James M. Swanson

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.

Parent and Teacher SNAP-IV Ratings of Attention Deficit Hyperactivity Disorder Symptoms: Psychometric Properties and Normative Ratings from a School District Sample.

To examine Swanson, Nolan, and Pelham—IV (SNAP-IV) psychometric properties, parent (N = 1,613) and teacher (N = 1,205) data were collected from a random elementary school student sample in a longitudinal attention deficit hyperactivity disorder (ADHD) detection study. SNAP-IV reliability was acceptable. Factor structure indicated two ADHD factors and an oppositional defiant disorder (ODD) factor. Parent and teacher scores varied by gender and poverty status (d = .49-.56) but not age; only teacher scores varied by race (d = .25-.55). Screening and diagnostic utility was evaluated with likelihood ratios (LRs) and posttest probabilities. Parent SNAP-IV scores above 1.2 increased probability of concern (LR > 10) and above 1.8, of ADHD diagnosis (LR > 3). Teacher hyperactivity/impulsivity scores above 1.2 and inattention scores above 1.8 increased probabilities of concern only (LR = 4.2 and >5, respectively). Higher teacher scores for African American children and race differences in measurement models require future study.

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)

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)

Functional adult outcomes 16 years after childhood diagnosis of Attention-Deficit/Hyperactivity Disorder:MTA results

OBJECTIVEnTo compare educational, occupational, legal, emotional, substance use disorder, and sexual behavior outcomes in young adults with persistent and desistent attention-deficit/hyperactivity disorder (ADHD) symptoms and a local normative comparison group (LNCG) in the Multimodal Treatment Study of Children with ADHD (MTA).nnnMETHODnData were collected 12, 14, and 16 years postbaseline (mean age 24.7 years at 16 years postbaseline) from 476 participants with ADHD diagnosed at age 7 to 9 years, and 241 age- and sex-matched classmates. Probands were subgrouped on persistence versus desistence of DSM-5 symptom count. Orthogonal comparisons contrasted ADHD versus LNCG and symptom-persistent (50%) versus symptom-desistent (50%) subgroups. Functional outcomes were measured with standardized and demographic instruments.nnnRESULTSnThree patterns of functional outcomes emerged. Post-secondary education, times fired/quit a job, current income, receiving public assistance, and risky sexual behavior showed the most common pattern: the LNCG group fared best, symptom-persistent ADHD group worst, and symptom-desistent ADHD group between, with the largest effect sizes between LNCG and symptom-persistent ADHD. In the second pattern, seen with emotional outcomes (emotional lability, neuroticism, anxiety disorder, mood disorder) and substance use outcomes, the LNCG and symptom-desistent ADHD group did not differ, but both fared better than the symptom-persistent ADHD group. In the third pattern, noted with jail time (rare), alcohol use disorder (common), and number of jobs held, group differences were not significant. The ADHD group had 10 deaths compared to one death in the LNCG.nnnCONCLUSIONnAdult functioning after childhood ADHD varies by domain and is generally worse when ADHD symptoms persist. It is important to identify factors and interventions that promote better functional outcomes.

Childhood Factors Affecting Persistence and Desistence of Attention-Deficit/Hyperactivity Disorder Symptoms in Adulthood: Results From the MTA

OBJECTIVEnTo determine childhood factors that predict attention-deficit/hyperactivity disorder (ADHD) persistence and desistence in adulthood.nnnMETHODnRegression analyses were used to determine associations between childhood factors and adult ADHD symptom persistence in 453 participants (mean age, 25 years) from the Multimodal Treatment Study of Children with ADHD (MTA). Childhood IQ, total number of comorbidities, child-perceived parenting practices, child-perceived parent-child relationships, parental mental health problems, marital problems of parents, household income levels, and parental education were assessed at a mean age of 8 years in all participants. Adult ADHD persistence was defined using DSM-5 symptom counts either with or without impairment, as well as mean ADHD symptom scores on the Conners Adult ADHD Rating Scale (CAARS). Age, sex, MTA site, and childhood ADHD symptoms were covaried.nnnRESULTSnThe most important childhood predictors of adult ADHD symptom persistence were initial ADHD symptom severity (odds ratio [OR]xa0= 1.89, standard error [SE]xa0= 0.28, pxa0= .025), comorbidities (ORxa0= 1.19, SExa0= 0.07, pxa0= .018), and parental mental health problems (ORxa0= 1.30, SExa0= 0.09, pxa0= .003). Childhood IQ, socioeconomic status, parental education, and parent-child relationships showed no associations with adult ADHD symptom persistence.nnnCONCLUSIONnInitial ADHD symptom severity, parental mental health, and childhood comorbidity affect persistence of ADHD symptoms into adulthood. Addressing these areas early may assist in reducing adult ADHD persistence and functioning problems.

Childhood Predictors of Adult Functional Outcomes in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (MTA).

OBJECTIVEnRecent results from the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (ADHD; MTA) have demonstrated impairments in several functioning domains in adults with childhood ADHD. The childhood predictors of these adult functional outcomes are not adequately understood. The objective of the present study was to determine the effects of childhood demographic, clinical, and family factors on adult functional outcomes in individuals with and without childhood ADHD from the MTA cohort.nnnMETHODnRegressions were used to determine associations of childhood factors (age range 7-10 years) of family income, IQ, comorbidity (internalizing, externalizing, and total number of non-ADHD diagnoses), parenting styles, parental education, number of household members, parental marital problems, parent-child relationships, and ADHD symptom severity with adult outcomes (mean age 25 years) of occupational functioning, educational attainment, emotional functioning, sexual behavior, and justice involvement in participants with (nxa0= 579) and without (nxa0= 258) ADHD.nnnRESULTSnPredictors of adult functional outcomes in ADHD included clinical factors such as baseline ADHD severity, IQ, and comorbidity; demographic factors such as family income, number of household members and parental education; and family factors such as parental monitoring and parental marital problems. Predictors of adult outcomes were generally comparable for children with and without ADHD.nnnCONCLUSIONnChildhood ADHD symptoms, IQ, and household income levels are important predictors of adult functional outcomes. Management of these areas early on, through timely treatments for ADHD symptoms, and providing additional support to children with lower IQ and from households with low incomes, could assist in improving adult functioning.