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.
In the late 1980 s, psychologists and educators began to notice increasing use of methylphendiate (MPH) by students (Lee & Hyman, 1995; Safer, Zito, & Fine, 1996). Diagnosis and treatment of attention-deficit/ hyperactivity disorder (ADHD) by family physicians and pediatricians was most commonly based on brief behavioral descriptions by parents and infrequently by comprehensive evaluation or formative assessment procedures. A survey of a large national sample of primary-care physicians indicated that the majority relied on observation of the child in their offices and positive response to stimulant medication as diagnostic of ADHD (Copeland, Wol raich, Lindgren, & Milic h, 1987). Much of this increase in reliance on MPH was based on physicians' belief that positive reaction to MPH is diagnostic in itself, despite research evidence to the contrary (Bellwoar, 1996).
Collaboration among physicians, psychologists, and educators provides the opportunity to combine the expertise of these classes of professionals to improve services to children with attention disorders. In recent years, professionals and parents have raised many concerns about how often MPH is prescribed under varying diagnostic conditions (Barkley, 1990; Gadow, 1982 a, 1982 b, 1993; Pelham, 1993). By the mid-1990 s, professionals were noting extremely large increases in the number of children being treated for ADHD, with concomitant increases in the demand for MPH. A recent study by Bellwoar (1996) indicated that 53% of pediatricians, 44% of family physicians, 35% of psychiatrists, and 10% of responding neurologists referred to a psychologist when evaluating ADHD. This suggests that half or fewer of the children diagnosed with ADHD by the four types of physicians polled were likely to have had the input of psychologists for either diagnosis or ongoing monitoring. Compared with the three other groups of physicians, psychiatrists were the most likely to monitor the effects of various doses of MPH and most often tended to depend on interviews with parents and / or teachers.
All four groups reported that they sometimes used parent or teacher rating scales to aid in diagnosis. Current guidelines from the American Academy of Child and Adolescent Psychiatry (AACAP, 1997) recommend a comprehensive evaluation, including use of rating scales, psycho educational assessment, and observations at school, for identification. The AACAP guidelines note that medication efficacy should be monitored closely via multiple outcome measures. However, Bellwoar's data suggested that physicians often did not use ongoing objective measures to determine the effects of various titrations of MPH; and placebo protocols to monitor titrations of MPH were almost never used. This raises the possibility that children were receiving medication that may not have been necessary, receiving incorrect doses, or being taken off medication that was actually effective. Bellwoar found that younger physicians of all types were significantly more likely to use multiple measures and referrals for diagnosis.
However, overall, the data suggested a need for critical scrutiny of the use of MPH, especially given contemporary concerns about the overuse of medications with children (e. g. , Det terman & Thompson, 1997). In the late 1980 s, Hyman and his colleagues began to explore the development of a school-based placebo protocol that would capitalize on school psychologist's collaboration with primary-care physicians (Hyman et al. , 1996; Lee & Hyman, 1995; Wojtowicz, 1995). School psychologists seem to be in a unique position to collaborate with physicians in MPH trials (e.
g. , see discussions in Du Paul, Barkley, & McMurray, 1992; and Power, Atkins, Osborne, & Blum, 1994). The attempt was to develop cost-effective and convenient, yet ecologically valid and reliable, techniques for the evaluation of medication effects on individual children. The growing awareness that school-based medication assessment measures might be the most ecologically valid (Carlson & Brunner, 1993; Gadow, 1993; Pelham, 1993; Platz man, Story, Brown, & Coles, 1992) led to the belief that school psychologists could effectively direct medication evaluation procedures in schools in collaboration with the prescribing physicians. The purpose of this article is to present a brief overview of the methodological and practical issues involved in ongoing attempts to develop ecologically sound placebo protocols, to determine the effectiveness of psycho stimulant drugs in the treatment of attention disorders. Selected data from a number of cases involved in an ongoing series of studies are presented by way of illustration..