Search

ObjectiveIt is estimated that childhood attention deficit hyperactivity disorder (ADHD) remits by adulthood in approximately 50% of cases; however, this conclusion is typically based on single endpoints, failing to consider longitudinal patterns of ADHD expression. The authors investigated the extent to which children with ADHD experience recovery and variable patterns of remission by adulthood.MethodsChildren with ADHD (N=558) in the Multimodal Treatment Study of ADHD (MTA) underwent eight assessments over follow-ups ranging from 2 years (mean age, 10.44 years) to 16 years (mean age, 25.12 years) after baseline. The authors identified participants with fully remitted, partially remitted, and persistent ADHD at each time point on the basis of parent, teacher, and self-reports of ADHD symptoms and impairment, treatment utilization, and substance use and mental disorders. Longitudinal patterns of remission and persistence were identified that considered context and timing.ResultsApproximately 30% of children with ADHD experienced full remission at some point during the follow-up period; however, a majority of them (60%) experienced recurrence of ADHD after the initial period of remission. Only 9.1% of the sample demonstrated recovery (sustained remission) by study endpoint, and only 10.8% demonstrated stable ADHD persistence across study time points. Most participants with ADHD (63.8%) had fluctuating periods of remission and recurrence over time.ConclusionsThe MTA findings challenge the notion that approximately 50% of children with ADHD outgrow the disorder by adulthood. Most cases demonstrated fluctuating symptoms between childhood and young adulthood. Although intermittent periods of remission can be expected in most cases, 90% of children with ADHD in MTA continued to experience residual symptoms into young adulthood.

Objective: Recent studies suggest attention-deficit/hyperactivity disorder (ADHD) may emerge post-childhood. We integrate qualitative methods to systematically characterize contextual factors that may (a) delay identification of ADHD in childhood and (b) inform why ADHD symptoms emerge post-childhood. Method: Suspected late-onset ADHD cases from the local normative comparison group of the Multimodal Treatment Study of ADHD completed a qualitative interview (14 young adults and 7 caregivers). Interviews were qualitatively analyzed. Results: We identified five themes. Three themes may attenuate or delay identification of childhood ADHD: external factors (e.g., supportive adults), internal factors (e.g., strong intellectual functioning), and other factors (e.g., dismissive attitudes toward ADHD). Two themes may accompany an increase in ADHD symptoms post-childhood: external factors (e.g., increased external demands) and internal factors (e.g., perceived stress). Conclusion: Clinicians should probe these factors in suspected late-onset cases to address (a) whether, how, and to what extent ADHD was attenuated in childhood and (b) why symptoms emerge post-childhood.

We examined developmental trajectories of attention-deficit/hyperactivity disorder (ADHD) symptoms, standardized achievement, and school performance for adolescents with and without ADHD who did and did not enroll in postsecondary education (PSE; N = 749; 79% boys; 63% White, 17% non-Hispanic Black, 10% Hispanic, and 10% other ethnicities). In a multisite study (recruitment based in New York, North Carolina, Pennsylvania, California, and Quebec), participants were originally enrolled between 1994 and 1998 at ages 7 to 9.9 and followed up through 2012 (M[subscript age] = 25 at final follow-up). Adolescents who eventually enrolled in PSE had less severe symptoms, but differences were modest and trajectories were similar over time. For all adolescents, standardized achievement trajectories declined up to two thirds of a standard deviation from ages 9 to 17. By the end of high school, the average GPA of adolescents with ADHD was three quarters of a point higher for those who eventually enrolled in PSE compared to those who did not. Overall, school performance mattered more than academic achievement for understanding eventual enrollment of adolescents with ADHD.

