Continuum beliefs and the perception of similarities and differences to a person with depression

OBJECTIVE

Both continuum beliefs (i.e., that mental disorder exists on a spectrum of normative behavior patterns) and the perception of similarities to a person with schizophrenia have shown mixed effects on reducing mental illness stigma. To our knowledge, this is the first study to address continuum beliefs and the perception of similarities to a person with depression in the context of depression-related stigma.

METHODS

This work is based on an online intervention study in an ethnically diverse sample recruited on Amazon MTurk including previously unanalyzed qualitive responses. Within this cross-sectional, mixed-methods online investigation (N = 304), we examined the relation of perceived similarities to continuum beliefs, social distance, and negative stereotypes in relation to a vignette about depression. A randomly assigned continuum beliefs intervention attempted to induce continuum beliefs about depression. An open-writing task asked participants to describe similarities and/or differences between themselves and the person depicted in the vignette.

RESULTS

The continuum beliefs intervention was associated to a greater number of perceived similarities to and fewer perceived differences from the target vignette. Moreover, perceived similarities were associated with increased continuum beliefs, less social distance, and less-negative stereotypes. Perceived differences from a person with depression were associated with increased social distance.

LIMITATIONS

Even though the continuum beliefs intervention did not significantly alter stigma measures directly, expressed continuum beliefs were associated to decreased mental illness stigma.

CONCLUSIONS

The findings emphasize that perceived similarities to an outgroup member (i.e., a person with depression) might augment the stigma-reducing mechanism of continuum beliefs.

Stigma and mental disorder: conceptions of illness, public attitudes, personal disclosure, and social policy

The end of the last millennium witnessed an unprecedented degree of public awareness regarding mental disorder as well as motivation for policy change. Like Sartorius, we contend that the continued stigmatization of mental illness may well be the central issue facing the field, as nearly all attendant issues (e.g., standards of care, funding for basic and applied research efforts) emanate from professional, societal, and personal attitudes towards persons with aberrant behavior. We discuss empirical and narrative evidence for stigmatization as well as historical trends regarding conceptualizations of mental illness, including the field's increasing focus on genetic and neurobiological causes and determinants of mental disorder. We next define stigma explicitly, noting both the multiple levels (community, societal, familial, individual) through which stigma operates to dehumanize and delegitimize individuals with mental disorders and the impact of stigma across development. Key developmental psychopathology principles are salient in this regard. We express concern over the recent oversimplification of mental illness as "brain disorder," supporting instead transactional models which account for the dynamic interplay of genes, neurobiology, environment, and self across development and which are consistent with both compassion and societal responsibility. Finally, we consider educational and policy-related initiatives regarding the destigmatization of mental disorder. We conclude that attitudes and policy regarding mental disorder reflect, in microcosmic form, two crucial issues for the next century and millennium: (a) tolerance for diversity (vs. pressure for conformity) and (b) intentional direction of our species' evolution, given fast-breaking genetic advances.

Symptom profiles in children with ADHD: effects of comorbidity and gender

OBJECTIVE

To examine ratings and objective measures of attention-deficit/hyperactivity disorder (ADHD) symptoms to assess whether ADHD children with and without comorbid conditions have equally high levels of core symptoms and whether symptom profiles differ as a function of comorbidity and gender.

METHOD

Four hundred ninety-eight children from the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA) were divided into comorbid groups based on the parent Diagnostic Interview Schedule for Children and assessed via parents' and teachers' Swanson, Nolan, and Pelham (SNAP) ratings and a continuous performance test (CPT). Comorbidity and gender effects were examined using analyses of covariance controlled for age and site.

RESULTS

CPT inattention, impulsivity, and dyscontrol errors were high in all ADHD groups. Children with ADHD + oppositional defiant or conduct disorder were rated as more impulsive than inattentive, while children with ADHD + anxiety disorders (ANX) were relatively more inattentive than impulsive. Girls were less impaired than boys on most ratings and several CPT indices, particularly impulsivity, and girls with ADHD + ANX made fewer CPT impulsivity errors than girls with ADHD-only.

CONCLUSIONS

Children with ADHD have high levels of core symptoms as measured by rating scales and CPT, irrespective of comorbidity. However, there are important differences in symptomatology as a function of comorbidity and gender.

Clinical relevance of the primary findings of the MTA: success rates based on severity of ADHD and ODD symptoms at the end of treatment

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.

Methylphenidate dosage for children with ADHD over time under controlled conditions: lessons from the MTA

OBJECTIVES

To examine the trajectory of methylphenidate (MPH) dosage over time, following a controlled titration, and to ascertain how accurately the titration was able to predict effective long-term treatment in children with attention-deficit/hyperactivity disorder (ADHD).

METHOD

Using the 14-month-treatment database of the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA), the outcome of the initial placebo-controlled, double-blind, randomized daily switch titration of MPH was compared with the subsequent maintenance pharmacotherapy. Children received monthly monitoring visits and, when needed, medication adjustments.

RESULTS

Of the 198 children for whom MPH was the optimal treatment at titration (mean +/- SD dose: 30.5 +/- 14.2 mg/day), 88% were still taking MPH at the end of maintenance (mean dose 34.4 +/- 13.3 mg/day). Titration-determined dose and end-of-maintenance dose were significantly correlated (r = 0.52-0.68). Children receiving combined pharmacotherapy and behavioral treatment ended maintenance on a lower dose (31.1 +/- 11.7 mg/day) than did children receiving pharmacotherapy only (38.1 +/- 14.2 mg/day). Of the 230 children for whom titration identified an optimal treatment, 17% continued both the assigned medication and dosage throughout maintenance. The mean number of pharmacological changes per child was 2.8 +/- 1.8 (SD), and time to first change was 4.7 months +/- 0.3 (SE).

CONCLUSIONS

For most children, initial titration found a dose of MPH in the general range of the effective maintenance dose, but did not prevent the need for subsequent maintenance adjustments. For optimal pharmacological treatment of ADHD, both careful initial titration and ongoing medication management are needed.

Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers

In 1992, the National Institute of Mental Health and 6 teams of investigators began a multisite clinical trial, the Multimodal Treatment of Attention-Deficit Hyperactivity Disorder (MTA) study. Five hundred seventy-nine children were randomly assigned to either routine community care (CC) or one of three study-delivered treatments, all lasting 14 months. The three MTA treatments-monthly medication management (usually methylphenidate) following weekly titration (MedMgt), intensive behavioral treatment (Beh), and the combination (Comb)-were designed to reflect known best practices within each treatment approach. Children were assessed at four time points in multiple outcome. Results indicated that Comb and MedMgt interventions were substantially superior to Beh and CC interventions for attention-deficit hyperactivity disorder symptoms. For other functioning domains (social skills, academics, parent-child relations, oppositional behavior, anxiety/depression), results suggested slight advantages of Comb over single treatments (MedMgt, Beh) and community care. High quality medication treatment characterized by careful yet adequate dosing, three times daily methylphenidate administration, monthly follow-up visits, and communication with schools conveyed substantial benefits to those children that received it. In contrast to the overall study findings that showed the largest benefits for high quality medication management (regardless of whether given in the MedMgt or Comb group), secondary analyses revealed that Comb had a significant incremental effect over MedMgt (with a small effect size for this comparison) when categorical indicators of excellent response and when composite outcome measures were used. In addition, children with parent-defined comorbid anxiety disorders, particularly those with overlapping disruptive disorder comorbidities, showed preferential benefits to the Beh and Comb interventions. Parental attitudes and disciplinary practices appeared to mediate improved response to the Beh and Comb interventions.

ADHD comorbidity findings from the MTA study: comparing comorbid subgroups

OBJECTIVES

Previous research has been inconclusive whether attention-deficit/hyperactivity disorder (ADHD), when comorbid with disruptive disorders (oppositional defiant disorder [ODD] or conduct disorder [CD]), with the internalizing disorders (anxiety and/or depression), or with both, should constitute separate clinical entities. Determination of the clinical significance of potential ADHD + internalizing disorder or ADHD + ODD/CD syndromes could yield better diagnostic decision-making, treatment planning, and treatment outcomes.

METHOD

Drawing upon cross-sectional and longitudinal information from 579 children (aged 7-9.9 years) with ADHD participating in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA), investigators applied validational criteria to compare ADHD subjects with and without comorbid internalizing disorders and ODD/CD.

RESULTS

Substantial evidence of main effects of internalizing and externalizing comorbid disorders was found. Moderate evidence of interactions of parent-reported anxiety and ODD/CD status were noted on response to treatment, indicating that children with ADHD and anxiety disorders (but no ODD/CD) were likely to respond equally well to the MTA behavioral and medication treatments. Children with ADHD-only or ADHD with ODD/CD (but without anxiety disorders) responded best to MTA medication treatments (with or without behavioral treatments), while children with multiple comorbid disorders (anxiety and ODD/CD) responded optimally to combined (medication and behavioral) treatments.

CONCLUSIONS

Findings indicate that three clinical profiles, ADHD co-occurring with internalizing disorders (principally parent-reported anxiety disorders) absent any concurrent disruptive disorder (ADHD + ANX), ADHD co-occurring with ODD/CD but no anxiety (ADHD + ODD/CD), and ADHD with both anxiety and ODD/CD (ADHD + ANX + ODD/CD) may be sufficiently distinct to warrant classification as ADHD subtypes different from "pure" ADHD with neither comorbidity. Future clinical, etiological, and genetics research should explore the merits of these three ADHD classification options.

Depression and self-esteem in boys with attention-deficit/hyperactivity disorder: associations with comorbid aggression and explanatory attributional mechanisms

It was tested whether boys with attention-deficit/hyperactivity disorder (ADHD), subgrouped by aggressive status, would show higher rates of depressive symptomatology and lower levels of self-esteem than would comparison boys and, in a subsample, explored attributional mechanisms that may be related to such internalizing features. Study 1 utilized 114 boys with ADHD (all prior recipients of stimulant medication) and 87 comparison boys, aged 7-12 years. Aggressive boys with ADHD reported more symptoms of depression than did nonaggressive boys with ADHD, who, in turn, reported more depression than did comparison boys. Effect sizes were moderate to large and did not vary with a depression rating scale uncontaminated by ADHD-related items. For self-esteem, the most pronounced effect was that aggressive boys with ADHD showed lower levels than did nonaggressive ADHD or comparison boys; effects were again moderate to large. Study 2 participants were a subsample of boys with ADHD from Study 1 (N = 27). We probed causal attributions in ADHD-related domains through responses to hypothetical vignettes, in which the protagonist's medication status (medicated, not medicated) was crossed with type of outcome (good, bad). Medication-related attributions were frequent. In describing the protagonist's success in relation to medication treatment, the sample showed significant associations between (a) medication-related attributions and (b) increased depressive symptomatology as well as decreased self-esteem. We discuss attributional processes that may help to explain the variation in internalizing symptoms among children with ADHD.

Externalizing symptomatology among adoptive youth: prevalence and preadoption risk factors

The extent of symptomatology related to attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) was examined in a statewide sample of adopted youth, aged 4-18 years (n = 808). The use of normed questionnaires in a nonclinical sample decreased biases associated with past research on adopted children. According to parental report, a striking number of the youth qualified as manifesting significant symptom levels of externalizing behavior problems: 21% met symptom cutoffs for ADHD (with or without ODD) and 20% met criteria for ODD (with or without ADHD), for a combined total of 29% of the sample. A number of parent-reported, preadoptive risk factors distinguished these groups from one another and from the nonexternalizing youth. The clearest associated factors included histories of preadoption abuse/neglect, later age of adoption, prenatal drug exposure, and placement in multiple foster homes prior to adoption. We discuss implications regarding both etiology and current controversies surrounding the disproportionate levels of behavioral difficulties in adopted youth.

