THE EFFECTS OF STIMULANT MEDICATION
ON THE SOCIAL BEHAVIOR OF CHILDREN WITH ADHD
DURING TIMES OF PLAY
A Dissertation
Submitted to the Graduate Faculty of the
Louisiana State University and
Agricultural and Mechanical College
In partial fulfillment of the
Requirements for the degree of
Doctor of Philosophy
in
The Department of Psychology
by
Robert H. LaRue Jr.
B.A., Rutgers University, 1995
M.A., Louisiana State University, 2000
December 2002
TABLE OF CONTENTS
LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . iv
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . v
CHAPTER
1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . 1
Overview of the Literature. . . . . . . . . . . . . 1
The Developmental Significance of Play. . . . . . . 6
The Effects of Stimulants on Play and Related
Social Behavior - Basic Research. . . . . . . . . . 8
The Effects of Stimulants on Related Social
Behavior in Rats and Non-Human Primates. . . . . . 10
The Effects of Stimulants on Play – Clinical
Research . . . . . . . . . . . . . . . . . . . . . 13
Rationale for the Current Study. . . . . . . . . . 22
2 METHODOLOGY . . . . . . . . . . .
Participants and Setting . . . .
Response Definitions . . . . . .
Data Collection and Measurement.
Procedure. . . . . . . . . . . .
Medication Status. . . . . . . .
Design . . . . . . . . . . . . .
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3 RESULTS . . . . . . . . . . . . . . . . . . .
Experiment 1 – Unstructured Recess . . . . .
Experiment 2 – Structured Sports Training. .
Experiment 3 – Alone Play. . . . . . . . . .
Experiment 4 – Tiger Camp Observations . . .
Experiment 5 – Social Reinforcer Assessment.
Teacher Rating Scale . . . . . . . . . . . .
Child Rating Scale . . . . . . . . . . . . .
Structured Child Interview . . . . . . . . .
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4 DISCUSSION . . . . . . . .
Limitations in the Current
Future Directions. . . . .
Summary and Conclusions. .
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Study
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REFERENCES. . . . . . . . . . . . . . . . . . . . . . . 77
APPENDIX A - CHILD RATING SCALE . . . . . . . . . . . . 87
APPENDIX B - TEACHER RATING SCALE . . . . . . . . . . . 88
ii
APPENDIX C - STRUCTURED CHILD INTERVIEW . . . . . . . . 89
APPENDIX D - UNSTRUCTURED RECESS GRAPHS . . . . . . . . 91
APPENDIX E – STRUCTURED SPORTS TRAINING GRAPHS . . . . 102
APPENDIX F - ALONE PLAY GRAPHS . . . . . . . . . . . . 110
APPENDIX G - TIGER CAMP OBSERVATION GRAPHS . . . . . . 117
APPENDIX H – SOCIAL REINFORCER ASSESSMENT GRAPHS . . . 125
VITA . . . . . . . . . . . . . . . . . . . . . . . . . 131
iii
LIST OF TABLES
1. Unstructured Recess Observations. . . . . . . . . . 41
2. Structured Sports Training Observations . . . . . . 47
3. Alone Play Observations . . . . . . . . . . . . . . 49
4. Tiger Camp Observations . . . . . . . . . . . . . . 51
5. Social Reinforcer Assessment Results. . . . . . . . 55
6. Teacher Rating Scale Results. . . . . . . . . . . . 58
7. Child Rating Scale Results. . . . . . . . . . . . . 61
iv
ABSTRACT
Psychomotor stimulants are the most commonly
prescribed medications for the treatment of ADHD in
children and adults. A vast literature has evolved
concerning the efficacy and potential side effects of
these drugs. Although stimulants are generally regarded
as safe and effective, there is concern that potential
problems may have been overlooked. Specifically, there
is some literature indicating that, at least in some
cases, stimulant medications may produce significant
disruptions in social behavior. To investigate these
effects, a number of different measurements were
employed with preschool children, including direct
observations during times of play, a social reinforcer
assessment and a number rating scale/interview measures.
The results indicate that three of the six participants
displayed heightened levels of anxiety or stereotyped
behaviors in specific settings while taking their
prescribed dose of stimulant medication. The social
reinforcer assessment revealed that the value of social
reinforcers (i.e., playing with others) decreased for
two of the participants while on their prescribed dose
of medication. A corresponding increase in the value of
nonsocial reinforcers (i.e., playing alone or quiet
v
time) was observed for both of these participants as
well. Another participant displayed the opposite effects
in the reinforcer assessment while taking stimulant
medication. The value of social reinforcers appeared to
increase for this participant while taking the
prescribed dose of stimulant medication. The findings
from the rating scales were inconclusive, and did not
correspond well with the direct observations. The
relevance of these findings from the direct and indirect
measures as well as the reinforcer assessment will be
discussed.
Key Words: Attention deficit hyperactivity disorder,
behavioral pharmacology, play, social behavior, stimulant
medication
vi
CHAPTER 1: INTRODUCTION
Attention deficit hyperactivity disorder (ADHD) is the
most commonly diagnosed childhood behavior disorder.
Current consensus is that the disorder affects
approximately 3 to 10% of school aged children (Murray &
Patel, 2001). It has been estimated that three to six
million children are currently receiving stimulant
medication, with an upward trend in recent decades that is
expected to continue (Murray & Patel, 2001; Safer, Zito &
Fine, 1997). Approximately 90% of children receiving a
diagnosis of ADHD are treated with stimulant medication at
some point in their lives (Pelham, 1993). In addition,
there is an increasing trend to prescribe stimulant
medication to young children (i.e., ages 3 to 5) (Zito,
Safer, dosReis, Gardner, Boles & Lynch, 2000). There is a
vast literature concerning the efficacy and side effects of
stimulant medications. The tenor of this literature is that
stimulants are both effective and benign.
Overview of the Literature
Stimulants have been the most exhaustively researched
medication in all of child psychiatry. Over the last
several decades, the short-term efficacy of stimulants for
the treatment of the core symptoms of ADHD (i.e.,
inattention, hyperactivity) has been well documented. The
1
literature indicates that 70% to 96% of children between
the ages of 6 and 18 have a positive response for the
treatment of the core symptoms of ADHD (Barkley, 1977a;
Elia, Borcherding, Rapoport & Keysor, 1991). Controlled
studies evaluating the effects of stimulants have
demonstrated their effectiveness for decreasing the
occurrence of interrupting class, reducing task-irrelevant
activity in school, improving attention and compliance,
increasing attentiveness during games of baseball,
improving parent-child interactions, improving teacherchild interactions and decreasing the occurrence of overt
and covert aggression (Barkley et al., 1985; Barkley, 1989;
Jacobvitz, Sroufe, Stewart & Leffert, 1990; Pelham, Gnagy,
Chronis, Burrows-MacLean, Fabiano, Onyango, Meichenbaum,
Williams, Aronoff, Steiner, 1999; Schachter, Pham, King,
Langford, Moher, 2001; Spencer, Biederman, Wilens, Harding,
O'Donnell, Griffin, 1996; Swanson, McBurnett, Wigal,
Pfiffner, Lerner, Williams, Christian, Tamm, Willcutt,
Crowley, Clevenger, Khouzam, Woo, Crinella & Fisher, 1993;
Tallmadge and Barkley, 1983; Whalen et al., 1980; Whalen et
al., 1981).
Although the literature pertaining to the effects of
stimulant medications on the core symptoms of ADHD is quite
convincing, the efficacy of these drugs for the treatment
2
of ancillary features of ADHD is not as clear. Stimulants
have not been shown to be effective for improving social
skills nor have they shown any consistent benefit in
academic performance (Carlson & Bunner, 1993; GittlemanKlein & Klein, 1976; Rie, Rie, Stewart & Ambuel, 1976a;
Rie, Rie, Stewart & Ambuel, 1976b).
Difficulties with peer relationships are extremely
common in children diagnosed with ADHD. These children tend
to engage in controlling behavior (i.e., being “bossy”),
are more aggressive than same-age peers, and have fewer
reciprocal social exchanges with peers (Landau & Milich,
1988). Reports of stimulant-induced decreases in aggression
are common, yet few studies have demonstrated improvements
in prosocial behavior. As will be discussed in more detail
later, several studies have shown that stimulants have the
potential to produce significant disruptions in social
behavior (Schliefer, Weiss, Cohen, Elman, Cvejic & Kruger,
1975; Whalen, Henker, Collins, McAuliffe & Vaux, 1979).
Additionally, children diagnosed with ADHD frequently
exhibit academic problems, including poor performance in
math and reading. Although some studies have suggested that
stimulant-induced improvements in attention span may
improve scholastic achievement, there has been little
evidence to indicate that stimulants produce any
3
significant improvements in direct measures of academic
skills, such as information retention, acquisition of new
skills or IQ scores (Gittleman-Klein & Klein, 1976; Rie et
al., 1976a; Rie et al., 1976b; Swanson et al., 1993).
Although stimulants have been extensively studied in
children aged 6 to 18, relatively few studies have
specifically investigated their effects in children under
six years of age. Since 1975, only nine double-blind
placebo controlled medication evaluations using stimulants
have been conducted with children in this age range
(Connor, 2002). Of these nine studies, eight reported
significant improvements for the core symptoms of ADHD
while taking stimulant medication (Barkley, 1988; Barkley,
Karlsson, Strzelecki, Murphy, 1984; Byrne, Bawden, DeWolfe,
Beattie, 1998; Conners, 1975; Cunningham, Siegel &
Crawford, 1985; Handen, Feldman, Lurier & Murray, 1999;
Mayes, Crites, Bixler, Humphrey & Mattison, 1994; MonteiroMusten, Firestone, Pisterman, Bennett & Mercer, 1997).
Several of these studies documented specific improvements
in behavioral domains, including hyperactivity and
impulsivity (Conners, 1975; Mayes et al., 1994; Byrne et
al., 1998) as well as improvements in interpersonal
domains, including decreases in inappropriate social
interaction and aggression (Barkley, et al., 1984; Barkley,
4
et al., 1988, Byrne, et al., 1998; Monteiro-Musten, et al.,
1997). Schliefer and colleagues (1999) determined that the
effects of stimulants are more variable in preschool
children and did not show clear beneficial effects for most
of the children (25 of 28 participants). Although not all
studies regarding the effects of stimulants are in
agreement, the literature indicates that stimulant
medications are beneficial for the treatment of ADHD in
preschool children.
Although the majority of these studies attest to the
efficacy of stimulants in preschool children, side effects
were not systematically evaluated in any these studies and
several did not report side effects at all. Two studies
have systematically evaluated side effects of stimulant
medication in preschool children with ADHD (Barkley et al.,
1985; Firestone, Monteiro-Musten, Pisterman, Mercer &
Bennett, 1998). The findings from these studies indicate
that side effects tend to be more common in young children
and include irritability, nightmares, sleep disturbances
and alterations in appetite. Although observed more
frequently in young children, stimulant side effects are
generally considered to be mild (Barkley, 1985; Connor,
2002; Firestone, 1998).
5
The Developmental Significance of Play
In spite of the prevailing attitude that stimulants,
as used to treat ADHD, are very safe, there is a literature
regarding their potential adverse effects on the social and
play behaviors of children that appears to be widely
overlooked. Basic research has consistently shown that
drugs such as methylphenidate and amphetamine decrease
social and play behavior in animals. Additionally, although
less definitive, a number of clinical studies suggest that
stimulants can produce significant disturbances in social
behavior in humans as well.
This is potentially important because disruption of
play and social behavior may have serious developmental
consequences. A major component of wakeful behavior in
higher mammals from the time of infancy to adulthood is
social play. Play is thought to provide the first
expression of many adult behaviors, including sexuality,
aggressiveness, affiliative behavior and parental behavior
(Pellis & Pellis, 1990; Poole & Fish, 1976; Taylor, 1980).
In addition, play may have a significant role in the
development of motor and sensory skills, language, and
intelligence (Hofer, 1981).
Surprisingly, the empirical literature regarding the
significance of play in children is sparse. Much of what is
6
known about the significance of play comes from basic
research with animals. Social play in rats displays an
inverted U-shaped function with respect to age; it emerges
about 18 days after birth, peaks during the fourth and
fifth week of life and then declines into adulthood (Meaney
& Stewart, 1981; Thor & Holloway, 1984; Vanderschuren,
Niesink & Van Ree, 1997). Researchers have found that the
opportunity to engage in social play is particularly
important for normal social development in the rat (Hol,
Van den Berg, Van Ree & Spruijt, 1999, Van den Berg, Hol,
Van Ree, Spruijt, Everts & Koolhas, 1999). Deprivation of
play during the fourth week of life produces serious
disruptions in normal sexual functioning and agonistic
behavior, while deprivation during the fifth week of life
does not appear to produce any significant differences in
social development (Hol, et al., 1999). These findings
indicate that there is a critical period in which social
play may have a particularly important effect on
development. Einon, Morgan and Kibbler (1978) found that
rats deprived of social interaction for extended periods of
time developed normally if allotted brief periods of play
(i.e. 60 minutes each day), whereas socially isolated rats
not allowed to play displayed abnormal social functioning.
This finding suggests that the observed abnormal social
7
development is the result of play deprivation, rather than
the deprivation of social contact per se.
A number of studies have investigated the effects of
social deprivation on the subsequent social development of
young non-human primates (Mason, 1963; Michael & Zumpe,
1998; Suomi, 1973; Suomi & Harlow, 1972). Socially deprived
monkeys exhibit a number of abnormal social behaviors
including decreased grooming and abnormal play behavior.
Although no non-human primate studies have specifically
investigated play, it is possible that deprivation of play
during periods of social isolation contributes to abnormal
social development.
The Effects of Stimulants on Play and Related Social
Behavior – Basic Research
A number of studies have examined the effects of
stimulants on play behavior in animals. Without exception,
these studies show that stimulant drugs significantly
decrease play behavior. Beatty, Dodge, Dodge, White and
Panksepp (1982) investigated the effects of stimulant
medications on a number of social behaviors in rats.
Specifically, they evaluated the effects of methylphenidate
(0, 0.5, 2, 4 mg/kg) and d-amphetamine (0, 0.25, 0.5, 1
mg/kg) on play fighting (instances of boxing, tail-pulling,
wrestling, pinning, aggressive grooming) and chasing in
8
rats. The researchers found that both drugs significantly
decreased play fighting in a dose-dependent manner.
The findings were replicated and expanded in a
subsequent study by Beatty, Costello & Berry (1984).
Amphetamine was administered to rats alone and in
conjunction with a number of other drugs (i.e.,
catecholamine antagonists, agonists and synthesis
inhibitors). As reported previously, amphetamine (0.5 and
1.0 mg/kg) significantly decreased the occurrence of play
behaviors (tail pulling, pouncing, boxing, wrestling,
pinning, chasing). Interestingly, none of the other drugs
(i.e., haloperidol, phenoxybenzamine, chlorpromazine,
propranalol, clonidine, alpha-methyltyrosine) altered the
play-inhibiting effects of amphetamine. The authors
concluded that although amphetamine clearly suppresses play
fighting, the exact mechanism through which it does so is
unknown.
Thor & Holloway (1983) evaluated the effects of
stimulant medication on play-soliciting behaviors in rats.
The dependent measures used in the experiment included
darting (running with abrupt stopping) and crossovers
(climbing over or under the stimulus animal). They found
that all doses of d-amphetamine (0.5, 1, 2 mg/kg)
significantly decreased the rate of crossovers and darting
9
and increased the latency to solicit play in a dosedependent manner. In addition, all doses of methylphenidate
(0.5, 1, 2 mg/kg) significantly decreased the frequency of
crossovers.
Rats generally exhibit heightened levels of play
behavior (i.e. pinning, chasing) following periods of
social deprivation (Beatty, Costello & Berry, 1984).
Stimulant medications have been shown to block this
increase in play in a dose-dependent manner (Beatty,
Costello & Berry, 1984; Beatty et al., 1982, Thor &
Holloway, 1983).
