ABSTRACT.Thesocialacceptabilityofmethyiphenidate, behavior modification, and methylphenidate plus behav ior modification was evaluated. Fifty mothers of children
with attention deficit hyperactivity disorder (ADHD) and 50 control mothers, along with 21 children with ADHD and 20 control children, read a case vignette of an 8-year old boy with ADHD and descriptions of the three treat
ment conditions. Subjects then rated the acceptability of
each treatment. The mothers of children with ADHD were reassessed 3.5 months later, after experience with
interventions for their children. Both ADHD and control families rated behavior modification as the most accept
able, methylphenidate as least acceptable, and the com bined condition intermediate between the other two. At follow-up, there was a significant improvement in the acceptability of methylphenidate and the combined con
dition. The increased acceptability of methyiphenidate
at follow-up was related to increases in parents' knowl edge about ADHD but not to the significant improve ments that occurred in the children's hyperactive behav ior. Pediatrics 1991;88:560—565;attention deficit hyper activity disorder, methyiphenidate, behavior modification.
ABBREVIATIONS.ADHD, attention deficit hyperactivitydis
order; ADD, attention deficit disorder; TEL, Treatment Evalu ation Inventory; ADDLQ, Attention Deficit Disorder Informa tion Questionnaire.
Psychostimulant medication and behavior mod ification are the two most common, effective, and
safe interventions for children with attention defi
cit hyperactivity disorder (ADHD).―2Effective im
Received for publication Jun 4, 1990; accepted Jul 30, 1990. Reprint requests to (A.L.R.) Psychology Division, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201. Copies of the materials may be obtained from A.L.R.
PEDIATRICS (ISSN 0031 4005). Copyright ©1991 by the American Academy of Pediatrics.
plementation of these treatments requires parental and child compliance with the practitioners' rec ommendations. Positive expectations and attitudes toward any such treatment facilitate such compli ance.3 While much research has attested to the efficacy of pharmacological and behavioral treat
ments for children with ADHD, relatively few in
vestigations have examined consumers' attitudes toward these interventions.47 Unfortunately, sen sational and erroneous media reports concerning stimulant medication have proliferated,6 poten
tially heightening the public's biases and fears to
ward such intervention and potentially decreasing patient compliance.
In an investigation of patient adherence to stim ulant medication, Firestone4 found that approxi mately 26% ofthe patients refused treatment, while 20% and 55% of those who accepted treatment stopped taking their medication by the end of the 4th and 10th months, respectively. Fewer than 10% of those who stopped using stimulant medication either notified or consulted with their physician before terminating the treatment. Similarly, Sum mers and Caplan7 presented a vignette to lay people which described the use of stimulant medication for ADHD and an anticonvulsant drug for seizure disorders. Subjects believed that parents of the epileptic children were more justified in giving their children medication than were the parents of the children with ADHD. Summers and Caplan argued that the subjects' negative attitude toward drug therapy for ADHD may be reflective of a belief that the behavioral problems of a child with ADHD are under the child's control rather than the result of organic factors. Thus, subjects believed that the child with ADHD should be able to control the
behaviors without relying on external sources such as prescribed medication.
Social Acceptabilityof Methylphenidateand
BehaviorModificationfor Treating Attention
Deficit HyperactivityDisorder
Christina Liu, PhD; Arthur L. Robin, PhD; Sheldon Brenner, DO; and
Jay Eastman, MD
The purpose of this study was to provide scien
tifically sound information about the acceptability of stimulant medication and behavior modification
in treating children with ADHD, comparing the lay public's ratings of three treatments: (1) methylphe nidate; (2) behavior modification; (3) methyiphe nidate plus behavior modification. Well-established methodology for studying social acceptability was
used.8'9
METHODS
Participants
One hundred parents (50 parents of children with ADHD and 50 control parents) and 41 of their children (21 ADHD patients and 20 control sub jects) served as participants. The mothers averaged 37.2 and 34.9 years of age and 41.1 and 43.6 on the
Hollingshead Four-Factor Index'° of social class,
respectively, in the ADHD and control groups. The 41 children averaged 10.0 and 10.6 years of age, respectively. Forty additional children were consid ered but not included because they were too young to understand the questionnaires and instructions. Thirty-one male and 10 female children partici pated. There were no significant differences be tween groups on demographic variables.