ObjectiveTo estimate long-term stimulant treatment associations on standardized height, weight, and body mass index trajectories from childhood to adulthood in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (MTA).MethodOf 579 children with DSM-IV ADHD-combined type at baseline (aged 7.0-9.9 years) and 289 classmates (local normative comparison group [LNCG]), 568 and 258 respectively, were assessed 8 times over 16 years (final mean age = 24.7). Parent interview data established subgroups with self-selected Consistent (n = 53, 9%), Inconsistent (n = 374, 66%), and Negligible (n = 141, 25%) stimulant medication use, as well as patients starting stimulants prior to MTA entry (n = 211, 39%). Height and weight growth trajectories were calculated for each subgroup.ResultsHeight z scores trajectories differed among subgroups (F = 2.22, p < .0001) and by stimulant use prior to study entry (F = 2.22, p < .001). The subgroup-by-assessment interaction was significant (F = 2.81, p < .0001). Paired comparisons revealed significant subgroup differences at endpoint: Consistent was shorter than Negligible (-0.66 z units /-4.06 cm /1.6 inches, t = -3.17, p < 0.0016), Consistent shorter than Inconsistent (-0.45 z units /-2.74 cm /-1.08 inches, t = -2.39, p < .0172), and the Consistent shorter than LNCG (-0.54 z units/+3.34 cm/ 1.31 inches, t = -3.30, p < 0.001). Weight z scores initially diverged among subgroups, converged in adolescence, and then diverged again in adulthood when the Consistent outweighed the LNCG (+ 3.561 z units /+7.47 kg /+16.46 lb, p < .0001).ConclusionCompared with those negligibly medicated and the LNCG, 16 years of consistent stimulant treatment of children with ADHD in the MTA was associated with changes in height trajectory, a reduction in adult height, and an increase in weight and body mass index.Clinical trial registration informationMultimodal Treatment Study of Children With Attention Deficit and Hyperactivity Disorder (MTA); https://clinicaltrials.gov/; NCT00000388.

ObjectiveMothers raising a child with ADHD can experience high parenting stress. We evaluated if mothers' personality traits and own ADHD symptoms could also affect parenting stress.Method430 biological mothers from the Multimodal Treatment Study of Children with ADHD (MTA mothers) and 237 of a local normative comparison group (LNCG mothers) were evaluated at baseline. Interactions were tested between mothers' group and maternal personality/ADHD symptoms related to parenting stress.ResultsCompared to LNCG, MTA mothers had higher parenting stress, self-reported ADHD, neuroticism, and lower conscientiousness and agreeableness. When personality and ADHD were evaluated together, ADHD symptoms interacted with mothers' group: high maternal ADHD was positively associated with parenting stress for LNCG but not MTA mothers.ConclusionPersonality traits or ADHD characteristics do not appear operative for the high parenting stress of mothers of a child with ADHD. However, high maternal ADHD or low conscientiousness are associated with stress levels similar to raising a child with ADHD.

ObjectiveAlthough substance use (SU) is elevated in ADHD and both are associated with disrupted emotional functioning, little is known about how emotions and SU interact in ADHD. We used a mixed qualitative-quantitative approach to explore this relationship.MethodNarrative comments were coded for 67 persistent (50 ADHD, 17 local normative comparison group [LNCG]) and 25 desistent (20 ADHD, 5 LNCG) substance users from the Multimodal Treatment Study of Children with ADHD (MTA) adult follow-up (21.7-26.7 years-old).ResultsSU persisters perceived SU positively affects emotional states and positive emotional effects outweigh negative effects. No ADHD group effects emerged. Qualitative analysis identified perceptions that cannabis enhanced positive mood for ADHD and LNCG SU persisters, and improved negative mood and ADHD for ADHD SU persisters.ConclusionPerceptions about SU broadly and mood do not differentiate ADHD and non-ADHD SU persisters. However, perceptions that cannabis is therapeutic may inform ADHD-related risk for cannabis use.

ObjectiveTo evaluate participants' perceptions about frequent use and reasons for substance use (SU) in the qualitative interview study, an add-on to the multimodal treatment study of ADHD (MTA).MethodUsing the longitudinal MTA database, 39 ADHD cases and 19 peers with Persistent SU, and 86 ADHD cases and 39 peers without Persistent SU were identified and recruited. In adulthood, an open-ended interview was administered, and SU excerpts were indexed and classified to create subtopics (frequent use and reasons for use of alcohol, marijuana, and other drugs).ResultsFor marijuana, the Persistent compared with Nonpersistent SU group had a significantly higher percentage of participants describing frequent use and giving reasons for use, and the ADHD group compared with the group of peers had a significantly higher percentage giving "stability" as a reason for use.ConclusionMotivations for persistent marijuana use may differ for adults with and without a history of ADHD.

