Stimulant Effects on Disruptive Behavior
Stimulant Effects on Disruptive Behavior
The goal of this study is to determine the effects of stimulant medication on disruptive
 behavior, function, preference and choice; however, it is primarily methodological and will
 add to current research by establishing an effective evaluation of the impact of stimulant
 medication on these behaviors. Three behavior assessments for children and adolescents
 diagnosed with AD/HD who exhibit disruptive behavior will be conducted:

 1. Preference assessments will be conducted to determine whether preference for social and
 nonsocial items and activities differs under medication and non-medication conditions.

 2. Functional analyses will be conducted to determine whether stimulant medication has an
 effect on the frequency and function or purpose of disruptive behavior.

 3. Choice assessments will be conducted to evaluate the impact of stimulant medication on
 impulse control/delay discounting.

 This study will be conducted in three phases. For each of the 5 to 10 participants there will
 be 8 total visits. The first 4 visits will entail a preference assessment, followed by a
 functional analysis. On visits 1 and 3, the participant will be asked to take his/her
 stimulant medication as is typically done; however, on visits 2 and 4, the participant will
 be asked to refrain from taking the medication.

 For visits 5-8, participants will continue to participate in preference assessments, but will
 also be presented with a choice arrangement with work and play. In the choice arrangement,
 participants will be given four work cards and four play cards that they can organize in any
 order. Work cards will be associated with a brief academic task and play cards will be
 associated with a brief play period using high-preferred toys/activities. On visits 5 and 7
 the participant will be asked to take his or her stimulant medication as usual, while on
 visits 6 and 8 the participant will be asked to refrain from taking his or her medication.
This study includes the consent, a pre-visit interview, and two assessment phases occurring
 at weekly visits. Phase I includes four visits, each lasting approximately 2 hours. Phase II
 includes four visits, each lasting approximately 1 hour. The following are the description of
 the consent, pre-visit, and Phases I and II:

 Consenting:

 A research team member will review eligibility criteria and study procedures with a
 prospective subject prior to requesting consent. Following consent, an interview will occur
 by phone or in person. If the caregiver desires, the interview may take place on the same
 visit as the consent (but following obtaining consent). In relation to the medication,
 withholding the medication will not occur until the second assessment visit (following the
 initial review and consent visit and also the interview).

 Pre-Visit Interview:

 If the interview is not conducted at the time of consent, it will be conducted either (a) at
 the first assessment visit, (b) by phone prior to the first visit or (c) in person prior to
 the first visit. The interview is standardized and gathers information on the subject's
 demographics, diagnosis/es, medications and stimulant medication history, disruptive
 behaviors and contexts, preferred items/activities, and common demands.

 Phase I (visits 1, 2, 3,& 4):

 Phase I of the study includes four visits total. Each visit will be conducted in the same
 manner and include three stages: (1) a free operant preference assessment, (2) a multiple
 stimulus without replacement preference assessment, and (3) three sessions of each test
 condition in a functional analysis. On visits 1 and 3 the subject will take his or her
 stimulant medication as expected before beginning the assessment procedures. Medications
 expected to have a delayed onset of action (e.g., Daytrana patch) will require the subject to
 take the medication greater than 60 minutes before the start of the assessments. On visits 2
 and 4, the subject will withhold medication for the period he or she is completing the three
 stages. All data collection will be done using DataPal computer scoring software in the
 observation area of the therapy room. Each of these assessments is described next:

 Stage 1: Free Operant Preference Assessment Upon arrival, the subject will enter the therapy
 room with a research team member, referred to as "researcher" henceforth. The therapy room
 will have no more than 10 items/activities, including up to 6 items/activities identified by
 the caregiver as "preferred", up to 2 items/activities selected by the researcher as
 potentially preferred, and up to 2 items/activities identified by the caregivers as neutral
 or "non preferred". The researcher will inform the subject that he or she may play with any
 of the items/activities within the therapy room. The researcher will make available his or
 her attention for the entirety of this portion of the assessment. No demands will be given to
 the subject and no consequences will be given for disruptive behavior. Data will be collected
 on the duration of item/activity engagement by the subject for each item/activity in the
 therapy room. This assessment will last 10 minutes. Items/activities with the greatest
 duration of engagement will be considered the highest preferred.

