Effects of the Removal of a Token Economy on Children with ADHD

Effects of the Removal of a Token Economy on Children with ADHD

A Token Economy and The History Behind It’s Therapeutic Application

A token economy is a type of behavior modification method that is used in multiple settings, but primarily in educational settings. In essence, a token economy aims to model and shape behavior by rewarding individuals with tokens when they display the desirable or target behaviors. As a result, individuals will either consciously or subconsciously decrease the undesirable behaviors and replace them with the aforementioned desirable behaviors. For this to be effective, several elements must be in effect. For starters, individuals must receive tokens immediately after displaying the desirable behavior and this is crucial to the implementation of a token economy because it allows participants to become aware of the fact that the behaviors they enact are the direct cause behind the tokens awarded. Tokens could also be anything such as coins, money, candy and anything else that can be collected and exchanged later on for a meaningful object or privilege (Ayllon, 1999). However, this only works if the object or privilege that can be earned is meaningful to the recipient because it is the incentive for the participants to depict the desirable behaviors in the first place.

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Secondly, there must be clearly defined target behaviors for the individuals participating. The desirable and undesirable behaviors must also be explained ahead of time, preferably at the beginning, in simple and very specific terms since the populations are most predominately school-aged children (Ayllon, 1999). The number of tokens awarded or lost for each behavior must also be specified in the initial introduction. As previously mentioned, participants exchange the tokens for meaningful objects or privileges, which are called back-up reinforcers. Examples of these include food, toys, extra play time, and even outings. To further improve the design of the token economy in place, the back-up reinforcers should also be chosen by the participants in treatment rather than by the staff or those implementing the treatment. This ensures that there will be an appeal of the back-up reinforcers and motivation to earn tokens. Lastly, consistent implementation of the token economy is a must. For a token economy to be successful, all staff involved must reward the same desirable behaviors enacted, hand out the appropriate number of tokens, and avoid giving back-up reinforcers for free (Martin, 1999). The structure and environment for the participants must be consistent as well in order to ensure the overall quality and consistency of the treatment in place.

Within the educational and mental health areas of psychology, token economies are just one of many forms of behavioral methods used to decrease or increase certain types of behavior (Filcheck, McNeil, Greco, & Bernard, 2004). The use of token economies in a therapeutic application is a relatively new concept that began in the late 1950’s. However, token economies have a long history of changing behaviors among humans. One of the first therapeutic applications of a token economy was delivered by Avendano Carderera in 1959 who gave tickets to children for enacting good behavior (Rodriguez, Montesinos, & Preciado, 2005). It has been argued that the use of a token economy actually arose even before the 1960’s as it can be traced back to work from the middle of the 19^th century. Joseph Lancaster started the trend with the use of tickets within large classrooms in the early 1800’s followed by the use of cherries and cakes in the early 1950’s to teach Latin and Greek to children. Regardless of the date experts believe the use of a token economy began, it is universally accepted that token economies entail the giving of tokens after the enactment of target behaviors. However, despite the research indicating its effectiveness, token economies are not currently used as often as they could or should be in educational settings.

Children with ADHD

Being one of the most controversial topics in the field of psychology, attention deficit hyperactivity disorder, ADHD for short, is one of the most common childhood disorders. Today it is estimated that one in nine children, two-thirds of which are boys, have been diagnosed with ADHD. It affects an estimated 4% to 12% of school-aged children worldwide with data also showing that up to 5% of college aged students and adults have ADHD as well (Wilens & Spencer, 2010). Aside from this staggering statistic, data also shows that nearly 2 of 3 children with ADHD also have at least one other mental, emotional or behavioral disorder such as depression, autism spectrum disorder and Tourette syndrome. Children diagnosed with ADHD all depict three kinds of behaviors: inattention, hyperactivity, and impulsivity. While all young children, for the most part, have trouble paying attention in school and at home, children should only be diagnosed if the behavior is much more extreme in these three key areas in comparison to other kids their age.

As previously stated, young children have trouble paying attention, staying calm, and stopping their impulses. However, it is also important to take into account the age of the child. Studies have shown that kindergarteners who are the youngest in their grade are 60% more likely to be diagnosed with ADHD than the oldest in their grade. Aside from kindergarten, studies have also found that in fifth and eighth grade, the youngest children were almost twice as likely as the oldest children to be prescribed medication for ADHD such as Ritalin and Adderall (Boorady, 2017). As humans age and develop, certain parts of our brain are growing at different rates and one of the last regions to fully develop is the pre-frontal cortex which is responsible for executive functioning. This affects how humans plan, focus, organize, and execute. Knowing the common behaviors associated with an ADHD diagnosis, one could make the case that those common behaviors are linked to the slow maturation of the pre-frontal cortex of young children. The most common medications for ADHD, Ritalin and Adderall, have two common chemicals which are critical for the aforementioned functions of the pre-frontal cortex: dopamine for decreasing signals from external stimuli that might be distracting to young children and norepinephrine for improving the signals the children are trying to focus on and pay attention to. If children are already diagnosed with ADHD, there is already over an 80% chance they are going to respond to medication and within that group, 50% will respond equally well to the two previously mentioned ADHD medications (Boorady, 2017).