The Effects of Stimulants on Related Social Behaviors in
Rats and Non-Human Primates
Several studies have examined the effects of stimulant
drugs on social behavior in rats and non-human primates.
Although many of the dependent variables used in these
studies are not direct measures of play (e.g., social
interaction), they are important in that they may be
considered prerequisites for social play behaviors.
Gambill and Kornetsky (1976) investigated the effects
of stimulants on a number of social behaviors in rats. In
this study, the researchers placed amphetamine treated rats
in cages with unfamiliar rats. Dependent measures included
rates of grooming, feeding, sex, sleeping, stereotypy,
10
agonistic behavior and their positioning (i.e., proximal or
distal) in relation to other rats. Amphetamine (8.0mg/kg)
significantly decreased the rate at which rats engaged in
social/agonistic behaviors. In addition, amphetaminetreated rats tended to remain distal from other rats.
Arakawa (1994) used a similar paradigm to investigate the
effects of stimulant drugs on the social behavior of rats.
Rats were injected with saline, and a range of doses of
methamphetamine or methylphenidate (0.008 - 5.0 mg/kg). The
treated rats were then placed in an open field either alone
or with an untreated rat. It was found that methylphenidate
at doses of 1.0 mg/kg or greater caused rats to remain
separate in the field.
Steinpreis, Sokolowski, Papanikolaou and Salamone.
(1994) used an intruder paradigm to evaluate the effects of
stimulant drugs in rats. This paradigm involves placing an
unfamiliar rat in a cage with an established colony
containing three other rats. For the purpose of this study,
the intruder rat was injected with either amphetamine or
placebo. The researchers found that amphetamine (4.0 mg/kg)
substantially reduced the occurrence of social behaviors in
the treated rats, including the number of social threats
initiated by the intruder rat, the frequency of side
11
mounting, as well as the occurrence of crawling under other
rats.
Researchers have also investigated the effects of
stimulant drugs on the social behavior of nonhuman
primates. Schlemmer & Davis (1981) found that chronic
administration of d-amphetamine (3.2 mg/kg daily for 12
days) significantly increased the number of submissive
gestures in stumptail macaque monkeys. Thierry Steru,
Chermat and Simon (1984) evaluated the effects of damphetamine on the greeting behavior of rhesus monkeys. In
this experiment, the researchers observed the social
interactions of pairs of d-amphetamine treated juvenile
rhesus monkeys that had been reunited after a separation of
two days. Dependent measures included greeting behavior
(social grooming, social play, and huddling) and frequency
of presentations and mounts. It was found that that damphetamine (0.1 and 0.2 mg/kg) significantly decreased
duration of greeting behaviors.
In another study, Schlemmer, Young and Davis (1996)
investigated the effects of amphetamine on the social
behavior of stumptail macaque monkeys. Baseline (no drug)
observations were conducted on 30 monkeys for 8 days. The
monkeys were then treated with d-amphetamine (1.6 mg/kg)
for 12 consecutive days. During amphetamine treatment,
12
monkeys were observed for a 30-second period every five
minutes during a 60-minute observation session each day.
Dependent measures included stereotypy, proximity to other
monkeys, social grooming and submissive behavior.
Amphetamine produced a number of profound disruptions in
social behavior, including increased submissive behavior,
increased stereotypy (specifically self-grooming), and
decreased social grooming.
The Effects of Stimulants on Play – Clinical Research
There has been a considerable amount of clinical
research concerning the effects of stimulant medications on
play and related social behaviors in humans. These studies
can be organized based on whether they examine stimulant
effects on non-social play, social play, or general social
behavior.
Effects on Non-Social Play. Several studies have
investigated the effects of stimulant medication on nonsocial play in humans. To evaluate the effects of
stimulants on attention span and general activity level,
researchers often observed children alone in clinic
playrooms with a variety of toys. Decreases in movement
(i.e., decreased hyperactivity) and fewer toy exchanges or
longer duration of toy play (i.e., increased attention
13
span) are usually reported as a positive medication
response.
Rapaport, Abramson, Alexander and Lott (1971) observed
the effects of 10 mg of d-amphetamine on playroom behavior
in hyperactive children aged 4 to 10. Children were
monitored in a playroom divided into quadrants. The
researchers measured the frequency of line crosses (i.e.,
moving to a different quadrant) and general movement as
measured by actometers. They found that d-amphetamine
significantly decreased the number of line crosses and
ankle movement, indicating that locomotor activity was
suppressed during times of play. Although decreases in
locomotor activity are considered to be a desired effect of
stimulant medication, these decreases in general activity
may have an adverse impact on play.
Barkley (1977b) examined the effects of
methylphenidate in 36 hyperactive boys aged 5 to 12 in a
number of settings. Children were on daily doses ranging
from 10-30 mg (mean = 18.6). Dependent measures included
number of vocalizations, the frequency of picking up and
leaving toys and general activity. In isolated free play
conditions, it was found that methylphenidate decreased the
amount of wrist movement, ankle movement, and general
locomotor activity, indicating that movement during play
14
was attenuated. In addition, the authors also noted a
significant decrease in the number of times medicated
children switched toys. Again, these findings are presented
as a positive response to methylphenidate (i.e., improved
attention span and decreased hyperactivity), yet this
positive response may have adverse effects on play.
Barkley & Cunningham (1979a) conducted a study
investigating the effects of methylphenidate on activity
level and attention span in a number of settings.
Participants in this study were 14 hyperactive boys aged 5
to 12. Prescribed doses of methylphenidate averaged 10.5 mg
daily. Dependent variables in this study included movement
as measured with wrist and ankle actometers, duration of
locomotion, activity changes, the mean time engaged in each
activity and the number of activities in which they
engaged. Results showed that methylphenidate significantly
decreased wrist movement as well as the number of different
social activities in which treated children engaged.
Handen, McAuliffe, Janosky, Feldman and Breaux (1995)
investigated the effects of methylphenidate on
developmentally disabled children with concurrent diagnoses
of ADHD during periods of independent play. Two doses of
methylphenidate (0.3 mg/kg and 0.6 mg/kg) and a placebo
control were examined in a within-subjects design.
15
Dependent measures included frequency and duration of play
behavior, physical movement, intensity of play,
vocalizations, and the frequency of picking up and leaving
toys. It was found that both doses of methylphenidate
significantly decreased the intensity of play (i.e.,
vigorous movement during play), the number of
vocalizations, and the amount of movement during play.
In
addition, the number of toy pickups and toy leaves
decreased significantly at the 0.6 mg/kg dose.
Effects on Social Play. Some studies have specifically
examined the effects of stimulants on social play in humans
during interactions between parents and their children with
ADHD. Cunningham and Barkley (1978) investigated the
effects of 10 mg of methylphenidate on the mother-child
interactions of five-year-old hyperactive identical twins
in a free-play setting. Researchers placed each child in a
small playroom with their mother and measured wrist and
ankle movements, the initiation of interactions, the
frequency of responses, the occurrence of solitary play,
and mother-directed play among other variables. They found
that methylphenidate produced a significant decrease in
sociability for both boys (i.e., decreased social
interaction and increased solitary play).
16
Barkley & Cunningham (1979b) conducted a similar study
with twenty children aged 5 to 12. Experimental conditions
included a no drug condition (neither drug nor placebo),
placebo, or methylphenidate given at individual prescribed
doses (mean = 14.6 mg/daily). Dependent measures included
wrist and ankle movement as measured with actometers, the
occurrence of mother child interactions, and a parental
questionnaire. As reported by other researchers, both ankle
and wrist activity decreased significantly while on
medication. In addition, children initiated significantly
fewer social interactions and responded less to their
mothers while on methylphenidate compared to placebo or no
drug conditions.
Effects on Play Related Social Behavior. Several
studies have examined the effects of stimulants on social
behavior of preschool children diagnosed with ADHD.
Although these studies do not specifically investigate
social play, they are relevant because they examine
behaviors that may be considered prerequisites for social
play, such as social interaction.
Schliefer and colleagues (1975) evaluated the effects
of methylphenidate in hyperactive preschool children aged 3
to 5 in unstructured settings. Doses of methylphenidate
started at 5 mg and then varied depending on observed
17
clinical effects. Children were observed in a nursery
school setting once each week. Data were taken on specific
social behaviors (e.g., aggression) during free-play
settings. Nursery school teachers filled out a three-point
hyperactivity scale for each participant. The experimenters
also employed several psychological tests to evaluate the
effects of methylphenidate (i.e., parts of the Cincinatti
Test of Preschool Autonomy and the Auditory Continuous
Performance Test). Additionally, mothers of the children
attending the program were given the Hyperactivity Rating
Scale (Werry, 1968). According to parental report, negative
behaviors (i.e., noncompliance and aggression) occurred
less frequently while on medication. However, the
researchers reported that, while receiving methylphenidate,
most of the children exhibited a variety of negative side
effects including sleep disturbances, increased solitary
play, altered mood and decreased social behavior. The
researchers determined that stimulant-induced adverse
effects on social functioning were sufficiently severe that
all but 3 of the 28 participants discontinued use of
methylphenidate at the conclusion of the study.
Northup, Gulley, Edwards and Fountain (in press)
evaluated the behavioral effects of methylphenidate in
three preschool children aged 4 to 6 in different settings
18
including a preschool classroom and recess. Dependent
measures used in the classroom included out-of-seat
behavior, off-task behavior, inappropriate vocalizations,
and playing with objects. Social engagement was measured
during recess. Social engagement was defined as initiating
a social interaction, participating in an interaction, or
following the rules of an activity. They found that, in
general, methylphenidate was effective for decreasing many
disruptive behaviors (i.e. out of seat, inappropriate
vocalizations, inappropriate object play) in the classroom.
However, they also found that all doses of methylphenidate
(0.3 mg/kg, 0.6 mg/kg and 1.0 mg/kg) decreased the
occurrence of social engagement during recess in a dosedependent manner for two of the three children.
A number of additional studies have documented the
effects of stimulants on social behavior in school-aged
children. Rie and colleagues (1975) conducted a study with
“underachieving children” aged 7 to 9 using several
different types of rating scales and achievement tests to
evaluate the effects of methylphenidate on disruptive
behavior and academic achievement. The main findings of
this study were that methylphenidate did not improve
achievement, but the researchers anecdotally observed a
number of negative effects of medication on social
19
behavior. The authors stated that, while on medication,
children, “exhibited little or no initiative or
spontaneity, offered little indication of either interest
or aversion, showed virtually no curiosity, surprise or
pleasure and seemed devoid of humor.” (p. 258). The authors
expressed concern regarding the effects of these druginduced reductions in responsivity on emotional
development. It is noteworthy that these children had been
prescribed relatively low doses of methylphenidate (5 to 20
mg daily).
Smith, Pelham, Evans, Gnagy, Molina, Bukstein,
Greiner, Myak, Presnell & Willoughby (1998) investigated
the effects of methylphenidate on social behavior in 46
adolescent children diagnosed with ADHD at a summer
treatment facility. Dosages used were 10 mg, 20, or 30 mg
in the morning and at lunch. Participants also received a
half dose at mid-afternoon (total dosage of methylphenidate
for the day was either 25, 50, or 75 mg). Dependent
measures focused mainly on social behavior as determined
with rating scales completed by counselors and teachers.
Overall, many participants exhibited improvements in social
behavior while on low doses of methylphenidate. The authors
noted, however, that as stimulant dose increased, the
beneficial effects of stimulants decreased, and the risk of
20
social side effects, including social withdrawal and
increased listlessness, increased significantly.
Stimulant drugs have been shown to produce significant
disruptions in the social behavior of developmentally
disabled individuals with ADHD. Helsel, Hersen, Lubetsky,
Fultz, Sisson & Harlovic (1989) investigated the effects of
stimulants on behavior in both structured and unstructured
social settings for four mentally retarded children aged 4
to 8 with concurrent diagnoses of ADHD. Several dosages of
methylphenidate were varied for each of the participants,
with doses ranging from 0.3 to 0.9 mg/kg. Assessment
procedures included a direct classroom observation during
academics, performance measures, affect rating measures,
and teacher rating scales (i.e., Connors Teacher Rating
Scale). In the classroom observation, dependent measures
included the occurrence of on-task behavior, in-seat
behavior, and talking out. Performance measures included
task accuracy and latency to task completion. As has been
established in many studies, they found that increasing
doses of methylphenidate improved on-task behavior.
Anecdotally, however, they noted a number of dose-related
negative changes in social behavior for all four
participants. One participant who was informally evaluated
for side effects exhibited severe social withdrawal and was
21
described as non-interactive while on the 0.6 mg/kg dose of
methylphenidate. The researchers did not systematically
evaluate the stimulant-related side effects in this study.
Another study with developmentally disabled children
with concurrent diagnoses of ADHD was conducted by Handen
and colleagues (1995). Participants were 27 children aged 6
to 12. The medication conditions in the study included
placebo and two doses of methylphenidate (0.3 mg/kg and 0.6
mg/kg). The researchers used a six-point 13-item rating
scale to determine the presence of side effects in the
participants. Measures on this scale included, motor
movements, drowsiness, sadness, staring, moodiness,
irritability, social withdrawal, anxiety, dizziness,
stomachaches, headaches, poor appetite, and activity level.
Although they were unable to detect any consistent pattern
of behavioral side effects, two subjects exhibited severe
social withdrawal on the 0.3 mg/kg dose.
Rationale for the Current Study
The primary purpose of the current study was to
evaluate the effects of stimulant medications on the play
and social behavior of children during an unstructured
recess setting, a structured play condition, and an alone
play condition. Children receiving the extended-release
stimulant medication, Concerta, were observed an additional
22
time in the afternoon to evaluate its effects over longer
periods of time. There have been few studies attempting to
document the effects of stimulant medications in
unstructured settings. Of the studies including
observations in unstructured settings, none have
specifically observed the effects of stimulants on
behaviors related to social play.
Another goal in the current study was to investigate
the effects of stimulant medications on the reinforcing
properties of social behavior and play by using a
concurrent-operants reinforcer assessment procedure (i.e.,
Northup, George, Jones & Broussard, 1996; Northup,
Fusilier, Swanson, Roane & Borrero, 1997) to determine if
stimulants altered the reinforcing value of play and/or
social interaction. Given that stimulants have been shown
to decrease the occurrence of play and related social
behaviors in rats and non-human primates, it is possible
that children taking these drugs may be less likely to
choose social play as a reinforcer.
There were a number of secondary goals for the present
study. The first of which was to document the effects of
stimulants on social behavior in both structured and
unstructured play settings. It is possible that the
structured or unstructured nature of the activity may
23
influence the effects of stimulant medication on social
behavior. Another goal was to document the effects of
stimulants on play behavior in solitary settings. This
condition enables comparison between the effects of
stimulants on behavior in solitary play settings and
structured and unstructured social play settings. The final
objective was to evaluate the accuracy of both teachers and
participants in reporting the presence of side effects.
This was evaluated with a teacher rating scale, a child
rating scale and a structured child interview.
24
CHAPTER 2: METHODOLOGY
Participants and Setting
Five children between the ages of 4 and 6 participated
in the current study. All participants were enrolled in the
Summer Treatment and Research Program (STAR Program) at
Louisiana State University. Enrollment in the program
required a prior diagnosis of ADHD based on the criteria of
the Diagnostic and Statistical Manual for Mental Disorders
(DSM-IV, American Psychiatric Association, 1994). In
addition, a consulting psychiatrist provided independent
confirmation that the children met the DSM-IV criteria for
ADHD based on parent interviews and scores at least two
standard deviations above established norms on either the
ADHD Rating Scale (DuPaul, 1991) or the Connors
Hyperactivity Scale (Connors, 1973). This study was
conducted in conjunction with IRB approved medication
evaluation procedures funded with a NIH grant.
Response Definitions
Data were collected for a variety of dependent
variables across each of the three play conditions (i.e.,
recess, sports training and alone play). Dependent
variables were defined as follows:
1) Toy/object play. Defined as any touching of a toy (or
object) during the interval.
25
2) Solitary play. Defined as engaging in playful activities
(i.e. toy/object play) without peers for at least five
seconds during the interval. The appropriateness of the
play was documented as well. Inappropriate play included
such behaviors as property destruction.
