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For internalizing symptoms (parent reported), combined treatment and medication management symbols overlapped at the 14-month data point. For parent-child arguing (power assertion, parent reported), medication management and intensive behavioral treatment symbols overlapped at the 3-month and 14-month data points. A, Combined treatment and medication management were more effective than community care. B, Combined treatment was more effective than behavioral treatment and community care. C, Combined treatment and medication management were more effective than community care. D, Combined and behavioral treatment were more effective than community care.
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The MTA Cooperative Group. A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. Arch Gen Psychiatry. 1999;56(12):1073–1086. doi:10.1001/archpsyc.56.12.1073
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Previous studies have demonstrated the short-term efficacy of pharmacotherapy and behavior therapy for attention-deficit/hyperactivity disorder (ADHD), but no longer-term (ie, >4 months) investigations have compared these 2 treatments or their combination.
A group of 579 children with ADHD Combined Type, aged 7 to 9.9 years, were assigned to 14 months of medication management (titration followed by monthly visits); intensive behavioral treatment (parent, school, and child components, with therapist involvement gradually reduced over time); the two combined; or standard community care (treatments by community providers). Outcomes were assessed in multiple domains before and during treatment and at treatment end point (with the combined treatment and medication management groups continuing medication at all assessment points). Data were analyzed through intent-to-treat random-effects regression procedures.
All 4 groups showed sizable reductions in symptoms over time, with significant differences among them in degrees of change. For most ADHD symptoms, children in the combined treatment and medication management groups showed significantly greater improvement than those given intensive behavioral treatment and community care. Combined and medication management treatments did not differ significantly on any direct comparisons, but in several instances (oppositional/aggressive symptoms, internalizing symptoms, teacher-rated social skills, parent-child relations, and reading achievement) combined treatment proved superior to intensive behavioral treatment and/or community care while medication management did not. Study medication strategies were superior to community care treatments, despite the fact that two thirds of community-treated subjects received medication during the study period.
For ADHD symptoms, our carefully crafted medication management was superior to behavioral treatment and to routine community care that included medication. Our combined treatment did not yield significantly greater benefits than medication management for core ADHD symptoms, but may have provided modest advantages for non-ADHD symptom and positive functioning outcomes.
ATTENTION-deficit/hyper-activity disorder (ADHD) occurs in 3% to 5% of school-aged children, accounts for as many as 30% to 50% of child referrals to mental health services,1,2 and results in substantial impairment in peer, family, and academic functioning.2,3 Although benefits of short-term treatments (principally stimulants, behavior therapy, and both combined) have been well documented,4-8 few controlled studies have examined effectiveness beyond 3 months. Two exceptions9,10 suggested that stimulant effects can persist 1 to 2 years when taken faithfully. However, the generalizability and usefulness of these 2 studies are constrained by sample sociodemographic homogeneity, exclusion of stimulant nonresponders, lack of unimodal comparisons (medication management vs behavioral interventions), and inadequate statistical power to examine subject factors that predict treatment response.9,10
Given public concerns regarding stimulant treatment,11,12 wide variations in treatment practices,13 and lack of evidence to guide long-term treatments of this chronic disorder, in 1992 the National Institute of Mental Health and Department of Education cosponsored a randomized clinical trial, the Multimodal Treatment Study of Children With ADHD (MTA). Its rationale14 and methods15-19 have been detailed previously.
The MTA Cooperative Group posed 3 questions: How do long-term medication and behavioral treatments compare with one another? Are there additional benefits when they are used together? What is the effectiveness of systematic, carefully delivered treatments vs routine community care? This report constitutes the first-ever description of the relative effectiveness of these treatments through 14 months, using an intent-to-treat analytic strategy with random-effects regression techniques.20,21
Recruitment, screening, and selection procedures aimed to collect a carefully diagnosed sample of impaired children with ADHD and a wide range of comorbid conditions and demographic characteristics representative of patients seen in clinical practice. To minimize site-specific referral biases, sites' referral sources necessarily included mental health settings, pediatricians, advertisements, and school notices. For eligibility, children (of either sex) were between ages 7 and 9.9 years, in grades 1 through 4, and in residence with the same primary caretaker(s) for the last 6 months or longer. All met the DSM-IV criteria for ADHD Combined Type (the most common subtype in this age group22), using the Diagnostic Interview Schedule for Children (DISC), parent report, version 3.0,23 supplemented with up to 2 symptoms identified by children's teachers for cases falling just below the DISC diagnostic threshold. Exclusion criteria were limited to situations that would prevent families' full participation in assessments or treatment, or that might require additional treatments incompatible with study treatments (Table 1).16-18 The presence of comorbid conditions, such as oppositional-defiant disorder (ODD), conduct disorder (CD), internalizing disorders, or specific learning disabilities, did not lead to exclusions per se; an important aim of the study was to examine their interactions with treatment outcomes.
A 4-phase entry procedure (Table 2) screened potential participants, determined ADHD diagnostic status, and assessed each recruit prior to randomization.17,18 Ninety-five percent of subjects entering the fourth-phase baseline assessment were randomized; they did not differ from initial telephone screen subjects in parental education, ethnicity, or sex. Informed consent (parental permission and child assent) was obtained for all participating families, using forms approved by both local institutional review boards and the National Institutes of Health Office for Protection From Research Risks, Bethesda, Md.
In a 4-group parallel design, children were assigned randomly to medication management, behavioral treatment, combined treatment, or community care for 14 months. (In the method articles for this study, treatment assignments were referred to as medication, psychosocial treatment, combined treatment, and community-treatment/assessment and referral. To reflect more accurately the actual treatments, we have changed the terminology for all outcome articles to medication management, behavioral treatment, combined treatment, and community care.)Rather than testing fixed single treatments, we designed each MTA treatment arm as a management strategy, such that each was sufficiently robust and flexible to stand on its own and to respond to individual patients' clinical needs throughout the study.
Power analyses indicated 24 subjects per treatment condition per site (96 families at each of 6 sites) for comparisons of core ADHD symptoms between any 2 treatment arms (critical effect size, 0.4; power, 0.81, with a 5% 2-tailed test).17,24,25 Accordingly, 576 subjects were required; 579 were recruited. Sample demographics, mean scores on standardized Conners teacher and parent scales,26 comorbidity profile, and impairment ratings (Columbia Impairment Scale) are typical of other ADHD samples this age26-30 (Table 3).
Randomization was done centrally by the National Institute of Mental Health Data Center, Rockville, Md, stratified by site in blocks of 16 (4 to each group). Sealed, ordered envelopes were sent to sites for successive entries. Treatment assignment was concealed until the family confirmed agreement to accept randomization.
Principal components analyses narrowed the selection of outcome domains from the comprehensive assessment battery,28 eliminating redundant measures. Six major outcome domains were identified. Within domains, the measures loading highest from each informant were selected: (1) ADHD symptoms were measured with inattention and hyperactivity-impulsivity subscales of parent- teacher-completed SNAP ratings (an acronym denoting the names of the instrument's developers)31; (2) oppositional/aggressive symptoms were measured with a parent and teacher SNAP oppositional-defiant disorder subscale; (3) social skills were measured with a parent- and teacher-completed subscale from the Social Skills Rating System (SSRS)32; (4) internalizing symptoms (anxiety and depression) were measured with an internalizing subscale from parent- and teacher-completed SSRS,32 and children's self-ratings on the Multidimensional Anxiety Scale for Children (MASC)33; (5) parent-child relations were measured with 2 composite scales from a parent-child relationship questionnaire; and (6) academic achievement was measured with 3 subscales from the Wechsler Individual Achievement Test34 (reading, math, and spelling). These measures show acceptable psychometric properties, and are reviewed extensively elsewhere.31-34 Subjects were assessed at baseline, and at 3, 9, and 14 months (treatment end point). Baseline and end-point values for the outcome domains are presented in Table 4.
The open parent, teacher, and child ratings for domains 1 through 5 were augmented by blinded ratings of school-based ADHD and oppositional/aggressive symptoms using the Abikoff Classroom Observational System35 and social skills and peer relations using peer sociometric procedures. Finally, we videotaped parent-child interactions during standardized laboratory tasks performed by raters blind to treatment condition. Videotaped interactions, parental characteristics, family functioning, cognitive ability, general impairment, and services use, attitudes, and barriers18 will be reported in later articles.
The 3 MTA-delivered treatment strategies were chosen for well-established efficacy (at least in the short term), portability, sufficient intensity to stand alone, and distinction from each other. For all 3 arms, subjects had up to 8 additional sessions provided when needed to address clinical emergencies or instances of possible study attrition.
