A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder
Comprehensive Overview
Published in Archives of General Psychiatry in 1999, this study, known as the MTA study, asked how medication, intensive behavioral therapy, and the combination of the two actually compare over more than a year of treatment for children with attention-deficit/hyperactivity disorder, a question earlier research had only addressed over a few months at most. Researchers at six sites, sponsored by the National Institute of Mental Health, randomly assigned 579 children ages 7 to 9.9 years, all diagnosed with the combined subtype of ADHD, to 14 months of one of four treatment strategies: carefully monitored medication management with monthly dose adjustments, intensive behavioral treatment involving parents, school, and the child directly, the combination of both, or routine treatment through community providers. Outcomes were assessed across six domains, including core ADHD symptoms, oppositional and aggressive behavior, social skills, and academic achievement, using reports from parents, teachers, and trained observers both before treatment and at the 14-month endpoint. The topline result was that all four groups improved over time, but children receiving carefully managed medication, whether alone or combined with behavioral treatment, showed significantly greater improvement in core ADHD symptoms than those given intensive behavioral treatment alone or routine community care.
Outcomes and Implications
The most important finding was that for core ADHD symptoms, medication management and combined treatment produced significantly greater improvement than intensive behavioral treatment or community care, but medication management and combined treatment did not differ significantly from one another on any direct comparison of ADHD symptoms specifically. Beyond core symptoms, though, combined treatment showed a distinct edge: it significantly outperformed behavioral treatment and community care on several additional measures, including oppositional and aggressive behavior, internalizing symptoms such as anxiety, teacher-rated social skills, parent-child relations, and reading achievement, areas where medication management alone did not show the same advantage. Notably, the carefully monitored medication management used in this study proved superior even to routine community care, despite the fact that two-thirds of children receiving community care were also taking medication, suggesting that how medication is monitored and adjusted matters as much as whether it is prescribed at all. Combined treatment achieved its results using significantly lower average doses of medication than medication management alone, hinting that behavioral treatment might allow for reduced medication exposure without sacrificing core symptom control. The authors conclude that carefully crafted medication management was superior to behavioral treatment and to typical community care for managing ADHD symptoms, that combined treatment did not significantly outperform medication management on core symptoms, but that combining the two approaches may offer modest additional benefits for related functioning and behavior beyond ADHD symptoms themselves.