3) Social play. Defined as engaging in cooperative
activities with peers (i.e. throwing a ball back and
forth, playing games) for at least five seconds during
the interval. The appropriateness of social play was
documented as well. Inappropriate social play included
such behaviors as property destruction, cheating, and
aggression.
4) Nonsocial vocalizations. Defined as vocalizations made by
the child that were not directed at others, such as
humming or whistling.
5) Social vocalizations. Defined as vocalizations directed
at either peers or the recess monitor. Occurrences of
inappropriate vocalizations, such as name calling or
complaining, were documented.
6) High activity level. Defined as the child walking,
running and/or jumping for at least five seconds of the
interval.
26
7) Game participation. Defined as the child remaining
oriented to the game (i.e., looking at the ball) for at
least five seconds of the interval.
8) Anxiety/stereotyped behavior. Defined as any instances of
crying, whining, nail biting, somatic complaints,
gratuitous hand movements (i.e., hand flapping) or skin
picking.
9) Number of escape attempts. Defined as any attempts or
requests to leave the designated play area.
10)
Social withdrawal. Defined as the child not
interacting or playing with peers and is at least three
feet from others for the entire ten second interval.
11)
Steps taken. Defined as the number of steps taken as
measured with digital pedometers attached to the waist of
each child. A second pedometer was worn by each child to
measure the reliability of the instruments.
Side Effects Measures. Side effects measures were
completed by the recess monitor/classroom teacher and each
participant daily. A side effect questionnaire was
developed from the items from Barkley’s Stimulant Drug Side
Effects Rating Scale (Barkley, 1981). However, items
specific to play and social behavior were added (See
Appendices A and B).
27
Self Report Measure.
Summer program staff members
conducted a brief structured interview for each participant
while taking each dose of stimulant medication (See
Appendix C). The self-report measure contained items
designed to assess if the children understood why they were
taking the medication and to provide information regarding
the child’s own perception of medication effects. This
measure represented a qualitative index of the childrens’
perception of medication effects.
Data Collection and Measurement
Data were collected daily for six weeks during the
summer treatment program. Participants were observed for
ten-minute periods during unstructured (recess), structured
(sports training), and alone conditions as described below.
Each ten-minute observation was divided into 60 ten-second
intervals. Both partial (i.e., any instance of the behavior
occurring in the interval) and whole (i.e., instances of
the behavior lasting for the entire interval) interval
recording was used for the dependent variables. Partial
interval data were recorded for most of the dependent
measures including: toy/object play, solitary and social
play, social and nonsocial vocalizations, high and low
activity levels, game participation, escape attempts and
anxiety behavior. Whole interval recording was used for the
28
measurement of social withdrawal. Frequency data were taken
for the number of steps taken and were measured with an
electronic pedometer attached to the waist of each
participant during all play conditions. The electric
pedometers approximate the number of steps taken.
Interobserver reliability data were collected for all
play conditions in the current study. Observers were
trained to at least 80% agreement before beginning the
study. For the recess observations, reliability data were
collected for 33.3% of sessions. Agreement for the recess
condition was 84.6% with a range from 50.0% to 100.0%
across all dependent variables. Agreement was determined by
taking the number of intervals in which there was agreement
for all of the variables, divided by the total number of
possible intervals and then multiplied by 100.
For the sports training observations, reliability data
were collected for 36.0% of sessions. Agreement for the
sports training condition was 85.9% with a range from 66.7%
to 100.0%.
29
For the alone play observations, reliability data were
collected for 52.8% of sessions. Agreement for the alone
play observations was 93.3% ranging from 75.0% to 100.0%.
Reliability data were collected for 33.8% of the
sessions in the reinforcer assessment. Agreement for the
reinforcer assessment was 100.0% for all sessions.
Procedure
Unstructured recess. The unstructured recess was a 15minute free-play condition conducted outdoors. Recess was
available to all children attending the summer treatment
program (n=12), although data were only collected for the
children participating in the current study. Children were
restricted to an 80 x 30 foot play area for observations.
Several common toys were made available for the
participants to play with (Bouncy Balls, plastic
trucks/cars, plastic baseball bat, etc.). Observers
remained outside the designated play area to minimize
extraneous social contact with the participants. A recess
monitor (the classroom teacher) was present in the recess
area to redirect children in cases of immediate harm to
self or others, or attempts to leave the designated play
area. Dependent variables for the recess setting included
toy/object play, social and nonsocial play, social and
nonsocial vocalizations, activity level, anxiety behavior,
30
escape attempts, social withdrawal and number of steps
taken.
Structured Sports Training. The structured sports
training condition was a behavior management program
designed to teach sportsmanship and social skills to
children with ADHD. This program was conducted daily for
six weeks during the summer treatment program.
Sportsmanship skills (i.e., clapping, cheering) were
trained during games of kickball. All children in the
summer treatment program were involved in the sports
training program, but for the purpose of the current
investigation, data were collected for only the six
participants in this study. Data collectors remained
outside of the playing area to minimize social contact with
the children. Dependent variables measured in this
condition included game participation, social and nonsocial
vocalizations, high activity level, escape attempts,
anxiety behavior and number of steps taken.
Alone play.
Alone play conditions were conducted
daily for six weeks during the summer treatment program. In
this condition, the children were placed alone in a room
with a number of common toys. They were told that someone
would be back for them in “a little while” and to do
whatever they would like. Observers collected data in an
31
adjacent room from behind a two-way mirror. Dependent
variables for this condition included toy/object play,
nonsocial vocalization, high activity level, escape
attempts and number of steps taken.
Tiger Camp Observations. Due to its extended duration
of action, children taking the stimulant, Concerta, were
observed at additional times during Monday, Wednesday, and
Friday afternoons while attending another summer program.
The children were observed during play conditions similar
to the morning recess or sports training conditions. Data
were not collected on days in which children were not
engaged in play activities (i.e., arts and crafts).
Although the onset of behavioral effects for Concerta is
expected in the same time as the short-acting preparation
of methylphenidate (within 30 minutes to an hour), peak
plasma concentrations of Concerta occur six to eight hours
after administration. Thus, the peak effects occur early in
the afternoon. Children were observed for ten minutes, as
was the case in the morning recess and sports conditions.
The dependent measures in the afternoon observations
included game participation, social and nonsocial
vocalizations, activity level, anxiety/stereotyped
behavior, escape attempts, and social withdrawal.
32
Reinforcer assessment.
A social reinforcer assessment
was conducted for five of the children during the study.
Assessment procedures were based on those of Northup, et
al. (1996) and Northup, et al. (1997). During baseline,
children were presented with a nonpreferred task (i.e.
placing blocks in a bucket). The experimenter then
instructed the participant to place as many or few blocks
in the bucket as they would like. The average number of
blocks placed in the bucket during baseline was used as the
criterion level to earn token coupons in the reinforcer
assessment condition.
During the assessment condition, the
participants had to place the criterion number of blocks in
the bucket to earn one of three coupons for a preferred
item, including a “play alone” coupon, a “play with
friends” coupon and a “quiet time” coupon. The children had
the opportunity to earn as few or as many coupons as they
would like within a five-minute period. Each “play alone”
coupon could be exchanged for the opportunity to play with
a number of toys in a room alone for two minutes. Each
“play with friends” coupon could be exchanged for the
opportunity to play with a friend for two minutes. Each
“quiet time” coupon could be exchanged for the opportunity
to read, sit in a chair quietly or rest quietly on a couch
for two minutes. Neither toys nor peers were available to
33
the participant in this condition. Immediately following
each assessment, children were able to “cash in” their
coupons by handing the cards to the experimenter. The type
of coupon, as well as the order in which they were cashed
in, were recorded.
Rating Scales/Child Interview. One teacher rating
scale for each participant was given to the classroom
teacher to be completed at the end of each day. The teacher
was required to complete the questionnaires before leaving
each day. A child rating scale was administered to each
participant daily. Additionally, a child interview was
conducted once while on each dose for each participant
(i.e., once while on placebo and once for each medication
dose condition). Both the child rating scale and the child
interview were conducted in a quiet room with only the
therapist and child present.
Medication Status
Participants received one of three previously
prescribed stimulant medications in this study. A
consulting child psychiatrist prescribed an alternating
course of placebo (i.e., sugar pills in capsule form) and
one dose of either Dexedrine (n=1), Adderall (n=2) or
Concerta (n=2) for each of the participants. One
participant received an alternating course of placebo and
34
two doses of Concerta (36 mg and 54 mg). There were two or
three possible dose conditions for each participant (1 to 2
medication dose levels and a placebo dose) during the
experiment. Two participants received Adderall in the
current study. One participant (Ruby) received 10 mg (0.4
mg/kg) while another (Eric) received 20 mg (0.8 mg/kg).
These doses of Adderall were the doses of medication that
had been prescribed prior to their admission to the summer
program and are representative of doses that are commonly
prescribed in clinical practice. One participant (Brad)
received 20 mg (0.8 mg/kg) of d-amphetamine (Dexedrine).
This participant had been prescribed this dose of Dexedrine
before his admission to the summer program. Three
participants received doses of Concerta. One participant
(Jack) received 36 mg (1.6 mg/kg) while another (Randy)
received 54 mg (2.4 mg/kg). The third participant receiving
Concerta was given two doses: 36 mg (1.6 mg/kg) and 54 mg
(2.4 mg/kg). For the first two participants receiving
Concerta, doses used were prescribed before their admission
to the summer program. The third participant had been
prescribed 36 mg of Concerta prior to his admission to the
summer program. During the summer program, the consulting
psychiatrist increased the dose to 54 mg. Doses of Concerta
for all participants were doses that are commonly used in
35
clinical practice. With the exception of the director of
the program, all observers were blind to the medication
dose. All drug conditions were compared to placebo. The
director of the program provided the parents with
instructions each day regarding medication dose for the
following day. Medication status as well as the time of
administration, were verbally confirmed with the parents
each morning.
Design
Medication status was alternated daily in a
multielement single case design (Sidman, 1960) and the
results were graphed and evaluated via visual inspection
(Kazdin, 1982). The multielement design was an alternating
course of treatment (i.e., stimulant medication) and nontreatment (i.e., placebo) that was rotated in a semi-random
manner. The alternation of dose conditions was not
completely random in an effort to have similar numbers of
observations for each dose condition. The differences
between dosage levels of each given medication were
evaluated with a randomization test which randomly assigns
observations of the dependent variable (e.g., percentage of
intervals) to the conditions of the independent variable
(e.g., drug dose or placebo) and then calculates an F-test
thousands of times until a stable, random distribution of
36
F-tests is created (Edgington, 1996). The F-test produced
by the actual results of the individual is then compared to
the randomized F-test distribution to determine the chance
probability of the actual results. The randomization test
is well suited for single-subject designs (i.e.,
multielement designs) given that it does not involve many
of the assumptions for population-based statistical tests
(i.e., normal distribution, independence of samples).
To illustrate how the randomization test functions, a
simple example will be provided. In the current example,
seven observations are conducted with a given participant.
Three of the seven observations represent a control
condition (i.e., placebo) and four represent an experimental
condition (i.e., stimulant dose). The scores from the
control condition are 17, 21, and 23 on a given dependent
variable (i.e., percent of intervals with social
withdrawal). The scores from the experimental condition are
22, 25, 25, and 26. If the null hypothesis is true, the
scores should have an equal probability of being in the
control or experimental condition. That is, the values are
“interchangeable”. The randomization test calculates all
possible combinations of the 7 observations in one group of
3 and another group of 4 (there are 35 such arrangements in
the current example). The relevant test statistic is created
37
for each arrangement, and the statistic obtained is compared
to that reference distribution (usually referred to as a
sampling distribution with parametric tests). The null
hypothesis is then either rejected or retained. In the
present example, there is only one arrangement of the data
that would have a smaller mean for control condition and a
larger mean for the experimental condition. The difference
obtained in the current example would occur only 2 times out
of 35, for a probability of approximately .1142.
38
CHAPTER 3: RESULTS
Experiment 1 – Unstructured Recess
Eric. Eric exhibited a significant increase in the
number of intervals of social vocalizations (from 39.9 to
58.9% of intervals) while on medication (p<0.01) (See Table
1 and Appendix D, Figure 4).
Brad. Brad demonstrated no significant medication
effects for any of the variables measured during the recess
condition (See Table 1 and Appendix D).
Ruby. Ruby exhibited fewer intervals with social
vocalizations/attempts at social contact while on
medication during the recess condition (35.2 to 16.0% of
intervals; p<0.001)(See Table 1 and Appendix D, Figure 4).
Randy. A significant medication effect was observed
for toy play during the recess period for Randy. Medication
significantly increased the number of intervals Randy
engaged in toy play (76.8 to 91.9% of intervals; p<0.05)
(See Table 1 and Appendix D, Figure 1).
Jack. Jack demonstrated no significant medication
effects for any of the variables measured during the recess
condition (See Table 1 and Appendix D).
Rick. A number of significant medication effects were
observed for Rick during the recess condition at both the
39
low (36 mg) and high (56 mg) Concerta dose. Rick exhibited
a significant decrease in the number of intervals with toy
play from 85.0 to 11.0% of intervals while on the high dose
of Concerta (p<0.001) (See Table 1 and Appendix D, Figure
1). Additionally, the high dose of Concerta produced a
decrease in solitary play (51.7 to 3.1%, p<0.001) (See
Table 1 and Appendix D, Figure 3). The high dose produced a
decrease in activity level from 59.1 to 14.6% of intervals
(p<0.001) (See Table 1 and Appendix D, Figure 6). The high
dose of Concerta produced a significant increase in
anxiety/stereotyped behavior from 1.3% to 45.6% of
intervals (p<0.001) (See Table 1 and Appendix D, Figure 7).
Both doses of Concerta produced significant decreases in
the occurrence of escape attempts. The high dose of
Concerta decreased the number of intervals with escape
attempts from 4.0% to 0.0% (p<0.01). The low dose of
Concerta decreased the number of intervals with escape
attempts from 4.0 to 0.0% (p<0.01) (See Table 1 and
Appendix D, Figure 8).
Summary. For the recess condition, the findings were
variable across participants. Both Eric and Ruby exhibited
significant medication effects for social vocalizations/
Table 1. Unstructured Recess Observations__________________
Eric
Brad
40
Ruby
Dependent
Variable
Toy
Play
Social
Play
Solitary
Play
Activity
Level
Anxiety
Behavior
Escape
Attempts
Social
Vocals
Nonsocial
Vocals
Social
Withdrawal
Steps
Taken
*
**
***
****
Pla
20 mg
Add
Pla
20 mg
Dex
Pla
10 mg
Add____
64.1%
66.8%
80.0%
69.4%
39.7%
64.0%
81.7%
85.5%
41.5%
51.6%
39.2%
21.3%
11.2%
12.0%
45.8%
31.3%
18.3%
44.8%
18.3%
20.1%
30.5%
43.6%
31.3%
29.3%
1.2%
5.2%
2.1%
4.9%
0.0%
0.0%
1.1%
0.2%
0.0%
0.9%
0.8%
0.3%
39.9%
22.1%
28.9%
35.2%
0.4%
58.9%
**
0.5%
6.4%
7.6%
0.5%
16.0%
****
0.3%
4.4%
0.8%
4.9%
10.1%
15.0%
18.7%
608.1
523.1
735.3
705.2
415.4
322.0
p<0.05
p<0.01
p<0.005
p<0.001
Pla = Placebo
Add = Adderall
Dex = Dexedrine
Table 1._(continued)
Randy
______
Jack
41
Rick
Dependent
Variable
Toy
Play
Social
Play
Solitary
Play
Activity
Level
Anxiety
Behavior
Escape
Attempts
Social
Vocals
Nonsocial
Vocals
Social
Withdrawal
Steps
Taken
*
**
***
****
Pla
76.8%
54 mg
Con
36 mg
Con
Pla
Pla
36 mg
Con
54 mg
Con_
73.5%
76.2%
85.0%
78.2%
44.0%
91.9%
*
45.9%
66.7%
75.8%
40.4%
31.4%
43.5%
50.5%
17.6%
15.0%
51.7%
52.9%
29.2%
41.9%
27.2%
32.1%
59.1%
48.1%
1.2%
3.3%
0.7%
0.2%
1.3%
7.5%
12.3%
0.4%
1.8%
1.6%
4.0%
38.8%
29.1%
47.3%
45.0%
21.9%
0.0%
**
15.4%
3.1%
****
14.6%
****
45.6%
****
0.0%
**
12.0%
1.2%
3.6%
1.5%
1.6%
7.0%
4.4%
2.0%
9.8%
11.5%
8.0%
2.5%
12.4%
16.9%
17.6%
670.0
670.0
818.5
801.9
595.5
519.2
269.5
p<0.05
p<0.01
p<0.005
p<0.001
Pla = Placebo
Con = Concerta
42
11.0%
****
26.6%
social interactions. Stimulant dose produced a 46.2%
increase in the number of intervals with social
vocalizations for Eric while Adderall produced a 54.5%
decrease in the number of social interaction/attempts at
social contact attempts made by Ruby. Randy demonstrated a
significant 19.7% increase in the number of intervals of
toy play.