Behavioral treatment included parent training, child-focused treatment, and a school-based intervention organized and integrated with the school year. The parent training, based on work by Barkley36 and Forehand and MacMahon,37 involved 27 group (6 families per group) and 8 individual sessions per family. It began weekly on randomization, concurrent with biweekly teacher consultation; both were tapered over time. The same therapist-consultant conducted parent training and teacher consultation, with each therapist-consultant having a caseload of 12 families
The child-focused treatment was a summer treatment program (STP) developed by Pelham38 as a therapeutic summer camp. The 8-week, 5-days-per-week, 9-hours per-day STP employed intensive behavioral interventions administered by counselors/aides, supervised by the same teacher-consultants who performed parent training and teacher consultation. Behavioral interventions were delivered in group-based recreational settings, and included a point system tied to specific rewards, time out, social reinforcement, modeling, group problem-solving, sports skills, and social skills training. Summer treatment program classrooms provided individualized academic skills practice and reinforcement of appropriate classroom behavior.
The school-based treatment had 2 components: 10 to 16 sessions of biweekly teacher consultation focused on classroom behavior management strategies8 and 12 weeks (60 school days) of a part-time, behaviorally trained, paraprofessional aide working directly with the child (methods adapted from Swanson31). The aides had been STP counselors, and the program continued in the fall classroom, which helped to generalize STP gains to classrooms. Throughout the school year, a daily report card linked home and school. The daily report card8,39 was a 1-page teacher-completed checklist of the child's successes on specific preselected behaviors, and was brought home daily by the child to be reinforced by the parent with home-based rewards (eg, television time, snacks).
The treatments outlined above constitute the maximum "dose" of behavioral treatment children/families could receive, given perfect attendance and compliance. In practice, families (given both behavioral and combined treatment) attended an average of 77.8% of parent training sessions and 36.2 of 40 possible STP days. The school component averaged 10.7 teacher consultation visits and 47.6 days (of 60 possible) of work with classroom aides. Sites differed significantly in the extent of attendance for 2 components (parent training and classroom aides), but there were no significant differences between behavioral and combined treatment, either within or across sites, in degree of attendance/implemenation for any behavioral components (tables available from the authors on request). As described in our companion report, a summary measure of attendance/compliance for all behavioral treatment components was unrelated to treatment outcomes; likewise, attendance did not mediate any site × treatment interactions on outcomes.40
Consistent with the time-limited involvement of providers in clinical practice, the involvement of our personnel in the delivery of the behavioral treatments was gradually tapered, with the goal that parents would increasingly manage the child's behavioral treatment. In most cases, therapist contact with parents had been reduced to once-monthly sessions or stopped altogether prior to end-point assessment.
Medication management15 started with a 28-day, double-blind, daily-switch titration of methylphenidate hydrochloride, using 5 randomly ordered repeats each of placebo, 5 mg, 10 mg, and 15 or 20 mg (higher doses for children >25 kg). Each of the doses listed was given at breakfast and lunch, with a half-dose (rounded to the nearest 5 mg) in the afternoon. Cross-site teams of experienced clinicians blindly reviewed graphs portraying parent and teacher ratings of responses to each of the 4 doses and by consensus selected each child's best dose. After agreement on best dose, the blind was broken, and the agreed-on dose (if not placebo) became the subject's initial maintenance dose. For subjects not obtaining an adequate response to methylphenidate during titration, alternate medications were titrated openly in the following order until a satisfactory one was found: dextroamphetamine, pemoline, imipramine, and, if necessary, others approved by a cross-site panel. Of 289 subjects assigned to medication management (n = 144) and combined treatment (n = 145) for initial titration, 18 had no titration: 17 because they refused the entire medication component and 1 who moved away. An additional 15 subjects started but did not complete titration: 4 because of side effects, 7 because of difficulties tolerating the titration procedures, and 4 who supplied inadequate data. Thus, 256 subjects (88.6%) successfully completed titration; of these, 198 (68.5%) of 289 subjects were assigned to an individually titrated best dose of methylphenidate, with average initial doses of 30.5 mg/d. The remaining titration completers were either openly titrated to dextroamphetamine (n = 26) because of unsatisfactory methylphenidate response or initially given no medication (n = 32) because of a robust placebo response (2 of these placebo responders failed to cooperate further after titration).
During half-hour monthly medication maintenance visits, pharmacotherapists provided support, encouragement, and practical advice (but not behavioral treatment). When deemed necessary by the clinician or requested by the parent, readings from an approved list were supplied. After careful review of parent- and teacher-provided information, pharmacotherapists could make algorithm-guided dose adjustments of ±10 mg/d of methylphenidate (or an equipotent amount if the subject was taking another drug). Additional adjustments beyond ±10 mg/d could be authorized by a cross-site panel of experienced pharmacotherapists. In general, dose reductions were allowed only to address dose-related side effects.
By study end, 212 (73.4%) of the 289 subjects given medication management and combined treatment were being successfully maintained on methylphenidate, 30 (10.4%) on dextroamphetamine, 4 (1.4%) on pemoline, 3 (1.0%) on imipramine, 1 (0.3%) on buproprion, 1 (0.3%) on haloperidol, and 18 (3.1%) on no medication (combined treatment [14 subjects] and medication management [4 subjects]) (3.1%), with 20 persistently unmedicated (18 since study outset, 2 during maintenance). There were no differences between the medication management and combined treatment groups in the proportion of subjects maintained on the various medications.
Side effects were monitored monthly—not present, mild, moderate, or severe—using the parent-completed 13-item Pittsburgh Side Effects Rating Scale,41 reviewed by the pharmacotherapist. At end point, 245 combined treatment/medication management families provided information on side effects, with some reporting more than one: 88 (35.9) reported no side effects, 122 (49.8%) reported mild side effects only, 28 (11.4%) reported moderate side effects, and 7 (2.9%) reported severe side effects. These figures may overestimate side effects, because 6 of 11 reported severe side effects (depression, worrying, or irritability) could have been due to nonmedication factors.
Combined treatment provided all treatments outlined above for medication management and behavioral treatment; namely, titration followed by monthly medication maintenance, parent group and individual sessions, teacher consultation, STP, and the classroom aide. However, to approximate clinical practice, we integrated the 2 treatment modalities; information was regularly shared between the teacher-consultant and pharmacotherapist and used to guide overall decisions. Manualized guidelines determined if and when an adjustment in one treatment should be made, vs intervening first with the other.16,17 Consequently, the multimodal combination was not the simple addition of the two unimodal treatments. Consistent with the literature,42 by treatment end point combined treatment subjects received lower total daily doses of methylphenidate (31.2 mg) than medication management subjects (37.7 mg). Though sites differed significantly in total daily methylphenidate doses (range of mean doses per site, 30.2-41.3 mg), there were no site × treatment interactions in total daily doses (treatment group: F = 14.6, P = .01; site: F = 3.2, P = .002; site × treatment group: F11,200 = 1.2, P = .24).
Community care participants received none of our treatments, but were provided a report of their initial study assessments, along with a list of community mental health resources. They were subsequently reassessed in parallel with participants in our 3 treatment arms. At each assessment point, the types of treatments they obtained in the community were documented. Most community care subjects (n = 97 [67.4%]) received ADHD medications (principally one of the stimulants) from their own provider during the 14 months: methylphenidate (n = 84), pemoline (n = 7), amphetamine (n = 6), tricyclics (n = 6), clonidine/guanfacine (n = 4), and/or buproprion (n = 1) (10 subjects received more than 1 medication). In addition, 16 of these 97 children were treated by their physician with another antidepressant (not counting tricyclics or buproprion). For those treated with methylphenidate, the mean total daily dose at study completion was 22.6 mg, averaging 2.3 doses per day (vs 3.0 doses per day for MTA-treated subjects). Information concerning community care psychotherapeutic treatments has not yet been coded and will not be presented in this article.
The MTA study achieved a high degree of adherence to protocol by cross-arm emphasis on subject rapport, manualization of all treatments, regular supervision of pharmacotherapists and psychotherapists by skilled clinician investigators, cross-site weekly treatment panels, and audiotaping of all sessions. Good compliance (reflected by acceptance and attendance at treatment sessions) by patients with the protocol was facilitated by monthly pill counts, intermittent saliva measurements to monitor taking of methylphenidate, and encouragement of families to make up missed visits. Only 13 (9.0%) of 144 medication management subjects and 5 (3.4%) of 145 combined treatment subjects failed to start medication. More remarkably, none of 144 behavioral treatment subjects and only 1 (0.7) of 145 combined treatment subjects refused behavioral treatment. There was no difference between medication management or combined treatment in medication session attendance, nor between behavioral treatment and combined treatment in the degree of behavioral treatment acceptance or attendance. These factors did not affect the overall findings.40
Subjects/families refusing their respective treatments were encouraged to reconsider their decision throughout the study, as well as to continue to complete all assessments. Thus, including all subjects who continued to participate in assessments (despite refusing part of all of their assigned treatments), the absolute attrition rate over the course of the study was 3.5%, with only 20 complete dropouts by 14 months (6 in the community care group, 3 in behavioral treatment, 8 in medication management, 3 in combined treatment).