In regard to a token economy, children with ADHD struggle with its implementation therapeutically. The very nature of ADHD implies that children will have increased difficulty with self-control, paying attention, listening to instructions at home and school, and following directions (Tamanini, 2016). Taking into account what the common behaviors for an ADHD diagnosis are, the complexity and intricacies of token economies can make it difficult for the young children to truly understand what is being asked of them. The inattention, hyperactivity, and impulsivity would also make it increasingly difficult for the children to earn the tokens necessary to earn the back-up reinforcers they desire. A few things must be understood when looking at implementing a token economy for children diagnosed with ADHD. First and foremost, more complicated token economies are less likely to succeed. It would be best to only focus on a few goals and target behaviors at a time as this allows for better understanding and comprehension on the child’s end. Second, anything new or different is usually met with some type of resistance, especially with children. Although it may be very difficult for the child and those working with him or her, it is important to remember that change takes time and you cannot eliminate undesirable behaviors; they must be replaced with desirable ones. Lastly, there will most likely be a longer application of a token economy on children diagnosed with ADHD. The goals must be kept in sight with an approach from a team perspective around the child. The old adage that states “it takes a village to raise a child” could not be any truer when it comes to children diagnosed with ADHD.

Research on Children with ADHD within a Token Economy

Since its recognition as a neurobiological disorder over 30 years ago, ADHD has become one of the most extensively researched disorders, especially among children and adolescents. Medication has been proved to be highly successful as a means of alleviating general symptoms of ADHD (Coelho et al., 2015). However, in a recent study conducted by Reitman, Hupp, O’Callaghan, Gulley, and Northup (2001), when the token economy and medication were compared in isolation, the token economy system appeared more effective in reducing disruptive behaviors for 2 of the 3 participants. In addition, there was significantly more improvement in attention when the token economy and the medication were combined. The main study conducted by Coelho et al. (2015) being focused on for the purpose of this paper will further analyze the use of cognitive behavioral therapy (CBT) with the Token Economy technique to alleviate problem behaviors for 25 participants with ADHD. Additionally, all the children were on methylphenidate, or Ritalin, medication during the full length of the study.

The sample size consisted of 25 young school-aged children with ADHD with a mean age of 10.11 (SD 1.79) and average IQ 108.20 (SD 12.27). The participants were in a ten-week treatment program which focused on keeping track of the frequency of ten specific behaviors which were reported by the parents and experts as being undesirable: impulsiveness, hyperactivity, disorganization, disobedience, poor self-care, verbal/physical aggression, frustration, compulsive behaviors, antisocial behavior, and lack of initiative and execution. The data was then later analyzed and compared from weeks one and ten. In relation to all the behaviors analyzed, the researchers found that there was in fact significant intervention time effect for seven of the ten behaviors analyzed. For impulsiveness, hyperactivity, disorganization, disobedience, poor self-care, frustration, and antisocial behavior there were significant reductions of their frequency over the 10-week period. See Appendix A.

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Overall the study by Coelho et al. (2015) showed that using a token economy as part cognitive behavioral therapy is extremely effective at diminishing the frequency of undesirable externalizing and internalizing behaviors. As spoken about earlier, the common behaviors associated with an ADHD diagnosis were on the list for the ten specific behaviors being kept tracked of in this study. Specifically, the frequency of inattention, hyperactivity, and impulsivity all decreased significantly in this study. Some limitations of the study were the small sample size and lack of a control group. Although the data is supportive of the use of a token economy for cognitive behavioral therapy, there was no control group that was not taking the medication. This raises the question of how much of a factor could ADHD medication be and also leads to a need for more studies that should examine the effects of a token economy on children with ADHD while they are on medication and a control group that is not on medication.

Sustainability and the Effects of the Removal of a Token Economy

The world economy where people go to work, do their job to earn money and then spend this money for things they want, or need is pretty much identical to what a classroom token economy looks like (Ayllon, T. & Azrin, N, 1968). The money people earn from employment itself isn’t really what they want; it is a means to an end. What people really want is what they can buy with that money because getting money means they get desired items and activities. This is the ideal program generalization where the use of back-up reinforcers can be faded and replaced with reinforcers that are more readily available in the natural environment such as money. The concept of fading is of vital importance for the sustainability of a token economy in the child’s future. As the child becomes increasingly successful in response to the token economy, increasing the desirable behaviors and decreasing the undesirable behaviors, then the fading of the token system can commence. A token economy can be faded by dispensing the tokens in an increasingly random and intermittent fashion and requiring more tokens to access the back-up reinforcers. However, even though a token economy can be successfully faded out, it is important to keep in mind that there may be a time in the future when the student will again benefit from the use of a token economy once again.