Rick displayed a number of significant medication
effects while receiving the high dose of Concerta,
including an 87.1% decrease in toy play, a 92.2% decrease
solitary play, a 69.6% decrease in locomotor activity, a
100.0% decrease in escape attempts as well as significant
increases in anxiety/stereotyped behaviors (508.0%
increase). These findings clearly indicate that the high
dose of Concerta produced a number of detrimental social
effects for Rick.
Experiment 2 – Structured Sports Training
Eric. A significant medication effect was observed for
Eric during the sports training condition. Medication dose
increased game participation from 82.2 to 94.7% (p<0.05)
(See Table 2 and Appendix E, Figure 1).
Brad. Brad exhibited a number of significant
medication effects during the sports training condition.
While on medication (20 mg Dexedrine), Brad displayed a
43
significant increase in game participation (56.4% to 84.2%
of intervals; p<0.001) (See Table 2 and Appendix E, Figure
1). Medication also produced a significant decrease in
activity level as measured by the percentage of intervals
with high activity as well as the number of steps taken.
During the kickball game, the percentage of intervals with
high activity decreased from 33.1% to 18.4 % (p<0.01) (See
Table 2 and Appendix E, Figure 4) while the number of steps
taken decreased from 842.3 to 375.2 steps (p<0.005) (See
Table 2 and Appendix E, Figure 7). A mild, but consistent
increase in anxiety/stereotyped behavior (2.1 to 9.0% of
intervals) was also observed while Brad was on Dexedrine
(p<0.005) (See Table 2 and Appendix E, Figure 5).
Ruby. Ruby demonstrated no significant medication
effects for any of the variables measured during the sports
training condition (See Table 2 and Appendix E).
Randy. Randy exhibited a number of significant
medication effects during the sports training condition,
including a significant increase in game participation
(from 49.9 to 76.0% of intervals; p<0.05) (See Table 2 and
Appendix E, Figure 1) and a significant increase the number
of intervals containing anxiety/stereotyped behavior (from
2.0 to 11.6%; p<0.05) (See Table 2 and Appendix E, Figure
5). Escape attempts decreased from 16.6 to 1.0% of
44
intervals while on Concerta (p<0.05) (See Table 2 and
Appendix E, Figure 6).
Jack. Jack demonstrated no significant medication
effects for any of the variables measured during the sports
training condition (See Table 2 and Appendix E).
Rick. Several significant effects were observed for
Rick at both the high and low doses of Concerta during the
sports training condition. Both doses of medication
produced significant increases in game participation (See
Table 2 and Appendix E, Figure 1). The low dose of Concerta
increased participation from 30.4 to 70.0% of intervals
(p<0.005). The high dose increased game participation from
30.4 to 86.4% of intervals (p<0.001). Both doses of
Concerta produced significant decreases in social
vocalizations during the sports training condition (See
Table 2 and Appendix E, Figure 2). The low dose decreased
social vocalizations from 36.0 to 18.6% of intervals
(p<0.05). The high dose of Concerta decreased social
vocalizations from 36.0% to 11.6% of intervals (p<0.01).
Significant increases in anxiety/stereotyped behavior were
observed for both dose conditions as well (See Table 2 and
Appendix E, Figure 5). The low dose of Concerta produce an
increase in the number of intervals of anxiety behavior
from 6.1% to 31.9% of intervals (p<0.05). The high dose
45
increased anxiety behavior from 6.1% to 66.6% of intervals
(p<0.001).
Summary. In the sports training condition, a number of
significant medication effects were observed. Four of the
six participants demonstrated significant increases in game
participation (Brad, Randy, Eric and Rick). However, for
three of these four children, a corresponding increase in
the amount of anxiety/stereotyped behavior was observed
while on their prescribed dose of medication (Brad, Randy
and Rick). Although there did appear to be an increase in
anxiety behavior for Eric while on Adderall (1.5% to 16.1%
of intervals), the findings were not statistically
significant (p=0.06).
A number of idiosyncratic effects were observed for
several of the participants in the sports training setting
as well. For instance, Rick exhibited a significant
decrease in the number of social vocalizations made during
the game at both the high and low dose of Concerta (53.2%
decrease for the low dose and 67.8% decrease for the high
dose). Brad displayed a significant decrease in locomotor
activity during the sports training condition.
46
Table 2. Structured Sports Training Observations _ ________
Eric
20 mg
Pla
Add
Dependent
Variable
Game
Particptn
Social
Vocals
Nonsocial
Vocals
Activity
Level
Anxiety
Behavior
Escape
Attempts
Steps
Taken
82.2%
28.7%
94.7%
*
24.4%
0.7%
*
**
***
****
Pla
10 mg
Add____
43.5%
49.0%
26.9%
10.5%
7.0%
0.9%
18.4%
10.3%
2.5%
0.0%
10.7%
10.3%
33.1%
17.0%
8.3%
1.5%
16.1%
2.1%
0.5%
3.8%
1.2%
0.0%
0.6%
18.4%
**
9.0%
***
0.5%
6.3%
2.0%
346.2
307.6
842.3
375.2
***
310.0
196.2
Randy
54 mg
Pla
Con
49.9%
56.4%
Ruby
84.2%
****
24.9%
Dependent
Variable
Game
Particptn
Social
Vocals
Nonsocial
Vocals
Activity
Level
Anxiety
Behavior
Escape
Attempts
Steps
Taken
Brad
20 mg
Pla
Dex
Jack
36 mg
Pla
Con
Pla
92.3%
95.7%
30.4%
30.1%
76.0%
*
21.5%
36.3%
31.8%
36.0%
2.4%
1.5%
1.0%
2.2%
19.2%
14.6%
26.5%
2.0%
11.6%
*
1.0%
*
236.1
16.6%
457.6
Rick
36 mg
Con
54 mg
Con_
11.3%
70.0%
***
18.6%
*
1.8%
86.4%
****
11.6%
**
0.0%
22.1%
19.0%
13.8%
8.0%
0.6%
3.4%
6.1%
1.8%
2.5%
9.0%
31.9%
*
2.6%
66.6%
****
0.6%
600.3
640.9
233.7
245.5
227.0
p<0.05
p<0.01
p<0.005
p<0.001
Pla
Con
Add
Dex
47
=
=
=
=
Placebo
Concerta
Adderall
Dexedrine
Experiment 3 - Alone Play
Eric. Medication dose produced a significant effect on
locomotor activity in the alone play condition for Eric.
Adderall decreased activity level from 18.4 to 5.3% of
intervals (p<0.05) (See Table 3 and Appendix F, Figure 3)
as well as the number of steps taken from 372.2 to 183.6
steps (p<0.05) (See Table 3 and Appendix F, Figure 6).
Brad. Brad exhibited significant medication effects
during alone play sessions. A significant decrease in
intervals with vocalizations was observed while Brad was on
Dexedrine. Vocalizations decreased from 38.0 to 5.9% of
intervals while on medication (p<0.01) (See Table 3 and
Appendix F, Figure 2). Additionally, Dexedrine decreased
the number of steps taken from 187.6 to 105.3 (p<0.05) (See
Table 3 and Appendix F, Figure 6).
Ruby. Ruby demonstrated no significant medication
effects for any of the variables measured during the alone
play condition (See Table 3 and Appendix F).
Randy. Randy demonstrated no significant medication
effects for any of the variables measured during the alone
play condition (See Table 3 and Appendix F).
Jack. Jack demonstrated no significant medication
effects for any of the variables measured during the alone
play condition (See Table 3 and Appendix F).
48
Table 3. Alone Play Observations
Eric
20 mg
Pla
Add
Dependent
Variable
__________________
Brad
20 mg
Pla
Dex
Ruby
10 mg
Pla
Add____
Toy
Play
Vocals
97.9%
95.9%
94.8%
97.1%
89.1%
64.5%
3.8%
0.9%
38.0%
20.1%
11.8%
Activity
Level
Anxiety
Behavior
Escape
Attempts
Steps
Taken
18.4%
8.5%
5.7%
10.0%
0.3%
5.3%
*
6.0%
5.9%
**
4.8%
0.9%
0.7%
0.4%
0.3%
0.7%
0.6%
0.2%
0.0%
15.1%
5.8%
372.2
183.6
*
187.6
105.3
*
128.4
166.2
Randy
54 mg
Pla
Con
Dependent
Variable
Jack
36 mg
Pla
Con
Pla
Rick
36 mg
Con
54 mg
Con_
Toy
Play
Vocals
99.3%
90.1%
95.5%
88.0%
99.3%
99.9%
99.2%
33.6%
22.4%
21.9%
10.5%
61.1%
58.6%
52.4%
Activity
Level
Anxiety
Behavior
Escape
Attempts
Steps
Taken
9.8%
8.4%
17.3%
29.5%
16.9%
13.0%
2.0%
0.0%
0.2%
0.0%
0.0%
0.0%
0.2%
0.6%
0.0%
0.2%
2.3%
1.3%
0.9%
0.2%
0.4%
172.8
106.1
359.4
470.1
135.2
247.7
341.8
*
**
***
****
Pla
Con
Add
Dex
p<0.05
p<0.01
p<0.005
p<0.001
49
=
=
=
=
Placebo
Concerta
Adderall
Dexedrine
Rick. Rick demonstrated no significant medication
effects for any of the variables measured during the alone
play condition (See Table 3 and Appendix F).
Summary. Relatively few significant medication effects
were observed in the alone play condition. Two of the six
participants demonstrated significant decreases in
locomotor activity while taking their prescribed dosage of
medication. For Eric, both the number of intervals of high
activity and the number of steps taken decreased
significantly while taking Adderall. For Brad, the number
of steps taken during alone conditions decreased as well.
Another idiosyncratic finding was the decrease in the
number of vocalizations made by Brad while on Dexedrine.
Experiment 4 – Tiger Camp Observations
Randy. Randy displayed higher levels of game
participation while on medication (45.0% to 86.0% of
intervals, 91.1% increase) during the Tiger Camp
observation (See Table 4 and Appendix G, Figure 1).
Additionally, higher levels of anxiety/stereotyped behavior
were observed while on medication (7.0% to 22.0% of
intervals, 214.3% increase) for Randy (See Table 4 and
Appendix G, Figure 5).
50
Table 4. Tiger Camp Observations
Dependent
Variable
Game
Particptn
Social
Vocals
Activity
Level
Anxiety
Behavior
Escape
Attempts
Social
Withdrawal
Pla
Con
Add
Dex
=
=
=
=
Randy
54 mg
Pla
Con
__________________
Jack
36 mg
Pla
Con
Pla
Rick
36 mg
Con
54 mg
Con_
45.0
86.0
60.0
100.0
78.5
100.0
100.0
3.0
18.2
13.5
27.7
3.5
9.0
8.0
15.0
19.2
16.7
21.3
15.0
21.5
3.0
7.0
22.0
3.0
1.0
44.0
19.0
42.0
0.0
0.0
0.0
0.0
17.5
0.0
0.0
0.0
1.0
0.0
0.0
0.0
0.0
0.0
Placebo
Concerta
Adderall
Dexedrine___________________________________________
Jack. Jack demonstrated no significant medication
effects for any of the variables measured during the Tiger
Camp observations (See Table 4 and Appendix G).
Rick. Rick displayed higher levels of game
participation while on medication (an increase from 78.5%
on placebo to 100.0% for both the low and high dose, 24.7%
increase) (See Table 4 and Appendix G, Figure 1).
Summary. In summary, there were relatively few
significant findings for the Tiger Camp observations.
Additionally, the findings that were significant must be
interpreted with caution due to the limited number of
51
observations conducted. Due to the limited number of
observations, statistical tests could not be conducted.
Experiment 5 – Social Reinforcer Assessment
Eric. Significant medication effects were observed
during the social reinforcer assessment for Eric. He
selected a greater proportion of peer play coupons while
taking Adderall (83.3% as compared to 71.8%). In addition,
the number of alone play coupons selected decreased while
on Adderall (28.2% to 16.7%). Eric selected fewer total
coupons (3.9 as compared to 3.0) while taking the
prescribed dose of medication
(See Table 5 and Appendix H,
Figures 4 and 5).
Brad. Significant medication effects were observed in
the social reinforcer assessment for Brad. He displayed a
significant decrease in number of peer coupons selected
while taking Dexedrine (86.5% to 63.9%). In addition, a
corresponding increase in the number of quiet time coupons
selected (8.1% to 27.8%) was observed while he was on
medication
(See Table 5 and Appendix H, Figure 5).
Randy. Some minor medication effects were observed
during the social reinforcer assessment for Randy. Concerta
decreased the percentage of peer coupons selected from
100.0% to 90.5%. Medication dose also produced a slight
increase in the amount of alone and quiet coupons selected
52
(from 0.0% to 2.4% for alone coupons and from 0.0% to 7.1%,
respectively) (See Table 5 and Appendix H, Figure 5).
Jack. No significant medication effects were observed
for the type of coupons selected by Jack during the
reinforcer assessment. The total daily number of coupons
selected by Jack increased from 3.5/day to 4.9/day (a 40.0%
increase) while on Concerta (See Table 5 and Appendix H,
Figure 4).
Rick. Rick exhibited a number of significant
medication effects during the social reinforcer assessment.
Rick selected significantly fewer peer coupons while on the
high dose of Concerta (67.7% to 40.0% of coupons).
Furthermore, a corresponding increase in alone play coupon
selection was observed while Rick was on the high dose of
Concerta (32.3% to 53.3% of coupons). Peer play coupons
were selected at the highest rate while on the low dose of
Concerta (86.7%). Additionally, alone coupons were selected
at the lowest rate while on the low medication dose (13.3%)
(See Table 5 and Appendix H, Figure 5).
Summary. A number of significant medication effects
were observed during the social reinforcer assessment. Brad
and Rick exhibited pronounced decreases in the number of
peer play coupons selected while on the high dose of
medication. The number of peer play coupons selected by
53
Brad decreased by 28.1% while taking his prescribed dose of
Dexedrine. The number of peer play coupons selected by Rick
decreased by 42.9% while taking the high dose of Concerta.
Additionally, a corresponding increase in the number of
alone play coupons (Rick) or quiet time coupons (Brad) was
observed. The number of alone play coupons selected by Rick
increased from 1.0 to 1.6 (60.0% increase) at the high dose
of Concerta. Brad displayed an increase in the number of
quiet time coupons while taking Dexedrine (0.3 to 1.0
coupons daily, 233.3% increase). Another participant
(Randy) appeared to exhibit a mild decrease in the number
of peer play coupons while on medication (4.3 to 3.8
coupons daily, 11.6% decrease).
One participant (Eric) selected more peer play coupons
while receiving his prescribed dose of medication. In
addition, a corresponding decrease in the number of alone
play coupons was observed while taking Adderall. These
findings indicate that, for Eric, stimulant medication may
have increased the reinforcing value of social play.