Given the well-described advantages of random-effects regression (RR) techniques over traditional analyses of variance for clinical trials data,43-46 we used RR whenever possible for our primary intent-to-treat analyses.20,21 Rather than define a single outcome, we specified multiple outcome variables, anticipating differential impacts of the treatment modalities on various outcome domains.5-7,14 Based on our data reduction procedures outlined above, the 6 domains were represented by 19 measures (Table 4). For each outcome variable, tests for site, time, time × treatment (the treatment effect over time), and site × treatment × time were conducted within the intent-to-treat RR analyses. When omnibus RR analyses comparing all 4 groups were significant, 3 sets of pairwise comparisons were performed, each set addressing 1 of the principal study questions: (1) medication management vs behavioral treatment (2 tailed); (2) combined treatment vs medication management and combined treatment vs behavioral treatment (1 tailed, assuming the superiority of combined treatment); and (3) community care vs medication management, community care vs behavioral treatment, and community care vs combined treatment (1 tailed, assuming the superiority of MTA treatments).
Bonferonni corrections were applied to all omnibus tests, based on the number of measures in the respective domain. Thus, for each of 5 measures within the ADHD domain, standard definitions of significance (P<.05) were corrected by dividing by 5, requiring P<.01 for significance. The 6 pairwise contrasts were likewise adjusted by dividing omnibus-corrected significance levels further by 6 (P<.01 ÷ 6 = .0017 in this example). Given our a priori hypotheses about the superiority of multimodal treatment (combined treatment vs medication management and behavioral treatment), as well as the superiority of all 3 of our treatments over community care (community care vs combined treatment, medication management, behavioral treatment), we used 1-tailed tests for these specific contrasts. This approach was taken as a means of striking a balance between the dangers of committing type II errors vs overinterpreting significant findings that occurred simply by chance (type I errors). Readers are encouraged to exercise caution when interpreting 1-tailed findings and may choose to double 1-tailed P values.
Because initial RR analyses revealed both quadratic and linear effects of time on treatment outcomes, we computed the log of the number of days since randomization for each assessment point and used these log values in all RR analyses.
Despite high compliance, we checked whether compliance with assessments (ie, missing data) could have changed our findings. Random-effects regression analyses were completed 2 ways: once with inclusion of all subjects, and then with only those subjects who provided data over multiple time points during the study. No differences emerged among these 2 sets of analyses, lending confidence to the overall findings.
For 10 of 19 variables, omnibus tests revealed significant treatment effects over time. For these analyses, we describe the results of the paired comparisons, in order of our original hypotheses.
Do medication and behavioral treatments result in comparable levels of improvement in pertinent outcomes at the end of treatment? Robust differences were found according to 2 different data sources, indicating the superiority of medication management over behavioral treatment for ADHD symptoms (Table 5); namely, parents' and teachers' ratings of inattention and teachers' ratings of hyperactivity-impulsivity. Medication management and behavioral treatment did not differ significantly on any other outcomes.
Do participants assigned to combined treatment show higher levels of improvement in overall functioning in pertinent outcome domains than those assigned to either medication management or behavioral treatment at the end of treatment (1-tailed hypotheses)? These analyses indicate that combined treatment and medication management did not differ significantly across any domain.
Compared with behavioral treatment, combined treatment was superior in benefitting ADHD symptoms, according to parents' and teachers' ratings of inattention and parent-rated hyperactivity-impulsivity. Combined treatment also significantly outperformed behavioral treatment on parents' SNAP oppositional/aggressive behaviors, parent-rated internalizing symptoms (Table 5), and Weschler Individual Achievement Test reading achievement score (Table 4).
Do participants assigned to each of the 3 MTA treatments (medication management, behavioral treatment, and combined treatment) show greater improvement over 14 months than those assigned to community care (1 tailed)? These analyses reveal that combined treatment and medication management were generally superior to community care for parent- and teacher-reported ADHD symptoms, whereas behavioral treatment was not (Table 5). In non-ADHD domains, medication management and behavioral treatment were superior to community care on 1 domain only (teacher-reported social skills and 1 measure of parent-child relations, respectively). In contrast, combined treatment was significantly superior to community care on all 5 non-ADHD domains of functioning (parent-reported oppositional/aggressive behaviors, internalizing symptoms, teacher-reported social skillls, parent-child relations, and Weschler Individual Achievement Test reading achievement scores).
Because our RR intent-to-treat analyses included all subjects' data points through 14 months, it is possible that some treatment groups (especially behavioral treatment, where 38 crossovers to medication occurred) may have fared better because of the number who had received additional treatments over the course of the study. To address this issue, we conducted additional RR analyses, censoring any observations obtained after crossover subjects had received the additional treatments. These analyses yielded no differences from the findings noted in Table 5 (analyses available from the authors on request).
Figure 1 shows the 4 RR analyses selected to highlight findings from different domains, as well as from raters who were likely to witness the target behaviors: hyperactivity-impulsivity (a core ADHD symptom)(teacher report), internalizing symptoms (parent report), social skills (teacher report), and parent-child arguing (power assertion, parent report). The remaining RR graphs are available from the authors on request.
All 4 groups showed marked reductions in symptoms over time, with significant differences among them in degrees of change. Combined treatment and medication management treatments were clinically and statistically superior to behavioral treatment and community care in reducing children's ADHD symptoms. Combined behavioral intervention and stimulant medication—multimodal treatment, the current criterion standard for ADHD interventions—yielded no significantly greater benefits than medication management for core ADHD symptoms; this parallels findings reported by others.10,42 Also consistent with previous reports, our combined treatment outcomes were achieved with significantly lower medication doses than used in medication management.42,47
For other areas of function (oppositional/aggressive behaviors, internalizing symptoms, social skills, parent-child relations, and academic achievement), few differences among our treatments were noted, and when found, were generally of smaller magnitude. In fact, combined treatment, medication management, and behavioral treatment never differed significantly among themselves, with 3 exceptions (combined treatment > behavioral treatment for parent-reported internalizing problems and oppositional/aggressive symptoms, and Weschler Individual Achievement Test reading achievement score).
With respect to comparisons of MTA treatments with community care, combined treatment and medication management fared substantially better than community care on most ADHD outcome measures, while behavioral treatment did not. According to least 1 informant, combined treatment also fared significantly better than community care for all 5 non-ADHD domains: parent-reported oppositional/aggressive symptoms, parent-reported internalizing problems, teacher-reported social skills, parent-child relations, and reading achievement. In contrast, medication management and behavioral treatment each fared better than community care in 1 non-ADHD domain only (teacher-rated social skills and parent-child relations).
Our finding that MTA treatments (most notably combined treatment) offered greater benefits than community care for oppositional/aggressive behaviors, internalizing symptoms, peer interactions, parent-child relations, and reading achievement has not been previously reported in long-term studies.3,5,14 However, the differential benefits in these non-ADHD domains are consistent with the theoretical aims of multimodal approaches.14 For example, medication is known to reduce negative peer interactions dramatically, but increases in positive social behavior are far less robust.48 Such changes might require intensive and long-term application of the behavioral components of combined treatments, such as those found in our STP and school-based interventions.38 Similarly, parent training, which includes positive parental attention and rewards for the child's appropriate behavior, when combined with medication, might be expected to decrease oppositionality and enhance parent-child relations more than medication alone. For internalizing symptoms, the relatively greater improvements for subjects given combined treatment are particularly noteworthy, as none of our treatments were designed to address this domain specifically.
The MTA study extends the findings of previous studies that demonstrated short-term, robust efficacy of medication management, showing that these benefits persist during treatment up to 14 months. In contrast to frequently expressed concerns, children given combined treatment and medication management tolerated medication well, including a third dose given in the afternoon. The relative improvements attributed to medication management also parallel findings from other, longer-duration stimulant trials.9,10,49 Given the MTA's size and scope, however, we saw effects across diverse settings, patient groups, provider characteristics, and outcome domains. These findings were further strengthened by the absence of any site×treatment interactions.