The children with ADHD and their mothers were attending either an inner-city or suburban branch of the Children's Hospital of Michigan Attention Deficit Disorder (ADD) Clinic for an initial evalu ation of attentional problems. The diagnosis of ADHD was established by a consensus of a staff
psychologist and pediatrician that a child met all of the following criteria: (1) the Diagnostic and
Statistical Manual of Mental Disorders (3rd ed, revised) criteria― for attention deficit hyperactivity disorder; (2) parent ratings on the Conners Parent Hyperactivity Index'2 greater than 15; and (3) teacher ratings on the Attention and Hyperactivity
scales of the ADD Comprehensive Teacher Evalu ation Rating Scales'3 at or below the 20th percent ile. The control group included non-ADHD children
and their mothers selected through media adver
tisements and personal contacts; telephone screen
ing and clinical interviews were used to establish that none of the children had a history of ADHD. The two groups were matched on children's age, sex, socioeconomic status, and race.
Measures
Acceptability Measure. The adult and child ver
sions of the Treatment Evaluation Inventory
(TEl)'4 were used to assess acceptability. The TEl
consists of 12 seven-point Likert items asking about
willingness to carry out treatment procedures, the
suitability of treatment for the presenting prob lems, liking of treatment, ethics of treatment, risks
of treatment, predicted effectiveness of treatment, and the side effects of treatment. A single score is obtained by summing across the 12 items. The TEl
has been found to be a reliable and valid instru
ment.9
Attention Deficit Disorder Information Question
naire (ADDIQ). The ADDIQ consists of 20 true! false questions assessing knowledge of ADHD and
its treatment. Items assess knowledge concerning
methylphenidate (eg, “¿Ritalinis a sedative―),un derstanding of ADHD (eg, “¿Notall attention deficit disorder children are hyperactive―),knowledge con cerning the etiology of ADHD (eg, “¿Poorparenting is a cause ofattention deficit disorder―),and knowl edge concerning behavior management (eg, “¿Taking away privileges is an effective punishment for ADHD children―).A single score was obtained by
summing the number of correct responses.
Parent and Teacher Rating Scales. Parents com
pleted the Conners Parent Hyperactivity Question naire, from which the 10-item hyperactivity index was scored.'2 Teachers completed the ADD Com prehensive Teacher Evaluation Rating Scale, from which the Hyperactivity raw score was used.'3
Procedures
The first author approached the ADHD patients' mothers after they had been interviewed by the evaluation team at their initial visit to the clinic and informed of their child's diagnosis, but before they were given definitive information about treat ment procedures. Mothers were invited to partici pate in a study of attitudes toward treatments for ADHD, and informed consent was obtained. Con
senting mothers were given the clinical case vi
gnette and three treatment descriptions to read. A TEl was completed after reading each treatment description. The order of treatments was counter balanced across subjects. Afterwards, mothers com pleted the ADDIQ. The parent and teacher rating
scales completed during the week prior to the clinic
visit were obtained from the chart with permission of the mother.
Children older than the age of 9 were approached after their mothers gave informed consent. The study was explained to them. Each child listened privately to an audiotaped version of the case vi gnette and treatment descriptions with supervision by the first author. The children completed the TEl after listening to each treatment description.
Approximately 3 months after the initial clinic
mailed the materials to complete again at home and return by mail. Follow-up phone calls and a $10 payment for return of completed materials were used to increase the return rate. Twenty-seven of the 50 mothers ofthe children with ADHD returned the follow-up measures at a mean interval of 3.5 months after the initial evaluation. The first author was able to contact 65% of the mothers who failed to return the follow-up measures; 75% of those contacted indicated that they did not return the measures because they had not complied with the recommendation to give their children stimulant medication and that they were generally opposed to the use of medication. Comparisons of mothers who returned vs mothers who did not return the follow-up measures revealed no significant differ ences on demographics, initial TEl scores, ADDIQ, or behavior rating scales.
The control families were assessed in their homes in a similar fashion to the ADHD group, but they were not reassessed at follow-up. Control families were paid $5 for their participation.
It was not necessary to pay the ADHD group for their initial participation because they were already at the clinic and did not have to make any special arrangements; the control group, by contrast, had
to set aside a time for a visit by the investigator. At
follow-up, the ADHD group was paid more than the initial payment to the control group because experience suggested that without a stronger ex trinsic motivator, they would have little intrinsic motivation to repeat the measures.
VigneftesandTreatmentDescriptions
The clinical case vignette described 8-year-old J.S., a boy who was having difficulty paying atten tion, acting without thinking, and being restless at school and at home. J. S. was described as unable to finish his work, easily distracted, loud and dis
ruptive, and unable to finish chores or homework
at home. A history of such ADHD symptoms since first grade was depicted, along with increasing pa rental and teacher frustration at J.S.' escalating problems. The process of referral and evaluation to a multidisciplinary ADD clinic was also described. The vignette carefully indicated that aggression and severe conduct problems were not part of J.S.' clinical picture.