54
Table 5. Social Reinforcer Assessment Results
Dependent
Variable
Eric
20 mg
Pla
Add
Peer
2.8
Play (71.8%)
Alone
1.1
Play (28.2%)
Quiet
0.0
Time (0.0%)
Total
3.9
(100%)
Dependent
Variable
Peer
Play
Alone
Play
Quiet
Time
Total
Pla
Con
Add
Dex
=
=
=
=
2.5
(83.3%)
0.5
(16.7%)
0.0
(0.0%)
3.0
(100%)
Jack
Brad
20 mg
Pla
Dex
3.2
(86.5%)
0.2
(5.4%)
0.3
(8.1%)
3.7
(100%)
2.3
(63.9%)
0.3
(8.3%)
1.0
(27.8%)
3.6
(100%)
Pla
36 mg
Con
Pla
3.5
(100%)
0.0
(0.0%)
0.0
(0.0%)
3.5
(100%)
4.9
(100%)
0.0
(0.0%)
0.0
(0.0%)
4.9
(100%)
2.1
(67.7%)
1.0
(32.3%)
0.0
(0.0%)
3.1
(100%)
Placebo
Concerta
Adderall
Dexedrine
55
_ _ _______
Randy
54 mg
Pla
Con____
4.3
(100%)
0.0
(0.0%)
0.0
(0.0%)
4.3
(100%)
Rick
36 mg
Con
1.3
(86.7%)
0.3
(13.3%)
0.0
(0.0%)
1.6
(100%)
3.8
(90.5%)
0.1
(2.4%)
0.3
(7.1%)
4.2
(100%)
54 mg
Con____
1.2
(40.0%)
1.6
(53.3%)
0.2
(6.7%)
3.0
(100%)
Teacher Rating Scale
Eric. No significant medication effects were noted for
Eric on any of the variables from the teacher rating scale
(See Table 6).
Brad. The teacher scale indicated that Brad was less
euphoric/unusually happy (p<0.05) and played alone more
frequently while taking medication (p<0.05) (See Table 6).
Ruby. A number of significant medication effects were
observed for Ruby on the teacher rating scale. According to
teacher report, Ruby stared more and daydreamed more
frequently (p<0.05), interacted less with others (p<0.05),
exhibited increased drowsiness (p<0.005), appeared more
sad/unhappy (p<0.05), was less playful with others
(p<0.01), played alone more on medication (p<0.01) and
appeared more socially withdrawn while on Adderall (p<0.05)
(See Table 6).
Randy. On the teacher rating scale, a number of
significant medication effects were reported for Randy.
Randy was reported to stare and daydream more frequently
while on Concerta (p<0.05). The teacher also reported that
Randy appeared to be less anxious (p<0.05), less euphoric
or happy (p<0.01) and played alone less while on medication
(p<0.01) (See Table 6).
56
Jack. No significant medication effects were noted for
any of the variables from the teacher rating scale (See
Table 6).
Rick. No significant medication effects were noted for
any of the variables from the teacher rating scale (See
Table 6).
Summary. The findings from the teacher rating scales
are especially interesting given that they did not appear
to correspond with direct observations from the other
phases in the current investigation. It is of particular
interest that the child exhibiting the most pronounced
social side effects in the direct observations (Rick) had
no significant behavioral side effects indicated on the
teacher rating scale.
Additionally, it is notable that the lowest
functioning child (Ruby) had the highest ratings for
medication side effects. According to teacher report, Ruby
exhibited a number of detrimental social side effects while
taking Adderall (e.g., low levels of social play, increased
social withdrawal, increased unhappiness). Again, these
findings did not correspond well with the results from the
direct observations.
57
Table 6. Teacher Rating Scale Results______________________
Eric
20 mg
Pla
Add
Brad
20 mg
Pla
Dex
Ruby
10 mg
Pla
Add _
1. Daydreams
0.9
0.8
0.6
1.7
1.33
4.2*
2. Talks less
1.6
1.4
1.4
2.2
1.5
4.4*
3. Uninterested
1.1
1.1
1.1
2.0
1.83
3.2
4. Appetite
n/a
n/a
n/a
n/a
n/a
n/a
5. Irritable
Dependent
Variable
1.2
1.4
2
1.9
1.5
1.2
6. Stomachaches
0
0
0
0
0
0
7. Headaches
0
0
0
0
0
0
8. Drowsiness
0
0
0
0.3
0.33
3.6***
9. Sad/unhappy
0.2
0.7
1
1.0
0.67
2.8*
10. Cry/whine
1.0
1.1
1.5
1.1
1.67
1.8
11. Anxious
1.5
1.7
1.8
2.5
1.83
1.4
12. Fingernails
0
0
0
0
0
0
13. Euphoric
3
2.4
3.1
1.3*
4.5
1.8
14. Dizziness
0
0
0
0
0
0
15. Tics
0.4
0.3
0
0
0.17
0
16. Playful
6.8
6.3
6.1
5.1
4.67
2.2**
17. Play alone
2
2.5
2.4
4.0*
4.5
7.2**
18. Withdrawn
1.6
1.8
1.8
1.9
2.83
5.4*
19. Nail biting
0
0
0
0
0
0
20. Skin pick
0
0
0
0
0
0
*
**
***
****
p<0.05
p<0.01
p<0.005
p<0.001
Pla = Placebo
Add = Adderall
Dex = Dexedrine
58
Table 6._(continued)
Dependent
Variable
__________
Randy
54 mg
Pla
Con
Jack
36 mg
Pla
Con
Pla
Rick
36 mg
Con
54 mg
Con_
1. Daydreams
0.7
1.6*
0.8
1.0
2.4
2.0
1.7
2. Talks less
1.6
2.0
1.7
1.8
3.6
3.2
2.0
3. Uninterested
2.1
1.7
2.1
1.4
3.6
3.8
2.3
4. Appetite
n/a
n/a
n/a
n/a
n/a
n/a
n/a
5. Irritable
1.0
1.3
4.1
2.6
2.6
2.1
1.3
6. Stomachaches
0
0
0
0
0
0
0
7. Headaches
0
0
0
0
0
0
0
8. Drowsiness
0
0
0
0
0.3
0.9
0.7
9. Sad/unhappy
0.6
0.4
3
2.1
1.9
1.6
1.3
10. Cry/whine
1.4
1
3.9
2.8
2
1.6
1.7
11. Anxious
2.1
0.7*
4
2.3
1.6
1.7
1.7
0
0
0
0
0
0
0
13. Euphoric
4.6
1.8**
2.5
1.3
3.1
1.7
1.0
14. Dizziness
0
0
0
0
0
0
0
0.1
0
0.3
0.1
0.9
0.5
0
5
5.92
6.4
7
3.4
3.8
4.0
17. Play alone
4.8
2.8**
2.6
2.1
6.4
5.5
6.0
18. Withdrawn
12. Fingernails
15. Tics
16. Playful
2.3
1.6
2.3
1.4
4.1
3.8
3.7
19. Nail biting
0
0
0
0
0
0
0
20. Skin pick
0
0
0
0
0
0
0
*
**
***
****
p<0.05
p<0.01
p<0.005
p<0.001
Pla = Placebo
Con = Concerta
59
Child Rating Scale
Eric. No significant medication effects were noted for
any of the variables for Eric on the child rating scale
(See Table 7).
Brad. While on his prescribed dose of Dexedrine, Brad
indicated that he felt less nervous while taking medication
(p<0.05). No other variables from the child rating scale
were significant (See Table 7).
Randy. No significant medication effects were noted
for any of the variables from the child rating scale (See
Table 7).
Ruby. Given her communication difficulties (i.e.,
selective mutism), the child rating scale was not
administered to Ruby.
Jack. No significant medication effects were noted for
any of the variables from the child rating scale (See Table
7).
Rick. On the child rating scale, Rick reported that it
was more difficult for him to have fun while receiving the
placebo dose (p<0.05) (See Table 7).
Summary. Only two significant findings were reported
with the child rating scale. Brad reported that he felt
less nervous while taking Dexedrine. Nick reported that it
was more difficult to have fun while on the placebo dose.
60
Table 7. Child Rating Scale Results______________________
Dependent
Variable
1. Somatic
complaints
2. Talk to
other kids
3. Pay
attention
4. Stay quiet
5. Tired
6. Sad
7. Nervous
8. Happy
9. Stay in your
seat
10. Dizzy
11. Play with
friends
12. Easy to do
work
13. Easy to be
good
14. Slow
15. Hard to
have fun
*
**
***
****
Eric
20 mg
Pla
Add
Brad
20 mg
Pla
Dex
Randy
10 mg
Pla
Add _
0
0
0
0.2
0.1
0.1
2.0
2.0
0.1
0
0.3
0.5
0.4
0.7
0.7
0.7
0.4
1.9
0
0.5
0.5
0.3
0.3
1.8
0
0
1.4
0.1
0.4
2.0
0
0.2
0.8
0
0*
1.9
0.1
0
0.6
0.4
0.3
1.3
0
0
0.2
0
0
1.4
0.4
1.1
0
0.5
0.4
0.2
0
0.2
0.3
0.6
0
0.3
1.8
1.8
1.8
2.0
1.5
1.4
1.9
2.0
2.0
2.0
1.5
1.6
1.7
1.0
1.8
0.5
2.0
0.4
2.0
0.4
1.3
0.6
1.6
0.4
0.6
0.3
0.3
0.4
0.3
0.4
p<0.05
p<0.01
p<0.005
p<0.001
Pla = Placebo
Add = Adderall
Dex = Dexedrine
61
Table 7. _(continued) ____
Dependent
Variable
1. Somatic
complaints
2. Talk to other
kids
3. Pay attention
4. Stay quiet
5. Tired
6. Sad
7. Nervous
8. Happy
9. Stay in your
seat
10. Dizzy
11. Play with
friends
12. Easy to do
work
13. Easy to be
good
14. Slow
15. Hard to
have fun
*
**
***
****
_____
Jack
36 mg
Pla
Con
Pla
Rick
36 mg
Con
54 mg
Con
0.3
0
1.2
1.3
2.0
0.5
0
0
0.2
0.2
0
1.5
0.4
0.2
0.2
0.2
0
0.2
1.2
1.2
1.2
1.2
1.6
0.8
1.2
1.6
1.3
1.8
1.5
1.5
1.0
1.3
1.8
1.5
2.0
2.0
2.0
1.0
2.0
2.0
0.2
0
0
0
2.0
1.2
1.8
1.5
2.0
2.0
1.0
0.9
1.6
1.8
1.5
0.3
0.7
1.6
1.2
2.0
0.3
0.2
0.7
0
2.0
1.6
1.8
1.0
2.0
2.0
0.17
0.2
2.0
0.8*
1.0
p<0.05
p<0.01
p<0.005
p<0.001
Pla = Placebo
Con = Concerta
62
_
No other significant findings were reported by any of the
participants.
Structured Child Interview
Eric. While taking medication, Eric reported that he
did not like the way it made him feel. While receiving the
placebo dose, Eric reported that he liked the way his
medication made him feel.
Brad. While on Dexedrine, Brad reported that he would
stop taking his medication if given the opportunity.
Conversely, while on the placebo dose, Brad reported that
he would not stop taking his medication if given the
chance.
Randy. While on Concerta, Randy reported that he would
stop taking his medication if given the opportunity.
Ruby. Given her communication difficulties (i.e.,
selective mutism), the child interview was not used with
Ruby.
Jack. No significant medication effects were noted for
any of the variables from the child interview.
Rick. No significant medication effects were noted for
any of the variables from the child interview.
Summary. Similar to what was seen with the child
rating scale, the children appeared to have difficulty
answering questions regarding their medication effects
63
accurately during the structured interview. The only
relatively consistent finding was that three of the
children (Brad, Randy and Eric) reported that they did not
like the way medication made them feel while they were
taking their prescribed dose of stimulant medication.
64
CHAPTER 4: DISCUSSION
The purpose of the current investigation was to
determine if stimulant medications alter play and related
social behavior in preschool children diagnosed with ADHD.
To evaluate these effects, a number of measurement
techniques were employed, including direct observations of
social behavior in a variety of different play conditions
(recess, sports training, alone play and Tiger Camp
observations), an evaluation of the reinforcing efficacy of
play with a social reinforcer assessment and child and
teacher rating scales/child interviews.
The findings from the recess observations illustrate
the variability in medication response across participants.
With the exception of Rick, relatively few significant
findings were ascertained in the recess observations. Rick
exhibited a number of pronounced medication effects while
on the high dose of Concerta (54 mg), including decreased
toy play, decreased solitary play, decreased activity level
and increased levels of anxiety/stereotyped behavior.
There were some other idiosyncratic effects during the
recess observations for two of the participants. Ruby
exhibited a significant decrease in the number of social
vocalizations while taking Adderall. Conversely, Adderall
increased the occurrence of social vocalizations made
65
during the recess period for Eric. The fact that the exact
opposite effects were observed on the same dependent
measure for two different participants illustrates the high
degree of variability in the individual response to
stimulant medications.
The purpose of the sports training condition was to
determine if stimulant medications have significant effects
on social behavior during structured play settings. In this
condition, stimulant medication significantly increased
game participation for several of the participants while
producing a corresponding increase in anxiety/stereotyped
behavior. With the exception of one participant (Rick), the
increase in anxiety/stereotyped behavior was observed
specifically in the structured sports training setting and
in neither unstructured play conditions (recess and alone
conditions). Rick exhibited heightened levels of
anxiety/stereotyped behavior, including lip picking and
nail biting, in both the sports training and the
unstructured recess conditions. Similar kinds of stimulantinduced stereotyped behaviors have previously been
documented in humans and have been referred to as “punding”
(Fernandez & Friedman, 1999; Schiorring, 1981). According
to Schiorring (1981), punding includes motor stereotypy
with repetitive, aimless activities involving various
66
objects, including one’s own body (e.g., hands and mouth).
Given the status of the current literature, the
improvements in game participation were expected and would
generally be considered beneficial. Conversely, the effects
of stimulant-induced anxiety/stereotyped behavior are
unknown and present a new avenue for future research.
The purpose of the alone play condition was to
evaluate the effects of stimulant medication on behavior in
an unstructured, nonsocial play setting. Again, the
findings from the alone play condition demonstrate the high
variability in individual medication response. Two of the
children exhibited minor decreases in locomotor activity
(i.e., activity level and/or steps taken) while taking
stimulant medication. This finding is consistent with
previous research documenting stimulant-induced decreases
in locomotor activity (Barkley & Cunningham, 1979a; Barkley
& Cunningham, 1979b; Cunningham & Barkley, 1978; Handen, et
al., 1995). Another participant exhibited a significant
decrease in the occurrence of vocalizations while on
stimulant medication.
The findings from the reinforcer assessment indicated
that stimulant medication significantly altered the
reinforcing value of specific types of play for several of
the participants. Stimulant medication decreased the
67
reinforcing value of social play while increasing the value
of solitary play (Rick) or quiet time (Brad) for two of the
participants. Stimulant medication had the opposite effect
for another participant (Eric). For this participant,
social play appeared to increase in value while on
stimulant medication. As had been observed in the direct
observations, the findings from the reinforcer assessment
indicate that the social effects of stimulant medication
can vary significantly across individuals.
The rating scales and child interview were designed to
determine if indirect measures were useful for detecting
social side effects and if these measures correlated well
with direct observations. The measures used in this
evaluation included a teacher rating scale, a child rating
scale and a structured child interview. Overall, the data
from the rating scales and interview did not correlate well
with direct observations or the social reinforcer
assessment. The child exhibiting the most pronounced side
effects in direct observations (i.e., Rick) had no
significant behavioral side effects indicated on any of the
variables from the teacher rating scale. Another
participant (i.e., Ruby) was reported to have a number of
social side effects that were not observed in the direct
observations.
68
Additionally, the participants from the study were
unable to reliably report their own side effects with the
daily child rating scale and a structured interview. It is
possible that preschool children are too young to
accurately report how medication makes them feel.