Although combined treatment and medication management were generally superior to community care, community treatments usually included medication; hence, it is unclear which components of the 2 MTA medication treatments may have rendered them more effective than community care. Further analyses of these findings are presented in our companion report,40 but reviewing the apparent differences is instructive. We used a manualized medication titration procedure and "thrice-daily" dosing, as well as higher, carefully monitored daily doses to maximize positive effects and minimize side effects.15 We met with parents monthly and obtained systematic feedback, from both them and the children's teachers. Parent guidance and selected readings were provided as needed; this is reported to provide benefits over simple pill dispensing alone.50 These components, particularly the systematic and regular feedback from teachers, do not seem to be part of routine pediatric ADHD treatment practices,13 and may have enhanced the effectiveness of our medication management.
The modest benefits for some non-ADHD domains obtained by multimodal treatments have been reported previously5,51,52 after 3 to 4 months of treatment. In contrast, the study by Hechtman and Abikoff10 failed to demonstrate these effects after 12 months of active treatment, perhaps because of their smaller sample (103 subjects distributed across 3 groups). In addition to the MTA's sample size advantages, its behavioral component design required that behavioral treatment interventions be delivered across multiple settings and caretakers (home, school, and STP), augmented with further strategies to facilitate the generalization of effects across settings and over time17,19—all enhancements not found in previous studies.8
Whether there is greater value for multimodal treatments for ADHD depends on which intervention is considered as the comparison. If one assumes that a behavioral intervention should always be used as the first-line ADHD treatment (often the preference for many parents, and the practice in many European countries), and that the possibly greater benefits of combined treatment should be determined, then combined treatment seems to offer a great deal of benefit over behavioral treatment alone. But if one provides carefully monitored medication treatment similar to that used in this study as the first line of treatment, our results suggest that many treated children may not require intensive behavioral interventions.47
The significantly lower total daily doses of methylphenidate in the combined treatment arm are noteworthy but not unforeseen.42,47 The importance of this finding is unclear, and a rigorous test of this question would likely require a different design. Nonetheless, this issue remains an ongoing source of concern of many parents and clinicians and should not be dismissed, particularly since side effects are usually related to dosage. If equivalent, sometimes better results can be obtained by a combined treatment that uses lower doses, such findings may have public health importance.
Concerning the relative benefits of our behavioral treatment alone, results must be understood within the context of the limitations of our study design. Most importantly, our design did not include a no-treatment or placebo group (an ethically unacceptable option for an ADHD study of this length), and most subjects given community care received medication for most of the study period—a treatment of known efficacy. Substantial improvement occurred over time across all groups (including community care), regardless of rating source or method. While some of this change could be regression to the mean, this explanation cannot account for the substantial group differences reported here. More than three fourths of subjects given behavioral treatment were successfully maintained without medication throughout the study. Consequently, it should not be concluded that behavioral treatment interventions did not work.
One caveat concerns our choice and number of outcome measures. We felt that the treatment effects in different domains and from different respondents might vary, and that these variations were necessary in interpreting the results of the study. Consequently, despite the loss of power caused by Bonferonni corrections, we chose 19 primary outcome measures rather than a single summary outcome score. Power calculations17 that underlay the setting of sample size were based on setting as the lower limit of clinical significance an effect size of 0.4 ("small to moderate"53) and on the requirement of 80% power (5% level of confidence) to detect effects of that magnitude. Thus, the chance is high of declaring effect sizes lower than 0.4 not statistically significant, even though some clinicians might regard such effects as clinically significant.
Hence, for purposes of assessing clinical significance, the overall pattern of results may be more instructive than any single test statistic or P value reported in Table 4 and Table 5. The general ordering of treatment groups' benefits is confirmed by simple inspection of the number of times each group placed first compared with all others on the 19 outcome measures: combined treatment, 12; medication management, 4; behavioral treatment, 2; and community care, 1. While combined treatment scored numerically "best" on most outcome measures, we did not have statistical power to detect small effects, such as those that might exist between combined treatment and medication management.25 Statistical significance, of course, cannot be interpreted as necessarily indicative of clinical or practical significance, and lack of significance is never proof of the equivalency of treatments.
By way of caution, we note that subgroup analyses may yield different treatment effects for specific patient groups than the main intent-to-treat analyses presented herein. In our companion article40 we report analyses indicating that children with ADHD who have co-occurring disorders, as well as those with fewer family resources, are more likely to benefit specifically from combined and behavioral treatments for some outcome domains. In addition, other unidentified individual factors may yield excellent responses to one of the several treatments.47 Response patterns and characteristics of such "excellent responders" will likely be obscured by large-group analyses. Future studies will examine these issues in more detail.
Such considerations highlight the need for caution in interpreting our results and argue against a "one size fits all" approach to treatment. Moreover, our results cannot necessarily be generalized beyond ADHD Combined Type; other ADHD subtypes (eg, inattentive subtype) may warrant somewhat different treatments.
Previous research has shown that the medication benefits persist only so long as treatment is continued.6,54 Whenever possible, our subjects given combined treatment and medication management received medication throughout the 14 months, including all assessment points. By contrast, and consistent with clinical practice, for subjects given behavioral treatment, the frequency of contact with therapists was gradually reduced to once-monthly contacts 3 to 6 months prior to posttreatment assessment; in general, they were assessed up to 1 month after their last treatment contact. Procedures for maintenance and generalization were incorporated throughout behavioral treatment's implementation; the goal was that benefits would persist as parents and children learned and consolidated their skills. However, our behavioral treatment procedures, increasingly nonintensive during the once-monthly contacts, were insufficient to produce overall effects comparable or additive with 14 months of ongoing medication management for core ADHD symptoms.
Unanswered in our study are important questions concerning behavioral and combined treatments for ADHD. Are there some children for whom medication management is no longer necessary,9 and if so, why does this occur? Might the behavioral component of combined treatment allow some children to be successfully tapered off medication? Can and should behavioral and pharmacologic treatments be tapered, and how can that be accomplished while maintaining effects? Will findings differ as children age, such that those who have learned increased skills via behavioral interventions eventually function better than those receiving only medication? Follow-up study of our subjects past 14 months (currently under way) will address some of these critical questions.
Since ADHD is now regarded by most experts as a chronic disorder,14 ongoing treatment often seems necessary. As with other chronic conditions, such as diabetes and asthma, the need for active treatment may wax and wane. Just as exercise, diet, and pollen load may affect these illnesses, persons' learning or work environments and intercurrent stressors may affect the need for, type, and intensity of ADHD treatments over the life course.55 Under such conditions, behavioral treatments may help families actively cope with their child's disorder and make the necessary life accommodations to optimize family functioning, even when such treatments are not as effective as medication in reducing children's ADHD symptoms. Indeed, 14-month end-point analyses indicated that parent satisfaction ratings differed significantly by treatment group; pairwise contrasts showed that treatment satisfaction scores for combined treatment and behavioral treatment parents were significantly superior to medication management parents' ratings (though not differing between themselves), suggesting that the behavioral treatment components benefitted this area of family-relevant outcomes.
The absence of any site×treatment×time interactions suggests that both our pharmacological and behavioral treatments could be delivered with fidelity across 6 very different clinical settings. However, the use of these treatments will ultimately be determined by the degree to which they are feasible, transportable, and affordable in real-world settings—topics for future research. In the interim, however, the MTA study, by virtue of its size; scope; length; parallel group design; explicit use of manualized, evidence-based treatments; high degree of compliance across arms and over the course of the study; and comprehensive range of outcome assessments, sets an important benchmark for future trials testing new treatments for childhood ADHD.
Accepted for publication July 28, 1999.
This study was supported by grants UO1 MH50461 (Drs Hinshaw and Elliot), UO1 MH50447 (Drs Conners, Wells, and March), UO1 MH50440 (Drs Swanson, Cantwell, and Wigal), UO1 MH50453 (Drs Abikoff and Hechtman), UO1MH50454 (Drs Greenhill and Newcorn), and UO1 MH50467 (Drs Pelham and Hoza), from the National Institute of Mental Health, Bethesda, Md.
The opinions and assertions contained in this study are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Health and Human Services, Washington, DC, or the National Institute of Mental Health, Bethesda, Md.
Principal Collaborators
National Institute of Mental Health, Rockville, Md: Peter S. Jensen, MD (Office of the Director); L. Eugene Arnold, MD (Department of Psychiatry, Ohio State University); John E. Richters, PhD (Developmental Psychopathology and Prevention Research Branch); Joanne B. Severe, MS (Research Projects and Publications Branch); Donald Vereen, MD (Office of Drug Control Policy); and Benedetto Vitiello, MD (Child and Adolescent Treatment and Preventive Interventions Research Branch).
Office of Special Education Programs, US Department of Education, Washington, DC: Ellen Schiller, PhD.
Principal Investigators and Coinvestigators
University of California, Berkeley/University of California, San Francisco: Stephen P. Hinshaw, PhD (Department of Psychology, University of California, Berkeley); Glen R. Elliott, MD, PhD (Department of Psychiatry, University of California, San Francisco).
