Children with attention deficit hyperactivity disorder (ADHD), the
most common of the psychiatric disorders that appear in childhood, are
often the subject of great concern on the part of parents and teachers.
Children with ADHD are unable to stay focused on a task, cannot sit
still, act without thinking, and rarely finish anything. If untreated,
the disorder can have long-term effects on a child's ability to make
friends or do well at school or in other activities. Over time, children
with ADHD may develop depression, lack of self-esteem, and other
Experts estimate that ADHD affects 3 to 5 percent of school-age
children and two to three times as many boys as girls. Children with
untreated ADHD have higher than normal rates of injury. ADHD frequently
co-occurs with other problems, such as depression and anxiety disorders,
conduct disorder, drug abuse, or antisocial behavior.
Although ADHD is relatively common, our knowledge of the problem is
incomplete. Current ADHD treatment includes a mix of approaches, such as
drug therapy, counseling, supportive services in schools and
communities, and various combinations of the three. The medical
literature offers many studies carried out over brief treatment periods
(3 months or less), but a pressing question remains: what is the best
kind of help we can offer children with ADHD over a longer term?
To answer this question, NIMH is sponsoring an ongoing, multisite,
cooperative agreement treatment study of children with ADHD entitled The
Multimodal Treatment Study of Children with Attention Deficit
Hyperactivity Disorder. The first findings from this study, which
were published in December 1999, provide important guidance for
physicians and parents of children with ADHD and are discussed below.
Ongoing follow-up reports will be published, with an additional 10-15
papers expected to be released in calendar year 2000.
Questions and Answers
Q. What is the Multimodal Treatment Study of Children with ADHD?
A. The Multimodal Treatment Study of Children with ADHD–"MTA"
for short–brought together 18 nationally recognized authorities in
ADHD at 6 different university medical centers and hospitals to evaluate
the leading treatments for ADHD, including various forms of behavior
therapy and medications. The study has included nearly 600 elementary
school children, ages 7-9, randomly assigned to one of four treatment
modes: (1) medication alone; (2) psychosocial/behavioral treatment
alone; (3) a combination of both; or (4) routine community care.
Q. Why is this study important?
A. ADHD is a major public health problem of great interest to many
parents, teachers, and health care providers. Up-to-date information
concerning the long-term safety and comparative effectiveness of its
treatments is urgently needed. While previous studies have examined the
safety and compared the effectiveness of the two major forms of
treatment, medication and behavior therapy, these studies generally have
been limited to periods up to 4 months. The MTA study demonstrates for
the first time the safety and relative effectiveness of these two
treatments (including a behavioral therapy-only group), alone and in
combination, for a time period up to 14 months, and compares these
treatments to routine community care. The children involved in the study
will be tracked into adolescence to document and evaluate long-term
Q. What are the major findings of this study so far?
A. The MTA results published in December 1999 indicate that long-term
combination treatments as well as medication-management alone are both
significantly superior to intensive behavioral treatments and routine
community treatments in reducing ADHD symptoms. The study also shows
that these differential benefits extend as long as 14 months. In other
areas of functioning (specifically anxiety symptoms, academic
performance, oppositionality, parent-child relations, and social
skills), the combined treatment approach was consistently superior to
routine community care, whereas the single treatments (medication-only
or behavioral treatment only) were not. In addition to the advantages
provided by the combined treatment for several outcomes, this form of
treatment allowed children to be successfully treated over the course of
the study with somewhat lower doses of medication, compared to the
medication-only group. These same findings were replicated across all
six research sites, despite substantial differences among sites in their
samples' sociodemographic characteristics. Therefore, the study's
overall results appear to be applicable and generalizable to a wide
range of children and families in need of treatment services for ADHD.
Q. Given the effectiveness of medication management, what is the
role and need for behavioral therapy?
A. As noted in the NIH ADHD Consensus Conference in November 1998,
several decades of research have amply demonstrated that behavioral
therapies are quite effective. What the MTA study has demonstrated is
that on average, carefully monitored medication management with monthly
follow-up is more effective than intensive behavioral treatment for ADHD
symptoms, for periods lasting as long as 14 months. All children tended
to improve over the course of the study, but they differed in the
relative amount of improvement, with the carefully done medication
management approaches generally showing the greatest improvement.