 Stage 2: Multiple Stimulus Without Replacement within a Concurrent Operants Design Following
 the free operant preference assessment, 6 items/activities will be selected for another
 preference assessment. These items/activities will be available with and without attention.
 This preference assessment will be conducted in the same therapy room by the same researcher
 as the previous preference assessment. The assessment will begin by asking the subject to
 choose his or her most preferred item/activity to play with and with or without attention.
 The subject will be allowed 2 minutes with the item/activity and then it will be removed from
 the array. The subject will choose the next preferred item/activity with or without attention
 for another 2 minutes before removing that item/activity. This will continue until all
 items/activities have been selected (approximately 15 minutes). Data will be collected on the
 order of selection, attention or no attention, and engagement during the 2 minutes of access
 to each respective item/activity.

 Stage 3: Functional Analysis of Problem Behavior

 Following the preference assessments in Stages 1 and 2, a functional analysis of problem
 behavior will be conducted to determine the function(s) of the subject's problem behaviors.
 Disruptive behaviors will be deemed "target behaviors" for the functional analysis. All
 sessions of the functional analysis will be conducted by the researcher in the same therapy
 room as the previous two phases. Each session will last 5 minutes total, with 3 sessions for
 each test condition and 3 free play sessions. This results in a total of 12, 5-minute
 sessions, which may last between 75 to 90 minutes total. The order of conditions will be
 randomized for each round (i.e., one test of each condition and a free play session), with a
 newly randomized order for each round. The conditions include Escape, Tangible, Attention,
 and Free Play and are described below:

 Free Play:

 This condition serves as a control condition. Toys and activities will be available, as well
 as the researcher's attention. No work materials will be present. The researcher will begin
 the session by informing the subject that he/she may play with any toys/activities in the
 therapy room and that attention is available (e.g., "John, you can play with any of the toys
 in the room. I'll play with you if you like."). If a target behavior occurs (as well as any
 other "problem" behavior), the researcher will continue with attention and avoid commenting
 on the behavior.

 Escape:

 In this condition the subject will asked to complete demands. The demands will be (a) within
 the subject's skill range and (b) known to be aversive. This could be an academic task or a
 domestic task. The researcher will begin the session by presenting the demand to the subject
 using clear instructions (e.g., "John, it is time to do some math problems."). The researcher
 will provide praise as he/she is actively working. Attention will never be diverted. Tasks
 will continue to be presented unless a target problem behavior is observed. If a target
 behavior is emitted the researcher will provide a 30-second break from the work task. Once
 the 30-second break has ended the researcher will return to work using a prompt similar to
 that when the session started. For any subsequent occurrence of the target behavior there
 will be another break for 30 seconds. All non-target problem behaviors are ignored.

 Tangible:

 In this condition an item/activity identified as "high-preferred" and an item/activity
 identified as "low preferred" will be used. Just prior to the start of this condition, the
 subject is allowed access to the high-preferred item/activity. Once the session begins, the
 high-preferred item/activity will be restricted by the researcher and the low-preferred
 item/activity will be presented for play. Attention is not restricted during this condition.
 If the subject emits a target behavior the high-preferred item/activity is returned to the
 subject for 30 seconds and subsequently restricted again. If no target behavior occurs then
 the low-preferred item/activity will be the only play option for the entire five minutes.

 Attention:

 In this condition the subject has access to preferred items and activities and no demands are
 presented. At the beginning of the session the researcher will inform the subject that he or
 she should play with the toys available but that the attention will be unavailable. The
 researcher will leave the play area, go to the other side of the therapy room and begin
 reading a book or magazine. If a target behavior is emitted the researcher will approach the
 subject and provide a brief statement of disapproval and reiterate the expectation to
 behavior appropriately, followed by a return to ignoring the subject. All appropriate
 behavior, including requests for attention, will be ignored for the entirety of the session.

 For the functional analysis, data will be collected and graphed on the frequency (rate per
 minute) of problem behavior. Visual inspection of graphs will determine differentiation
 across the four conditions (three test conditions and the freeplay/control condition) to
 identify the function(s) of the target behavior.