Duke University, Durham, NC: C. Keith Conners, PhD, Karen C. Wells, PhD, and John March, MD (Department of Psychiatry and Behavioral Sciences).
University of California, Irvine/University of California at Los Angeles: James Swanson, PhD, and Timothy Wigal, PhD (Department of Pediatrics and Cognitive Science, University of California, Irvine); Dennis P. Cantwell, MD (deceased) (Department of Psychiatry, Neuropsychiatric Institute, University of California at Los Angeles).
Long Island Jewish Medical Center, New York, NY/Montreal Children's Hospital, Montreal, Quebec: Howard B. Abikoff, PhD (Department of Psychiatry, New York University School of Medicine); Lily Hechtman, MD (Department of Psychiatry, McGill University, Montreal).
New York State Psychiatric Institute/Columbia University/Mount Sinai Medical Center, New York, NY: Laurence L. Greenhill, MD (Department of Psychiatry, Columbia University); Jeffrey H. Newcorn, MD (Department of Psychiatry, Mount Sinai School of Medicine).
University of Pittsburgh, Pittsburgh, Pa: William E. Pelham, PhD (Department of Psychology, State University of New York at Buffalo); Betsy Hoza, PhD (Department of Psychological Sciences, Purdue University, West Lafayette, Ind).
Statistical and Design Consultation
Helena C. Kraemer, PhD (Department of Psychiatry and Behavioral Science, Stanford University, Palo Alto, Calif).
Corresponding author: Peter S. Jensen, MD, Department of Child Psychiatry, Unit 78, Center for the Advancement of Children's Mental Health, New York State Psychiatric Institute/Columbia University, 1051 Riverside Dr, New York, NY 10032 (e-mail: email@example.com).


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Jewish Congress Prepares To Meet in Hungary Amid Claims of Anti-Semitism
The World Jewish Congress's upcoming quadrennial assembly, scheduled for May 5 in Budapest, Hungary, promises to be a complicated affair. It arrives just one month after WJC President Ronald Lauder's public condemnation of his host country's prime minister for presiding over "a xenophobic and increasingly anti-Semitic country."
In fact, Lauder says proudly, this is precisely why he has decided to hold his group's annual gathering in Hungary. And Hungarian Prime Minister Viktor Orban's acceptance of the WJC's invitation to address its opening dinner will only add to the anticipated high drama.
WJC spokesman Michael Thaidigsmann said Lauder's condemnation of Orban was not meant as a "slap in the face" and that the WJC looks forward to hearing "what [Orban] has to say."
But for all the stagecraft the WJC has devoted to delivering a message to Hungary's government, many others involved, including key Jewish leaders, say that Lauder's depiction of Orban's government as pandering to anti-Semitism is simplistic. Abraham Foxman, national director of the Anti-Defamation League, told the Forward, "We're encouraged that the Orban government is showing greater awareness of the problem of anti-Semitism in Hungary and has begun to improve its responsiveness."
It was on April 4 that Lauder, the billionaire cosmetics heir, former ambassador to Austria and longtime Jewish leader, published an opinion piece lashing out at Orban. In the jeremiad, which appeared in Süddeutsche Zeitung, a German newspaper, Lauder accused the Hungarian leader of having "lost his political compass" and of transforming himself from a once "dynamic, but pragmatic conservative" into "an ideologue for Hungarian nationalism."
"The number of anti-Semitic or anti-Roma [Gypsy] statements increased dramatically in recent years, and some of them have come from senior members of the prime minister's party or his government," Lauder wrote.
A Hungarian government official, who did not wish to be named because he had not been authorized to speak on the matter, said that Lauder's statement was a shock, particularly because it came shortly after Orban had accepted Lauder's invitation to address his group's dinner, which kicks off the two-day conference.
"This is how life treats you very well if you are an NGO," the Hungarian official said, referring to the WJC's status as a nongovernmental organization. "You can say what you want, and don't have to bother with facts."
The official said Lauder mischaracterized the situation in Hungary. He directed the Forward to testimony delivered before a U.S. House of Representatives hearing on anti-Semitism in February, in which a former Hungarian government minister rejected the idea that the Orban government was anti-Semitic.
The former minister, Tamas Fellegi, admitted that racism was on the rise in Hungary, but he told the hearing committee that the Orban government had done more than any previous administration to curtail hate speech and to promote and support the "rebirth of Jewish culture."
Critics accuse Orban's center-right party, Fidesz, of pandering to extreme nationalist sentiment in order to win the 2010 general election. Although Fidesz won comfortably, with 53% of the vote, the other big winner of the election was the far-right party, Jobbik, which won 17% of the vote. Today, Jobbik is the third-largest party in Hungary's parliament.
Jobbik ran on a populist platform that attacked incompetent and corrupt Hungarian officials, Roma "criminals" and nefarious Israeli businessmen, who were accused of buying up Hungary.
The rise of Jobbik in recent years has coincided with a sharp increase in anti-Roma and anti-Semitic discourse in Hungary. Andras Kovacs, a professor at Budapest's Central European University and an expert on anti-Semitism, published a recent study noting that about 28% of the Hungarian population displayed anti-Semitic attitudes in 2010 compared with about 12.5% in 1990.
The Anti-Defamation League paints an even bleaker picture. It said that anti-Semitic attitudes in Hungary rose to 63% of the population in 2012 from 47% in 2009.
Yet the ADL is careful when discussing Hungary's problems. Michael Salberg, the ADL's director of international affairs, said that a few years ago Fidesz politicians were slow to react to anti-Semitism, but today they have begun to act more swiftly. "We are seeing a greater sensitivity [to anti-Semitism], a greater willingness [to speak out]," Salberg said.
As examples, Salberg pointed to the government's recent ban on an anti-Semitic rally organized by far-right bikers to coincide with a Holocaust memorial march. He also noted the adoption of a constitutional amendment to curtail hate speech.
That amendment was proposed following a couple of anti-Semitic statements made by Jobbik politicians in the Hungarian parliament last year. On the eve of Passover, a Jobbik lawmaker gave a speech resurrecting a 19th-century blood libel. In the fall, another MP called for a list of Jews to be drawn up, including politicians who have Jewish roots and "represent a certain national security risk for Hungary."
Although Fidesz has tried to distance itself from Jobbik, it is still blamed by some for pandering to far-right sentiments. Fidesz "often presents itself as a bulwark against Jobbik when it comes to issues of anti-Semitism," said Andrew Baker, the American Jewish Committee's director of international Jewish affairs. "But you have a leader in Viktor Orban, who still flirts with Jobbik voters."
Baker said Orban has spoken out against anti-Semitism. "That's important and shouldn't be discounted," he said. But, he added, "I think they're more interested in doing PR than getting some of these issues addressed."
In some cases, Fidesz has appeared to support nationalist sentiment. This year, anti-Semitic Hungarian writers such as Jozsef Nyiro, who was a pro-Nazi member of Hungary's World War II-era parliament, and Albert Wass have been introduced into Hungary's new national curriculum. In March, Hungary's minister of human resources was forced to apologize after his ministry awarded a national honor to Ferenc Szaniszlo, a TV journalist who has a record of making anti-Roma and anti-Semitic statements.
Gyorgy Szabo, who leads a government-financed organization that administers Holocaust restitution funds to the Jewish community, said he knows the human resources minister personally and that he is not an anti-Semite. "It was a mistake," Szabo said.
Szabo said that since the fall of communism in Hungary in 1990, a succession of governments have failed to quell anti-Semitism. He said hate speech is only worse now because of Hungary's economy, which took a beating during the global recession. A recent report from the International Monetary Fund noted that "Hungary has been plagued by low growth and high debt for much of the last decade." Unemployment is at about 11%.
Peter Feldmajer, head of Hungary's Jewish community, echoed Szabo, saying that the Fidesz government is not anti-Semitic. Feldmajer said the real problem in Hungary is at the local level, where several municipalities have begun to erect statues of Miklos Horthy, a military dictator who ruled Hungary from the end of World War I through most of World War II. Horthy is an incendiary figure in Hungarian-Jewish history because more than 500,000 Jews were murdered or sent to death camps while Horthy remained nominally in power during the German occupation.
Feldmajer compared the present Jewish situation in Hungary favorably with that of nearby countries — particularly France, where physical assault, even murder, has become a real threat. But while most of the active animosity being directed at Jews in countries such as France comes from Arab and Muslim communities, in Hungary hate emanates from ethnic Hungarians who make up 92% of the population.
