Howard Abikoff

The MTA at 8 Years: Prospective Follow-up of Children Treated for Combined-Type ADHD in a Multisite Study

OBJECTIVESnTo determine any long-term effects, 6 and 8 years after childhood enrollment, of the randomly assigned 14-month treatments in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA; N = 436); to test whether attention-deficit/hyperactivity disorder (ADHD) symptom trajectory through 3 years predicts outcome in subsequent years; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers (local normative comparison group; N = 261).nnnMETHODnMixed-effects regression models with planned contrasts at 6 and 8 years tested a wide range of symptom and impairment variables assessed by parent, teacher, and youth report.nnnRESULTSnIn nearly every analysis, the originally randomized treatment groups did not differ significantly on repeated measures or newly analyzed variables (e.g., grades earned in school, arrests, psychiatric hospitalizations, other clinically relevant outcomes). Medication use decreased by 62% after the 14-month controlled trial, but adjusting for this did not change the results. ADHD symptom trajectory in the first 3 years predicted 55% of the outcomes. The MTA participants fared worse than the local normative comparison group on 91% of the variables tested.nnnCONCLUSIONSnType or intensity of 14 months of treatment for ADHD in childhood (at age 7.0-9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. Innovative treatment approaches targeting specific areas of adolescent impairment are needed.

The ecological validity of delay aversion and response inhibition as measures of impulsivity in AD/HD: a supplement to the NIMH multimodal treatment study of AD/HD

Impulsivity is a primary symptom of the combined type of Attention Deficit/Hyperactivity Disorder (AD/HD). The Stop Signal Paradigm is premised upon a primary deficit in inhibitory control in AD/HD, whereas the Delay Aversion Hypothesis, by contrast, conceptualizes impulsivity in AD/HD, not as an inability to inhibit a response, but rather as a choice to avoid delay. This study compared the ecological validity of the Stop Signal Task (SST) and Choice-Delay Task (C-DT) measure of delay aversion, with respect to their relative utility in discriminating AD/HD children from normal control participants, and their correlations with classroom observations and with ratings of impulsivity and other core AD/HD symptoms on the Conners and SNAP-IV checklists. The tasks exhibited modest discriminant validity when used individually and excellent discriminant validity when used in combination. The C-DT correlated with teacher ratings of impulsivity, hyperactivity, and conduct problems, and with observations of gross motor activity, physical aggression, and an AD/HD composite score. The SST correlated with the observations only. These results suggest that delay aversion is associated with a broad range of AD/HD characteristics whereas inhibitory failure seems to tap a more discrete dimension of executive control

Teachers' ratings of disruptive behaviors: the influence of halo effects

This study evaluated the accuracy of teachers ratings and examined whether these ratings are influenced by halo effects. One hundred thirtynine elementary school teachers viewed videotapes of what they believed were children in regular fourth-grade classrooms. In fact, the children were actors who followed prepared scripts that depicted a child engaging in behaviors characteristic of an attention-deficit hyperactivity disorder (ADHD), an oppositional defiant disorder or a normal youngster. The findings provide support for a bias that was unidirectional in nature. Specifically, teachers rated hyperactive behaviors accurately when the child behaved like an ADHD youngster. However, ratings of hyperactivity and of ADHD symptomatic behaviors were spuriously inflated when behaviors associated with oppositional defiant disorder occurred. In contrast, teachers rated oppositional and conduct problem behaviors accurately, regardless of the presence of hyperactive behaviors. The implications of these findings regarding diagnostic practices and rating scale formats are discussed.

Child and parent response to the 1993 World Trade Center bombing.

This study evaluated childrens symptoms 3 and 9 months after the 1993 bombing of the World Trade Center, and the relationship between parent and child reactions when only the children had been in the building. Nine children who had been trapped in an elevator, 13 who had been on the observation deck, and 27 controls completed the Posttraumatic Stress Reaction Index and a Fear Inventory. Parents completed these measures about the children and comparable measures about themselves. Exposed children reported posttraumatic stress disorder (PTSD) symptoms and disaster-related fears; their parents reported experiencing PTSD symptoms. Only parents rated childrens symptoms as decreasing significantly over time. Association between child symptoms and parent symptoms increased over time. Childrens initial distress predicted parents distress 9 months postdisaster.