ObjectiveQualitative interviews with 183 young adults (YA) in the follow-up of the Multimodal Treatment Study of Children With and Without ADHD (MTA) provide rich information on beliefs and expectations regarding ADHD, life's turning points, medication use, and substance use (SU).MethodParticipants from four MTA sites were sampled to include those with persistent and atypically high SU, and a local normative comparison group (LNCG). Respondents were encouraged to "tell their story" about their lives, using a semistructured conversational interview format.ResultsInterviews were reliably coded for interview topics. ADHD youth more often desisted from SU because of seeing others going down wrong paths due to SU. Narratives revealed very diverse accounts and explanations for SU-ADHD influences.ConclusionQualitative methods captured the perspectives of YAs regarding using substances. This information is essential for improving resilience models in drug prevention and treatment programs and for treatment development for this at-risk population.

ObjectiveThis study examines the behavior beliefs, social supports, and turning points in individuals with/without ADHD related to their substance use/abuse (SU/A) decisions.MethodThe coded interviews from 60 participants with/without ADHD were compared for their SU/A decisions and precipitants with these decisions among abstainers, persisters, and desisters.ResultsADHD participants reported fewer social advantages to avoid SU/A than non-ADHD participants. Desisters and persisters reported more social advantages of using drugs than abstainers. Persisters reported both more negative and positive psychological/physiological effects of SU/A. ADHD participants reported fewer positive role models in their lives. Non-ADHD patients reported more positive turning points than ADHD participants, regardless of SU/A status.ConclusionADHD individuals face challenges in making healthy decisions about SU/A due to lack of positive role models. Reinforcing accurate behavioral beliefs may be important to change behaviors in individuals with SU/A or to prevent SU/A initiation in ADHD individuals.

Despite enormous social-psychological and economic consequences of substance abuse in youth and young adults, too little is known about effective interventions among substance users, both with and without ADHD. This special issue reports on four linked investigations that employed a novel research strategy when the Multimodal Treatment Children with ADHD Study (MTA) participants were between ages 21.7 and 27.3 years old (14-16 years after initial assessments). Using combination of in-depth qualitative narrative interviews and quantitative analyses ("mixed methods") of 183 participants from four to six original MTA sites, investigators sought to obtain a more complete understanding of factors contributing to youths' substance use (SU) initiation, maintenance, and desistence, (both among youth with ADHD and control participants). The articles in this special issue illuminate important new insights about possible influences contributing to SU, particularly persistent use/abuse. Findings also illustrate the benefits of mixed-methods studies, not only to better understand the linkages between ADHD and SU, but also to understand other areas of child/adult psychopathology.

ObjectiveRecent 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.MethodRegressions 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 (n = 579) and without (n = 258) ADHD.ResultsPredictors 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.ConclusionChildhood 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.

BackgroundThe Multimodal Treatment Study (MTA) began as a 14-month randomized clinical trial of behavioral and pharmacological treatments of 579 children (7-10 years of age) diagnosed with attention-deficit/hyperactivity disorder (ADHD)-combined type. It transitioned into an observational long-term follow-up of 515 cases consented for continuation and 289 classmates (258 without ADHD) added as a local normative comparison group (LNCG), with assessments 2-16 years after baseline.MethodsPrimary (symptom severity) and secondary (adult height) outcomes in adulthood were specified. Treatment was monitored to age 18, and naturalistic subgroups were formed based on three patterns of long-term use of stimulant medication (Consistent, Inconsistent, and Negligible). For the follow-up, hypothesis-generating analyses were performed on outcomes in early adulthood (at 25 years of age). Planned comparisons were used to estimate ADHD-LNCG differences reflecting persistence of symptoms and naturalistic subgroup differences reflecting benefit (symptom reduction) and cost (height suppression) associated with extended use of medication.ResultsFor ratings of symptom severity, the ADHD-LNCG comparison was statistically significant for the parent/self-report average (0.51 ± 0.04, p

ObjectiveLongitudinal studies of children diagnosed with ADHD report widely ranging ADHD persistence rates in adulthood (5-75%). This study documents how information source (parent vs. self-report), method (rating scale vs. interview), and symptom threshold (DSM vs. norm-based) influence reported ADHD persistence rates in adulthood.MethodFive hundred seventy-nine children were diagnosed with DSM-IV ADHD-Combined Type at baseline (ages 7.0-9.9 years) 289 classmates served as a local normative comparison group (LNCG), 476 and 241 of whom respectively were evaluated in adulthood (Mean Age = 24.7). Parent and self-reports of symptoms and impairment on rating scales and structured interviews were used to investigate ADHD persistence in adulthood.ResultsPersistence rates were higher when using parent rather than self-reports, structured interviews rather than rating scales (for self-report but not parent report), and a norm-based (NB) threshold of 4 symptoms rather than DSM criteria. Receiver-Operating Characteristics (ROC) analyses revealed that sensitivity and specificity were optimized by combining parent and self-reports on a rating scale and applying a NB threshold.ConclusionThe interview format optimizes young adult self-reporting when parent reports are not available. However, the combination of parent and self-reports from rating scales, using an 'or' rule and a NB threshold optimized the balance between sensitivity and specificity. With this definition, 60% of the ADHD group demonstrated symptom persistence and 41% met both symptom and impairment criteria in adulthood.

