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The Effects of Reward and Punishment on the Performance and Motivation of Children with ADHD
One of the more frustrating and confusing aspects of ADHD for parents is how their child's performance and motivation for tasks can seem to fluctuate so dramatically from one day to the next. Homework can go relatively smoothly on one night and then seem close to a total nightmare the next. One way of trying to deal with this issue is through a combination of rewards (i.e. receiving tangible notice for doing something well) and response cost (i.e. taking something away for the failure to perform as expected - this is akin to a mild form of punishement). What is the impact of such procedures on the motivation and performance of children with ADHD?
This interesting and important question was addressed in a study published recently in the Journal of Consulting and Clinical Psychology (Carlson, C., & Tamm, L. (2000). Responsiveness of children with ADHD to reward and response cost: Differential impact on performance and motivation. JCCP, 68, 73-83.) In this study, the authors were interested in examining 3 fundamental questions that have important implications for the use of behavioral interventions with ADHD children. These questions were:
- 1. Compared to children without ADHD, how is the performance of children with ADHD affected by reward (R) and response cost (RC)?
- 2. Do the affects of reward or response cost vary for children with ADHD depending on whether they are engaged in a high- or low-interest task?
- 3. Does the use of either reward or response cost negatively affect the motivation of children with ADHD?
Participants in this study were 44 children between the ages of 8 and 10. Twenty-two had been diagnosed with ADHD, Combined Type (i.e. they had both inattentive and hyperactive/ impulsive symptoms) and 22 did not have ADHD and served as control subjects. Approximately 30% of the children in each group were girls. Children diagnosed with ADHD for this study had been carefully and systematically evaluated using a variety of standardized behavior rating scales and clinical interviews. Although many of the ADHD children were being treated with medication, all tasks completed during the study occurred after an 18-hour medication "wash out" period. Because the effects of stimulant medications typically do not persist beyond 4-8 hours, one can safely assume that the results reported below would not have been influenced by a child's being on medication. There were no differences in IQ between children with ADHD and control subjects.
In this study, children participated in 2 separate computer tasks. The first, called Crazy Symbols, was purposely designed to be of low interest. In this task, the child was presented with a set of 5 different individual symbols on the computer screen and was required to match this to one of eight choices of figure sets positioned circularly around the target figure. The child made a selection by clicking the mouse on the selected figure set and received immediate auditory feedback from the computer about whether his or her choice was correct. After each choice, the child pressed a key to initiate the next trial. As noted above, this task was purposely designed to be relatively boring to children and it was expected that most participants would find it to be uninteresting.
The second computer task was called Jet Pack. In this task the child used the keyboard direction buttons to maneuver a figure around a maze, with the goal of "picking up" the correct key from a display of keys of various colors. For each trial, the child was presented with a particular colored key set at the bottom of the screen to indicate which color key was supposed to be picked up. Once again, the child received immediate auditory feedback from the computer when they picked up the correct key. In contrast to the task described above, the Jet Pack task was designed to be interesting and engaging to children in the study.
During the study, children participated in these tasks under several different conditions. In the reward condition, they were given the opportunity to earn dimes for every trial they completed successfully. Forty different trials were allowed providing the opportunity to earn up to $4.00. In the response cost condition they were given $4.00 in dimes to begin with and a dime was taken away each time the child solved a problem incorrectly or failed to solve it correctly within the allotted time. Finally, there was also a no contingency condition in which children completed the same tasks without receiving any feedback from the computer or reward for their performance. These tasks were completed during separate sessions and the order - of both the tasks and the contingency condition - was carefully balanced to insure that any differences found could not be attributed to order of administration.
By setting up these contingencies for the two different computer tasks, the experimenters created conditions that enabled them to carefully examine the impact of rewards and response cost on the problem-solving performance of children with ADHD during high- and low-interest tasks. At the end of each task, children were also asked to provide ratings of how much they enjoyed each task, how well they thought they had performed, and how much they would like to do the task again.
Results
The major findings of this study were as follows:
The use of both reward and response cost contingencies had a significant and positive impact on the performance of children with ADHD. In contrast, the performance of children without ADHD was not similarly affected.
The impact of either contingency on ADHD children was really quite dramatic. For example, during the Crazy Symbol task, the % correct response for ADHD children were just over 90% in either the reward or response cost condition and below 70% when neither contingency was in place. They also made an average of less than 2 mistakes during the reward or response cost condition compared to 10 mistakes during the no contingency condition. Similar differences were found for the Jet Pack task, although these were not as pronounced, probably because this was a more inherently interesting task for the children. For the control children, in contrast, performance during the reward, response cost, and no contingency condition was essentially identical.
