited by 51 · see citing works
“…that children and adolescents with ADHD worry about their performance and behavior, their susceptibility to embarrassment and future events (Strauss, Last, Hersen, & Kazdin, 1988), and, as a result, manifest overt signs and symptoms of anxiety (see Jensen et al., 2001; Molina et al., 2009).”
Background1H MRSI of Middle Frontal Gyrus in Pediatric ADHD
Tafazoli, S., O'Neill, J., Bejjani, A., Ly, R., Salamon, N., McCracken, J., Alger, J., & Levitt, J. G. (2012) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2012.11.011 · Cited by 51 · see citing works
“These symptoms (Jensen et al., 2001), along with impaired neurocognitive performance on multiple instruments (Aron et al.”
BackgroundPelsser, L., Frankena, K., Buitelaar, J., & Rommelse, N. (2010) · European Journal of Pediatrics · doi:10.1007/s00431-010-1196-5 · Cited by 51 · see citing works
“To date, pharmacotherapy, combined with behavioural management, is the most effective treatment of ADHD [20].”
BackgroundRecidivism and Psychiatric Symptom Outcomes in a Juvenile Mental Health Court
Ramirez, A. M., Andretta, J. R., Barnes, M. E., & Woodland, M. H. (2015) · doi:10.1111/jfcj.12025 · Cited by 51
Wehmeier, P., Dittmann, R., & Banaschewski, T. (2015) · ADHD Attention Deficit and Hyperactivity Disorders · doi:10.1007/s12402-014-0156-8 · Cited by 50 · see citing works
“Both psychostimulants and the non-stimulant atomoxetine are known to be effective in the treatment of children and adolescents with ADHD (Jensen et al. 2001; Banaschewski et al. 2006; Cheng et al. 2007).”
BackgroundVoigt, R. G., Katusic, S. K., Colligan, R. C., Killian, J. M., Weaver, A. L., & Barbaresi, W. J. (2016) · Journal of Developmental & Behavioral Pediatrics · doi:10.1097/dbp.0000000000000358 · Cited by 54 · see citing works
ADHD Service Use Patterns in Youth
Leslie, L. K., & Wolraich, M. L. (2007) · Ambulatory Pediatrics · doi:10.1016/j.ambp.2006.05.002 · Cited by 18 · see citing works
“Second, findings from the Multimodal Treatment Study of Children With ADHD (MTA study) suggest that tightly titrated medication use, requiring close communication between the prescribing clinician and the child’s teacher, yields improved outcomes over standard community care.(12) Teachers’ input is thus essential for…”
Background
- Authors
- JENSEN, P. S., HINSHAW, S. P., SWANSON, J. M., GREENHILL, L. L., CONNERS, C. K., ARNOLD, L. E., ABIKOFF, H. B., ELLIOTT, G., HECHTMAN, L., HOZA, B., MARCH, J. S., NEWCORN, J. H., SEVERE, J. B., VITIELLO, B., WELLS, K., & WIGAL, T.
- Affiliations
- New York State Psychiatric Institute (US)
- Columbia University (US)
- Corresponding author
- JENSEN, PETER S.
- ARNOLD, L. EUGENE
- HOZA, BETSY
- SEVERE, JOANNE B.
- VITIELLO, BENEDETTO
- ORCID
- Venue
- Journal of Developmental & Behavioral Pediatrics
- Published
- 2001-02
- Volume
- 22
- Issue
- 1
- Pages
- 60-73
- ISSN
- 0196-206X (ISSN-L)
- OpenAlex
- W1983120213
- Cited by
- 591
- References
- 32
- Citations by year
- 2026: 7 · 2025: 8 · 2024: 5 · 2023: 20 · 2022: 18 · 2021: 16 · 2020: 53 · 2019: 20 · 2018: 23 · 2017: 16 · 2016: 19 · 2015: 28 · 2014: 34 · 2013: 21 · 2012: 30
- FWCI
- 11.60
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Developmental & Behavioral Pediatrics (publishedVersion)
- PubMed (publishedVersion)
- Institutional Research Information System University of Turin (University of Turin) (submittedVersion)
- 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, methylphenidate, medication management, combination therapy, primary care, comorbid anxiety disorders, disruptive behavior disorders, parental attitudes
- MeSH terms
- Central Nervous System Stimulants, Attention Deficit Disorder with Hyperactivity, Behavior Therapy, Child, Combined Modality Therapy, Female, Humans, Male, Methylphenidate, Primary Health Care, Treatment Outcome
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