ObjectiveTo 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).MethodData 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.ResultsThree 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.ConclusionAdult 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.

ObjectiveTo determine childhood factors that predict attention-deficit/hyperactivity disorder (ADHD) persistence and desistence in adulthood.MethodRegression 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.ResultsThe most important childhood predictors of adult ADHD symptom persistence were initial ADHD symptom severity (odds ratio [OR] = 1.89, standard error [SE] = 0.28, p = .025), comorbidities (OR = 1.19, SE = 0.07, p = .018), and parental mental health problems (OR = 1.30, SE = 0.09, p = .003). Childhood IQ, socioeconomic status, parental education, and parent-child relationships showed no associations with adult ADHD symptom persistence.ConclusionInitial 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.

Does changing context play a role in the decline in ADHD symptoms in adulthood? Insufficient research has explored the functioning of adults with ADHD. As adults, individuals with ADHD have significantly more latitude to control aspects of their day-to-day environments. Do the new contexts young adults find themselves in alter their experience of ADHD? Are there particular occupational or educational contexts in which young adults report functioning better than others? To examine this issue, we conducted semi-structured interviews at four North American sites in 2010-11 with 125 young adults, originally diagnosed with ADHD as children, regarding their work and post-secondary educational environments. Many subjects describe their symptoms as context-dependent. In some contexts, participants report feeling better able to focus; in others, their symptoms-such as high energy levels-become strengths rather than liabilities. Modal descriptions included tasks that were stressful and challenging, novel and required multitasking, busy and fast-paced, physically demanding or hands-on, and/or intrinsically interesting. Consistent with a developmental psychopathology framework, ADHD is experienced as arising from an interaction between our subjects and their environments. These findings demonstrate the need to account for the role of context in our understanding of ADHD as a psychiatric disorder, especially as it manifests in young adulthood.

We here describe a multimodality neuroimaging containing data from healthy volunteers and patients, acquired within the Lundbeck Foundation Center for Integrated Molecular Brain Imaging (Cimbi) in Copenhagen, Denmark. The data is of particular relevance for neurobiological research questions related to the serotonergic transmitter system with its normative data on the serotonergic subtype receptors 5-HT1A, 5-HT1B, 5-HT2A, and 5-HT4 and the 5-HT transporter (5-HTT), but can easily serve other purposes. The Cimbi database and Cimbi biobank were formally established in 2008 with the purpose to store the wealth of Cimbi-acquired data in a highly structured and standardized manner in accordance with the regulations issued by the Danish Data Protection Agency as well as to provide a quality-controlled resource for future hypothesis-generating and hypothesis-driven studies. The Cimbi database currently comprises a total of 1100 PET and 1000 structural and functional MRI scans and it holds a multitude of additional data, such as genetic and biochemical data, and scores from 17 self-reported questionnaires and from 11 neuropsychological paper/computer tests. The database associated Cimbi biobank currently contains blood and in some instances saliva samples from about 500 healthy volunteers and 300 patients with e.g., major depression, dementia, substance abuse, obesity, and impulsive aggression. Data continue to be added to the Cimbi database and biobank.