Evidence, Interpretation, and Qualification From Multiple Reports of Long-Term Outcomes in the Multimodal Treatment Study of Children With ADHD (MTA) Part I: Executive Summary

Objective: To review the primary and secondary findings from the Multimodal Treatment study of ADHD (MTA) published over the past decade as three sets of articles. Method: In a two-part article—Part I: Executive Summary (without distracting details) and Part II: Supporting Details (with additional background and detail required by the complexity of the MTA)—we address confusion and controversy about the findings. Results: We discuss the basic features of the gold standard used to produce scientific evidence, the randomized clinical trial, for which was used to contrast four treatment conditions: medication management alone (MedMgt), behavior therapy alone (Beh), the combination of these two (Comb), and a community comparison of treatment “as usual” (CC). For each of the three assessment points we review three areas that we believe are important for appreciation of the findings: definition of evidence from the MTA, interpretation of the serial presentations of findings at each assessment point with a different definition of long-term, and qualification of the interim conclusions about long-term effects of treatments for ADHD. Conclusion: We discuss the possible clinical relevance of the MTA and present some practical suggestions based on current knowledge and uncertainties facing families, clinicians, and investigators regarding the long-term use of stimulant medication and behavioral therapy in the treatment of children with ADHD. (J. of Att. Dis. 2008; 12(1) 4-14)

The Effects of Auditory Stimulation on the Arithmetic Performance of Children with ADHD and Nondisabled Children

This study evaluated the impact of extra-task stimulation on the academic task performance of children with attention-deficit/hyperactivity disorder (ADHD). Twenty boys with ADHD and 20 nondisabled boys worked on an arithmetic task during high stimulation (music), low stimulation (speech), and no stimulation (silence). The music “distractors were individualized for each child, and the arithmetic problems were at each childs ability level. A significant Group x Condition interaction was found for number of correct answers. Specifically, the nondisabled youngsters performed similarly under all three auditory conditions. In contrast, the children with ADHD did significantly better under the music condition than speech or silence conditions. However, a significant Group x Order interaction indicated that arithmetic performance was enhanced only for those children with ADHD who received music as the first condition. The facilitative effects of salient auditory stimulation on the arithmetic performance of the children with ADHD provide some support for the underarousal/optimal stimulation theory of ADHD.

Treatment-Related Changes in Objectively Measured Parenting Behaviors in the Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder

The present study examined treatment outcomes for objectively measured parenting behavior in the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (ADHD). Five hundred seventy-nine ethnically and socioeconomically diverse children with ADHD-combined type (ages 7.0-9.9 years) and their parent(s) were recruited at 6 sites in the United States and Canada and randomly assigned to 1 of 4 treatment groups for 14 months of active intervention: medication management (MedMgt), intensive behavior therapy, combination of the 2 (Comb), or a community-treated comparison (CC). Baseline and posttreatment laboratory observations of parent-child interactions were coded by observers blind to treatment condition. Comb produced significantly greater improvements in constructive parenting than did MedMgt or CC, with effect sizes approaching medium for these contrasts. Treatment effects on child behaviors were not significant. The authors discuss the importance of changes in parenting behavior for families of children with ADHD and the need for reliable and objective measures in evaluating treatment outcome.

Evidence, interpretation, and qualification from multiple reports of long-term outcomes in the Multimodal Treatment Study of children with ADHD (MTA): Part II: supporting details.

Objective: To review and provide details about the primary and secondary findings from the Multimodal Treatment study of ADHD (MTA) published during the past decade as three sets of articles. Method: In the second of a two part article, we provide additional background and detail required by the complexity of the MTA to address confusion and controversy about the findings outlined in part I (the Executive Summary). Results: We present details about the gold standard used to produce scientific evidence, the randomized clinical trial (RCT), which we applied to evaluate the long-term effects of two well-established unimodal treatments, Medication Management (MedMGT) and behavior therapy (Beh), the multimodal combination (Comb), and treatment “as usual” in the community (CC). For each of the first three assessment points defined by RCT methods and included in intent-to-treat analyses, we discuss our definition of evidence from the MTA, interpretation of the serial presentations of findings at each assessment point with a different definition of long-term varying from weeks to years, and qualification of the interim conclusions about long-term effects of treatments for ADHD based on many exploratory analyses described in additional published articles. Conclusions: Using a question and answer format, we discuss the possible clinical relevance of the MTA and present some practical suggestions based on current knowledge and uncertainties facing families, clinicians, and investigators regarding the long-term use of stimulant medication and behavioral therapy in the treatment of children with ADHD. (J. of Att. Dis. 2008; 12(1) 15-43)

An Evaluation of Cognitive Behavior Therapy for Hyperactive Children

Hyperactivity (attention deficit disorder with hyperactivity, ADDH) is characterized by the primary symptoms of inattentiveness, impulsivity, and restlessness. Other features that are frequently associated with the disorder include poor school performance and inadequate interpersonal relationships.

Cognitive training in academically deficient ADDH boys receiving stimulant medication

This study evaluated the effectiveness of a 16-week intensive cognitive training program in stimulant-treated, academically deficient ADDH boys. Cognitive training focused exclusively on academic skills and tasks, and included attack strategy training as well as self-monitoring and self-reinforcement of problem-solving behaviors and response accuracy. Control groups included remedial tutoring plus medication, and medication alone. Despite the scope of the program, the results provided no support for the notion that academically based cognitive training ameliorates the performance and achievement of academically deficient ADDH youngsters. Further, this intervention did not enhance self-esteem or attributional perceptions of academic functioning. There was poor agreement between teacher ratings of academic competence and test score changes. The lack of concordance between measures, and the scarcity of academically deficient ADDH children are discussed.