There are several factors to keep in mind when it comes to the sustainability of the desired behaviors once the token economy has been successfully faded out and removed. The age of the participant within the token economy is an important variable. For sustainability, children must also learn self-motivation and self-improvement with an additionally basic understanding of what society expects from us. To aid in this process of learning how to self-motive and self-improve, control of the token economy may also be transferred to the student as part of the process (Ayllon, 1999). This can be accomplished by allowing the student the opportunity to do some or all of the following: identify behaviors to target for change, determine how many tokens should be earned, determine when to dispense tokens, and determine when to exchange tokens for the back-up reinforcers. However, younger children might not yet understand the significance of it all and just want the prize and reward here and now. The understanding of life’s consequences along with learning how to self-motivate & self- improve is a vital part of the maintenance and sustainability of the desired behaviors and this might be something that comes a lot easier to older children compared to younger children.

Personal Thoughts and Assessment of Research

Taking into account all the research on token economies and the population at hand, I believe it is best to have a multidimensional approach when it comes to cognitive behavioral therapy for children diagnosed with ADHD. The use of a token economy for CBT has proven very effective at reducing undesirable behaviors and replacing them with desirable behaviors. However, the research looked at shows that this was also accompanied with the use of medication for all 25 of the participants in the respective study. In my personal experience working with children that are diagnosed with ADHD in a token economy system, I believe the multidimensional approach is best. Children diagnosed with ADHD need as much structure around them as possible. This includes the implementation of the token system at school, at home, and if necessary, the addition of medication. However, when having the token economy system in multiple environments, it is crucial that everyone working with the child, including the parents, knows how to keep the consistency of the system. From my personal experience, parent training, knowledge and implementation of the token system is extremely important because home is where the child will spend most of his or her time. Aside from that, it is also important for the simple fact that it allows for the sustainability of the token system and the ease of its eventual fading and removal.

The age variable is something that I believe also plays a much bigger role in the implementation of a token economy for school-aged children. Based on my personal work experience on this topic, I have personally noticed that it is increasingly more difficult for younger children to earn the tokens and back-up reinforcers compared to the older children that I work with. There are many factors to be considered such as medication and brain maturation, but the concept of cause and effect is important. Understanding that our actions and even lack of action are a cause that have an effect is a difficult concept for young children to understand and grasp. There are young adults who seem to have a hard time understanding the concept, so when it comes to young children diagnosed with ADHD it is not easy for them. The use of token economies in a therapeutic application is a relatively new concept and there is still a lot left to be learned and desired. Despite the research indicating its effectiveness, token economies are not currently used as often as they could or should be in educational settings. There needs to be more research conducted on token economies in isolation on children diagnosed with ADHD. Most of the research gathered for the purpose of this paper depicted studies in which other variables such as medication, intervention, and other cognitive behavioral therapies were involved while a token economy was in place. To really understand and drive the future of token economies for therapeutic purposes, more research needs to conducted in the aforementioned area. Although its history is brief, the data showing the effectiveness of token economies is overwhelming and cannot be denied. The future is bright and once more research is conducted and a better understanding is had, the future youth of the world will benefit greatly as a result.

Appendix A

References

• Ayllon, Teodoro. (1999). How to Use Token Economy and Point Systems. 2nd ed. Austin, Texas: Pro-Ed, 1999.
• Ayllon, T. & Azrin, N. (1968). The Token Economy: A Motivational System for Therapy and Rehabilitation. New York: Appleton Century Crofts.
• Boorady, R. (2017). ADHD Medications for Children | ADHD Treatment. Retrieved from https://childmind.org/article/understanding-adhd-medications/
• Coelho, L. F., Barbosa, D. L., Rizzutti, S., Muszkat, M., Bueno, O. F., & Miranda, M. C. (2015). Use of Cognitive Behavioral Therapy and Token Economy to Alleviate Dysfunctional Behavior in Children with Attention-Deficit Hyperactivity Disorder. Frontiers in psychiatry, 6, 167. doi:10.3389/fpsyt.2015.00167
• Filcheck, Holly & Mcneil, Cheryl & Greco, Laurie & S. Bernard, Rebecca. (2004). Using a whole‐class token economy and coaching of teacher skills in a preschool classroom to manage disruptive behavior. Psychology in the Schools. 41. 351 - 361. 10.1002/pits.10168.
• Martin, Garry. Behavior Modification: What It Is and How to Do It. 6th ed. Upper Saddle River, New Jersey: Prentice-Hall, 1999.
• Reitman, D., Hupp, S. D., O’Callaghan, P. M., Gulley, V., & Northup, J. (2001). The Influence of a Token Economy and Methylphenidate on Attentive and Disruptive Behavior during Sports with Adhd-Diagnosed Children. Behavior Modification, 25(2), 305-323. doi:10.1177/0145445501252007
• Rodriguez, J. O., Montesinos, L., & Preciado, J. (2005). A 19th century predecessor of the token economy. Journal of applied behavior analysis, 38(3), 427.
• Tamanini, K. (2016). Setting Up a Behavior Management Plan for an ADHD Child. Psych Central. Retrieved on November 17, 2018, from https://psychcentral.com/lib/setting-up-a-behavior-management-plan-for-an-adhd-child/
• Wilens, T. E., & Spencer, T. J. (2010). Understanding attention-deficit/hyperactivity disorder from childhood to adulthood. Postgraduate medicine, 122(5), 97-109.