So far, the Roma have borne the brunt of the bigotry. Paramilitary groups allied with Jobbik have terrorized Roma communities since 2006, according to a report by the European Roma Rights Center. In recent years, seven Roma have been killed, including a 5-year-old boy, in 22 known cases of anti-Roma violence cataloged by the ERRC.
Hungarian Jews said they do not feel physically threatened. But they agreed that racial discourse has become poisonous. "The most problematic thing is the atmosphere, what is in the air," Feldmajer said. "It's a bad feeling for Jews, for Romas, because the hate speech is so strong in Hungary."
Shlomo Koves, a Chabad rabbi, said that he suffered more physical attacks during a couple of years living in Paris during the late 1990s than he has experienced during the past decade in Budapest. But Koves said that in Budapest, "the verbal anti-Semitism is becoming really bad." He said that in the past couple of years he has been spat at and people have screamed at him "Dirty Jew!" or "Hungary belongs to Hungarians."
Contact Paul Berger at [email protected] or on Twitter @pdberger

subset: commoncrawl


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Makers or Mayhem - Boys - Athletic Grey
Makers or Mayhem - Boys - Athletic Grey
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We want you to have your order as fast as possible! But, please allow between 1-2 weeks to print and process your order!


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The UAB Piano Series this season will feature performances by world-class pianists Nikolai Lugansky on Oct. 28, 2012, Alexander Shtarkman on Jan. 13, 2013, and Sara Daneshpour on March 10, 2013.
|Nikolai Lugansky
Performances in the UAB Piano Series are held at 4 p.m. in UAB's Alys Stephens Performing Arts Center, Reynolds-Kirschbaum Recital Hall, 1200 10th Ave. South. Tickets are $15 for general admission and $5 for UAB students with valid I.D. Season tickets for all three performances are available. Call 205-975-2787 for tickets. The UAB Piano Series is presented by the UAB Department of Music; visit the department online at www.uab.edu/music.
Lugansky, set to perform Sunday, Oct. 28, is among the world's top five pianists, says UAB Professor of Piano Yakov Kasman, D.M.A. Born to research scientists in Moscow, Lugansky's musical ability shone brightly at an early age. When he was only five, before he had even been taught to read music, he went to a neighbor's house and played a Beethoven sonata from memory, having learned the music by ear. He won first prize in the All-Union Competition in Tbilisi in 1988 and the silver medal at the International Bach Competition in Leipzig. In 1990 he took second prize at Moscow's Rachmaninoff Competition. He was awarded "Best Pianist" in 1992 at the International Summer Academy Mozarteum in Austria. In 1994, after recovering from back and foot injuries sustained in an accident, and after the death of his teacher, he won the 1994 Tchaikovsky Competition.
|Alexander Shtarkman
Today, Lugansky is considered one of the world's great interpreters of piano repertoire. His concerts, recitals and chamber music performances throughout Europe, Asia and the Americas have earned him rave reviews. His recordings include Chopin's "Etudes," as well as Rachmaninoff's "Preludes and Moments Musicaux" and Chopin's "Preludes," all of which won Diapason d'Or de L'Annee awards. In addition to performing, Lugansky teaches at the Moscow Conservatory.
Shtarkman, set to perform Sunday, Jan. 13, has wowed critics and audiences alike. His debut recitals in Los Angeles, Chicago and New York City prompted strong words of praise. Martin Bernheimer of the Los Angeles Times wrote, "Alexander Shtarkman. Remember the name.... He plays the piano with all the strength, flash and eagerness that his age would suggest. He also plays with the sensitivity and mellow refinement one associates with certain grand old men of the keyboard, most of them Russian."
In August 1995, Shtarkman was awarded the First Prize of the Busoni International Piano Competition in Bolzano, Italy. As a result, he has been offered more than 60 European recitals and orchestral engagements. Shtarkman also is a winner of the 1989 Van Cliburn International Piano Competition and the 1994 Tchaikovsky Piano Competition. He won first prize at the First Taipei International Piano Competition. He is a frequent guest performer at the prestigious Great and Small Halls of the Moscow Conservatory. Since 2002, Shtarkman has been a member of the piano faculty at the Peabody Conservatory of Music.
Daneshpour, set to perform Sunday, March 10, is a finalist for the ProLiance Energy Classical Fellowship Awards of the American Pianists Association. She won first prize this year at the XII Concours International de Musique du Maroc, in Morocco; second prize in the 2007 William Kapell International Piano Competition; first prize and gold medal of the 2007 International Russian Music Piano Competition; and first prize at the 2003 Beethoven Society of America Competition. Daneshpour is a graduate of the Curtis Institute of Music, studying under Leon Fleisher, and is pursuing her master's degree at the Juilliard School with Yoheved Kaplinsky. Daneshpour has performed in her native city of Washington, D.C., and in New York, Philadelphia, Cleveland, Russia, Germany, Finland, Estonia, Denmark and Sweden. She has been heard on the stages of prestigious venues including the Kennedy Center, Carnegie Hall and the Great Hall of the Moscow Tchaikovsky Conservatory.
Of her performance with the Baltimore Symphony Orchestra, The Washington Post wrote "she created transfixing poetry. And she found delightful details in passagework and incidents that other pianists treat as routine." The Baltimore Sun stated that she "delivered a powerhouse account of Tchaikovsky's Concerto No.1, producing enough tone for two pianists in the process," while The Mercury News called her performance "sensational," adding: "Strength, finesse, passion; it was all there."


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Thai Heart is pleased to open its doors and welcome you into a new traditional Thai atmosphere with authentic, home-style Thai cooking. We have carefully blended traditional and modern Thai style in both the décor and the cuisine in order to provide you with a very special dining experience.
Our Chefs in Thai Heart have many years experience cooking Thai food not only in the US but also at their family's restaurant in Thailand. They bring an authentic style and flavor not found in most Thai restaurants in the Scott Valley Area. Their extensive experience and true passion for cooking is evident in the intricate flavors and delicate blending of herbs and spices. Of course, there are a few of the usual spicy Thai dishes for those who like the fire of Thai chilis. However, there are many mild dishes as well. But whether cooking spicy or mild, our Chefs carefully prepare each dish from the freshest authentic Thai ingredients. Thai food you will find anywhere.
Closed All Lunch / we do take out togo take home order No!Seating inside
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NoSeating inside , we' re do just take out only
831-438-1800 if it's Busy Please Try Again. Thank You


text: Every sport has its fans, and the Phoenix Suns basketball team is finding that use of social networking has become one of the main ways to keep in touch with its fan base -- though it can get dicey when basketball fans across the NBA go a little wild before big games."Social media is big, like Twitter and Facebook," says Bill Bolt, vice president of information technology for the Phoenix Suns, the NBA team whose home arena is the US Airways Center in Phoenix, Ariz. "And now there's Google."IN PICTURES: Best and worst celebrity technology moments of 2011Online interaction with fans started years ago with the team's website and email, and now there are five employees of the Phoenix Suns coordinating outreach on social media, whether it's tweeting team news, posting video interviews with coaches or team stars like Jared Dudley and Steve Nash, or selling game tickets through direct interaction with potential customers.But sometimes things can get a little out of hand when emotions run high and fans from competing teams run wild across the Internet.The craziness comes into play when there are direct attacks on the Phoenix Suns network and "some people will try to log into the network," says Bolt, saying the Phoenix Suns' information technology department also detects attempts to try to get into email or Twitter accounts associated with basketball stars. These incidents are most apparent as ongoing battles that occur at playoff times when emotions run high among fans of competing teams."Some of this crosses the line," says Bolt, adding the Phoenix Suns have to dedicate resources to screening and eliminating expressions of virulent hate or verbal abuse coming in via Facebook and other sources.There are also attempts to send email floods to the Phoenix Suns and attempts at phishing to steal identities. The Phoenix Suns makes use of security gear from Check Point, McAfee, SonicWall and LogRhythm, among others, to hold down the fort by monitoring, detecting and filtering out attack traffic. Most of these types of attacks tend to be cyclical and tied to big games.Most of this strikes Bolt as not deep-down malicious but just basketball fans going zany at their computers for a short spell. But there are also attacks that suggest someone would like to infiltrate the Phoenix Suns, perhaps for more nefarious purposes.Bolt says his IT team, which includes three technicians, keeps close watch on information related to Microsoft vulnerabilities and dangerous new malware types, and when there are worries, will write custom anti-malware signatures or temporarily block access to certain Microsoft servers. "When we interact with the outside, we're always cautious to protect the systems bringing traffic back in," says Bolt. "I'm using a lot of security products."Bolt pointed out that the Phoenix Suns website is hosted by Turner Entertainment in Atlanta as part of a contract with the National Basketball Association and its teams. The Phoenix Suns uploads content to Turner. And in other complexity, the IT staff at the Phoenix Suns is responsible for assisting with events taking place at the US Airways Center arena."So if the circus, for instance, comes for a visit, it asks for Wi-Fi resources so they can do their business while in the building. Or they may want to do simulcast. We give them the bandwidth they need," says Bolt, adding these kinds of visitors get network credentials to log in to a separate VLAN with access to the Internet.Since a lot of events go on in the evening, it's helpful that the LogRhythm monitoring is set up to automatically watch whether the variety of databases, servers and network resources are not only up and running but working optimally. "One of the most serious things it discovered was it warned me databases were potentially running out of space," says Bolt, adding that would have left a lot of employees doing nothing if it hadn't been detected.Ellen Messmer is senior editor at Network World, an IDG publication and website, where she covers news and technology trends related to information security.Read more about wide area network in Network World's Wide Area Network section.