There were some differences in the impact of reward and response cost contingencies on ADHD children that are worth noting. Children with ADHD got fewer problems incorrect in the response cost condition than in the reward condition. Thus, when faced with the loss of a dime for an incorrect response, they made significantly fewer errors than when they would simply gain a dime for a correct response.
Overall, children with ADHD performed significantly worse than control children when no contingency was in place. During the reward or response cost condition, however, their performance on the two computer tasks was essentially equal to that of the control children. As noted above, however, the response cost contingency appeared to produce the greatest gains in the performance of children with ADHD.
The use of either reward or response cost contingency did not have an adverse impact on the motivation of either children with ADHD or control children.
When the idea of using either reward or response cost programs to help manage the behavior of children with ADHD is introduced, some parents and educators are concerned about providing this "artificial" source of motivation. A frequent question is why should a child be rewarded for something he or she should be doing anyway? A flip-side of this concern is that by introducing any form or "artificial" motivation (i.e. rewards contingent on the child's performance), the child's natural or inherent motivation for the task will be adversely affected.
In this study, however, there was no indication at all that the use of either contingency had an adverse affect on the child's motivation to engage in the task. In fact, all children tended to report that they enjoyed the games more when they had the opportunity to earn rewards; this seemed to be especially true for the children with ADHD. Of course, one can not generalize from this relatively short experimental task to what would happen over an extended period in the real world, and one does need to pay attention to whether the use of reward contingencies adversely affect a child's own motivation for a task.
There is, however, an important qualifier to this general conclusion that is important to note. When the authors looked at the motivation and task liking for the ADHD children alone, they did find evidence that the response cost procedure may reduce motivation and task liking in certain conditions. Specifically, during the less-interesting computer task (i.e. Crazy Symbols), although response cost was associated with slightly better performance for children with ADHD, it also led to less enjoyment of the task and reduced motivation to perform it again.
Summary And Implications
Overall, the results of this study provide a careful demonstration of how the systematic use of contingencies can enhance the task performance of children with ADHD. In fact, in this study, the use of either reward or response cost improved the performance of children with ADHD to the point that it no longer differed significantly from children without ADHD. This does not mean, of course, that findings from an experimental study such as this can be translated immediately into the classroom or home environment (i.e. that such procedures will "normalize" the behavior and performance of children with ADHD), but they do emphasize what an important and powerful tool they can be.
What does this study tells us about the use of reward and response cost contingencies in the behavioral treatment of children with ADHD? First, it is important to be clear about exactly what these two contingencies involve: providing a reward for a desired response vs. removing something the child values when he or she behaves in a non-desired way.
Recall that in this study, response cost was found to enhance the performance of children with ADHD (i.e. they made fewer errors) relative to the reward condition. During the low interest task, however, this came at the expense of reducing liking of the task and motivation to engage in it again relative to the reward condition. Thus, in some circumstances, the beneficial affects of response cost on performance may need to be weighed against the adverse affects - relative to a reward contingency - on enjoyment and motivation.
This has potentially important clinical implications as it suggests that response cost - although more effective - may be less palatable to children with ADHD than reward. If behavioral interventions involving the use of response cost are less acceptable to children, they may be less consistently implemented by parents and teachers and be decreasingly effective over time. This may vary, of course, from child to child, but it does argue for the importance of considering both effectiveness and desirability in designing treatment programs.
For example, imagine setting up a behavior plan designed to reduce the likelihood of careless mistakes on school assignments. The reward approach would simply involve providing an incentive for every problem answered correctly. The response cost approach would involve taking something away for every problem on which a careless error was made. A combination approach would involve providing a reward for each problem answered correctly, and taking something away for each careless error. For children without ADHD, doing well on the assignements may be a sufficient "reward" to promote careful and conscientious work. For a child with ADHD, however, it is often necessary - as the results of this study demonstrate - to include more tangible rewards to promote good performance. (Note: These incentives do not necessarily have to be something tangible like the dimes that were used in this study. Simply rewarding points for pre-specified behaviors that can be accumulated and later traded in for more "concrete" rewards - e.g. "buying" access to television or computer time - can work very well for many children.)
The data from this study also suggest that the response cost approach will actually yield better performance for most children with ADHD (i.e. fewer careless mistakes). If, however, a child is especially prone to become upset when a desired object is removed, then this added benefit may not be worth it. This is something to carefully consider when thinking about developing a behavioral intervention for your child and designing such an intervention in consultation with a child mental health professional.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.