In the methyiphenidate treatment, a pediatrician explained that Ritalin is a stimulant that enhances concentration and impulse control by impacting brain functioning and described the positive effects and side effects to expect from Ritalin. The pedia trician then prescribed two doses per day to help with school functioning. A regular follow-up plan
for monitoring and adjusting medication was out lined. In the behavior modification treatment de scription, a psychologist taught J.S.' parents and teacher to define and record specific target behav iors, design and implement a daily school/home note system with home-based reinforcement for school behavior, and implement reward and punish ment contingencies at home for additional target behaviors. The methylphenidate plus behavior modification treatment description was a compila tion of the two individual treatment descriptions.
A panel of 15 physicians and psychologists who specialized in treating ADHD reviewed the vi gnettes and treatment descriptions. They rated the accuracy and representativeness of each set of ma
terials on a 5-point Likert scale. The clinical case
vignette received a mean rating of 4.6, while the descriptions of methyiphenidate, behavior modifi cation, and methylphenidate plus behavior modifi cation received mean accuracy ratings of 4.4, 4.5, and 4.3, respectively. One-way analyses of variance revealed no significant differences between the rat ings of the three treatment descriptions. Thus, the materials were considered representative and ac curate.
Design
The design consisted of a three-treatment (meth
ylphenidate, behavior modification, methylpheni
date plus behavior modification) by two-group (ADHD vs control) model, with repeated measures on the treatment factor. For the follow-up data, a second two-level repeated-measures factor (time) was added. Parent and child data were analyzed separately.
RESULTS
InitialEvaluationData
Table 1 presents the mean TEl ratings for par ents and children. The TEl ratings were entered
into a three-treatment by two-group analysis of
variance with repeated measures on the treatment factor. For parents, there was a significant main
TABLE 1. Means and StandardDeviationsfor the
Treatment Evaluation Inventory*
Treatment Mothers
(n = 100)
65.3 (14.3) 60.8 (14.6)
Children (n = 41)
62.5 (9.2) 58.8 (13.0) Behavior
modificationMethyiphenidate
+ be
havior
modificationMethylphenidate
47.7 (16.7) 56.4 (11.5)
* Standard deviations in parentheses. Higher scores in
InitialFollow-upTElBehavior
modification63.6 (15.6)63.7 (12.9)Methylphenidate
+ be 62.2 (11.7)69.6 (8.0)havior
modificationMethylphenidate51.8
(14.5)60.2 (12.2)ADDIQ15.1
(3.3)17.0 (2.0)Conners
Hyperactivity16.4 (4.9)10.1 (4.7)Index
effect of treatment, F(2,198) = 46.98, P < .001, but
no significant effects of group or group X treatment
interaction. Newman-Keuls post hoc pairwise com
parisons indicated that both the ADHD and control mothers rated behavior modification as more acceptable than either the combined condition or methylphenidate. Behavior modification plus med ication was rated as significantly more acceptable than methyiphenidate.
For children, there was also a significant main effect of treatment, F(2,80) = 5.17, P < .01, but no significant main effect of group or group x treat ment interaction. Neuman-Keuls post hoc compar isons indicated that behavior modification was sig nificantly more acceptable than methylphenidate or behavior modification plus methyiphenidate, but there was no difference between behavior modifi cation plus methyiphenidate and methyiphenidate.
Follow-upData
Table 2 presents the mean TEl scores at the
initial and follow-up evaluations for these 27 par
ticipants. Their TEl scores were submitted to a three-treatment by two-time repeated-measures factorial analysis of variance. There were signifi cant main effects of treatment, F(2,52) = 6.96, P < .01, time, F(1,16) = 10.90, P < .01, and a significant treatment X time interaction, F(2,52) = 5.94, P < .01. Paired t tests indicated that ADHD mothers increased their acceptability ratings of methyiphe
nidate, t(26) = 3.90, P < .001, and methylphenidate
plus behavior modification, t(26) = 3.27, P < .003, from the initial to the follow-up assessment. Their acceptability ratings of behavior modification did not change significantly over time, starting and staying high. At follow-up, methylphenidate plus
behavior modification received the highest accept
ability ratings, followed by behavior modification and methyiphenidate.