Impairment and deportment responses to different methylphenidate doses in children with ADHD: the MTA titration trial

OBJECTIVE

Results of the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA) were analyzed to determine whether a double-blind, placebo-controlled methylphenidate (MPH) titration trial identified the best MPH dose for each child with attention-deficit/hyperactivity disorder (ADHD).

METHOD

Children with ADHD assigned to MTA medication treatment groups (n = 289) underwent a controlled 28-day titration protocol that administered different MPH doses (placebo, low, middle, and high) on successive days.

RESULTS

A repeated-measures analysis of variance revealed main effects for MPH dose with greater effects on teacher ratings of impairment and deportment (F3 = 100.6, n = 223, p = .0001; effect sizes 0.8-1.3) than on parent ratings of similar endpoints (F3 = 55.61, n = 253, p = .00001; effect sizes 0.4-0.6). Dose did not interact with period, dose order, comorbid diagnosis, site, or treatment group.

CONCLUSIONS

The MTA titration protocol validated the efficacy of weekend MPH dosing and established a total daily dose limit of 35 mg of MPH for children weighing less than 25 kg. It replicated previously reported MPH response rates (77%), distribution of best doses (10-50 mg/day) across subjects, effect sizes on impairment and deportment, as well as dose-related adverse events.

Multimodal treatment of ADHD in the MTA: an alternative outcome analysis

OBJECTIVE

To conduct a post hoc investigation of the utility of a single composite measure of treatment outcome for the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA) at 14 months postbaseline.

BACKGROUND

Examination of multiple measures one at a time in the main MTA intent-to-treat outcome analyses failed to detect a statistically significant advantage of combined treatment (Comb) over medication management (MedMgt). A measure that increases power and precision using a single outcome score may be a useful alternative to multiple outcome measures.

METHOD

Factor analysis of baseline scores yielded two "source factors" (parent and teacher) and one "instrument factor" (parent-child interactions). A composite score was created from the average of standardized parent and teacher measures.

RESULTS

The composite was internally consistent (alpha = .83), reliable (test-retest over 3 months = 0.86), and correlated 0.61 with clinician global judgments. In an intent-to-treat analysis, Comb was statistically significantly better than all other treatments, with effect sizes ranging from small (0.28) versus MedMgt, to moderately large (0.70) versus a community comparison group.

CONCLUSIONS

A composite of ADHD variables may be an important tool in future treatment trials with ADHD and may avoid some of the statistical limitations of multiple measures.

Parent cognitions as predictors of child treatment response in attention-deficit/hyperactivity disorder

Using a subsample of 105 children and their parents (100 mothers, 57 fathers) from the Multimodal Treatment Study of Children with ADHD (the MTA), the value of parents' baseline cognitions as predictors of children's treatment outcome at 14 months was examined. Measures of parents' cognitions about themselves, their ADHD children, and their parenting, as well as a self-report measure of dysfunctional discipline were included. Both mothers' and fathers' self-reported use of dysfunctional discipline predicted worse child treatment outcome. Low self-esteem in mothers, low parenting efficacy in fathers, and fathers' attributions of noncompliance to their ADHD child's insufficient effort and bad mood also were associated with worse child treatment outcome. All of these predictive relations were obtained even after MTA treatment effects had been taken into account. Secondary analyses indicated that mothers had a more external locus of control, lower self-esteem, lower parenting efficacy, and a greater tendency to attribute noncompliance to their ADHD child's bad mood than did fathers.

Parenting and family stress treatment outcomes in attention deficit hyperactivity disorder (ADHD): an empirical analysis in the MTA study

Parenting and family stress treatment outcomes in the MTA study were examined. Male and female (579), 7-9-year-old children with combined type Attention Deficit Hyperactivity Disorder (ADHD), were recruited at six sites around the United States and Canada, and randomly assigned to one of four groups: intensive, multi-faceted behavior therapy program alone (Beh); carefully titrated and monitored medication management strategy alone (MedMgt); a well-integrated combination of the two (Comb); or a community comparison group (CC). Treatment occurred over 14 months, and assessments were taken at baseline, 3, 9, and 14 months. Parenting behavior and family stress were assessed using parent-report and child-report inventories. Results showed that Beh alone, MedMgt alone, and Comb produced significantly greater decreases in a parent-rated measure of negative parenting, Negative/Ineffective Discipline, than did standard community treatment. The three MTA treatments did not differ significantly from each other on this domain. No differences were noted among the four groups on positive parenting or on family stress variables. Results are discussed in terms of the theoretical and empirically documented importance of negative parenting in the symptoms, comorbidities and long-term outcomes of ADHD.

Familial aggregation of ADHD characteristics

Patterns of familial aggregation of ADHD symptoms in parents of ADHD and non-ADHD children were examined. Within the ADHD sample, symptom aggregation was examined as a function of biological relationship, parent and child gender, and children's comorbid diagnoses. Participants consisted of parents of 579 children with ADHD, Combined Type participating in the multimodal treatment study of children with ADHD and parents of 288 normal control participants. Adult symptoms of ADHD were measured by both self-report and report of a significant other. Results indicated that the parents of children with ADHD had higher ratings of inattention/cognitive problems, hyperactivity/restlessness, impulsivity/emotional lability, and lower self-concept than parents of children without ADHD on both self-report and other-report ratings. Within the ADHD sample of children, other-report ratings of inattention/cognitive problems and impulsivity/emotional lability were higher for biological parents compared to nonbiological parents whereas self-ratings were not related to biological status. These findings support previous research documenting familial aggregation of ADHD and appear to strengthen the hypothesis that there is a genetic contribution to ADHD.

