SPECIAL SECTION: ADHD COMORBIDITY AND TREATMENT OUTCOMES IN THE MTA
Clinical Relevance of the Primary Findings of the MTA: Success Rates Based on Severity of ADHD and ODD Symptoms at the End of Treatment

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ABSTRACT

Objectives

To develop a categorical outcome measure related to clinical decisions and to perform secondary analyses to supplement the primary analyses of the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA).

Method

End-of-treatment status was summarized by averaging the parent and teacher ratings of attention-deficit/hyperactivity disorder and oppositional defiant disorder symptoms on the Swanson, Nolan, and Pelham, version IV (SNAP-IV) scale, and low symptom-severity (“Just a Little”) on this continuous measure was set as a clinical cutoff to form a categorical outcome measure reflecting successful treatment. Three orthogonal comparisons of the treatment groups (combined treatment [Comb], medication management [MedMgt], behavioral treatment [Beh], and community comparison [CC]) evaluated hypotheses about the MTA medication algorithm (“Comb + MedMgt versus Beh + CC”), multimodality superiority (“Comb versus MedMgt”), and psychosocial substitution (“Beh versus CC”).

Results

The summary of SNAP-IV ratings across sources and domains increased the precision of measurement by 30%. The secondary analyses of group differences in success rates (Comb = 68%; MedMgt = 56%; Beh = 34%; CC = 25%) confirmed the large effect of the MTA medication algorithm and a smaller effect of multimodality superiority, which was now statistically significant (p < .05). The psychosocial substitution effect remained negligible and nonsignificant.

Conclusion

These secondary analyses confirm the primary findings and clarify clinical decisions about the choice between multimodal and unimodal treatment with medication.

Section snippets

Subjects and Procedures

Methods described elsewhere (Hinshaw et al., 1997) were used to recruit 579 children with ADHD-combined type from geographic locations spread across North America (New York City [Columbia University]; Irvine, CA [UC Irvine]; Pittsburgh [Western Psychiatric Institute and Clinic]; Berkeley, CA [UC Berkeley]; Durham, NC [Duke University]; Queens, NY [Long Island Jewish Medical Center]/ Montreal, Quebec [Montreal Children's Hospital]). Each of these subjects was randomly assigned to one of the four

Continuous Outcome Measures

Descriptive statistics were calculated based on end-of-treatment scores. We used the last observation carried forward (LOCF) technique to replace missing observations at the 14-month assessment. We present information in Table 1 for the three domains from parent SNAP-IV ratings (InattP, H/ImpP, and O/DP) and the three domains from teacher SNAP-IV ratings (InattT, H/ImpT, and O/DT). Similar descriptive statistics were presented in the primary analyses (MTA Cooperative Group, 1999a, Tables 4 and

Three Clarifications of the Primary Findings

The secondary analyses presented here confirm and extend the results of the primary analyses (MTA Cooperative Group, 1999a, MTA Cooperative Group, 1999b). First, these secondary analyses confirm the large ES (Cohen d = 0.59; LOR = 2.79) associated with exposure to the MTA Medication Algorithm (“Comb + MedMgt versus Beh + CC”). The logistic regression analysis revealed that the ES were consistently large at all sites in this study. The clinical impact on “success rate” was substantial: under

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    The NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA) is a cooperative treatment study performed by six independent research teams in collaboration with the staff of the Division of Services and Intervention Research of the NIMH, Rockville, MD, and the Office of Special Education Programs (OSEP) of the U.S. Department of Education (DOE). The NIMH Principal Collaborators are Peter S. Jensen, M.D., L. Eugene Arnold, M.Ed., M.D., John E. Richters, Ph.D., Joanne B. Severe, M.S., Donald Vereen, M.D., and Benedetto Vitiello, M.D. Principal Investigators and Coinvestigators from the six sites are as follows: University of California at Berkeley/San Francisco (UO1 MH50461): Stephen P. Hinshaw, Ph.D., Glen R. Elliott, M.D., Ph.D.; Duke University (UO1 MH50447): C. Keith Conners, Ph.D., Karen C. Wells, Ph.D., John S. March, M.D., M.P.H.; University of California at Irvine/Los Angeles (UO1 MH50440): James M. Swanson, Ph.D., Dennis P. Cantwell, M.D., Timothy Wigal, Ph.D.; Long Island Jewish Medical Center/Montreal Children's Hospital (UO1 MH50453): Howard B. Abikoff, Ph.D., Lily Hechtman, M.D.; New York State Psychiatric Institute/Columbia University/Mount Sinai Medical Center (UO1 MH50454): Laurence L. Greenhill, M.D., Jeffrey H. Newcorn, M.D.; University of Pittsburgh (UO1 MH50467): William E. Pelham, Ph.D., Betsy Hoza, Ph.D. Helena C. Kraemer, Ph.D. (Stanford University) is statistical and design consultant. The OSEP/DOE Principal Collaborator is Ellen Schiller, Ph.D.

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