The present findings show that stimulants can have
detrimental effects in some children. The prevailing
opinion is that stimulant medications either have no
significant detrimental effects on social behavior (Dulcan
& Benson, 1997; Hinshaw, 1991; MTA Cooperative Group, 2000;
NIH Consensus Statement, 1998), or improve it (Granger,
Whalen & Henker, 1993; Smith, et al., 1998; Pelham,
Greenslade, Vodde-Hamilton, Murphy, Greenstein, Gnagy,
Guthrie, Hoover & Dahl 1990, Klein, 1993). One possible
reason for this apparent contradiction is that some
observers may mistakenly perceive the absence of disruptive
behavior as an improvement in adaptive behavior. As is done
with other disorders (e.g., schizophrenia), it is possible
to conceptualize the symptoms of ADHD as being either
positive or negative. Positive symptoms are undesired
behaviors, such as inappropriate vocalizations or out-ofseat behavior in the classroom. As reviewed previously,
stimulants have been shown to be quite effective for
reducing the occurrence of such symptoms (Greenhill,
69
Halperin & Abikoff, 1999; Pelham, 1993). Negative symptoms
are behaviors that are desired, yet deficient, such as
academic achievement and prosocial behavior. Stimulants
have not been shown to be effective for improving the
negative symptoms associated with ADHD (i.e., Rie et al.,
1975). A possible explanation for conflicting views about
the efficacy of stimulants in improving social behaviors in
ADHD is that they reduce positive symptoms by decreasing
social interaction and play.
The results from the current study illustrate the high
degree of individual variability in medication response
across participants. Medication had a number of detrimental
social effects in some participants while other children
displayed improvements in social behavior (i.e., social
interaction). These findings demonstrate the utility of
single subject research for clinical medication evaluation.
Another important contribution from the current study
was the finding that stimulant medication can significantly
alter the reinforcing efficacy of social play. Stimulant
medication decreased the value of social play for some
children, while it increased its value for another. These
findings are of particular importance given that they
illustrate how stimulants influence the motivation to
engage in particular activities, including social play. The
70
implications of these results are that stimulant
medications can significantly affect the reinforcing
properties of certain items and/or activities, which can
therefore influence the effectiveness of behavioral
interventions.
Another important finding from the current study was
the lack of correspondence between direct observations and
the results from the rating scales and child interview.
Given that most medication changes are based on anecdotal
report and/or rating scale data, this lack of agreement is
of great significance. The results from this investigation,
specifically the teacher rating scale, raise a number of
questions regarding the validity of rating scales. There is
a need for research investigating the characteristics that
make side effects for some children more likely to be
noticed than in others. It is possible that side effect
detection varies as a function of time spent with the
child. It is also likely that children who are disruptive
tend to be observed more closely by teachers and parents.
The current investigation presented some unique
methods for assessing the value of social play in children.
Direct observations, although logically appealing, are
rarely used in the context of medication assessments. The
observation procedures used in this investigation may
71
provide researchers with a useful resource for assessing
the social effects of psychotropic medication.
Additionally, the social reinforcer assessment
presented a unique way to evaluate the effects of
psychotropic medication on the value of social reinforcers.
The reinforcer assessment provided useful insight regarding
the effects of these medications and required very little
time to conduct. The results from the current study
demonstrate that reinforcer assessments can be used as an
effective medication assessment tool.
The current study was also unique in that it included
a number of supplemental self-report measures. There has
been little research investigating the use of such measures
in young children. Although the reliability of child selfreport was questionable in the current study, it indicated
that it is an area that requires further investigation.
Limitations in the Current Study
There were a number of limitations in the current
investigation. The first of which was the limited number of
dose conditions for each participant in the study. With the
exception of Rick, only two dose conditions were used for
each child (i.e., placebo and one drug dose). A greater
number of significant social effects may have been observed
had higher doses been used for some of the participants.
72
Several of the children in the current study were
prescribed relatively low doses of stimulant medication.
Another limitation in the current study was the
difficulty having an equal number of observations for each
medication condition. Due to absences, clinical necessity
and time constraints, it was not possible to have an equal
number of observations for each medication condition.
Another constraining factor in this investigation was
the limited amount of reinforcers (i.e., coupons) available
during the reinforcer assessment. The coupons used in the
current assessment were redeemable for 2 minutes of the
preferred activity (social play, alone play or quiet time).
Due to time constraints during the day, the total number of
coupons that could be redeemed was limited. Due to this
ceiling effect, the sensitivity of the assessment may have
been limited.
Future Directions
The current investigation indicates that there are a
number of areas in need of further research. First, there
is a need to place greater emphasis on the inclusion and
measurement of play and social behaviors in future
evaluations of stimulant medication effects. The majority
of previous research has emphasized the effects of
stimulant drugs on maladaptive behavior. Effects on
73
adaptive, particularly prosocial behavior and play, need to
be studied as well. This is particularly important
considering the central role that such behavior is assumed
to play in normal development.
Second, there is a need for the development of
objective medication evaluation procedures that can be used
in a wide variety of settings. As has been previously
discussed, medication evaluation procedures are frequently
limited to anecdotal report and rating scales. A number of
basic behavioral methodologies, such as direct observation,
functional analyses and reinforcer assessments, may provide
researchers with useful tools for the objective evaluation
of medication effects (Fisher, Piazza, Bowman, Hagopian,
Owens & Slevin, 1992; Iwata; Dorsey, Slifer, Bauman &
Richman, 1994; Northup, et al., 1996).
Third, there is a need for pharmacological research
with young children. As discussed previously, there is a
considerable amount of literature indicating that the
adverse social effects of stimulant drugs occur at an
especially high rate in young children (Firestone, et al.,
1996; Northup, in press; Schliefer, et al., 1975). Given
this and the fact that use of stimulant drugs in this
population is off label (stimulants have been approved for
use in children aged 7 or older), use of stimulants in
74
preschool children is becoming a central issue.
Also
needed are more studies of the long-term efficacy and side
effects from the use of these medications.
Summary and Conclusions
It is widely accepted as axiomatic that play and
social interaction are important to normal childhood
development. The present study highlights a number of
potentially useful techniques for assessing the social
effects of stimulants in children. Although numerous
studies have evaluated the social effects of stimulant
medication, in many of these studies social behavior and
play have been peripheral considerations, and therefore not
studied thoroughly, systematically, and with methodologic
rigor.
Second, the clinical literature suggests that the
behavioral effects of stimulants, including those on social
behavior and play, are highly idiosyncratic (Handen, et
al., 1995, Northup, et al., in press; Rapaport, et al.,
1994; Whalen, Henker, Swanson, Granger, Kliewer & Spencer,
1987).
Reliance on group designs, which is the norm in
psychopharmacology research, as opposed to single subject
designs, tends to obscure such individual differences.
Third, there has been an over-reliance on rating scales and
“clinical impressions” for determining the presence of the
adverse effects of psychotropic medications. Although
75
useful, rating scales have a number of limitations for the
evaluation social and play behaviors. In addition to rater
bias and possible halo effects, most current rating scales
focus almost exclusively on the core symptoms of ADHD
(i.e., attention, hyperactivity and impulsivity) and/or
disruptive classroom behavior rather than social behavior.
It is noteworthy that the most commonly used rating scale
for ADHD has only one question that is generally related to
social behavior.
In conclusion, stimulants are now being administered
to children on an unprecedented scale. Although serious
problems affecting high percentages of children have not
been detected despite decades of use, medical history has
shown, sometimes tragically (e.g., in the case of
thalidomide), that drugs can have hidden dangers. Given the
vulnerability of the principal patient population and the
scale on which these drugs are being used, any hint of risk
should be given serious consideration.
76
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Schlemmer, R., Young, J. & Davis, J. (1996).
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86
APPENDIX A - CHILD RATING SCALE
Side Effect Rating Scale
Child Form
1. My head/stomach hurts
today (or any other
somatic complaints).
2. I didn’t feel like
talking to other kids
today
3. It was hard to pay
attention today
4. I had a hard time
staying quiet today
5. I feel tired today
Not at
all
Little Some
bit
A lot
All the
time
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
0
1
1
2
2
3
3
4
4
6. I feel sad today
0
1
2
3
4
7. I feel nervous today
0
1
2
3
4
8. I feel happy today
0
1
2
3
4
9. It was hard to stay
in my seat today
0
1
2
3
4
10. I feel dizzy today
0
1
2
3
4
11. Playing with friends
was fun today
0
1
2
3
4
12. It was easy to do my
work today
0
1
2
3
4
13. It was easy to be
good today
0
1
2
3
4
14. I felt slow today
0
1
2
3
4
15. It was hard to have
fun today
0
1
2
3
4
87
APPENDIX B - TEACHER RATING SCALE
Side Effects Rating Scale
Recess Monitor/Teacher
Version
Behavior
Absent
Stares a lot or daydreams
0
1
2
3
4
5
6
7
8
9
Talks less with others
0
1
2
3
4
5
6
7
8
9
Uninterested in others
0
1
2
3
4
5
6
7
8
9
Decreased appetite
0
1
2
3
4
5
6
7
8
9
Irritable
0
1
2
3
4
5
6
7
8
9
Stomachaches
0
1
2
3
4
5
6
7
8
9
Headaches
0
1
2
3
4
5
6
7
8
9
Drowsiness
0
1
2
3
4
5
6
7
8
9
Sad/unhappy
0
1
2
3
4
5
6
7
8
9
Prone to crying/whining
0
1
2
3
4
5
6
7
8
9
Anxious
0
1
2
3
4
5
6
7
8
9
Bites fingernails
0
1
2
3
4
5
6
7
8
9
Euphoric/unusually happy
0
1
2
3
4
5
6
7
8
9
Dizziness
0
1
2
3
4
5
6
7
8
9
Tics or nervous movements
0
1
2
3
4
5
6
7
8
9
Playful with others
0
1
2
3
4
5
6
7
8
9
Played alone
0
1
2
3
4
5
6
7
8
9
Socially withdrawn
0
1
2
3
4
5
6
7
8
9
Nail biting
0
1
2
3
4
5
6
7
8
9
Skin picking
0
1
2
3
4
5
6
7
8
9
88
Serious
APPENDIX C - STRUCTURED CHILD INTERVIEW
Date:
Participant:
Medication Dose:
1. Do you normally take medication?
2. What is it called?
3. Why are you taking __________?
4. Do you like taking __________?
5. What is __________ supposed do for you?
6. Does __________ help you…
a.
pay attention to
the teacher?
b.
stay clam?
c.
remain in your
seat?
d.
keep from fighting?
e.
to be nice?
f.
to walk rather than
run?
g.
to be patient?
h.
Get along with your
friends?
89
YES
YES
NO
NO
YES
YES
YES
NO
NO
NO
YES
YES
NO
NO
YES
NO
7. When you take __________, is there anything you dislike
about the way it makes you feel?
8. Does __________ make you smarter?
9. Does __________ make it harder for you the have fun with
friends or toys?
10.
Does __________ ever make you feel sick?
11.
If you could stop taking __________, would you?
12.
What would happen if you stopped taking __________?
13.
Do your friends know that you take __________?
14.
Do you care if they know that you take ___________?
15. Do you know what Attention Deficit Hyperactivity
Disorder is? What is it? Do you have it?
90
APPENDIX D – UNSTRUCTURED RECESS GRAPHS
Figure 1. Percent of intervals with toy play
Figure 2. Percent of intervals with social play
Figure 3. Percent of intervals with solitary play
Figure 4. Percent of intervals with social vocalizations
Figure 5. Percent of intervals with nonsocial
vocalizations
Figure 6. Percent of intervals activity level
Figure 7. Percent of intervals with anxiety/stereotyped
behavior
Figure 8. Percent of intervals with escape attempts
Figure 9. Percent of intervals with social withdrawal
Figure 10. Number of steps taken
91
100
90
80
70
60
50
40
30
20
10
0
BRAD
% OF INTERVALS
% OF INTERVALS
ERIC
PLACEBO
20 MG ADDERALL
0
5
10
15
20
25
30
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
20 MG DEXEDRINE
0
5
10
SESSIONS
RANDY
54 MG
CONCERTA
0
5
10
PLACEBO
15
25
30
20
25
PLACEBO
10 MG ADDERALL
0
30
3
6
9
SESSIONS
SESSIONS
12
15
RICK
JACK
100
90
80
70
60
50
40
30
20
10
0
20
RUBY
100
90
80
70
60
50
40
30
20
10
0
% OF INTERVALS
% OF INTERVALS
100
90
80
70
60
50
40
30
20
10
0
15
SESSIONS
100
90
% OF INTERVALS
% OF INTERVALS
80
36 MG
CONCERTA
PLACEBO
70
60
50
PLACEBO
36 MG
CONCERTA
40
30
54 MG
CONCERTA
20
10
0
0
5
10
15
SESSIONS
20
25
30
0
5
10
15
SESSIONS
20
25
Figure 1. Percent of intervals with toy play. A
significant decrease was observed for Rick at the 54 mg
Concerta dose (p<0.001). A significant increase in toy
play was observed for Randy (p<0.05).
92
30
BRAD
100
100
90
80
70
60
50
40
30
20
10
0
20 MG DEXEDRINE
90
80
% OF INTERVALS
% OF INTERVALS
ERIC
20 MG ADDERALL
70
60
50
40
30
20
PLACEBO
PLACEBO
10
0
5
10
15
20
25
30
0
0
5
10
15
54 MG
CONCERTA
100
90
80
70
60
50
40
30
20
10
0
RANDY
5
10
15
20
25
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
10 MG ADDERALL
0
30
3
6
5
10
JACK
15
9
12
15
SESSIONS
20
25
PLACEBO
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
0
30
PLACEBO
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
25
RUBY
PLACEBO
0
20
SESSIONS
% OF INTERVALS
% OF INTERVALS
SESSIONS
30
0
5
10
RICK
36 MG
CONCERTA
15
20
54 MG
CONCERTA
25
Figure 2. Percent of intervals with social play. No
significant medication effects were observed for social
play.
93
30
BRAD
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
20 MG ADDERALL
0
5
10
15
20
SESSIONS
25
30
20 MG DEXEDRINE
0
5
10
PLACEBO
15
20
5
10
15
100
90
80
70
60
50
40
30
20
10
0
10 MG ADDERALL
20
25
30
3
6
9
JACK
RICK
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
5
0
SESSIONS
36 MG
CONCERTA
0
PLACEBO
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
10
15
30
RUBY
54 MG
CONCERTA
PLACEBO
0
25
SESSIONS
% OF INTERVALS
% OF INTERVALS
RANDY
100
90
80
70
60
50
40
30
20
10
0
100
90
80
70
60
50
40
30
20
10
0
% OF INTERVALS
% OF INTERVALS
ERIC
20
25
30
12
15
36 MG
CONCERTA
54 MG
CONCERTA
PLACEBO
0
5
10
15
20
25
Figure 3. Percent of intervals with solitary play. A
significant decrease in solitary play was observed for
Rick while on the 54 mg dose of Concerta.
94
30
100
90
80
70
60
50
40
30
20
10
0
BRAD
20 MG
ADDERALL
PLACEBO
0
5
10
15
20
100
90
80
70
60
50
40
30
20
10
0
% OF INTERVALS
% OF INTERVALS
ERIC
25
PLACEBO
0
30
5
10
15
25
30
RUBY
100
90
80
54 MG
70
CONCERTA
60
50
40
30
20
10
0
20
25
30
PLACEBO
PLACEBO
% OF INTERVALS
% OF INTERVALS
RANDY
0
5
10
15
10 MG ADDERALL
0
3
6
SESSIONS
JACK
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
0
5
10
15
12
15
RICK
PLACEBO
100
90
80
70
60
50
40
30
20
10
0
9
SESSIONS
% OF INTERVALS
% OF INTERVALS
20
SESSIONS
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
20 MG
DEXEDRINE
20
25
30
PLACEBO
0
5
10
36 MG
54 MG
CONCERTA
CONCERTA
15
20
25
30
SESSIONS
SESSIONS
Figure 4. Percent of intervals with social vocalizations.