 Phase II (visits 5, 6, 7, & 8):

 Following completion of the first three stages (visits 1-4), four additional visits will be
 required (visits 5-8). These additional visits will consist of three stages: (1) free operant
 preference assessment; (2) multiple stimulus without replacement preference assessment in a
 concurrent operants design; and (3) work-break schedule with choice. Stages 1 and 2 will be
 conducted the same as Phase I. On visits 5 and 7 the subject will take his or her stimulant
 medication as expected before beginning and on visits 6 and 8, the subject will be asked to
 withhold medication for the period he or she is completing the three stages. All data
 collection will be done using DataPal computer scoring software that is installed on
 computers in the observation area of the therapy room.

 Stage 1: Free Operant Preference Assessment This assessment will be conducted just as
 described for Phase I of the study.

 Stage 2: Multiple Stimulus Preference Assessment within a Concurrent Operants Design This
 assessment will be conducted just as described for Phase I of the study.

 Stage 3: Work-Play Schedule with Choice The purpose of this assessment is to evaluate delayed
 discounting and impulse control in choice making. In this stage, 8 picture cards and a
 schedule board (a plastic board with 8 Velcro placeholders for the picture cards) will be
 presented to the subject. Four of the picture cards will show a picture of a child working
 and the text "work". Four picture cards will depict a child playing and the text "play". Each
 "work" card will represent an academic work task. The worksheet(s) will take an estimated 5
 minutes to complete Each "play" card will represent 3 minutes of play time with the
 high-preferred item/activity identified through the preference assessments in Stages 1 and 2.
 Attention will not be available during work or play; however, the subject may request help
 with the work if needed. Completion of the schedule will take approximately 32 minutes.

 At the outset, the subject will be asked to organize the schedule in any sequence desired.
 There are many sequences the subject could choose (e.g., work(w)-play(p)-w-p-w-p-w-p;
 wwwwpppp, wwppwwpp, ppppwwww) and there will be no restriction on the sequence as long as all
 of the work and play cards are used in the sequence. Once the schedule is set by the subject
 the researcher will ask the subject to respond "final".

 Following the sequencing of the schedule, the researcher direct and remind the subject of all
 transitions from one activity to the next. Each completed activity will result in the removal
 of the picture card from the schedule until all picture cards have been removed. The
 researcher will check the worksheets to ensure completion and will require the subject to
 complete any unfinished work items and redo incorrect work items until he or she has achieved
 80% accuracy or better. Problem behavior will be placed on extinction (i.e., it will be
 ignored by the researcher and there will be no programmed consequences).. Data will be
 collected on the sequence chosen, compliance, on-task/off-task behavior, and problem
 behavior.
Inclusion Criteria:

 1. Participant must be a child or adolescent between the ages of 4 years, 0 months, and
 13 years, 0 months (participants must not be older than 12 years, 11 months).

 2. Participant must have a valid diagnosis of attention deficit/hyperactivity disorder
 (AD/HD). No specification of type (e.g., predominately inattentive type, predominately
 hyperactive-impulsive type, or combined type) will be necessary.

 3. Participant must exhibit disruptive behavior, defined as one or more of the following:

 1. physical or verbal aggression towards others: Hitting, kicking, biting,
 scratching, choking, spitting at, or throwing items at another person, and/or
 making insults, threats, or swearing at another person.

 2. self-injury: Hitting self, biting self, banging head on an object/hard surface,
 pinching self, or scratching self with visual skin damage.

 3. destruction: Damaging (or attempts to damage) personal or public property (e.g.,
 breaking an object into two or more pieces, using an object to break other
 objects, ripping objects or parts of objects from walls, floors, or furniture,
 and denting cars, objects, or walls.)

 4. noncompliance:Regular occurrence of verbal refusal (e.g., saying "no", "I don't
 want to", "I won't do it" or "not now") to any academic or non-academic request,
 and/or any response that does not match the delivered instruction within 30
 seconds from the time the instruction was delivered.

 5. tantrum:Crying (i.e., any vocalizations [sounds or words] accompanied by facial
 contraction with and without tears for any period of time) and/or screaming
 (occurrence of vocalizations above normal conversational volume for any period of
 time), with or without body flailing.

 6. an active diagnosis of disruptive behavior disorder or oppositional defiant
 disorder.

 4. Participant must already be prescribed a stimulant medication for the treatment of
 AD/HD symptoms and at an approved dose for age.

 Exclusion Criteria:

 1. a diagnosis of autism, conduct disorder, or intellectual disability in the moderate,
 severe or profound range.

 2. prescribed or taking a stimulant dosage outside of recommended therapeutic range.