AimTo determine the prevalence of bipolar disorder (BD) and sub-threshold symptoms in children with attention deficit hyperactivity disorder (ADHD) through 14 years' follow-up, when participants were between 21-24 years old.MethodsFirst, we examined rates of BD type I and II diagnoses in youth participating in the NIMH-funded Multimodal Treatment Study of ADHD (MTA). We used the diagnostic interview schedule for children (DISC), administered to both parents (DISC-P) and youth (DISCY). We compared the MTA study subjects with ADHD (n = 579) to a local normative comparison group (LNCG, n = 289) at 4 different assessment points: 6, 8, 12, and 14 years of follow-ups. To evaluate the bipolar variants, we compared total symptom counts (TSC) of DSM manic and hypomanic symptoms that were generated by DISC in ADHD and LNCG subjects. Then we sub-divided the TSC into pathognomonic manic (PM) and non-specific manic (NSM) symptoms. We compared the PM and NSM in ADHD and LNCG at each assessment point and over time. We also evaluated the irritability as category A2 manic symptom in both groups and over time. Finally, we studied the irritability symptom in correlation with PM and NSM in ADHD and LNCG subjects.ResultsDISC-generated BD diagnosis did not differ significantly in rates between ADHD (1.89%) and LNCG 1.38%). Interestingly, no participant met BD diagnosis more than once in the 4 assessment points in 14 years. However, on the symptom level, ADHD subjects reported significantly higher mean TSC scores: ADHD 3.0; LNCG 1.7; P < 0.001. ADHD status was associated with higher mean NSM: ADHD 2.0 vs LNCG 1.1; P < 0.0001. Also, ADHD subjects had higher PM symptoms than LNCG, with PM means over all time points of 1.3 ADHD; 0.9 LNCG; P = 0.0001. Examining both NSM and PM, ADHD status associated with greater NSM than PM. However, Over 14 years, the NSM symptoms declined and changed to PM over time (df 3, 2523; F = 20.1; P < 0.0001). Finally, Irritability (BD DSM criterion-A2) rates were significantly higher in ADHD than LNCG (χ(2) = 122.2, P < 0.0001), but irritability was associated more strongly with NSM than PM (df 3, 2538; F = 43.2; P < 0.0001).ConclusionIndividuals with ADHD do not appear to be at significantly greater risk for developing BD, but do show higher rates of BD symptoms, especially NSM. The greater linkage of irritability to NSM than to PM suggests caution when making BD diagnoses based on irritability alone as one of 2 (A-level) symptoms for BD diagnosis, particularly in view of its frequent presentation with other psychopathologies.

This study examines the prevalence and characteristics of services reported by school staff for 543 high school students participating in the 8 year follow-up of the multi-site Multimodal Treatment study of ADHD (MTA). Overall, 51.6% of students with a history of attention-deficit/hyperactivity disorder (ADHD) were receiving services through an Individualized Educational Plan (IEP) or a 504 plan, a rate higher than expected for this age group. Less than 5% of these had 504 plans; 35.5% attended special education classes. Very few services (except tutoring) were provided outside of an IEP or 504 plan. Almost all students with services received some type of academic intervention, whereas only half received any behavioral support or learning strategy. Less than one-fourth of interventions appear to be evidence-based. Students receiving services showed greater academic and behavioral needs than those not receiving services. Services varied based upon type of school, with the greatest number of interventions provided to students attending schools that only serve those with disabilities. Original MTA treatment randomization was unrelated to services, but cumulative stimulant medication and greater severity predicted more service receipt. Results highlight a need for accommodations with greater evidence of efficacy and for increased services for students who develop academic difficulties in high school.

ObjectivesTo determine long-term effects on substance use and substance use disorder (SUD), up to 8 years after childhood enrollment, of the randomly assigned 14-month treatments in the multisite Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA; n=436); to test whether (a) medication at follow-up, (b) cumulative psychostimulant treatment over time, or (c) both relate to substance use/SUD; to compare substance use/SUD in the ADHD sample to the non-ADHD childhood classmate comparison group (n=261).MethodMixed-effects regression models with planned contrasts were used for all tests except the important cumulative stimulant treatment question, for which propensity score matching analysis was used.ResultsThe originally randomized treatment groups did not differ significantly on substance use/SUD by the 8 year follow-up or earlier (M age = 17 years). Neither medication at follow-up (mostly stimulants) nor cumulative stimulant treatment was associated with adolescent substance use/SUD. Substance use at all time points, including use of two or more substances and SUD, were each greater in the ADHD than non-ADHD samples, regardless of sex.ConclusionsMedication for ADHD did not protect from, nor contribute to, visible risk of substance use or SUD by adolescence, whether analyzed as randomized treatment assignment in childhood, as medication at follow-up, or as cumulative stimulant treatment over an 8 year follow-up from childhood. These results suggest the need to identify alternative or adjunctive adolescent-focused approaches to substance abuse prevention and treatment for boys and girls with ADHD, especially given their increased risk for use and abuse of multiple substances that is not improved with stimulant medication. Clinical trial registration information—Multimodal Treatment Study of Children with Attention Deficit and Hyperactivity Disorder (MTA); http://clinical trials.gov/; NCT00000388.