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A Petition to require Boulder, Colorado County Commissioners to fully fund all county road maintenance
During the past two decades, the Boulder County Commissioners have increasingly abrogated their responsibility of fully maintaining all county roads - including those in county subdivisions. These are roads that were totally paid for by the residents of those subdivisions, given to the County Government for FREE, accepted by the County Government with their promise to fully maintain said roads, and for which the County has implemented and collected taxes for the maintenance of those roads for decades. Now, the county, after years of declining financial support and physical maintenance of said roads, has redefined the word maintenance and maintains that the subdivision residents must pay, again, the cost of maintaining their roads. Residents must now pay a THIRD time for their own roads - once when initially constructed, secondly over the decades via taxes supposedly for their maintenance, and now a third time via a special assessment. Via this petition, the undersigned hereby petition the Boulder County Commissioners to fulfill their moral, ethical, and perhaps legal obligation to meet their guaranteed commitments when they accepted ownership of the county subdivision roads. We petition the Boulder County Commissioners to fully maintain all county roads, including those in subdivisions for which they have accepted ownership utilizing funds from within their existing, ongoing budget - without implementation any additional fees, assessments, or taxes of any kind. Full maintenance is specifically to include road replacement, overlay, chip sealing and any and all other maintenance and upkeep activities for said roads.


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The E-flat major String Quartet, op. 127, is a key work not only in Beethoven's Oeuvre but in the entire history of the genre. The first of the late quartets, it "transfers the formal and symbolic aspects of his two major works for chorus and orchestra [the Missa solemnis and the Ninth Symphony] to the more intimate domain of chamber music" (William Kinderman). For years, music lovers have been waiting for a new edition based on the scholarly text from the new Beethoven Gesamtausgabe. The wait has paid off! The highly complex source situation was examined for the first time and thus Beethoven's "final intentions" are now available in an urtext edition. The set of parts (HN 740) and the score (HN 9740) both come with a detailed preface and editorial notes.
- String Quartet E flat major op. 127
- Anhang: Allegretto for String Quartet b minor WoO 210
In 1822, after a twelve-year hiatus, Beethoven again began to show an interest in the string quartet, a genre central to his œuvre. The first portents of his renewed interest were vague and tentative allusions in letters to various publishers. These exploratory probes were probably not backed up by specific compositional projects. The decisive stimulus to Beethoven's vague … 続き
Ludwig van Beethoven
No composer has had as profound and sustained an influence on immediately following generations to the present day as Beethoven. His instrumental music, especially his symphonies, served as touchstones for symphonic composition throughout the nineteenth century. The extraordinarily high standard of his music and his relative independence as a freelance composer have led to his being characterized as the greatest composer of all time.
|Baptized in Bonn on December 17, thus probably born on December 16, the son of Johann van Beethoven, a tenor in the court chapel of the prince-elector. First musical instruction from his father.
|First public performance.
|around 1780
|Musical training with the deputy court organist Christian Gottlob Neefe, who in 1783 presented him in Cramer's "Magazin der Musik" as a second Mozart.
|Acquaintance with the Breuning family, where his literary interest is aroused. First publication: Piano Variations in C minor on a March by Dressler, WoO 63.
|Harpsichordist in the court chapel; 1784 assistant to the court organist.
|Journey to Vienna. Here he very likely meets Mozart, who probably gives him some lessons. After a short while he must return home to his mother, who is ill with tuberculosis.
|He travels a second time to Vienna, where he will remain until the end of his life. Count von Waldstein sends him on his way with the famous words: "With steady diligence you will receive Mozart's spirit from Haydn's hands." In Vienna he studies with Haydn, Albrechtsberger, Schuppanzigh, and Salieri. As a pupil of Joseph Haydn, he achieves extraordinary recognition among the Viennese nobility and receives financial support. Great demand for his compositions from publishing houses: chamber music and piano sonatas from the Bonn and early Viennese years are issued. His first works printed in Vienna (among them the piano sonatas, Op. 2) already bear the hallmark of his compositional style: a forward-advancing, spirited, process-related character.
|Concert tours to Prague, Berlin, Leipzig, and Dresden, which cement his fame.
|Piano Sonata in C Minor, "Pathétique," Op. 13.
|String quartets, Op. 18.
|Symphony No. 1 in C major, Op. 21
|Piano Concerto No. 1 in C major, Op. 15
|Piano sonatas, Op. 27, "quasi una fantasia," including the Moonlight Sonata, Op. 27 No. 2.
|Composition of the Symphony No. 2 in D major, Op. 36 (until 1802). Publication of the Piano Concerto No. 2 in B-flat major, Op. 19.
|Crisis brought on by incipient hearing loss, documented in the "Heiligenstadt Testament." Thereafter he begins, by his own admission, a "New Path" in his compositions, reflected particularly in the piano sonatas, Op. 31 (including the Tempest Sonata); the piano variations, Op. 34 and 35; and the Symphony No. 3 in E-flat major, "Eroica," Op. 55: they are characterized by enhanced structural development as well as by the use of Baroque techniques and models from other genres.
|Frenzy of creativity; these years are dubbed Beethoven's "heroic period". Written during this phase are Symphonies Nos. 3 through 8 (Opp. 55, 60, 67, 68, 92, 93); Piano Concerti Nos. 3 through 5 (Opp. 37, 58, 73); the Violin Concerto in D major, Op. 61; the Triple Concerto, Op. 56; string quartets (the Razumovsky quartets, Op. 59; the Harp Quartet in E-flat major, Op. 74; the String Quartet in F minor, "serioso," Op. 95); piano trios (among them the "Ghost" Trio, Op. 70); piano sonatas (including the Waldstein Sonata in C major, Op. 53; the Appassionata in F minor, Op. 57; and "Les Adieux" in E-flat major, Op. 81a); songs (including "An die Hoffnung," Op. 32); the Mass in C major (Op. 86); and the opera "Fidelio" (Op. 72, first version 1804/5).
|Beethoven rejects an offer to become the First Kapellmeister at the court in Kassel because his patrons, Archduke Rudolph, Prince Kinsky, and Prince Lobkowitz, provide him with a comparable yearly salary.
|Travels to the spa at Teplitz, where he meets Goethe. In 1812, the letter to the "immortal beloved," whose identity (Antonie Brentano or Josephine Deym) is still uncertain.
|Piano Sonata in E minor, Op. 90; third version of the opera "Fidelio." Extraordinarily successful concert with Symphonies Nos. 7 and 8. Still, financial crisis brought about by currency devaluation and the absence of yearly stipends from Kinsky and Lobkowitz.
|Death of his brother Caspar Carl and the beginning of the years-long battle for the guardianship of his nephew Karl.
|Song cycle "An die ferne Geliebte," Op. 98; Piano Sonata in A major, Op. 101.
|Hammerklavier Sonata in B-flat major, Op. 106.
|Beethoven begins keeping conversation books due to increasing hearing loss.
|Missa solemnis, Op. 123.
|Diabelli Variations, Op. 120.
|Piano Sonata in E major, Op. 109, marks the beginning of his glorious late period, which is characterized by exceeding the boundaries of forms, by extreme pitch registers, advanced harmonies, and an increased penchant for contrapuntal forms such as fugue; standing in opposition to the propensity for esotericism in his chamber music is the monumentality of Symphony No. 9.
|Piano Sonatas in A-flat major, Op. 110 (with fugue in the final movement), and C minor, Op. 111 (reduction to two movements).
|String quartets, Opp. 127, 130, 131, 132, 135, as well as the Grosse Fuge, Op. 133, which originally formed the final movement of Op. 130.
|Completion of the Symphony No. 9 in D minor, Op. 125, which for the first time in the history of the genre includes voice parts (Schiller's "Ode to Joy"). It will become the most famous and most frequently played symphony of all time.
|Death in Vienna on March 26.