A significant increase in the number of intervals with
social vocalizations was observed for Eric at the 20 mg
Adderall dose (p<0.01). A significant decrease in social
interactions was observed for Ruby while on 20 mg of
Adderall (p<0.001)
95
BRAD
100
90
80
70
60
50
40
30
20
10
0
20 MG
ADDERALL
0
5
PLACEBO
10
15
20
25
% OF INTERVALS
% OF INTERVALS
ERIC
30
100
90
80
70
60
50
40
30
20
10
0
20 MG
DEXEDRINE
PLACEBO
0
SESSIONS
5
10
15
20
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
PLACEBO
0
5
10
15
20
25
0
30
3
6
% OF INTERVALS
% OF INTERVALS
PLACEBO
10
15
12
15
RICK
36 MG
CONCERTA
5
9
SESSIONS
JACK
0
PLACEBO
10 MG ADDERALL
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
30
RUBY
100
90
80
70
60
50
40
30
20
10
0
% OF INTERVALS
% OF INTERVALS
RANDY
25
20
25
30
100
90
80
70
60
50
40
30
20
10
0
SESSIONS
PLACEBO
36 MG
CONCERTA
0
5
10
54 MG
CONCERTA
15
20
SESSIONS
25
30
Figure 5. Percent of intervals with nonsocial
vocalizations. No significant medication effects were
observed for nonsocial vocalizations.
96
100
90
80
70
60
50
40
30
20
10
0
BRAD
PLACEBO
20 MG ADDERALL
0
5
10
15
20
25
% OF INTERVALS
% OF INTERVALS
ERIC
100
90
80
70
60
50
40
30
20
10
0
30
20 MG DEXEDRINE
0
5
10
SESSIONS
15
10
15
20
25
100
90
80
70
60
50
40
30
20
10
0
% OF INTERVALS
% OF INTERVALS
54 MG
CONCERTA
5
30
10 MG ADDERALL
0
3
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
PLACEBO
0
5
10
15
30
20
25
30
6
PLACEBO
9
12
54 MG
CONCERTA
0
5
10
15
20
25
Figure 6. Percent of intervals with high activity. A
significant decrease in activity level was observed for
Rick at the 54 mg Concerta dose (p<0.001).
97
15
SESSIONS
RICK
36 MG
PLACEBO
CONCERTA
JACK
100
90
80
70
60
50
40
30
20
10
0
25
RUBY
PLACEBO
0
20
SESSIONS
RANDY
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
30
BRAD
PLACEBO
0
% OF INTERVALS
% OF INTERVALS
20 MG
ADDERALL
5
10
15
20
SESSIONS
25
54 MG
CONCERTA
PLACEBO
0
5
10
15
20
25
30
5
10
0
5
10
15
25
30
10 MG ADDERALL
0
3
6
PLACEBO
9
12
15
SESSIONS
JACK
PLACEBO
15
20
SESSIONS
RUBY
100
90
80
70
60
50
40
30
20
10
0
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
20 MG
DEXEDRINE
PLACEBO
0
RANDY
100
90
80
70
60
50
40
30
20
10
0
100
90
80
70
60
50
40
30
20
10
0
30
% OF INTERVALS
% OF INTERVALS
ERIC
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
20
25
RICK
100
90
80
70
60
50
40
30
20
10
0
30
54 MG CONCERTA
36 MG
CONCERTA
PLACEBO
0
5
10
15
20
25
30
Figure 7. Percent of intervals with anxiety/stereotyped
behaviors. A significant increase in anxiety/stereotyped
behaviors was observed for Rick at the 54 mg Concerta
dose (p<0.001).
98
BRAD
100
90
80
70
60
50
40
30
20
10
0
% OF INTERVALS
% OF INTERVALS
ERIC
20 MG ADDERALL
PLACEBO
0
5
10
15
20
25
100
90
80
70
60
50
40
30
20
10
0
30
20 MG DEXEDRINE
PLACEBO
0
5
10
SESSIONS
15
PLACEBO
54 MG
CONCERTA
0
5
10
15
20
25
0
30
3
6
0
5
10
15
9
12
15
SESSIONS
RICK
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
PLACEBO
30
PLACEBO
10 MG
ADDERALL
SESSIONS
JACK
100
90
80
70
60
50
40
30
20
10
0
25
RUBY
100
90
80
70
60
50
40
30
20
10
0
% OF INTERVALS
% OF INTERVALS
RANDY
100
90
80
70
60
50
40
30
20
10
0
20
SESSIONS
20
25
30
36 MG
CONCERTA
0
5
10
54 MG
CONCERTA
PLACEBO
15
20
25
Figure 8. Percent of intervals with escape attempts. A
significant decrease in escape attempts was observed for
Rick at both the 36 mg and 54 mg Concerta dose (p<0.05).
99
30
100
90
80
70
60
50
40
30
20
10
0
BRAD
% OF INTERVALS
% OF INTERVALS
ERIC
PLACEBO
20 MG ADDERALL
0
5
10
15
20
25
100
90
80
70
60
50
40
30
20
10
0
20 MG DEXEDRINE
PLACEBO
0
30
5
10
15
% OF INTERVALS
% OF INTERVALS
RANDY
PLACEBO
54 MG
CONCERTA
0
5
100
90
80
70
60
50
40
30
20
10
0
10
15
0
5
20
25
30
10 MG ADDERALL
PLACEBO
0
3
6
9
SESSIONS
JACK
RICK
10
20
25
30
12
15
36 MG
CONCERTA
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
15
30
RUBY
100
90
80
70
60
50
40
30
20
10
0
SESSIONS
36 MG
CONCERTA
25
SESSIONS
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
20
PLACEBO
54 MG
CONCERTA
0
5
10
15
20
25
30
Figure 9. Percent of intervals with social withdrawal. No
significant effects were observed for social withdrawal.
100
BRAD
ERIC
1000
1400
PLACEBO
PLACEBO
1200
% OF INTERVALS
% OF INTERVALS
800
600
400
20 MG
ADDERALL
200
1000
800
600
400
0
0
5
20 MG
DEXEDRINE
200
10
15
20
25
0
30
0
5
10
SESSIONS
15
SESSIONS
RANDY
% OF INTERVALS
% OF INTERVALS
1000
800
600
400
200
PLACEBO
700
600
500
400
300
200
100
0
0
5
10
SESSIONS
36 MG
CONCERTA
1600
1400
15
0
20
JACK
PLACEBO
1200
1000
800
% OF INTERVALS
0
% OF INTERVALS
30
10 MG ADDERALL
800
PLACEBO
1200
25
RUBY
54 MG
CONCERTA
1400
20
600
2
4
6
SESSIONS
8
RICK
1200
PLACEBO
1000
800
10
36 MG
CONCERTA
54 MG
CONCERTA
600
400
400
200
200
0
0
5
10
15
20
25
0
0
5
10
15
20
25
Figure 10. Number of steps taken. No significant
medication effects were observed for the number of steps
taken.
101
APPENDIX E – STRUCTURED SPORTS TRAINING GRAPHS
Figure 1. Percent of intervals with game participation
Figure 2. Percent of intervals with social vocalizations
Figure 3. Percent of intervals with nonsocial
vocalizations
Figure 4. Percent of intervals with high activity level
Figure 5. Percent of intervals with anxiety/ stereotyped
behavior
Figure 6. Percent of intervals with escape attempts
Figure 7. Number of steps taken
102
100
90
80
70
60
50
40
30
20
10
0
% OF INTERVALS
% OF INTERVALS
ERIC
20 MG
ADDERALL
PLACEBO
0
5
10
15
20
25
30
20 MG
DEXEDRINE
100
90
80
70
60
50
40
30
20
10
0
BRAD
PLACEBO
0
5
10
SESSIONS
15
PLACEBO
54 MG
CONCERTA
0
5
10
15
20
25
30
10 MG ADDERALL
0
2
4
36 MG
CONCERTA
50
PLACEBO
30
% OF INTERVALS
% OF INTERVALS
80
40
20
10
0
0
5
10
15
8
10
12
RICK
90
60
6
SESSIONS
JACK
70
30
PLACEBO
SESSIONS
100
25
RUBY
100
90
80
70
60
50
40
30
20
10
0
% OF INTERVALS
% OF INTERVALS
RANDY
100
90
80
70
60
50
40
30
20
10
0
20
SESSIONS
20
25
100
90
80
70
60
50
40
30
20
10
0
30
36 MG
CONCERTA
54 MG
CONCERTA
PLACEBO
0
5
10
15
20
25
30
SESSIONS
SESSIONS
Figure 1. Percent of intervals with game participation.
Significant increases in game participation were observed
for Eric (p<0.05), Brad (p<0.001), Randy (p<0.05) and
Rick (both doses: 36 mg Concerta p<0.005; 56 mg Concerta
p<0.001).
103
BRAD
ERIC
20 MG
ADDERALL
0
5
10
15
PLACEBO
20
25
% OF INTERVALS
% OF INTERVALS
100
90
80
70
60
50
40
30
20
10
0
30
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
0
5
10
20
30
RUBY
54 MG
CONCERTA
PLACEBO
90
80
70
60
50
PLACEBO
10 MG ADDERALL
40
30
20
10
0
5
10
15
20
25
0
30
0
2
4
6
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
10
12
36 MG
CONCERTA
54 MG
CONCERTA
PLACEBO
% OF INTERVALS
36 MG
CONCERTA
5
10
RICK
PLACEBO
100
90
80
70
60
50
40
30
20
10
0
8
SESSIONS
JACK
0
25
100
% OF INTERVALS
% OF INTERVALS
RANDY
% OF INTERVALS
15
SESSIONS
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
20 MG
DEXEDRINE
15
20
SESSIONS
25
30
0
5
10
15
20
25
30
SESSIONS
Figure 2. Percent of intervals with social vocalizations.
A significant decrease in social vocalizations was
observed for Rick at both the 36 mg the 54 mg Concerta
dose (p,0.05 and p<0.01, respectively).
104
100
90
80
70
60
50
40
30
20
10
0
20 MG
ADDERALL
0
5
BRAD
PLACEBO
10
15
20
25
100
90
80
70
60
50
40
30
20
10
0
% OF INTERVALS
% OF INTERVALS
ERIC
30
20 MG
DEXEDRINE
PLACEBO
0
SESSIONS
5
10
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
PLACEBO
0
5
10
15
20
25
30
PLACEBO
0
2
4
5
10
PLACEBO
15
20
SESSIONS
8
10
12
RICK
25
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
% OF INTERVALS
% OF INTERVALS
0
6
SESSIONS
JACK
36 MG
CONCERTA
30
10 MG ADDERALL
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
25
RUBY
100
90
80
70
60
50
40
30
20
10
0
% OF INTERVALS
% OF INTERVALS
RANDY
15
20
SESSIONS
30
36 MG
CONCERTA
0
5
10
15
20
SESSIONS
54 MG
CONCERTA
25
Figure 3. Percent of intervals with nonsocial
vocalizations. No significant medication effects for
nonsocial vocalizations were observed.
105
30
ERIC
PLACEBO
20 MG ADDERALL
0
5
10
15
20
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
% OF INTERVALS
% OF INTERVALS
100
90
80
70
60
50
40
30
20
10
0
BRAD
25
30
20 MG DEXEDRINE
0
5
10
SESSIONS
15
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
54 MG
CONCERTA
0
5
10
15
20
25
10 MG
ADDERALL
0
30
2
4
6
15
12
20
25
36 MG
CONCERTA
% OF INTERVALS
% OF INTERVALS
PLACEBO
10
10
RICK
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
5
8
SESSIONS
JACK
0
30
PLACEBO
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
25
RUBY
% OF INTERVALS
% OF INTERVALS
RANDY
20
30
54 MG
CONCERTA
PLACEBO
0
5
10
15
20
25
Figure 4. Percent of intervals with high activity. A
significant decrease in activity level was observed for
Brad at the 20 mg Dexedrine dose (p<0.01).
106
30
100
90
80
70
60
50
40
30
20
10
0
BRAD
% OF INTERVALS
% OF INTERVALS
ERIC
20 MG
ADDERALL
PLACEBO
0
5
10
15
20
25
30
100
90
80
70
60
50
40
30
20
10
0
20 MG DEXEDRINE
PLACEBO
0
SESSIONS
5
10
15
20
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
0
5
10
15
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
20
25
30
10 MG ADDERALL
PLACEBO
0
2
4
6
5
10
15
12
20
25
30
54 MG
CONCERTA
% OF INTERVALS
% OF INTERVALS
0
10
RICK
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
PLACEBO
8
SESSIONS
SESSIONS
JACK
100
90
80
70
60
50
40
30
20
10
0
30
RUBY
% OF INTERVALS
% OF INTERVALS
RANDY
25
25
30
36 MG
CONCERTA
PLACEBO
0
5
10
15
20
Figure 5. Percent of intervals with anxiety/stereotyped
behaviors. A significant increase in anxiety/stereotyped
behavior was observed for Brad (p<0.005), Randy (p<0.05)
and Rick at both the 36 mg and 54 mg dose of Concerta
(p<0.05 and p<0.001, respectively). The apparent increase
in anxiety/stereotyped behaviors for Eric did not achieve
statistical significance (p=0.06).
107
100
90
80
70
60
50
40
30
20
10
0
BRAD
% OF INTERVALS
% OF INTERVALS
ERIC
20 MG ADDERALL
PLACEBO
0
5
10
15
20
25
100
90
80
70
60
50
40
30
20
10
0
20 MG DEXEDRINE
0
30
5
10
SESSIONS
15
20
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
54 MG
CONCERTA
0
5
10
15
20
SESSIONS
25
0
30
2
4
% OF INTERVALS
% OF INTERVALS
PLACEBO
5
10
15
6
8
SESSIONS
10
12
RICK
36 MG
CONCERTA
0
30
PLACEBO
10 MG
ADDERALL
JACK
100
90
80
70
60
50
40
30
20
10
0
25
RUBY
% OF INTERVALS
% OF INTERVALS
RANDY
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
20
25
30
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
36 MG
CONCERTA
0
5
10
54 MG
CONCERTA
15
20
25
30
Figure 6. Percent of intervals with escape attempts. A
significant decrease in escape attempts was observed for
was observed for Randy at the 54 mg Concerta dose (p<0.05).
108
BRAD
ERIC
20 MG
ADDERALL
600
NUMBER OF STEPS
NUMBER OF STEPS
800
PLACEBO
400
2000
20 MG
DEXEDRINE
1600
PLACEBO
1200
800
200
400
0
0
0
5
10
15
20
0
25
5
10
15
SESSIONS
SESSIONS
1600
PLACEBO
1200
54 MG
CONCERTA
800
25
RUBY
NUMBER OF STEPS
NUMBER OF STEPS
RANDY
20
400
600
500
PLACEBO
10 MG ADDERALL
400
300
200
100
0
0
0
5
10
15
20
0
2
4
JACK
36 MG
CONCERTA
1000
8
10
SESSIONS
RICK
NUMBER OF STEPS
NUMBER OF STEPS
SESSIONS
6
PLACEBO
800
600
400
200
PLACEBO
500
54 MG
CONCERTA
36 MG
CONCERTA
400
300
200
100
0
0
0
5
10
15
20
25
0
5
10
15
20
Figure 7. Number of steps taken. A significant decrease
in the number of steps taken was observed for Brad at the
20 mg Dexedrine dose (p<0.005).