Anxiety as a predictor and outcome variable in the multimodal treatment study of children with ADHD (MTA)

Initial moderator analyses in the Multimodal Treatment Study of Children with ADHD (MTA) suggested that child anxiety ascertained by parent report on the Diagnostic Interview Schedule for Children 2.3 (DISC Anxiety) differentially moderated the outcome of treatment. Left unanswered were questions regarding the nature of DISC Anxiety, the impact of comorbid conduct problems on the moderating effect of DISC Anxiety, and the clinical significance of DISC Anxiety as a moderator of treatment outcome. Thirty-three percent of MTA subjects met DSM-III-R criteria for an anxiety disorder excluding simple phobias. Of these, two-thirds also met DSM-III-R criteria for comorbid oppositional-defiant or conduct disorder whereas one-third did not, yielding an odds ratio of approximately two for DISC Anxiety, given conduct problems. In this context, exploratory analyses of baseline data suggest that DISC Anxiety may reflect parental attributions regarding child negative affectivity and associated behavior problems (unlike fearfulness), particularly in the area of social interactions, another core component of anxiety that is more typically associated with phobic symptoms. Analyses using hierarchical linear modeling (HLM) indicate that the moderating effect of DISC Anxiety continues to favor the inclusion of psychosocial treatment for anxious ADHD children irrespective of the presence or absence of comorbid conduct problems. This effect, which is clinically meaningful, is confined primarily to parent-reported outcomes involving disruptive behavior, internalizing symptoms, and inattention; and is generally stronger for combined than unimodal treatment. Contravening earlier studies, no adverse effect of anxiety on medication response for core ADHD or other outcomes in anxious or nonanxious ADHD children was demonstrated. When treating ADHD, it is important to search for comorbid anxiety and negative affectivity and to adjust treatment strategies accordingly.

Family processes and treatment outcome in the MTA: negative/ineffective parenting practices in relation to multimodal treatment

To elucidate processes underlying therapeutic change in a large-scale randomized clinical trial, we examined whether alterations in self-reported parenting practices were associated with the effects of behavioral, medication, or combination treatments on teacher-reported outcomes (disruptive behavior, social skills, internalizing symptoms) in children with attention-deficit hyperactivity disorder (ADHD). Participants were 579 children with Combined-type ADHD, aged 7-9.9 years, in the Multimodal Treatment Study of Children with ADHD (MTA). We uncovered 2 second-order factors of parenting practices, entitled Positive Involvement and Negative/Ineffective Discipline. Although Positive Involvement was not associated with amelioration of the school-based outcome measures, reductions in Negative/Ineffective Discipline mediated improvement in children's social skills at school. For families showing the greatest reductions in Negative/Ineffective Discipline, effects of combined medication plus behavioral treatment were pronounced in relation to regular community care. Furthermore, only in combination treatment (and not in behavioral treatment alone) was decreased Negative/Ineffective Discipline associated with reduction in children's disruptive behavior at school. Here, children in families receiving combination treatment who showed the greatest reductions in Negative/Ineffective Discipline had teacher-reported disruptive behavior that was essentially normalized. Overall, the success of combination treatment for important school-related outcomes appears related to reductions in negative and ineffective parenting practices at home; we discuss problems in interpreting the temporal sequencing of such process-outcome linkages and the means by which multimodal treatment may be mediated by psychosocial processes related to parenting.

Psychosocial treatment strategies in the MTA study: rationale, methods, and critical issues in design and implementation

The Collaborative Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (ADHD), the MTA, is the first multisite, cooperative agreement treatment study of children, and the largest psychiatric/psychological treatment trial ever conducted by the National Institute of Mental Health. It examines the effectiveness of Medication vs. Psychosocial treatment vs. their combination for treatment of ADHD and compares these experimental arms to each other and to routine community care. In a parallel group design, 579 (male and female) ADHD children, aged 7-9 years, 11 months, were randomly assigned to one of the four experimental arms, and then received 14 months of prescribed treatment (or community care) with periodic reassessments. After delineating the theoretical and empirical rationales for Psychosocial treatment of ADHD, we describe the MTA's Psychosocial Treatment strategy applied to all children in two of the four experimental arms (Psychosocial treatment alone; Combined treatment). Psychosocial treatment consisted of three major components: a Parent Training component, a two-part School Intervention component, and a child treatment component anchored in an intensive Summer Treatment Program. Components were selected based on evidence of treatment efficacy and because they address comprehensive symptom targets, settings, comorbidities, and functional domains. We delineate key conceptual and logistical issues faced by clinical researchers in design and implementation of Psychosocial research with examples of how these issues were addressed in the MTA study.

Behavioral versus behavioral and pharmacological treatment in ADHD children attending a summer treatment program

As part of the behavioral treatment in the Multimodal Treatment Study of Children with ADHD (MTA9), children participated in an intensive summer treatment program (STP). This study examined the differences between 57 children in the combined treatment (Comb) group, who were medicated, and 60 children in the behavioral treatment (Beh) group, who were unmedicated throughout the STP. Comb children were significantly better than Beh on 5 measures: rule following, good sportsmanship, peer negative nominations, and STP teacher posttreatment ratings of inattention/overactivity. Groups did not differ on any of the other 30 measures, and responded similarly to the STP over time. Comparisons to normative data revealed that Comb children were more likely to fall within the normative range on 6 measures. The differences between these results and the main MTA results, in which Comb was always superior to Beh, are discussed in terms of the relative intensity of combined treatments. The implications for future studies of pharmacological and behavioral treatment for ADHD are discussed.

Emotion regulation and parenting in AD/HD and comparison boys: linkages with social behaviors and peer preference

Children's emotion regulation strategies and parenting responses in a family task that elicited frustration are investigated by comparing core attention-deficit/hyperactivity disorder (AD/HD) symptomatology, emotional reactivity, and emotional regulation in the prediction of social behaviors and peer social preference. Participants were boys, ages 6-12 years, either with AD/HD (n = 45) or without problem behaviors (comparison; n = 34). A high-aggressive subgroup of AD/HD boys showed a significantly less constructive pattern of emotional coping than did both a low-aggressive AD/HD subgroup of boys and nondiagnosed comparison boys, who did not differ. With statistical control of core AD/HD symptomatology, noncompliance in a naturalistic summer camp was predicted by boys' overall emotion regulation and three specific strategies (emotional accommodation, problem solving, negative responses) during the parent-child interaction. Emotional accommodation and negative responses to the frustration task also marginally predicted social preference at the camp. These emotion regulation variables outperformed emotional reactivity in predicting such outcomes. Some emotion-related parenting behaviors were associated with child coping in the task. We discuss the relationship of emotion regulation to core AD/HD symptomatology and emotional reactivity, and the role of parents' behaviors in influencing children's emotional responses.

