REVIEW OF: The MTA Cooperative Group, Arch Gen Psychiatry 1999;56(12):1073–1086   

The Multimodal Treatment Study of Children with ADHD (MTA) published its first and most important results 21 years ago, answering fundamental questions about the roles for medicine and behavioral treatment in childhood ADHD.

Funded by NIMH, the study enrolled 579 children (ages 7−9.9 years) with combined-type ADHD for 14 months of treatment. Investigators randomly assigned children into four groups. Control arm kids (“community care”) saw their pediatrician for medication. Medication arm kids had monthly 30-minute visits with a psychopharmacologist. These prescribers methodically titrated patients to an optimal dose of immediate-release methylphenidate, prescribed 3 times daily, and could switch to another medicine if needed. The behavioral management arm received multiple interventions: Kids attended an 8-week, 9 hour/day therapeutic summer day camp; a treating clinician delivered about 30 hours of parent training and 10 hours of school consultation; and kids had 60 days of in-school coaching by a dedicated paraprofessional. The combined group got the best of both worlds—medication and behavioral treatments. The study measured outcomes with multiple observers using standard rating scales.

The groundbreaking result was that for the core symptoms of ADHD, medication management was equivalent to combined treatment, and it was superior to behavioral therapy alone. For ADHD-adjacent outcomes (aggression/oppositionality, internalizing symptoms, social skills, parent-child relations, and academics), medication and behavioral treatment were equivalent. Compared to the control group, combined treatment looked stronger than either modality alone for these functional domains.

Many of us were surprised that beyond expert medication treatment, elaborate behavioral treatments added little to the treatment of core ADHD symptoms. For all domains affected by ADHD, medication was necessary to get the best outcome. Compared to medication management, control kids receiving medicine were taking it less often (3 doses/day vs 2.3 doses/day) and in lower doses (31–38 mg vs 23 mg). Follow-up reports on these cohorts have found that after the interventions ended, medication was used less intensively and systematically over time. Concomitantly, differences between the treatment groups dissipated. However, there is accumulating evidence from other studies that ongoing stimulant treatment for ADHD is effective and is associated with long-term academic gains and reductions in criminality (Lichtenstein P et al, N Engl J Med 2012;367(21):2006–2014; Jangmo A et al, J Am Acad Child Adolesc Psychiatry 2019;58(4):423–432).

CCPR’s Take
This landmark study supported adequate dosing and the development of extended-release treatments. Since this study, we have learned that behavioral treatments and coaching offer added effect, although cost can be a limiting factor. For all patients, the abiding lesson is the importance of sustaining ongoing, expert-delivered psychopharmacological care for patients with ADHD across childhood and into adulthood.