ARTICLES: SPECIAL SECTION: MULTIMODAL TREATMENT STUDY OF ADHD-MTA
Delinquent Behavior and Emerging Substance Use in the MTA at 36 Months: Prevalence, Course, and Treatment Effects

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ABSTRACT

Objective:

To compare delinquent behavior and early substance use between the children in the Multimodal Treatment Study of Children With ADHD (MTA; N = 487) and those in a local normative comparison group (n = 272) at 24 and 36 months postrandomization and to test whether these outcomes were predicted by the randomly assigned treatments and subsequent self-selected prescribed medications.

Method:

Most MTA children were 11 to 13 years old by 36 months. Delinquency seriousness was coded ordinally from multiple measures/reporters; child-reported substance use was binary.

Results:

Relative to local normative comparison group, MTA children had significantly higher rates of delinquency (e.g., 27.1% vs. 7.4% at 36 months; p = .000) and substance use (e.g., 17.4% vs. 7.8% at 36 months; p = .001). Children randomized to intensive behavior therapy reported less 24-month substance use than other MTA children (p = .02). Random effects ordinal growth models revealed no other effects of initial treatment assignment on delinquency seriousness or substance use. By 24 and 36 months, more days of prescribed medication were associated with more serious delinquency but not substance use.

Conclusions:

Cause-and-effect relationships between medication treatment and delinquency are unclear; the absence of associations between medication treatment and substance use needs to be re-evaluated at older ages. Findings underscore the need for continuous monitoring of these outcomes as children with attention-deficit/hyperactivity disorder enter adolescence.

Section snippets

Participants

Participants were 579 MTA children with DSM-IV ADHD Combined type and an additional 289 LNCG children (described below). Each of 6 sites randomized 96 to 98 children to one of four treatment groups: intensive multicomponent behavior therapy (Beh), intensive medication management (MedMgt), the combination of Beh and MedMgt (Comb), or referral to usual community care (CC). At baseline (pretreatment), participants were 7.0-9.9 years of age (mean 8.5 years, SD 0.8). The MTA recruitment strategy,

Level of Delinquency for the MTA and LNCG

Table 1 shows the percentages of MTA and LNCG children at each level of delinquency seriousness for all assessment points (recall that the LNCG began at the 24-month assessment). Following established practice (Lee and Hinshaw, 2004), the right side of Table 1 shows the percentages of children with either moderate (code 3) or serious (codes 4-5) delinquency at each of the assessments, separately for the MTA and LNCG children.

Across all of the assessments, most of the MTA children were not

DISCUSSION

We found that the majority of the MTA children were not seriously delinquent or were not experimenting prematurely with alcohol, tobacco, or illicit drugs by the 36-month assessment when most participants were 11 to 13 years old. Nevertheless, these behaviors were more prevalent among the MTA than LNCG children, with more than one fourth of the probands evidencing moderate or serious delinquency by the 36-month follow-up. The time course was quadratic: there was a significant decrease in

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    The Multimodal Treatment Study of Children with ADHD (MTA) was a National Institute of Mental health (NIMH) cooperative agreement randomized clinical trial involving six clinical sites. Collaborators from the National Institute of Mental Health: Peter S. Jensen, M.D. (currently at Columbia University, New York), L. Eugene Arnold, M.D., M.Ed. (currently at Ohio State University), Joanne B. Severe, M.S. (Clinical Trials Operations and Biostatistics Unit, Division of Services and Intervention Research), Benedetto Vitiello, M.D. (Child & Adolescent Treatment and Preventive Interventions Research Branch), Kimberly Hoagwood, Ph.D. (currently at Columbia University); previous contributors from NIMH to the early phase: John Richters, Ph.D. (currently at National Institute of Nursing Research); Donald Vereen, M.D. (currently at National Institute on Drug Abuse). Principal investigators and co-investigators from the clinical sites are University of California, Berkeley/San Francisco: Stephen P. Hinshaw, Ph.D. (Berkeley), Glen R. Elliott, M.D., Ph.D. (San Francisco); Duke University: C. Keith Conners, Ph.D., Karen C. Wells, Ph.D., John March, M.D., M.P.H., Jeffery Epstein, Ph.D.; University of California, Irvine/Los Angeles: James Swanson, Ph.D. (Irvine), Dennis P. Cantwell, M.D. (deceased, Los Angeles), Timothy Wigal, Ph.D. (Irvine); Long Island Jewish Medical Center/Montreal Children's Hospital: Howard B. Abikoff, Ph.D. (currently at New York University School of Medicine), Lily Hechtman, M.D. (McGill University, Montreal); New York State Psychiatric Institute/Columbia University/Mount Sinai Medical Center, New York: Laurence L. Greenhill, M.D. (Columbia University), Jeffrey H. Newcorn, M.D. (Mount Sinai School of Medicine); University of Pittsburgh: William E. Pelham, Ph.D. (currently at State University of New York, Buffalo), Betsy Hoza, Ph.D. (currently at University of Vermont, Burlington), Brooke Molina, Ph.D. Original statistical and trial design consultant: Helena C. Kraemer, Ph.D. (Stanford University). Follow-up phase statistical collaborators: Robert D. Gibbons, Ph.D. (University of Illinois, Chicago), Sue Marcus, Ph.D. (Mt. Sinai School of Medicine), Kwan Hur, Ph.D. (University of Illinois, Chicago). Kate Flory, Ph.D. (University of South Carolina at Columbia). Andrew Greiner, B.S. (State University of New York at Buffalo). Collaborator from the Office of Special Education Programs/U.S. Department of Education: Thomas Hanley, Ed.D. Collaborator from Office of Juvenile Justice and Delinquency Prevention/Department of Justice: Karen Stern, Ph.D.

    The work reported was supported by cooperative agreement grants and contracts from the National Institute of Mental Health to the following: University of California, Berkeley: U01 MH50461 and N01MH12009; Duke University: U01 MH50477 and N01MH12012; University of California, Irvine: U01 MH50440 and N01MH 12011; Research Foundation for Mental Hygiene (New York State Psychiatric Institute/Columbia University): U01 MH50467 and N01 MH12007; Long Island-Jewish Medical Center U01 MH50453; New York University: N01MH 12004; University of Pittsburgh: U01 MH50467 and N01 MH 12010; and McGill University N01MH12008.- The Office of Special Education Programs of the U.S. Department of Education, the Office of Juvenile Justice and Delinquency Prevention of the Justice Department, and the National Institute on Drug Abuse also participated in funding.

    Appreciation is extended to Dr. Patrick Curran, University of North Carolina, Chapel Hill, and Dr. Linda Muthén, Muthén & Muthén, Los Angeles, for their guidance regarding the technical aspects of the growth modeling used in this article, and to Drs. Magda Stouthamer-Loeber, Rolf Loeber, and Steven Lee for their assistance regarding the delinquency coding strategies used herein.

    The opinions and assertions contained in this report are the private views of the authors and are not to be construed as official or as reflecting the views of the National Institute of Mental Health, the National Institutes of Health, or the Department of Health and Human Services.

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    Copyright © 2007 The American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.