ARTICLES: SPECIAL SECTION: MULTIMODAL TREATMENT STUDY OF ADHD-MTA
3-Year Follow-up of the NIMH MTA Study

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ABSTRACT

Objective:

In the intent-to-treat analysis of the Multimodal Treatment Study of Children With ADHD (MTA), the effects of medication management (MedMgt), behavior therapy (Beh), their combination (Comb), and usual community care (CC) differed at 14 and 24 months due to superiority of treatments that used the MTA medication algorithm (Comb+MedMgt) over those that did not (Beh+CC). This report examines 36-month outcomes, 2 years after treatment by the study ended.

Method:

For primary outcome measures (attention-deficit/hyperactivity disorder [ADHD] and oppositional defiant disorder [ODD] symptoms, social skills, reading scores, impairment, and diagnostic status), mixed-effects regression models and orthogonal contrasts examined 36-month outcomes.

Results:

At 3 years, 485 of the original 579 subjects (83.8%) participated in the follow-up, now at ages 10 to 13 years, (mean 11.9 years). In contrast to the significant advantage of MedMgt+Comb over Beh+CC for ADHD symptoms at 14 and 24 months, treatment groups did not differ significantly on any measure at 36 months. The percentage of children taking medication >50% of the time changed between 14 and 36 months across the initial treatment groups: Beh significantly increased (14% to 45%), MedMed+Comb significantly decreased (91% to 71%), and CC remained constant (60%-62%). Regardless of their treatment use changes, all of the groups showed symptom improvement over baseline. Notably, initial symptom severity, sex (male), comorbidity, public assistance, and parental psychopathology (ADHD) did not moderate children's 36-month treatment responses, but these factors predicted worse outcomes over 36 months, regardless of original treatment assignment.

Conclusions:

By 36 months, the earlier advantage of having had 14 months of the medication algorithm was no longer apparent, possibly due to age-related decline in ADHD symptoms, changes in medication management intensity, starting or stopping medications altogether, or other factors not yet evaluated.

Section snippets

Sample

Table 1 shows the demographics, clinical characteristics, and original treatment assignment for 485 subjects (83.8% of the original 579) evaluated at 36 months. We found no significant differences in baseline characteristics between subjects participating in the 36-month assessment and those we were unable to follow (p value range, 0.15-1.0 except for sex, p = .07). Follow-up rates across sites ranged from 75.0% to 95.8%, but these differences were not significant. Similarly, follow-up rates

Intent-to-Treat Analyses of Original Treatment Groups

Table 2 shows the 36-month outcomes by originally assigned treatment groups for the five outcome domains. By 36 months, none of the randomly assigned treatment groups differed significantly on any of the five clinical and functional outcomes (parent and teacher ADHD and ODD symptoms, reading achievement scores, social skills, and functional impairment.

Figure 1 shows the changes over time in between-group differences for ADHD and ODD symptoms and functional impairment, i.e., the substantial

DISCUSSION

Our primary (intent-to-treat) analyses revealed that the modest significant advantages we found at the 24-month assessment for the MTA Medication Algorithm (i.e., Comb or MedMgt vs. Beh or CC [The MTA Cooperative Group, 2004a, The MTA Cooperative Group, 2004b]) were completely lost by 36 months. Likewise, we found no differences in rates of ADHD diagnosis and other comorbid conditions across the originally assigned treatment groups at 36 months.

Even though medication use patterns changed

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    The Multimodal Treatment Study of Children With ADHD (MTA) was a National Institute of Mental Health (NIMH) cooperative agreement randomized clinical trial involving six clinical sites. Collaborators from the National Institute of Mental Health: Peter S. Jensen, M.D. (currently at Columbia University, New York), L. Eugene Arnold, M.D., M.Ed. (currently at Ohio State University), Joanne B. Severe, M.S. (Clinical Trials Operations and Biostatistics Unit, Division of Services and Intervention Research), Benedetto Vitiello, M.D. (Child and Adolescent Treatment and Preventive Interventions Research Branch), Kimberly Hoagwood, Ph.D. (currently at Columbia University, New York); previous contributors from NIMH to the early phase: John Richters, Ph.D. (currently at National Institute of Nursing Research); Donald Vereen, M.D. (currently at National Institute on Drug Abuse). Principal investigators and co-investigators from the clinical sites are University of California, Berkeley/San Francisco: Stephen P. Hinshaw, Ph.D. (Berkeley), Glen R. Elliott, M.D., Ph.D. (San Francisco); Duke University: C. Keith Conners, Ph.D., Karen C. Wells, Ph.D., John March, M.D., M.P.H., Jeffery Epstein, Ph.D.; University of California, Irvine/Los Angeles: James Swanson, Ph.D. (Irvine), Dennis P. Cantwell, M.D. (deceased, Los Angeles), Timothy Wigal, Ph.D. (Irvine); Long Island Jewish Medical Center/Montreal Children's Hospital: Howard B. Abikoff, Ph.D. (currently at New York University School of Medicine), Lily Hechtman, M.D. (McGill University, Montreal); New York State Psychiatric Institute/Columbia University/Mount Sinai Medical Center, New York: Laurence L. Greenhill, M.D. (Columbia), Jeffrey H. Newcorn, M.D. (Mount Sinai School of Medicine); University of Pittsburgh: William E. Pelham, Ph.D. (currently at State University of New York, Buffalo), Betsy Hoza, Ph.D. (currently at University of Vermont, Burlington), Brooke Molina, Ph.D. Original statistical and trial design consultant: Helena C. Kraemer, Ph.D. (Stanford University). Follow-up phase statistical collaborators: Robert D. Gibbons, Ph.D. (University of Illinois, Chicago), Sue Marcus, Ph.D. (Mt. Sinai College of Medicine), Kwan Hur, Ph.D.(University of Illinois, Chicago). Collaborator from the Office of Special Education Programs/U.S. Department of Education: Thomas Hanley, Ed.D. Collaborator from Office of Juvenile Justice and Delinquency Prevention/Department of Justice: Karen Stern, Ph.D.

    The work reported was supported by cooperative agreement grants and contracts from the National Institute of Mental Health to the following: University of California, Berkeley: U01 MH50461 and N01MH12009; Duke University: U01 MH50477 and N01MH12012; University of California, Irvine: U01 MH50440 and N01MH 12011; Research Foundation for Mental Hygiene (New York State Psychiatric Institute/Columbia University): U01 MH50467 and N01 MH12007; Long Island-Jewish Medical Center U01 MH50453; New York University: N01MH 12004; University of Pittsburgh: U01 MH50467 and N01 MH 12010; and McGill University N01MH12008. The Office of Special Education Programs of the U.S. Department of Education and the Office of Juvenile Justice and Delinquency Prevention of the Justice Department also participated in funding.

    Article Plus (online only) materials for this article appear on the Journal's Web site: www.jaacap.com.

    The opinions and assertions contained in this report are the private views of the authors and are not to be construed as official or as reflecting the views of the National Institute of Mental Health, the National Institutes of Health, or the Department of Health and Human Services.

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