Ritalin vs. Response Cost: ADHD Treatment

Overview

• The study compares methylphenidate (Ritalin) and response cost effectiveness in reducing off-task behavior in two boys (ages 7 and 8) diagnosed with attentional deficit disorder with hyperactivity.
• Response cost, with free-time as the reinforcer, proved more effective than Ritalin in increasing on-task behavior and academic performance.

Introduction

• Attentional deficit disorder with hyperactivity is a common and debated childhood issue, affecting about 1.19% of elementary school students across all grades.
• Key characteristics include impulsivity, attentional challenges, and poor classroom performance.
• Medication, notably methylphenidate (Ritalin), is a standard treatment.
• Alternatives to medication are gaining traction (Pelham, Schnedler, Bologna, & Contreras, 1980).

Previous Research

• Studies have assessed behavioral and medication approaches, divided into "behavior therapy" and "direct contingency management."
• Behavior therapy involves initial teacher training in behavior management followed by consultations.
• Direct contingency management uses immediate reinforcement for good behavior, point reduction for bad behavior, or continuous teacher attention.
• Direct contingency management tactics have matched or exceeded drug therapy effects, in contrast to behavior therapy which has often been less effective than medication.
• Disparity in results may stem from differences in dependent variables, failure to compare contingency management with titrated medication dosages, and the possibility that direct contingency management is more potent than traditional behavior therapy.

Additional Considerations

• Shortcomings of contingency management interventions: unrealistic time demands, high adult-child ratios, major teacher training.
• Response cost is a viable alternative, proving effective for classroom disruptions.
• Response cost has been found to be more effective than neuroleptic medication or positive reinforcement.
• Response cost typically lacks the side effects of aversive procedures.

Study Purpose

• Primary aims:
  • Develop a user-friendly behavioral intervention as an alternative to standard reinforcement for hyperactive children in classrooms.
  • Systematically assess and compare response cost intervention and titrated methylphenidate using various measures against baseline performance.
  • Determine any functional relationships between target behaviors and different doses of stimulant medication in a classroom setting.

Method

• Two hyperactive boys (ages 7 and 8) were diagnosed independently by a doctor and psychologist as having Attentional Deficit Disorder with Hyperactivity based on DSM III criteria.
• Additional criteria included high scores on the Abbreviated Conners Teacher Rating Scale (ACTRS > 15), no history of hyperactivity medication, and observed behaviors such as, short attention span, low rates of academic completion, disruptive behavior, impulsivity, and on-task behavior below 60%.
• Participants had average intelligence and low to middle socioeconomic status, observed in a standard second-grade classroom with a regular teacher over two school years.

Apparatus

• For Brian: wooden stands with numbered cards (20 to 0) flipped down by teacher/student.
• For Mitch: Electronic counter starting at zero that increased by one each minute. Teacher used a handheld device to reduce the display by one and illuminate a 15 sec red light when Mitch was off-task.

Assessment

• During each observation period, the class did in-seat academic work assigned by the teacher (observed twice daily in 20-minute blocks starting at 9:00 and 9:40 am).
• Graduate psychology students observed Brian and Mitch for 80 intervals, dividing each interval to 10 sec observation and 5 seconds for recording.
• Observers were unaware when medication was administered or dosage levels, although, not blind to response cost procedures.

Teacher Ratings

• Each Friday, the classroom teacher completed the Abbreviated Conners Teacher Rating Scale (ACTRS) on the two participants as well as two control children.
• The ratings reflected the week's behavior and were sensitive to impacts from behavior therapy and medication.

Child Behavior

• Categorized as on-task or off-task.
• Off-task was visual nonattention to materials for >2 sec unless the student was talking to the teacher, had a raised hand, or was adjusting/glancing at the response cost apparatus.

Academic Measures

• Phonics: Scott Foresman Basics in Reading: Daisy Days Series (1978) with accompanying work, graded by the teacher from their manual for the percentage completed and correct.
• Arithmetic: Holt School Mathematics Series (1974) problems included basic addition, subtraction and word problems.

Reliability

• Child behavior's reliability was checked on 39% and 28% of days for Brian and Mitch.
• Occurrence, nonoccurrence, and overall agreement was over 88%, and 96% mean for both.
• Academic measures were checked during (48%) and 42% of the occasions for Brian and Mitch, agreement defined as agreement on the number of problems completed with a very high observer-teacher agreement.

