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evident
Original paper
1999Arch Gen PsychiatryPsychiatry

MTA

A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD

RCTADHD

On this page

Overview

In childhood ADHD, medication management beat behavioral treatment and community care for core symptoms; adding behavior therapy did not further improve those symptoms.

Clinical takeaway

For core ADHD symptoms over 14 months, carefully crafted medication management outperformed intensive behavioral treatment and routine community care. Combined treatment was not better than medication management for core ADHD symptoms; it was superior to behavioral treatment and/or community care on some non-ADHD and functioning outcomes, while medication management was not.

Key result

All four arms improved. Combined treatment and medication management improved ADHD symptoms more than intensive behavioral treatment and community care; those two medication-containing arms did not differ from each other on direct comparisons.

Practice impact

Use systematic medication management for core ADHD symptoms; do not expect combination therapy to beat medication alone for those symptoms.

Evidence

Study design

Fourteen-month randomized clinical trial assigning children to medication management, intensive behavioral treatment, the two combined, or standard community care, analyzed by intent-to-treat random-effects regression.

Enrollment

579

Follow-up

14 months, with outcomes assessed before and during treatment and at treatment end point.

Geography

Not listed

Clinical question

Over 14 months, how do medication management, intensive behavioral treatment, their combination, and standard community care compare for children with ADHD Combined Type?

Population

  • 579 children with ADHD Combined Type, aged 7 to 9.9 years.

Intervention

Fourteen months of medication management (titration followed by monthly visits), intensive behavioral treatment (parent, school, and child components, with therapist involvement gradually reduced), or the two combined. Combined treatment and medication management continued medication at all assessment points.

Comparator

Standard community care (treatments by community providers). Two thirds of community-treated subjects received medication during the study period.

Primary outcome

Outcomes in multiple domains at the 14-month treatment end point; the abstract does not designate a single primary end point. The conclusions feature ADHD symptoms.

For most ADHD symptoms, combined treatment and medication management showed significantly greater improvement than intensive behavioral treatment and community care. Combined treatment and medication management did not differ significantly on any direct comparisons.

Key results

  • All four groups showed sizable reductions in symptoms over time, with significant differences among them in degrees of change.
  • For most ADHD symptoms, combined treatment and medication management showed significantly greater improvement than intensive behavioral treatment and community care.
  • Combined treatment and medication management did not differ significantly on any direct comparisons.
  • In several instances (oppositional/aggressive symptoms, internalizing symptoms, teacher-rated social skills, parent-child relations, and reading achievement), combined treatment was superior to intensive behavioral treatment and/or community care while medication management was not. Study medication strategies were superior to community care despite two thirds of community-treated subjects receiving medication.

Harms

Not listed.

Clinical Use

Practice impact

  • Treat core ADHD symptoms with systematic medication management rather than relying on community care or behavioral treatment alone.
  • Reserve combined treatment when non-ADHD symptoms or functioning (oppositionality, internalizing symptoms, social skills, parent-child relations, reading) are also targets; it did not beat medication management for core ADHD symptoms.

Applicability

  • Most applicable to children aged 7 to 9.9 years with ADHD Combined Type treated over 14 months.

Limitations

  • The abstract reports no effect estimates, confidence intervals, or p-values for the pairwise comparisons.
  • Community care was an active usual-care arm, and two thirds of those children received medication, so this is not a comparison with no treatment.
  • The abstract does not name the study medication or report adverse effects.

Common misinterpretations

  • Do not say combined treatment is better than medication management for core ADHD symptoms; those arms did not differ on any direct comparisons.
  • Do not treat community care as an unmedicated control; two thirds of community-treated children received medication.

Citation

A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry. 1999;56(12):1073-1086. doi:10.1001/archpsyc.56.12.1073

For ADHD symptoms, our carefully crafted medication management was superior to behavioral treatment and to routine community care that included medication.