UnlabelledABSTBACKGROUND: Evidence-based practices have not been routinely adopted in community mental health organizations despite the support of scientific evidence and in some cases even legislative or regulatory action. We examined the association of clinician attitudes toward evidence-based practice with organizational culture, climate, and other characteristics in a nationally representative sample of mental health organizations in the United States.MethodsIn-person, group-administered surveys were conducted with a sample of 1,112 mental health service providers in a nationwide sample of 100 mental health service institutions in 26 states in the United States. The study examines these associations with a two-level Hierarchical Linear Modeling (HLM) analysis of responses to the Evidence-Based Practice Attitude Scale (EBPAS) at the individual clinician level as a function of the Organizational Social Context (OSC) measure at the organizational level, controlling for other organization and clinician characteristics.ResultsWe found that more proficient organizational cultures and more engaged and less stressful organizational climates were associated with positive clinician attitudes toward adopting evidence-based practice.ConclusionsThe findings suggest that organizational intervention strategies for improving the organizational social context of mental health services may contribute to the success of evidence-based practice dissemination and implementation efforts by influencing clinician attitudes.

Family-to-family services are emerging as an important adjunctive service to traditional mental health care and a vehicle for improving parent engagement and service use in children's mental health services. In New York State, a growing workforce of Family Peer Advocates (FPA) is delivering family-to-family services. We describe the development and evaluation of a professional program to enhance Family Peer Advocate professional skills, called the Parent Engagement and Empowerment Program (PEP). We detail the history and content of PEP and provide data from a pre/post and 6-month follow up evaluation of 58 FPA who participated in the first Statewide regional training effort. Self-efficacy, empowerment, and skills development were assessed at 3 time points: baseline, post-training, and 6-month follow-up. The largest changes were in self-efficacy and empowerment. Regional differences suggest differences in Family Peer Advocate workforce across areas of the state. This evaluation also provides the first systematic documentation of Family Peer Advocate activities over a six-month period. Consistent with peer specialists within the adult health care field, FPA in the children's mental health field primarily focused on providing emotional support and service access issues. Implications for expanding family-to-family services and integrating it more broadly into provider organizations are described.

Saliva methylphenidate samples from participants in the Multimodal Treatment Study of Children with Attention Deficit and Hyperactivity Disorder reveal that nearly half of them had some degree of nonadherence to treatment. This suggests that nearly half of the parent reports of medication use are inaccurate.

The studies included in this special issue add significantly to the nascent literature on teacher consultation models for attention deficit hyperactivity disorder (ADHD) and provide wonderful illustrations of how teachers might "unpack" and better understand their interventions. In this introductory essay, the authors offer suggestions for future research that might build on these findings. First, future studies should focus on relationship and working alliance factors between consultant and teacher. Second, this line of research should be careful to address the possible impact, cumulative effects, and interactions of consultation with other interventions (i.e., medications, therapy, one-on-one instructional aides on the classroom) that the children and families may be receiving. Third, they suggest that participants such as consultants, teachers, and families should be involved to help individuals understand their perspectives on the research process and the experiences that they have had. Lastly, and perhaps most important from the perspective of developing and testing consultation models, they suggest that their field might benefit from a theoretical framework to guide their research agenda and help them understand and identify specific "mechanisms of change" in their teacher consultation models.

The study examines the general public's perceptions of, and response to, mental disorders in children by using the National Stigma Study-Children. Results concluded that lack of knowledge, skepticism, and misinformed beliefs are the reasons for low utilization rates for children's mental health problems.