General Procedure

• The teacher wrote assignments on the chalkboard, gave specific instructions, and gave the class a 1-hr period to complete, split into 20-min intervals with some time teacher-held math groups.
• No data was recorded when the children were in their respective math groups.

Experimental Procedures

• Study used an ABACBC within-subjects design. These letters translate to: Baseline I, Medication I, Baseline II, Response cost I, Medication II, and Response cost II.
• Varied effects of methylphenidate and response cost on on-task behavior, academic completion, accuracy, and social behavior were compared during these phases.
• The teacher was blind to the medication and dosage levels, but not the response cost procedures.

Experimental Phases

• Baseline I: On-task behavior, academic performance, and accuracy were recorded for several days to reflect pre-intervention.
• Medication I: Parents gave methylphenidate following White's dosage schedule (5-mg increments/week) until improvement/stability.
• Placebo was not used because it was considered clinically unadvisable. Expectation effects were controlled for by telling the boys they were taking "vitamin pills".
• Dosages were adjusted as necessary, with changes occurring over weekends.
• Baseline II: Medication stopped before this second baseline phase to allow for a wash-out period.
• Response Cost I: The response cost program was initiated, where children completed assignments at their desks while teacher conducted small groups.
• Students could earn up to 20 min of free time, with the teacher flipping a card down (Brian) or activating her apparatus (Mitch) to deduct time (1 min) when a student was off-task.
• Medication II: The most effective methylphenidate dosage from Medication I administered daily.
• Response cost II: Response cost intervention occurred on both phonics and arithmetic assignments following a medication-free weekend to allow for a wash out period.

Results - On-Task Behavior

• Without intervention, both children were attentive less than half the intervals; high variability across days.
• With 5 mg/day Ritalin, on-task intervals increased but also with high variability.
• Increasing the dosage to 10 mg/day resulted in no significant improvement for Brian, only a slight increase for Mitch.
• 15 mg/day of Ritalin increased Brian's on-task behavior in phonics but unchanged for math. Mitch was essentially unchanged in on-task behavior but restricted daily variability.
• During no-treatment reversal phase, both children decreased close to baseline levels.
• The response cost program saw high engagement across academic assignments. It also allowed for two direct comparisons were made between baseline and response cost conditions.

Results -Academic Performance

• Figures 3 and 4 show both children completed 60% or fewer of daily assignments on average, high variability.
• 5 mg/day increased numbers of problems completed, especially in math. 10 mg/day increased Mitch's phonics completion rate.
• 15 mg/day continued to increase Mitch's math assignment (but not phonics).
• No medication day ("probe") in Figure 3 decreased math performance.
• The 20 mg/day decreased the percentage of problems completed in both phonics and math.

Synthesizing Results

• Ritalin may improve assignment completion rates in hyperactive children. There appears to be a U-shaped dose-response curve, meaning high dosages worsened responding.
• Response cost resulted in unprecedented performance levels and similar results were observed in Mitch's academic performance.
• The study suggests both interventions produce positive changes, but response cost is more effective.

Results - Teacher Ratings

• Lower scores on the teacher rating scale mean the child's behavior improved.
• Control children were "normal" children without learning or behavior problems.
• The 15 mg/day Ritalin and response cost conditions were most effective in reducing teacher-viewed hyperactivity.

Discussion

• In agreement with the teacher ratings, the results show both response cost and stimulant medication (methylphenidate) interventions helped increase on-task behavior and academic performance.
• Response cost resulted in the greatest improvement.
• Directing the child's attention toward specific tasks using immediate positive or negative consequences is an important success factor. Although positive reinforcement is more, sometimes negative is helpful to stay on-task.
• Quick responses help hyperactive children with their impulsivity.
• Behavior therapy programs may be viewed as less effective due to teacher excessive time demands and impracticality.
• Response cost only required 15 mins + 2 feedback sessions of teacher training and limited time involvement by the teacher.

Further Considerations

• The present study aligns with lab findings. Hyperactive children perform better on memory tasks with low doses (.30 mg/kg) and get worse on high doses (1.0 mg/kg) of stimulant medication.
• This also matched similar findings on repeated acquisition tasks that were also the most high at being at .70 mg/kg for completing.

Limitations

• Questionnaires at the end of the study suggest that both teacher and students viewed response cost positively.
• It may be that some hyperactive children will continue to improve with Ritalin dosages falling between these levels (i.e., .30 and 1.0 mg/kg).
• Caution should be taken when generalizing to other hyperactive children because only two children were studied.