Insgesamt ist zu sagen, dass sämtliche Revisionen der vorliegenden Studien-Edition der Beethoven'schen Streichquartette den hohen Maßstäben einer sachlichen und kompetenten Textkritik standhalten, und dass damit dem ausübenden Musiker ein Notentext in die Hand gegeben wird, der aufgrund textkritischer Probleme zu einer intensiven Auseinandersetzung mit Beethovens Kompositionen führen möge.
Henle have given us their customarily precise and scholarly reconstruction of this quartet. ...The 17 by 24 cm score has a spacious layout of no more than 16 staves per page (four parts bracketed together) and is easily readable, making an indispensable tool for rehearsals. The parts are cleverly arranged so that three pages unfold where necessary; for example in the long slow movement where there are barely any rests.
Henle acknowledges that it does not have all the answers to Beethoven's many discrepancies and unconventional styles of notation, but nevertheless motivates us to confront this magnificent work more deeply and to seek the composer's true intent.


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It seems like that the rumors about the next Samsung Galaxy S smartphone were actually true. A few hours ago Samsung Galaxy S III has been officially unveiled from the Samsung Mobile Unpacked 2012 event held at Earl's Court, London. This new beast from Samsung was the main highlight of the event, a new smartphone inspired by nature that comes in two colors for you to choose from – marble white or pebble blue. Looking on the features of this new phone will surely make you want to buy the new Samsung Galaxy S III. This new smartphone really defines the word "smart" with its new functionality and features.
Technical Specifications of Samsung Galaxy S III – Overview
Samsung Galaxy S III, as I've said defines the word "smart" but that's just me because I was really amazed with those highlights, specifications and features of this yet best Android smartphone for 2012. It was JK Shin, President of Samsung Mobile Communications, whom unveiled officially the new Galaxy S III smartphone discussing some technical specifications – now this is really interesting. From the rumors now into reality. Here are some of the mentioned specifications of the new Samsung Galaxy S III. But for me JK Shin only mentioned the overview of the specifications. I will try to dig into this more and lay it all out for you. For now, this handset sports at 1.4 GHz Exynos 4 Quad-core processor with 1GB of RAM for your memory. It is as said, will have a 4.8-inches SUPER AMOLED touchscreen with a resolution of 1280×720 pixels. The whole handset will be using a 2100 mAH battery pack. While it also sports the same camera as with its predecessor Samsung Galaxy S II, an 8MP rear camera and also a front camera is also there for video chatting. The thickness of this smartphone is 8.6mm and weighs at about 133 grams. I already mentioned the available colors for Samsung Galaxy S III – marble white and pebble blue. Yes, it is a LTE ready but it depends on your country.
Features of Samsung Galaxy S III
Here are some of the highlighted features of the new Samsung Galaxy S III that I am pretty sure you're going to love and decide to buy. First, this smartphone has a sensor that can continuously detect if you are looking or facing your smartphone prohibiting the screen from dimming so you can enjoy reading or viewing a message or watching a video from your phone. Another sensor that detects if you are about to place a call by just lifting your phone unto your ear. It also detects whenever you are away from your handset, and nudge you when you missed a call or a SMS message. It also have a social tagging that lets you know the current SNS status of your friend by just looking into your friends' photos. And this is one of the best and official Siri-like for Android called S Voice where you can talk to your smartphone and do some small tasks for you like to wake up, call a friend, set a meeting, and even capture a picture. There's another feature called the S Beam which lets two Samsung Galaxy S III to transfer photos, music, videos, and many more by just placing them back-to-back. The AllShare Cast, if you are a gamer you can beam your game into a bigger screen (i.e. smartTV) and lets your smartphone act as the controller. The Buddy photo share feature acts like the Facebook facial recognition whenever you upload a photo. Samsung Galaxy S III immediately recognizes the face of your friends where you have the option to share it by emailing them those captured moments. AllShare Play lets you share your contents such as documents and multimedia files to everyone or where ever you wanted to access them. Here's another one called the Pop up play where multi tasking takes into action and lets you send a message while you watch a video – all at the same time. This smartphone also have the Best Photo feature which automatically takes a shutter-like 8 shots to make a continuous scene.
According to the presentation during the event, Samsung Galaxy S III HSPA+ version will be landing soon and will initially be launched in Europe sometime on the 29th of May – a few weeks from now. The Samsung Galaxy S III 4G version will come after this summer and will be launched to North America. The latter has not been confirmed as to when will be the official date but it looks like almost all of the major network carriers will have this new Galaxy S. As for the rest of the world, we just need to wait as Samsung Galaxy S III will be shipped globally gradually.
And if you are interested to witness the recent Samsung Mobile Unpacked 2012 presentation, you can watch their official video presentation below.
For more information about this new Samsung smartphone, you can go to the official website of Samsung Galaxy S III.


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Heartiest Congratulations to Roger Federer who took home the US Open trophy for the 5th consecutive time! What a beauty and pure joy it is to watch him play. The best player ever to play the game of tennis, IMO. Always a class act and ever so generous with all these great achievements, the sign of a true champion!!
Coming back to today's post, here are some pictures from my recent trip to Napa Valley, food related of course ;) I managed to convince all in my group to spare some time and go visit the popular St. Helena's farmers market out there. It was a beautiful bright day and we did pick up quite a few things from there. From the lovely produce of fresh fruits and vegetables, to various flavored honeys, to all kinds of pesto's possible, to handmade scarves, to fine crafted soaps, to indoor plants, they seemed to have it all! I happened to leave some pesto and jalapeno relish jars in my handbag and had to leave it at the airport :( Anyway, I'm very happy with my other purchases from there including the mega white peaches ;)
Let me leave you with the recipe of Zuke-A-mole, a smart twist to the ever popular guacamole using Zucchini which I've adapted from here. Made it a few times and it is one tasty dip! I've tried it with bread, idli's and makes a good accompaniment to desi meals as well.
3 Zucchini
1 sweet onion chopped
2-3 green chili, as per taste
2-3 garlic cloves, chopped
1/2 cup coriander leaves
1/4 cup mint leaves or basil leaves (can make without it as well)
salt & pepper to taste
1-2 tbsp oil
2tbsp lemon juice, as per taste
1. Heat oil. Add onion, green chili and garlic, saute 2 minutes.
2. Add chopped zucchini and cook till done.
3. Add salt & pepper, coriander leaves, mint leaves and switch off the gas. Add lemon juice. Cool and blend smooth.
4. Enjoy this tasty dip as you would any other dip. The original recipe asks for roasting of zucchini and onion in an oven for 90mins, that will definitely bring about an intense flavor, but is quite time consuming for me! I thoroughly enjoyed this take on the ever favorite guacamole.


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Born in the Ukraine in 1896, St. John first attended a military academy but when his family fled to Yugoslavia at the time of the Russian Revolution, he then switched to study theology, was tonsured a monk, and later ordained a priest. Because of his asceticism and great zeal, he was revered by many as a truly angelic man, an icon of a true monk. Consecrated a bishop at age 39, in 1934 he was sent to Shaghai where he built churches, an orphanage, and a hospital. When the Communist Party came to power in China, he fled with most of the Russian emigrees to the Phillipines, going next to Paris and then Brussels.
In 1962, St. John was appointed Archbishop of Western America and San Francisco, and celebrated Divine Liturgy daily, prayed all night (sleeping only about 45 minutes a night in short naps) and visited the sick. He comforted and healed many people, both Orthodox and non-Orthodox alike. This great wonder-worker died in 1966. His incorrupt relics were uncovered at his Cathedral 26 years later, and in 1994 was glorified as a universal saint. O Holy Father John of San Francisco, pray unto God for us!


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New Hunter
These are My MOW gauntlets that i got last week. this is my first experience with using an airbrush but i think they came out good. be honest and let me know how to improve if you see anything wrong. Now I'm just waiting on my BM armor and and helmet....... being that i spent $400 on nice airbrush equipment i may offer my painting services if anyone think I'm good enough. I will post pics of my painted armor and bucket when finished... o and my camera is 5 years so sorry about the bad pics.


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You may have noticed that recently many new Bike Lane features have been installed throughout the City of Modesto. Watch videos for information on how to properly use these bike lanes, whether your vehicle of choice is a bike or a car.
A variety of Class I, II, III and IV bikeways are located throughout the city.
The City of Modesto is dedicated to expanding the bicycle lane network with each rehabilitation project that we do. This means if a street receives an overlay, slurry seal or is reconstructed that segment of roadway will be enhanced with some type of bike lane feature.
The MJC Campus Connection is a 2.2 mile protected bike path that gives students and faculty the opportunity to commute between east and west campuses by bicycle.