The abduction of disorder in psychiatry

The evolutionary cornerstone of J. C. Wakefield's (1999) harmful dysfunction thesis is a faulty assumption of comparability between mental and biological processes that overlooks the unique plasticity and openness of the brain's functioning design. This omission leads Wakefield to an idealized concept of natural mental functions, illusory interpretations of mental disorders as harmful dysfunctions, and exaggerated claims for the validity of his explanatory and stipulative proposals. The authors argue that there are numerous ways in which evolutionarily intact mental and psychological processes, combined with striking discontinuities within and between evolutionary and contemporary social/cultural environments, may cause nondysfunction variants of many widely accepted major mental disorders. These examples undermine many of Wakefield's arguments for adopting a harmful dysfunction concept of mental disorder.

The abduction of disorder in psychiatry

The evolutionary cornerstone of J. C. Wakefield's (1999) harmful dysfunction thesis is a faulty assumption of comparability between mental and biological processes that overlooks the unique plasticity and openness of the brain's functioning design. This omission leads Wakefield to an idealized concept of natural mental functions, illusory interpretations of mental disorders as harmful dysfunctions, and exaggerated claims for the validity of his explanatory and stipulative proposals. The authors argue that there are numerous ways in which evolutionarily intact mental and psychological processes, combined with striking discontinuities within and between evolutionary and contemporary social/cultural environments, may cause nondysfunction variants of many widely accepted major mental disorders. These examples undermine many of Wakefield's arguments for adopting a harmful dysfunction concept of mental disorder.

Reports of stress: a comparison between eating disordered and non-eating disordered adolescents

This study utilizes a unique method to examine reports of stressful life events provided by eating disordered and non-eating disordered adolescents. Subjects (all females) participated in a standardized procedure to obtain reports of stressful life events. The Life Events and Coping Inventory (LECI) was used to categorize reported stressors. Eating disorder subjects discussed more stressors than non-eating disorder subjects only when eating disorder events were included. Furthermore, eating disorder subjects reported more events that could not be classified within the LECI and were rated as non-normative. The findings point to the importance of qualitative rather than purely quantitative approaches to stressful life events assessment with adolescents.

Parent personality traits and psychopathology associated with antisocial behaviors in childhood attention-deficit hyperactivity disorder

Although a role for family and parent factors in the development of behavioral problems in childhood is often acknowledged, the roles of specific parental characteristics in relation to specific child actions need further elucidation. We studied parental "Big Five" personality traits and psychiatric diagnoses in relation to their children's antisocial diagnoses and naturalistically observed antisocial behaviors, in boys with and without the diagnosis of Attention-Deficit Hyperactivity Disorder (ADHD). First, regardless of comorbid antisocial diagnosis, boys with ADHD, more often than comparison boys, had mothers with a major depressive episode and/or marked anxiety symptoms in the past year, and fathers with a childhood history of ADHD. Second, compared to the nondiagnosed group, boys with comorbid ADHD + Oppositional Defiant or Conduct Disorder (ODD/CD) had fathers with lower Agreeableness, higher Neuroticism, and more likelihood of having Generalized Anxiety Disorder. Third, regarding linkages between parental characteristics and child externalizing behaviors, higher rates of child overt antisocial behaviors observed in a naturalistic summer program were associated primarily with maternal characteristics, including higher Neuroticism, lower Conscientiousness, presence of Major Depression, and absence of Generalized Anxiety Disorder. The association of maternal Neuroticism with child aggression was larger in the ADHD than in the comparison group. In contrast, higher rates of observed child covert antisocial behaviors were associated solely with paternal characteristics, including history of substance abuse and higher Openness. Results provide external validation in parent data for a distinction between overt and covert antisocial behaviors and support inclusion of parent personality traits in family studies. The interaction of maternal Neuroticism and child ADHD in predicting child aggression is interpreted in regard to a conceptualization of child by parent "fit."

National Institute of Mental Health Collaborative Multimodal Treatment Study of Children with ADHD (the MTA). Design challenges and choices

The Collaborative Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (ADHD), the MTA, is the first child multisite cooperative agreement treatment study of children conducted by the National Institute of Mental Health, Rockville, Md. It examines the long-term effectiveness of medication vs behavioral treatment vs both for treatment of ADHD and compares state-of-the-art treatment with routine community care. In a parallel-groups design, 576 children (age, 7-9 years) with ADHD (96 at each site) are thoroughly assessed and randomized to 4 conditions: (1) medication alone, (2) psychosocial treatment alone, (3) the combination of both, (4) or community comparison. The first 3 groups are treated for 14 months and all are reassessed periodically for 24 months. Designers met the following challenges: framing clinically relevant primary questions; defining the target population; choice, intensity, and integration and combination of treatments for fair comparisons; combining scientific controls and standardization with clinical flexibility; and implementing a controlled clinical trial in a nonclinical setting (school) controlled by others. Innovative solutions included extensive decision algorithms and manualized adaptations of treatments to specific needs.