109
APPENDIX F – ALONE PLAY GRAPHS
Figure 1. Percent of intervals with toy play
Figure 2. Percent of intervals with vocalizations
Figure 3. Percent of intervals with activity level
Figure 4. Percent of intervals with anxiety/stereotyped
behavior
Figure 5. Percent of intervals with escape attempts
Figure 6. Percent of intervals with steps taken
110
BRAD
100
90
80
70
60
50
40
30
20
10
0
100
90
80
PLACEBO
20 MG ADDERALL
70
% OF INTERVALS
% OF INTERVALS
ERIC
60
20 MG DEXEDRINE
50
40
PLACEBO
30
20
10
0
5
10
15
20
25
0
30
0
5
10
15
RANDY
30
90
90
80
70
% OF INTERVALS
80
% OF INTERVALS
25
RUBY
100
100
PLACEBO
60
50
40
54 MG
CONCERTA
30
20
70
60
PLACEBO
50
40
10 MG ADDERALL
30
20
10
10
0
0
5
10
15
20
25
0
30
0
3
6
SESSIONS
9
12
15
SESSIONS
RICK
JACK
100
100
90
90
80
80
70
PLACEBO
60
% OF INTERVALS
% OF INTERVALS
20
SESSIONS
SESSIONS
36 MG
CONCERTA
50
40
30
70
PLACEBO
60
50
54 MG
36 MG
CONCERTA
CONCERTA
40
30
20
20
10
10
0
0
0
5
10
15
20
25
30
SESSIONS
0
5
10
15
20
25
30
SESSIONS
Figure 1. Percent of intervals with toy play. No
significant medication effects on toy play were observed.
111
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
20 MG
ADDERALL
0
5
BRAD
10
15
20
25
PLACEBO
100
90
80
70
60
50
40
30
20
10
0
% OF INTERVALS
% OF INTERVALS
ERIC
20 MG
DEXEDRINE
0
30
5
10
15
0
5
10
54 MG
CONCERTA
15
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
20
25
30
10 MG ADDERALL
0
3
6
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
36 MG
CONCERTA
5
10
15
12
RICK
PLACEBO
% OF INTERVALS
% OF INTERVALS
JACK
0
9
15
SESSIONS
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
30
RUBY
% OF INTERVALS
% OF INTERVALS
RANDY
PLACEBO
25
SESSIONS
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
20
20
25
30
SESSIONS
54 MG
CONCERTA
36 MG
CONCERTA
0
5
10
15
20
25
SESSIONS
Figure 2. Percent of intervals with vocalizations. A
significant decrease in vocalizations was observed for
Brad at the 20 mg Dexedrine dose (p<0.01).
112
30
BRAD
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
% OF INTERVALS
% OF INTERVALS
ERIC
20 MG ADDERALL
0
5
10
15
20
25
100
90
80
70
60
50
40
30
20
10
0
30
PLACEBO
20 MG DEXEDRINE
0
5
10
SESSIONS
15
% OF INTERVALS
% OF INTERVALS
PLACEBO
5
10
15
20
25
30
10 MG ADDERALL
PLACEBO
0
3
6
JACK
36 MG
CONCERTA
0
5
10
15
9
12
15
SESSIONS
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
30
RUBY
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
0
25
SESSIONS
RANDY
100
90
80
70
60
50
40
30
20
10
0
20
PLACEBO
20
25
RICK
100
90
80
70
60
50
40
30
20
10
0
30
PLACEBO
36 MG
CONCERTA
0
5
10
15
54 MG
CONCERTA
20
25
Figure 3. Percent of intervals with high activity. A
significant decrease in activity level was observed for
Eric at the 20 mg Adderall dose (p<0.05).
113
30
BRAD
100
100
90
80
70
60
50
40
30
20
10
0
20 MG
ADDERALL
90
% OF INTERVALS
% OF INTERVALS
ERIC
PLACEBO
80
70
60
50
PLACEBO
40
20
10
0
5
10
15
20
25
0
30
0
5
10
15
SESSIONS
20
25
30
SESSIONS
RANDY
RUBY
100
100
90
80
70
60
50
40
30
20
10
0
90
80
% OF INTERVALS
% OF INTERVALS
20 MG DEXEDRINE
30
54 MG
CONCERTA
PLACEBO
70
60
50
40
30
10 MG ADDERALL
PLACEBO
20
10
0
5
10
15
20
25
30
0
0
SESSIONS
3
6
9
12
15
SESSIONS
RICK
JACK
100
100
90
80
70
60
50
40
30
20
10
0
90
80
70
60
50
40
PLACEBO
36 MG
CONCERTA
PLACEBO
30
36 MG
CONCERTA
54 MG
CONCERTA
20
10
0
0
5
10
15
20
25
30
0
5
10
15
20
25
30
Figure 4. Percent of intervals with anxiety/stereotyped
behaviors. No significant medication effects were observed
for anxiety/stereotyped behavior.
114
100
90
80
70
60
50
40
30
20
10
0
BRAD
% OF INTERVALS
% OF INTERVALS
ERIC
20 MG ADDERALL
PLACEBO
0
5
10
15
20
25
30
100
90
80
70
60
50
40
30
20
10
0
0
SESSIONS
PLACEBO
5
10
15
20
25
30
10
15
20
SESSIONS
0
5
10
0
3
6
9
12
15
SESSIONS
RICK
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
15
30
PLACEBO
JACK
PLACEBO
25
10 MG
ADDERALL
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
RUBY
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
0
5
% OF INTERVALS
% OF INTERVALS
RANDY
100
90
80
70
60
50
40
30
20
10
0
20 MG DEXEDRINE
20
25
30
PLACEBO
0
5
10
36 MG
CONCERTA
15
54 MG
CONCERTA
20
25
Figure 5. Percent of intervals with escape attempts. No
significant medication effects were observed.
115
30
ERIC
PLACEBO
600
20 MG
ADDERALL
NUMBER OF STEPS
NUMBER OF STEPS
700
BRAD
20 MG DEXEDRINE
500
400
300
200
100
0
0
5
10
15
20
25
30
400
350
300
250
200
150
100
50
0
PLACEBO
0
5
10
SESSIONS
15
20
SESSIONS
RANDY
NUMBER OF STEPS
400
350
54 MG
CONCERTA
300
250
200
150
100
10 MG ADDERALL
250
PLACEBO
200
150
100
50
0
50
0
0
5
10
15
20
25
30
0
3
SESSIONS
6
800
PLACEBO
600
400
200
0
0
5
10
15
12
15
RICK
20
NUMBER OF STEPS
36 MG
CONCERTA
1000
9
SESSIONS
JACK
NUMBER OF STEPS
30
RUBY
300
NUMBER OF STEPS
PLACEBO
25
25
800
700
600
500
400
300
200
100
0
54 MG
CONCERTA
36 MG
CONCERTA
PLACEBO
0
5
10
15
20
25
Figure 6. Number of steps taken. A significant decrease
in the number of steps taken was observed for Eric on the
20 mg Adderall dose (p<0.05) and at the 20 mg Dexedrine
dose (p<0.05).
116
APPENDIX G – TIGER CAMP OBSERVATION GRAPHS
Figure 1. Percent of intervals with game participation
Figure 2. Percent of intervals with social vocalizations
Figure 3. Percent of intervals with nonsocial vocalizations
Figure 4. Percent of intervals with activity level
Figure 5. Percent of intervals with anxiety/ stereotyped
behavior
Figure 6. Percent of intervals with escape attempts
Figure 7. Percent of intervals with social withdrawal
117
% OF INTERVALS
RANDY
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
PLACEBO
0
1
2
3
4
5
6
SESSIONS
% OF INTERVALS
JACK
100
90
80
70
60
50
40
30
20
10
0
36 MG CONCERTA
PLACEBO
0
1
2
3
4
5
% OF INTERVALS
SESSIONS
RICK
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
36 MG
CONCERTA
PLACEBO
0
1
2
3
SESSIONS
4
5
Figure 1. Percent of intervals with game participation.
An increase in game participation was observed for Randy
while taking the 54 mg Concerta dose.
118
% OF INTERVALS
RANDY
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
PLACEBO
0
1
2
3
4
5
6
% OF INTERVALS
SESSIONS
JACK
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
PLACEBO
0
1
2
3
4
5
% OF INTERVALS
SESSIONS
NICK
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
36 MG
CONCERTA
0
1
PLACEBO
2
3
4
5
SESSIONS
Figure 2. Percent of intervals with social vocalizations.
No significant medication effects were observed for social
vocalizations.
119
RANDY
% OF INTERVALS
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
0
1
2
PLACEBO
3
4
5
6
SESSIONS
JACK
% OF INTERVALS
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
PLACEBO
0
1
2
3
SESSIONS
4
5
RICK
% OF INTERVALS
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
0
1
PLACEBO
2
3
SESSIONS
54 MG
CONCERTA
4
5
Figure 3. Percent of intervals with nonsocial
vocalizations. No significant medication effects were
observed for nonsocial vocalizations.
120
% OF INTERVALS
RANDY
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
PLACEBO
0
1
2
3
4
SESSIONS
5
6
JACK
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
PLACEBO
0
1
2
3
4
5
RICK
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
0
1
54 MG
CONCERTA
PLACEBO
2
3
4
5
Figure 4. Percent of intervals with high activity. No
significant medication effects for activity level were
observed.
121
% OF INTERVALS
RANDY
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
PLACEBO
0
1
2
3
4
5
6
SESSIONS
JACK
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
PLACEBO
0
1
2
3
4
5
RICK
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
36 MG
CONCERTA
PLACEBO
0
1
2
3
4
5
Figure 5. Percent of intervals with anxiety/stereotyped
behavior. An increase in anxiety/stereotyped behavior was
observed for Randy at the 54 mg Concerta dose.
122
% OF INTERVALS
RANDY
100
90
80
70
60
50
40
30
20
10
0
54 MG
CONCERTA
0
1
2
3
PLACEBO
4
5
6
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
% OF INTERVALS
JACK
36 MG
CONCERTA
0
1
100
90
80
70
60
50
40
30
20
10
0
2
3
SESSIONS
PLACEBO
4
5
% OF INTERVALS
RICK
PLACEBO
54 MG
CONCERTA
36 MG
CONCERTA
0
1
2
3
SESSIONS
4
5
Figure 6. Percent of intervals with escape attempts. No
significant effects were observed for escape attempts.
123
% OF INTERVALS
100
90
80
70
60
50
40
30
20
10
0
RANDY
54 MG
CONCERTA
% OF INTERVALS
0
1
2
PLACEBO
3
4
5
6
SESSIONS
JACK
100
90
80
70
60
50
40
30
20
10
0
36 MG
CONCERTA
PLACEBO
0
1
2
3
4
5
% OF INTERVALS
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
RICK
36 MG
CONCERTA PLACEBO
0
1
2
3
SESSIONS
54 MG
CONCERTA
4
5
Figure 7. Percent of intervals with social withdrawal. No
significant medication effects for social withdrawal were
observed.
124
APPENDIX H – SOCIAL REINFORCER ASSESSMENT GRAPHS
Figure 1. Coupons selected while on placebo dose
Figure 2. Coupons selected while on low dose of stimulant
medication
Figure 3. Coupons selected on the high dose of stimulant
medication
Figure 4. Total coupons selected
Figure 5. Percent of coupons selected
125
50
45
40
35
30
25
20
15
10
5
0
PEER
ALONE
QUIET
0
2
4
6
8
10
NUMBER OF COUPONS SELECTED
NUMBER OF COUPONS SELECTED
BRAD
ERIC
50
45
40
35
30
25
20
15
10
5
0
PEER
ALONE
0
2
50
45
40
35
30
25
20
15
10
5
0
NUMBER OF COUPONS SELECTED
RANDY
PEER
QUIET
ALONE
0
2
4
6
8
10
12
4
6
SESSIONS
8
10
RICK
50
45
40
35
30
25
20
15
10
5
0
PEER
ALONE
0
1
2
3
QUIET
4
5
SESSIONS
NUMBER OF COUPONS SELECTED
NUMBER OF COUPONS SELECTED
SESSIONS
QUIET
JACK
50
45
40
35
30
25
20
15
10
5
0
PEER
QUIET
ALONE
0
2
4
6
8
10
Figure 1. Coupons selected while on placebo dose. These
are cumulative graphs depicting the number of each kind
of coupon selected while on the placebo dose. The data
show that the children mainly selected peer play coupons
while on placebo.
126
NUMBER OF COUPONS SELECTED
RICK
50
45
40
35
30
25
20
15
10
5
0
PEER
ALONE
QUIET
0
2
4
6
8
10
Figure 2. Number of coupons selected while on the low
dose of stimulant medication. This is a cumulative graph
depicting the number of each kind of coupon selected by
Rick while on the low dose of stimulant medication (36 mg
of Concerta). The data show that the Rick mainly selected
peer play coupons while on the low dose of Concerta.
127
ALONE
0
2
QUIET
4
6
8
10
12
NUMBER OF COUPONS SELECTED
SESSIONS
RANDY
50
45
40
35
30
25
20
15
10
5
0
QUIET ALONE
2
4
6
8
50
45
40
35
30
25
20
15
10
5
0
BRAD
PEER
ALONE
QUIET
0
2
10
4
6
SESSIONS
10
QUIET
ALONE
PEER
0
1
2
3
4
5
SESSIONS
SESSIONS
NUMBER OF COUPONS SELECTED
8
RICK
50
45
40
35
30
25
20
15
10
5
0
PEER
0
NUMBER OF COUPONS SELECTED
PEER
NUMBER OF COUPONS SELECTED
NUMBER OF COUPONS SELECTED
ERIC
50
45
40
35
30
25
20
15
10
5
0
JACK
50
45
40
35
30
25
20
15
10
5
0
PEER
QUIET
ALONE
0
2
4
6
8
10
SESSIONS
Figure 3. Number of coupons selected while on the high
dose of stimulant medication. This is a cumulative graph
depicting the number of each kind of coupon selected by
the participants while on the high dose of stimulant
medication. The data show that two of the participants
selected alone play coupons more frequently while on the
high dose of stimulant medication.
128
6
100
90
80
70
60
50
40
30
20
10
0
100
90
80
70
60
50
40
30
20
10
0
RA
PLACEBO
20 MG
ADDERALL
0
5
10
15
20
BRAD
RA
20 MG DEXEDRINE
BL
BLOCKS IN BUCKET
BLOCKS IN BUCKET
ERIC
BL
25
PLACEBO
0
30
5
10
15
RA
BLOCKS IN BUCKET
BLOCKS IN BUCKET
54 MG
CONCERTA
PLACEBO
0
5
10
15
SESSIONS
20
100
90
80
70
60
50
40
30
20
10
0
25
RA
BL
36 MG
CONCERTA
PLACEBO
54 MG
CONCERTA
0
5
10
15
SESSIONS
20
25
JACK
RA
BL
BLOCKS IN BUCKET
180
160
140
120
100
80
60
40
20
0
30
RICK
RANDY
BL
25
SESSIONS
SESSIONS
100
90
80
70
60
50
40
30
20
10
0
20
36 MG
CONCERTA
PLACEBO
0
5
10
15
20
25
30
SESSIONS
Figure 4. Total number of blocks placed in the bucket. No
significant medication effects were observed for the total
number of blocks placed in the bucket.
129
ERIC
PLACEBO
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
20 MG ADDERALL
RICK
RANDY
% OF COUPONS SELECTED
% OF COUPONS SELECTED
PLACEBO
20 MG DEXEDRINE
DOSE CONDITION
DOSE CONDITION
100
90
80
70
60
50
40
30
20
10
0
BRAD
% OF COUPONS SELECTED
% OF COUPONS SELECTED
100
90
80
70
60
50
40
30
20
10
0
36 MG CONCERTA
DOSE CONDITION
100
90
80
70
60
50
40
30
20
10
0
PLACEBO
36 MG
CONCERTA
54 MG
CONCERTA
DOSE CONDITION
% OF COUPONS SELECTED
JACK
100
90
80
70
60
50
40
30
20
10
0
PEER
ALONE
QUIET
PLACEBO
36 MG CONCERTA
DOSE CONDITION
Figure 5. Percent of coupons selected. These graphs show
that both Brad and Rick selected a higher percentage of
nonsocial coupons (i.e., alone play and quiet time coupons)
while on the high dose of stimulant medication. The
opposite effect was observed for Eric. Eric selected a
higher percentage of peer play coupons while on the high
dose of stimulant medication.
130
Vita
Robert H. LaRue Jr. is a graduate student at Louisiana
State University. He is currently completing his
predoctoral internship at the Marcus Institute in Atlanta,
Georgia. His research interests include psychopharmacology,
school psychology, pediatric feeding disorders, and the
treatment of severe behavior problems. The degree of Doctor
of Philosophy will be conferred at the December 2002
Commencement.
131