School-Based Methylphenidate Placebo Protocols

Abstract

Around 1990, psychologists and educators began to notice increasing use of methylphenidate by students. Diagnosis of attention-deficit/hyperactivity disorder by family physicians and pediatricians was most commonly based on brief behavioral descriptions by parents and, infrequently, by use of rating scales. At that time, the present researchers began to explore the development of a school-based, methodologically sound, and inexpensive method of assessing the efficacy of stimulant medications, which would ensure reasonable compliance by teachers, parents, and students in monitoring the effects of medications and placebos. This article focuses on the methodological issues involved in choosing instruments to monitor behavior, once a comprehensive evaluation has suggested trials on Ritalin. Case examples illustrate problems of teacher compliance in filling out measures, supplying adequate placebos, and obtaining physician cooperation, and with the practical issue of providing adequate data without overwhelming the time and resources of participants. Emerging school-based methodologies are discussed with recommendations for future efforts.

Training school psychologists in psychopharmacology consultation

“…Specific evaluation measures include behavior rating scales (e.g., The Behavior Assessment System for Children, Second Edition [BASC-II], Parent Rating Scales [PRS]; Reynolds & Kamphaus, 2004), direct observations of the target behavior (e.g., Barkley's ADHD Behavior Coding System; Barkley, 1990), review of permanent products (e.g., completed assignments), direct measures of academic performance (e.g., curriculum-based assessment), and, when necessary, cognitive tests (Phelps, Brown, & Power, 2002;Power et al, 2003). Specific school-based medication evaluation procedures might also be considered, including the School-Based Medication Evaluation Program (SBME; Gadow, 1993) and the Methylphenidate Placebo Protocol (Hyman et al, 1998).…”

An agile behavioral model for monitoring the effects of stimulant medication in school settings

“…Constructing customized rating scales by drawing from items of existing measures (Hyman et al, 1998) or selecting key variables for the creation of daily report cards (e.g., Greenhill et al, 1996) may serve as potential adjuncts to the use of standardized rating scales in their commercial form. It should be noted, however, that little is known about the psychometric properties of such hybrid instruments.…”

“…Behavioral observation is among the most widely used assessment procedures by school psychologists, with naturalistic observation (e.g., recording all behaviors as they happen with no predetermined behaviors in mind) being used twice as often as systematic observation, or those procedures involving a predetermined set of behaviors and coding conventions (Wilson & Reschly, 1996). Nevertheless, school-based medication evaluation procedures relying heavily on observations have been criticized because of a perceived lack of trained observers in school settings (Hyman et al, 1998). Certainly, the time involved in training and carrying out systematic observations poses a barrier to their use in evaluation procedures.…”

“…This is unfortunate, because this shortcut fails to take into consideration practice effects resulting from repeated measurement. Although this may be less of a concern in alternating treatment designs where theoretically practice effects are spread across all dose conditions (Hyman et al, 1998). However, because baseline reports of stimulant side effects vary widely across children, it is particularly important to collect baseline side-effect ratings for comparison (c.f., Barkley, McMurray, Edelbrock, & Robbins, 1990;DuPaul, Anastopoulos, Kwasnik, & McMurray, 1996).…”

“…Several authors have advocated procedures designed to gather extensive information about the effects of medication on children in schools, using single-case methodology (e.g., Gadow, Nolan, Paolicelli, & Sprafkin, 1991;Hyman et al, 1998;Pelham, 1993). Following the tradition of controlled clinical trials, they are expensive and time-consuming procedures to implement.…”