Covert visual spatial attention in boys with attention deficit hyperactivity disorder: lateral effects, methylphenidate response and results for parents

We report three related studies of covert visual spatial orienting in child attention deficit hyperactivity disorder (ADHD). In Study 1, we examined covert visual spatial orienting in ADHD and comparison boys, Study 2 comprised a dose-response study of methylphenidate for the ADHD group, and Study 3 was an investigation of biological and adoptive parents. In contrast with comparison subjects (n = 17). ADHD boys aged 6-12 (n = 27) showed both slower reaction times overall and within-condition (lateral) asymmetries in reaction times. Specifically, boys with ADHD reacted more slowly to uncued targets in the left visual field than in the right visual field. Responses to stimuli in the two visual fields were differentially affected by methylphenidate for the ADHD group. Medication equalized visual field responses to the uncued targets, resulting in a significant cue x dose x visual field interaction. Further, medication altered the relative cue responsivity in the two visual fields, resulting in a significant dose x visual field interaction for the Validity Effect. Biological parents of ADHD boys (n = 16) also showed slower reaction times to uncued left visual field targets than to right visual field targets; in addition they showed slower response to invalidity cued targets in the right visual field. These literal effects were not observed in adoptive parents of ADHD boys (n = 12) or biological parents of comparison boys (n = 14). Possible abnormal hemispheric asymmetry of attention functions in boys with ADHD and their biological parents is discussed.

Medication treatment strategies in the MTA Study: relevance to clinicians and researchers

OBJECTIVE

Clinicians have difficulty applying drug research findings to clinical practice, because research protocols use methods different from those used in daily office practice settings.

METHOD

To design a medication protocol for a multisite clinical trial involving 576 children with attention-deficit hyperactivity disorder (ADHD) while maintaining relevance to clinical practice, investigators from the NIMH Collaborative Multisite Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA study) developed novel medication strategies. These were designed to work either in a monomodal or multimodal format and to ensure standard approaches are used across diverse sites. Each child randomized to medication (projected N = 288) is individually titrated to his or her "best" methylphenidate dose and has individual ADHD symptoms monitored. Decision rules were developed to guide "best dose" selection, dose changes, medication changes, the management of side effects, and integration with psychosocial treatments.

CONCLUSIONS

The MTA study uses a controlled method to standardize the identification of each child's "best" methylphenidate dose in a national, multisite cooperative treatment program. Although the titration protocol is complex, the study's individual dosing approach and algorithms for openly managing ADHD children's medication over time will be of interest to clinicians in office practice.

Neuropsychological functioning, motor speed, and language processing in boys with and without ADHD

We administered a neuropsychological battery to boys aged 6 to 12 years old diagnosed with attention-deficit hyperactivity disorder (ADHD; n = 51) and to comparison boys of the same age range (n = 31). Boys with ADHD had greater difficulty than comparison youngsters on nonautomated language and motor tasks administered with a fast instructional set and on one of two traditional frontal executive measures (Porteus mazes). When tasks requiring automatic processing were paired with similar tasks requiring greater use of selective attention processes, the latter, controlled processing tasks differentiated groups better than did automated tasks. This differential effect of otherwise similar tasks is interpreted in terms of an output deficit mediated by response organization as detailed in the information processing literature. The ADHD group also exhibited slow gross motor output, measured independently of verbal output. The findings are evaluated in terms of both Luria's (1973) tripartite model of neurocognitive organization and frontal striatal models, with an emphasis on output processes. The observed language deficits could represent frontal lobe processes intricately related to self-monitoring and planning. The utility of controlled processing, self-paced tasks with fast instructional sets in assessing language and motor skills in ADHD is highlighted.

What they want and what they get: the social goals of boys with ADHD and comparison boys

Twenty-seven boys diagnosed with attention-deficit hyperactivity disorder (ADHD) and 18 comparison boys participated in a competitive tetradic interaction task. Boys were individually interviewed before the game about their goals for the interaction, and adult observers inferred boys' social goals from videotapes of the interaction. Social acceptance was determined by combining positive and negative sociometric nominations collected through individual interviews at the end of the summer research program in which the interaction was held. In their self-reports, ADHD-high aggressive boys prioritized trouble-seeking and fun at the expense of rules to a greater extent than did both ADHD-low aggressive and comparison boys. Observers judged ADHD-high aggressive boys to seek attention more strongly and seek fairness less strongly than of the other two groups. Self-reported goals of defiance and cooperation predicted boys' end-of-program social standing, even with interactional behaviors and subgroup status controlled statistically. Observer-inferred goals were differentially associated with social acceptance for ADHD and comparison boys, suggesting discontinuities in peer interaction processes. Differentiation of goals from behavior and the integral role of children's goals in peer acceptance are discussed.

NIMH collaborative multisite multimodal treatment study of children with ADHD: I. Background and rationale

OBJECTIVE

The National Institute of Mental Health's recently initiated 5-year, multisite, multimodal treatment study of children with attention-deficit hyperactivity disorder (MTA) is the first major clinical trial in its history focused on a childhood mental disorder. This article reviews the major scientific and clinical bases for initiating the MTA.

METHOD

A selective review of the literature is presented in the service of describing the estimated prevalence of ADHD among children and adolescents, its core clinical features, evidence concerning psychopharmacological and psychosocial treatment effects, and related research issues and trends leading to the development of the MTA.

RESULTS

Despite decades of treatment research and clinical practice, there is an insufficient basis for answering the following manifold question: under what circumstances and with what child characteristics (comorbid conditions, gender, family history, home environment, age, nutritional/metabolic status, etc.) do which treatments or combinations of treatment (stimulants, behavior therapy, parent training, school-based intervention) have what impacts (improvement, stasis, deterioration) on what domains of child functioning (cognitive, academic, behavioral, neurophysiological, neuropsychological, peer relations, family relations), for how long (short versus long term), to what extent (effect sizes, normal versus pathological range), and why (processes underlying change)?

CONCLUSIONS

The important scientific, clinical, and public health issues nested within this manifold question provide both the impetus and scaffolding for the MTA.