Objective: In the intent-to-treat analysis of the Multimodal Treatment Study of Children With ADHD (MTA), the effects of medication management (MedMgt), behavior therapy (Beh), their combination (Comb), and usual community care (CC) differed at 14 and 24 months due to superiority of treatments that used the MTA medication algorithm (Comb+MedMgt) over those that did not (Beh+CC). This report examines 36-month outcomes, 2 years after treatment by the study ended. Method: For primary outcome measures (attention-deficit/hyperactivity disorder [ADHD] and oppositional defiant disorder [ODD] symptoms, social skills, reading scores, impairment, and diagnostic status), mixed-effects regression models and orthogonal contrasts examined 36-month outcomes. Results: At 3 years, 485 of the original 579 subjects (83.8%) participated in the follow-up, now at ages 10 to 13 years, (mean 11.9 years). In contrast to the significant advantage of MedMgt+Comb over Beh+CC for ADHD symptoms at 14 and 24 months, treatment groups did not differ significantly on any measure at 36 months. The percentage of children taking medication greater than 50% of the time changed between 14 and 36 months across the initial treatment groups: Beh significantly increased (14% to 45%), MedMed+Comb significantly decreased (91% to 71%), and CC remained constant (60%-62%). Regardless of their treatment use changes, all of the groups showed symptom improvement over baseline. Notably, initial symptom severity, sex (male), comorbidity, public assistance, and parental psychopathology (ADHD) did not moderate children's 36-month treatment responses, but these factors predicted worse outcomes over 36 months, regardless of original treatment assignment. Conclusions: By 36 months, the earlier advantage of having had 14 months of the medication algorithm was no longer apparent, possibly due to age-related decline in ADHD symptoms, changes in medication management intensity, starting or stopping medications altogether, or other factors not yet evaluated. (Contains 2 tables and 4 figures.)

Objective: To determine whether impulsive aggression (IA) is a meaningful clinical construct and to ascertain whether it is sufficiently similar across diagnostic categories, such that parallel studies across disorders might constitute appropriate evidence for pursuing indications. If so, how should IA be assessed, pharmacological studies designed, and ethical issues addressed? Method: Experts from key stakeholder communities, including academic clinicians, researchers, practicing clinicians, U.S. Food and Drug Administration, National Institute of Mental Health, industry sponsors, and patient and family advocates, met for a 2-day consensus conference on November 4 and 5, 2004. After evaluating summary presentations on current research evidence, participants were assigned to three workgroups, examined core issues, and generated consensus guidelines in their areas. Workgroup recommendations were discussed by the whole group to reach consensus, and then further iterated and condensed into this report post-conference by the authors. Results: Conference participants agreed that IA is a substantial public health and clinical concern, constitutes a key therapeutic target across multiple disorders, and can be measured with sufficient precision that pharmacological studies are warranted. Additional areas of consensus concerned types of measures, optimal study designs, and ethical imperatives. Conclusion: Derived from scientific evidence and clinical experience, these consensus-driven recommendations can guide the design of future studies. (Contains 2 tables and 2 figures.)

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.

Objective: In 1998, the Texas Department of Mental Health and Mental Retardation developed algorithms for medication treatment of attention-deficit/hyperactivity disorder (ADHD). Advances in the psychopharmacology of ADHD and results of a feasibility study of algorithm use in community mental health centers caused the algorithm to be modified and updated. Method: We convened a consensus conference of academic clinicians and researchers, practicing clinicians, administrators, consumers, and families to revise the algorithms for the pharmacotherapy of ADHD itself as well as ADHD with specific comorbid disorders. New research was reviewed by national experts, and rationales were provided for proposed changes and additions to the algorithms. The changes to the algorithms were discussed and approved both by the national experts and experienced clinicians from the Texas public mental health system. Results: The panel developed consensually agreed-upon algorithms for ADHD with and without comorbid disorders. The major changes included elimination of pemoline as a treatment option, adding atomoxetine to the algorithm, and refining guidelines for treating ADHD with comorbid depression, aggressive behaviors, and tic disorders. Conclusions: Medication algorithms for ADHD can be modified to keep abreast of developments in the field. Although these evidence- and consensus-based treatment recommendations may be a useful approach to guide the treatment of ADHD in children, additional research is needed to determine how these algorithms can be used to maximally benefit child outcomes. (Contains 5 figures and 1 table.)

Background: While studies have increasingly investigated deficits in reaction time (RT) and RT variability in children with attention deficit/hyperactivity disorder (ADHD), few studies have examined the effects of stimulant medication on these important neuropsychological outcome measures. Methods: 316 children who participated in the Multimodal Treatment Study of Children with ADHD (MTA) completed the Conners' Continuous Performance Test (CPT) at the 24-month assessment point. Outcome measures included standard CPT outcomes (e.g., errors of commission, mean hit reaction time (RT)) and RT indicators derived from an Ex-Gaussian distributional model (i.e., mu, sigma, and tau). Results: Analyses revealed significant effects of medication across all neuropsychological outcome measures. Results on the Ex-Gaussian outcome measures revealed that stimulant medication slows RT and reduces RT variability. Conclusions: This demonstrates the importance of including analytic strategies that can accurately model the actual distributional pattern, including the positive skew. Further, the results of the study relate to several theoretical models of ADHD.