TABLE2. Follow-upMeansfor the TreatmentEvalu ation Inventory (TEl), Attention Deficit Disorder Infor mation Questionnaire (ADDIQ), and Conners Parent Hyperactivity Index (n = 27)*
Comparisonof ParentandChildAcceptability
Rating
There were no significant correlations between parents' and children's acceptability ratings for any of the treatments. t Tests comparing the absolute level of parent vs child acceptability ratings re vealed that children rated methyiphenidate more positively than their parents, t(40) = 2.82, P < .01, but there were no differences for the other two treatment.
ADDIOand BehaviorRatingScales
Mothers' knowledge about ADHD (ADDIQ) cor related significantly with their acceptability ratings (TEl) of methylphenidate, r = .33, P < .001, and methylphenidate plus behavior modification, r = .42, P < .001, but not behavior modification (r = .17). These correlations were even stronger when examining the ADHD parent subgroup (r = .51; r
= .70). There were no significant relationships be
tween acceptability scores and parent or teacher behavior ratings for any of the treatment condi tions. To examine the relationship between change in acceptability, knowledge, and behavior ratings for the ADHD mothers, two analyses were under
taken. First, paired t tests comparing ADDIQ and
parent Conners Hyperactivity Index scores at the initial and follow-up evaluations revealed a signif icant increase in knowledge, t(26) = 3.49, P < .01, and a significant decrease in parental ratings of hyperactive behavior, t(21) = 6.07, P < .001. Sec ond, correlational analyses revealed that increased knowledge about ADHD was related to increased social acceptability for methylphenidate, r = .45, P
< .01, and methyiphenidate plus behavior modifi
cation, r = .70, P < .01, but not for behavior modification. There were no significant correla
tions between improvement in parental ratings on the Hyperactivity Index and changes in social
acceptability.
DISCUSSION
The results of this study indicate that parents and children who are actual or potential consumers of interventions for ADHD have definite prefer ences about the acceptability of alternative treat
ments and that those preferences may change as a
function of actual experience with the interven
tions. Both the ADHD and non-ADHD families
initially rated behavior modification to be a more acceptable intervention than stimulant medication, with a combined condition receiving intermediate ratings. These results are consistent with past so cial acceptability studies and clinical experience,
* Standard deviations in parentheses. Higher scores in
which have found medication conditions to receive lower ratings than a variety of psychosocial inter ventions.8―4
It is interesting that a group of mothers bringing
their children to a hospital-based ADHD clinic
where they might expect stimulant medication to be one of the recommended interventions nonethe
less preferred alternative, psychosocial interven tions. The significant correlation between their
knowledge and their ratings of the acceptability of medication suggests that lack of accurate informa tion about methyiphenidate may promote appre hension and low acceptability. As the mothers' knowledge increased through experience with their children's medication and information supplied by the clinic staff, their acceptability ratings also in creased, further confirming the importance of pro viding accurate information in fostering acceptance of stimulant medication. By the follow-up assess ment, an intervention that combined psychosocial and biological treatments received the highest acceptability ratings. The lack of relationship be tween parent ratings of the children's hyperactive behavior and acceptability of stimulant medication
suggests that the changes in acceptability were not
simply an effect of the mother's satisfaction with the clinical improvements in their children's behav ior.
Because this study was not an experimental eval uation of methyiphenidate vs behavior modifica tion, it was not possible to standardize the treat ments received during the follow-up period. Be cause only four of the mothers in the follow-up group did not receive methylphenidate for their children, it was also difficult to associate, even in a post hoc fashion, changes in acceptability and the type of treatment actually given to the child. The dose schedule for the methylphenidate followed standard procedures in effect at the Children's Hos
pita! ADD Clinic, while the behavioral interven tions varied as a function of the psychologist pro
viding the services. Thus, although the changes in acceptability, knowledge, and parent hyperactivity
ratings and the relationships between these van ables are suggestive of the importance of knowledge
as a contributor to preferences, competing expla nations cannot be definitively ruled out until a random-assignment, experimental evaluation is conducted. The fact that similar results were found with both an ADHD group and a demographically matched control group increases confidence in the generalizability of the results, but further investi
gations using a stratified random sample represent
ative of the United States census will be necessary
before concluding that people in general prefer be
havioral to medical interventions for ADHD.