Mother-child interactions in ADHD and comparison boys: relationships with overt and covert externalizing behavior

Reciprocal relationships between child characteristics and such familial factors as parental psychopathology and interaction style with the child characterize the development and maintenance of attention-deficit hyperactivity disorder (ADHD) as well as its comorbidity with antisocial behavior. Our goal was to ascertain the ability of negative maternal behavior exhibited during mother-son interactions to predict independently observed overt and covert externalizing behavior in the child, controlling for current maternal symptomatology and the boy's acting out behavior during the interaction. Participants were 49 boys with ADHD and 37 comparison boys, aged 6 to 12 years. Hierarchical multiple-regression analyses revealed that, even with maternal psychopathology and child negativity with the mother partialed, maternal negative behaviors predicted both observed noncompliance exhibited in class and play settings and laboratory stealing. Stealing was predicted from maternal negativity even with child interactional compliance controlled. Differential predictions of noncompliance were revealed in ADHD versus comparison families, yet similar patterns emerged for stealing within each group. Results are discussed in light of the high risk for antisocial behavior in ADHD children.

Academic underachievement, attention deficits, and aggression: comorbidity and implications for intervention

Although comorbidity with specific learning disabilities is less frequent than commonly reported, externalizing behavior disorders--particularly attention-deficit hyperactivity disorder (ADHD)--often overlap with various indices of academic underachievement during childhood. Furthermore, by adolescence, delinquency is clearly associated with school failure. Because the link between behavioral and learning problems often appears before formal schooling, and because the co-morbid problems predict a negative course, early intervention is a necessity. Controlled treatment investigations with youngsters who show these combined problems are rare, and such studies present a host of methodologic and practical problems. I discuss issues surrounding multimodality treatment programs and the potential for long-term interventions to break cycles of school failure and externalizing behavior.

Self-management therapies and attention-deficit hyperactivity disorder. Reinforced self-evaluation and anger control interventions

The lack of sufficiency of the primary treatment modalities for children with Attention-Deficit Hyperactivity Disorder (ADHD)-operant behaviormodification procedures and psychostimulant medications-have prompted exploration of cognitive-behavioral self-management treatments as altematives or adjuncts. Although self-instructional treatments are not adequate interventions for such children, reinforcement-and rehearsal-based behavioral interventions can be combined with self-management approaches to supplement and extend the gains induced by behavioral procedures. After presenting background material regarding cognitive-behavioral treatments for ADHD, we present case material related to multimodality treatment, with focus on training in anger management and self-evaluation skills. We argue against unsubstantiated claims for the efficacy of cognitive-behavioral interventions but contend that, when combined with pharnacologic and behavioral approaches, self-management procedures deserve consideration for the difficult social and behavioral problems of ADHD children.

Prosocial behavior in hyperactive boys: effects of stimulant medication and comparison with normal boys

To clarify the effects of stimulant medication on hyperactive (ADHD) children's prosocial as well as aversive behaviors toward peers, 19 hyperactive boys, aged 7-12, were observed as they acted as "leaders" for groups of 2-4 unfamiliar younger children. In a double-blind crossover design, subjects were observed twice, once on placebo and again on a moderate (0.6 mg/kg) dose of methylphenidate (Ritalin). Thirteen comparison boys, without problems in attention and behavior, were also observed in the same leader roles. Relative to comparison boys, hyperactive boys on placebo were more socially engaged, used more aversive leadership techniques, and were rated as less likable by the younger children in their groups. Aversive social behaviors were the strongest predictors of being disliked by the younger children. No differences were found between comparison and unmedicated hyperactive boys for any aspect of prosocial behavior. Stimulant medication had a general dampening effect on social behavior, significantly reducing social engagement and increasing (mild) dysphoria relative to the placebo condition. The implications of these findings for understanding and treating the peer relationship difficulties of hyperactive children are discussed.

Academic underachievement, attention deficits, and aggression: Comorbidity and implications for intervention

Although comorbidity with specific learning disabilities is less frequent than commonly reported, externalizing behavior disorders--particularly attention-deficit hyperactivity disorder (ADHD)--often overlap with various indices of academic underachievement during childhood. Furthermore, by adolescence, delinquency is clearly associated with school failure. Because the link between behavioral and learning problems often appears before formal schooling, and because the co-morbid problems predict a negative course, early intervention is a necessity. Controlled treatment investigations with youngsters who show these combined problems are rare, and such studies present a host of methodologic and practical problems. I discuss issues surrounding multimodality treatment programs and the potential for long-term interventions to break cycles of school failure and externalizing behavior.

Externalizing behavior problems and academic underachievement in childhood and adolescence: causal relationships and underlying mechanisms

Conceptual and measurement issues surrounding externalizing behavior problems and academic underachievement, the strength and specificity of the covariation between these domains, and the viability of explanatory models that link these areas are reviewed. In childhood, inattention and hyperactivity are stronger correlates of academic problems than is aggression; by adolescence, however, antisocial behavior and delinquency are clearly associated with underachievement. Whereas investigations with designs that allow accurate causal inference are scarce, unidirectional paths from 1 domain to the other have received little support. Indeed, the overlap of externalizing problems with cognitive and readiness deficits early in development suggests the influence of antecedent variables. Low socioeconomic status, family adversity, subaverage IQ, language deficits, and neurodevelopmental delay are explored as possible underlying factors.

Externalizing behavior disorders, situational generality, and the type A behavior pattern

Measures of the Type A Behavior Pattern (TABP) in children have demonstrated good sensitivity but problematic specificity. Using the most popular measure of childhood TABP, a teacher rating scale called the MYTH, we sought to (a) replicate earlier findings of extensive overlap between TABP and externalizing behavior problems, (b) further distinguish between and extend the empirical networks for the positive (Competition) and negative (Impatience-Aggression) components of TABP, and (c) explore cross-situational generality. Normal boys and those with attention-deficit hyperactivity disorder (ADHD) were assessed on multiple instruments in diverse contexts. ADHD boys obtained higher TABP Total and Impatience-Aggression scores than normal boys, and these scores were associated with a wide array of behavior problems and peer difficulties. In contrast, the Competition subscale was related to popularity and athleticism and, inversely, to internalizing problems. Discussion focused on the construct validity of the MYTH, the heterogeneity of boys identified by the MYTH as showing the TABP, and the need for distinguishing research uses of the measure from applications of the TABP concept.