Nonetheless, children's responses varied enormously, and some children
clearly did very well in each of the treatment groups. For some outcomes
that are important in the daily functioning of these children (e.g.,
academic performance, familial relations), the combination of behavioral
therapy and medication was necessary to produce improvements better than
community care. Of note, families and teachers reported somewhat higher
levels of consumer satisfaction for those treatments that included the
behavioral therapy components. Therefore, medication alone is not
necessarily the best treatment for every child, and families often need
to pursue other treatments, either alone or in combination with
Q. Which treatment is right for my child?
A. This is a critical question that must be answered by each family
in consultation with their health care professional. For children with
ADHD, no single treatment is the answer for every child; a number of
factors appear to be involved in determining which treatments are best
for which children. For example, even if a particular treatment might be
effective in a given instance, the child may have unacceptable side
effects or other life circumstances that might prevent that particular
treatment from being used. Furthermore, findings indicate that children
with other accompanying problems, such as co-occurring anxiety or high
levels of family stressors, may do best with approaches that combine
both treatment components, (i.e., medication management and intensive
behavioral therapy). In developing suitable treatments for ADHD, each
child's needs, personal and medical history, research findings, and
other relevant factors need to be carefully considered.
Q. Why do many social skills improve with medication?
A. This question highlights one of the surprise findings of the
study: although it has long been generally assumed that the development
of new abilities in children with ADHD (e.g., social skills, enhanced
cooperation with parents) often requires the explicit teaching of such
skills, the MTA study findings suggest that many children can often
acquire these abilities when given the opportunity. Children treated
with effective medication management (either alone or in combination
with intensive behavioral therapy) manifested substantially greater
improvements in social skills and peer relations than children in the
community comparison group after 14 months. This important finding
indicates that symptoms of ADHD may interfere with their learning of
specific social skills. It appears that medication management may
benefit many children in areas not previously well known to be salient
medication targets, in part by diminishing symptoms that had previously
interfered with the child's social development.
Q. Why were the MTA medication treatments more effective than
community treatments that also usually included medication?
A. There were substantial differences between the study-provided
medication treatments and those provided in the community, differences
mostly related to the quality and intensity of the medication management
treatment. During the first month of treatment, special care was taken
to find an optimal dose of medication for each child receiving the MTA
medication treatment. After this period, these children were seen
monthly for one-half hour at each visit. During the treatment visits,
the MTA prescribing therapist spoke with the parent, met with the child,
and sought to determine any concerns that the family might have
regarding the medication or the child's ADHD-related difficulties. If
the child was experiencing any difficulties, the MTA physician was
encouraged to consider adjustments in the child's medication (rather
than taking a "wait and see" approach). The goal was always to
obtain such substantial benefit that there was "no room for
improvement" compared with the functioning of children not
suffering from ADHD. Close supervision also fostered early detection and
response to any problematic side effects from medication, a process that
may have facilitated efforts to help children remain on effective
treatment. In addition, the MTA physicians sought input from the teacher
on a monthly basis, and used this information to make any necessary
adjustments in the child's treatment. While the physicians in the MTA
medication-only group did not provide behavioral therapy, they did
advise the parents when necessary concerning any problems the child may
have been experiencing, and provided reading materials and additional
information as requested. Physicians delivering the MTA medication
treatments generally used 3 doses per day and somewhat higher doses of
stimulant medications. In comparison, the community-treatment physician
generally saw the children face-to-face only 1-2 times per year, and for
shorter periods of time each visit. Furthermore, they did not have any
interaction with the teachers, and prescribed lower doses and
twice-daily stimulant medication.
Q. How were children selected for this study?
A. In all instances, the child's parents contacted the investigators
to learn more about the study, after first hearing about it through
local pediatricians, other health care providers, elementary school
teachers, or radio/newspaper announcements. Children and parents were
then carefully interviewed to learn more about the nature of the child's
symptoms, and rule out the presence of other conditions or factors that
may have given rise to the child's difficulties. In addition, extensive
historical information was gathered and diagnostic interviews were
conducted to establish whether or not the child exhibited the
long-standing pattern of symptoms characteristic of ADHD across home,
school, and peer settings. If children met full criteria for ADHD and
study entry (and many did not), informed parental consent with child
assent and school permission were received; the children and families
then were eligible for study entry and randomization. Children who had
behavior problems but not ADHD were not eligible for study
Q. Where is this study taking place?
A. Research sites include:
- New York State Psychiatric Institute at Columbia University, New
- Mount Sinai Medical Center, New York, N.Y.
- Duke University Medical Center, Durham, N.C.
- University of Pittsburgh, Pittsburgh, PA.
- Long Island Jewish Medical Center, New Hyde Park, N.Y.
- Montreal Children's Hospital, Montreal, Canada
- University of California at Berkeley, CA.
- University of California at Irvine, CA.