As far as can be ascertained from the literature,
this is the first investigation to ask children about to receive treatment for ADHD their preferences for alternative interventions and to compare those preferences to a matched control group of non ADHD children. Despite similarity in the direction ality of the children and the parents' mean accept ability ratings, there was no correlation between their TEl scores; in fact, the children also rated methylphenidate more highly than their parents. Thus, within the same family, mothers and children may have completely different opinions of the
a!-ternative treatments for ADHD. Clinically, parents often are more concerned about the safety and side
effects of alternative treatments, while children are more concerned about peer acceptance and self
esteem issues. These findings emphasize the impor
tance of including the child in the decision-making and information-sharing process regarding the choice of a treatment for ADHD, as well as further investigating the different factors that contribute to parental vs child acceptability ratings of medical vs psychosocial interventions.
The present study did not include a direct test of the relationship between acceptability and compli ance with medical vs behavioral interventions for ADHD. Clearly, one would expect increased accept ability to promote increased compliance with treat
ment recommendations. However, the fact that
many ADHD mothers who failed to return the follow-up measures also indicated they had failed to give the prescribed medication indirectly points to a relationship between compliance and accepta bility. Inasmuch as our earlier analyses found no difference between the initial TEl scores of the mothers who returned or did not return the follow up questionnaires, factors not assessed in the pres ent investigation must have contributed to the de cision not to comply with the recommendation for treatment of ADHD. There may be concern that the attrition at follow-up biased the results; while one cannot rule out this possibility with certainty, the differences between conditions at the initial assessment were identical whether one analyzed the entire sample or only those who later returned the follow-up measures.
CONCLUSIONS
5. Cohen NJ, ThompsonL. Perceptionsand attitudesof hy
peractive children and their mothers regarding treatment with methylphenidate. Can J Psychiatry. 1982;27:40—42 6. Slimmer LW, Brown RT. Parents' decision making process
in medication administration for control of hyperactivity. J
School Health. 1985;55:221—225
7. Summers JA, Caplan PJ. Laypeople's attitudes towards drug treatment for behavior control depend on which disorder and which drug. Clin Pediatr (Phila). 1987;26:258—263 8. Finfrock-Mittl V, Robin AL. Acceptability of alternative
treatments for parent-adolescent conflict. Be/iou Assess. 1987;9:417—428
9. Kazdin AE. Acceptability of alternative treatments for de viant child behavior. J Appl Behav Anal. 1980;13:259—273 10. Hollingshead A. Four-factor socioeconomic scale. New Ha
yen, CT: Yale University; 1975
11. American Psychiatric Association, Committee on Nomen clature and Statistics. Diagnostic and Statistical Manual of
Mental Disorders. 3rd ed, revised. Washington, DC: Amen
can Psychiatric Association; 1987
12. Goyette CH, Conners CK, Ulrich RF. Normative data on revised Conners parent and teacher rating scales.
13. Ullman R, Sleator E, Sprague R. A new rating scale for diagnosis and monitoring of attention deficit children. Psy
chopharmacol Bull. 1983;20:160—164
14. Kazdin AE, French NH, Scherick RB. Acceptability of al ternative treatments for children: evaluations by inpatient children, parents, and staff. J Consult Clin PsychoL 1981;49:900—907
extremists may contribute to lower acceptability of
these interventions by parents and children. The
children who do not receive needed treatment may eventually suffer. Pediatricians and psychologists who advocate for children need to take an assertive stance against such misrepresentations and encour age reasoned discussion based on accurate infor mation of all interventions for ADHD.
ACKNOWLEDGMENT
Completion of this study was partially funded by the Ethel and James Flinn Family Foundation, Detroit, Michigan.
REFERENCES
1. Barkley RA. Attention deficit hyperactivity disorder. In: Mash EJ, Barkley RA, eds. Treatment of Childhood Disor ders. New York, NY: Guilford Press; 1989:39—72
2. Barkley RA. Attention Deficit Hyperactivity Disorder: Diag
nosis and Treatment. New York, NY: Guilford Press; 1990 3. Ross DM, Ross SA. Hyperactivity: Current Issues, Research,
and Theory. 2nd ed. New York, NY: Wiley; 1982
4. Firestone P. Factors associated with children's adherence to stimulant medication. Am J Orthopsychiatry. 1982;52:447— 457
ANNOUNCEMENT
1992PEDIATRICRHEUMATOLOGY
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1991;88;560
Pediatrics
Christina Liu, Arthur L. Robin, Sheldon Brenner and Jay Eastman
Attention Deficit Hyperactivity Disorder
Social Acceptability of Methylphenidate and Behavior Modification for Treating
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Pediatrics
Christina Liu, Arthur L. Robin, Sheldon Brenner and Jay Eastman
Attention Deficit Hyperactivity Disorder
Social Acceptability of Methylphenidate and Behavior Modification for Treating
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