Anger control in response to verbal provocation: effects of stimulant medication for boys with ADHD

Although stimulant medication reduces hyperactive children's aggression in naturalistic settings, stimulant effects on anger control have not been demonstrated. We therefore assessed the role of methylphenidate in enhancing response to verbal provocation from familiar peers and from role-playing adults. Twenty-four boys with attention deficit-hyperactivity disorder (ADHD), aged 6-12, received small-group cognitive-behavioral intervention in anger management skills. During posttraining assessments, the children were randomly assigned to placebo versus .6 mg/kg of methylphenidate. In the peer provocations, methylphenidate enhanced self-control, decreased physical retaliation, and marginally increased the display of coping strategies. Medication and prompting were minimally beneficial in the delayed, adult-administered generalization assessments. Among the issues discussed are (a) differences between peer and adult provocation and (b) the roles of medication dosage and multimodality intervention for promoting socially competent behavior in children with ADHD.

Does stimulant medication improve the peer status of hyperactive children?

Although stimulants improve the social behaviors of hyperactive children, analogous changes in peer status have not been previously demonstrated. We compared peer appraisals of hyperactive boys (N = 25) after placebo, 0.3 mg/kg, and 0.6 mg/kg methylphenidate (Ritalin). With the higher dose generally producing stronger effects, methylphenidate enhanced social standing, increasing nominations of hyperactive boys as best friends, cooperative, and fun to be with. These medication-related improvements, although important, did not normalize peer appraisals, and there was marked interindividual variability in medication response.

Factorial dimensions of the Revised Behavior Problem Checklist: replication and validation within a kindergarten sample

The factor structure of the Revised Behavior Problem Checklist (RBPC) was examined in a large sample of suburban kindergarten children. Teacher-rated dimensions of Conduct Disorder, Attention Problems-Immaturity, Anxiety-Withdrawal, and Psychotic Behavior were closely replicated, and a new factor labeled Unmotivated-Isolated was also revealed. These principal components were consistent across gender and across subsamples of children differing as to risk status for learning failure. Evidence was found for the divergent validity of the externalizing dimensions of Conduct Disorder and Attention Problems-Immaturity with respect to criterion measures of alternative behavior ratings, cognitive functioning, and academic achievement. Parent-rated components of Conduct Disorder, Attention Problems-Immaturity, Hyperactive-Impatient, Tense-Withdrawn, Anxiety, and Passive-Conforming were less clearly validated, and parent-teacher agreement was modest. It was concluded that the RBPC shows promise for the assessment of preschool-aged children and that narrow-band externalizing dimensions of inattentive versus conduct-disordered behavior are reasonably distinct at this age.

Signs of neurobehavioral dysfunction in a sample of learning disabled children: stability and concurrent validity

Of 270 learning disabled children with average intelligence and significant delays in reading comprehension a sample of 37 were evaluated for signs of neurobehavioral dysfunction. All such signs--primitive reflexes, equilibrium reactions, and postrotary nystagmus--were reliably assessed. A subsample of 19 children was compared with developmentally normal and mentally retarded samples for the occurrence of tonic neck reflexes and equilibrium reactions. The learning disabled children consistently showed deviancies like those of the retarded children; both of these groups differed from the normal children on most measures. These deviant responses persisted over a 9-mo. period for the learning disabled group. Compared with norms, the total learning disabled sample displayed hyponystagmus, and this depressed nystagmus persisted for 11 mo. Results are discussed in relation to the lack of correlation among the various signs of neurobehavioral dysfunction in the learning disabled children.

Cognitive-behavioral therapies for hyperactive children: premises, problems, and prospects

The impetus for the widespread use of CBT for children with attention deficit disorder (hyperactivity) is examined, followed by an evaluation of various facets of treatment efficacy. The many "unknowns" concerning treatment ingredients, targets of change, domain specificity, individual differences, palatability, and treatment-emergent side effects are then reviewed. The final section focuses on future directions, specifying some reasons for optimism despite the disappointing outcomes to date. Nontraditional uses of CBT are also proposed, including the implementation of cognitive strategies to counteract undesirable emanative effects of extant treatments and to facilitate drug discontinuance in children taking psychoactive medication.

Self-control in hyperactive boys in anger-inducing situations: effects of cognitive-behavioral training and of methylphenidate

The effects of cognitive-behavioral intervention and methylphenidate on anger control in hyperactive boys were investigated in two studies. The anger-inducing stimuli in both studies involved verbal provocation from peers. Study 1 assessed a brief intervention using self-control strategies, while Study 2 employed a longer training period and a control intervention that focused on enhancement of empathy. Both studies included methylphenidate versus placebo comparisons. Methylphenidate reduced the intensity of the hyperactive boys' behavior but did not significantly increase either global or specific measures of self-control. Cognitive-behavioral treatment, when compared to control training, was more successful in enhancing both general self-control and the use of specific coping strategies. There was no advantage for the combination of methylphenidate plus cognitive-behavioral intervention. Implications for intervention to ameliorate the social and interpersonal difficulties of hyperactive children are discussed.

Child and adolescent perceptions of normal and atypical peers

Students at 4 grade levels (grades 4, 6, 8, and 10) evaluated hypothetical male age-mates who were portrayed as normal, hyperactive, antisocial, or mildly mentally retarded. The focus was on behavioral characteristics, predicted outcomes, anticipated peer reactions, recommended parental interventions, and diagnostic labels. The results indicated that the students made social inferences that extended far beyond the specific behavioral information provided. The atypical boys were viewed as substantially more deviant than the normal boy within broad-ranging social, affective, and intellectual domains. Future problems were predicted for all 3 atypical boys, and parental interventions were recommended. Within this global negative perspective, clear distinctions were drawn among the 3 types of atypicality. The mildly retarded boy was viewed as most similar to the normal boys, and the antisocial boy was seen as the most dissimilar. Some gender differences and grade trends also emerged, with females and older students generally expressing more benign views of the atypical youths.