The Use of Reinforcer Assessments in Evaluating Psychotropic Medication Effects

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Journal of Developmental andPhysical Disabilities ISSN 1056-263XVolume 24Number 5 J Dev Phys Disabil (2012) 24:515-528DOI 10.1007/s10882-012-9282-4

The Use of Reinforcer Assessments inEvaluating Psychotropic Medication Effects

Gwendolyn Carlson, John Pokrzywinski,Kirstin Uran & Maria Valdovinos

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REVIEW ARTICLE

The Use of Reinforcer Assessments in EvaluatingPsychotropic Medication Effects

Gwendolyn Carlson & John Pokrzywinski &Kirstin Uran & Maria Valdovinos

Published online: 27 April 2012# Springer Science+Business Media, LLC 2012

Abstract Psychotropic medications are increasingly being prescribed for the treatmentof problem behavior, particularly in combination with behavioral interventions. Previ-ous research has demonstrated the motivating operation (MO) effects of psychotropicmedications, which may lead to changes in stimulus preference or changes in themagnitude of reinforcers maintaining the problem behavior under treatment. Althoughpreference and reinforcer assessments have been conducted to examine changes in itempreference and reinforcer effectiveness, there is limited research regarding how medica-tions impact outcomes on these assessments. The purpose of this paper is to demonstratethe need for research on the effects psychotropic medications have on preference andreinforcer assessment outcomes. The implications of these findings are also discussed.

Keywords Reinforcer assessment . Preference assessment . Psychotropicmedications . Motivating operations

Use of Reinforcer Assessments in Evaluating Psychotropic Medication Effects

Reinforcer assessments evaluate the operating strength reinforcers have on thebehaviors that precede them. However, motivating operations (MOs) may influencethe efficacy of reinforcers by causing either an increase or decrease in their effec-tiveness. Medications have been suggested to function as MOs (e.g., Dicesare et al.2005; Northup et al. 1997). If medications can alter the magnitude or value ofreinforcers, conducting reinforcer assessments following changes in medicationwould capture that change and allow for the development and implementation ofeffective behavioral interventions. The purpose of this paper is to demonstrate theneed for future applied investigations utilizing these assessments to determine howmedications may alter reinforcers, which may serve to maintain problem behavior.

J Dev Phys Disabil (2012) 24:515–528DOI 10.1007/s10882-012-9282-4

G. Carlson : K. Uran :M. Valdovinos (*)Drake University, Des Moines, IA, USAe-mail: [email protected]

J. PokrzywinskiWoodward Resource Center, Woodward, IA, USA

Author's personal copy

This will be accomplished by briefly reviewing the literature on preference andreinforcer assessments as it pertains to demonstrating the role of psychotropicmedications as motivating operations.

Brief Review of Preference and Reinforcer Assessments

Research has demonstrated that reinforcement-based interventions are an effective wayto change behavior (Chowdhury and Benson 2011). Two methods for identifying whichstimuli function as reinforcers are preference and reinforcer assessments. Preferenceassessments may present a single stimulus, a pair, or array of stimuli and may assessthe choice of one stimulus over another, the order in which an individual selectsstimuli, or the length of time an individual engages with a stimulus. Based on theresults, choice assessments categorize the stimuli as high, middle, and low preferenceitems and then the reinforcing properties of these stimuli are compared. Althoughresearch has demonstrated that choice assessments, both extended and brief (five-minute), can be used to identify high preference items which consistently function asreinforcers (e.g., Piazza et al. 1996; Roane et al. 1998), the method of preferenceassessment employed may produce different results. For instance, Piazza and col-leagues (1996) found that a force-choice assessment was a more accurate method ofidentifying preferences than single-item presentation. When comparing “multiple-stimulus with replacement” and “free-operant” preference methods of assessment,Kodak and colleagues (2009) determined that the order of selection did not neces-sarily predict potential reinforcing value as some stimuli were selected before othersbut later chosen stimuli were engaged with longer (presumably the more reinforcingstimuli). Based on these findings, it is important that information obtained frompreference assessments be interpreted with caution as preference assessment proce-dures may not always predict that a stimulus will function as a reinforcer.

A second and more reliable method for determining if a stimulus is a reinforcer isto conduct a reinforcer assessment. These assessments are designed to determine howwell an item functions as a reinforcer for a particular individual. In a reinforcerassessment, a developmentally appropriate task for the participant is presented, andreinforcement is delivered contingent upon task completion. Increases in task com-pliance are attributed to the reinforcer delivered relative to other stimuli used andbaseline levels of responding. Once a reinforcer is identified, it can then be used toreinforce positive behavior in a behavioral intervention procedure. For example,Northup (2000) found reinforcer assessments to be more accurate in determiningreinforcer efficacy than reinforcer surveys. Just as with preference assessments, thereare multiple methods employed for conducting reinforcer assessments. Twoapproaches are progressive ratio and concurrent schedules of reinforcement (Jeromeand Sturmey 2008; Taylor et al. 2005).

Progressive Ratio and Concurrent Schedules of Reinforcement Progressive ratio (PR)schedules of reinforcement are used as a means of evaluating the relative strength of areinforcing event without reference to rate of responding (Hodos 1961; Hodos andKalman 1963). The behavior of an organism reinforced on a PR schedule is requiredto systematically increase in number for each successive reinforcer. The rationale for

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a PR schedule is that the break point, a period at which an organism ceases responding,should be a good measure of reinforcer strength. [For a detailed of review of PRschedules, the Summer 2008 issue of the Journal Of Applied Behavior Analysiscontained a collection of studies on progressive-ratio schedules of reinforcement(Francisco et al. 2008; Jerome and Sturmey 2008; Penrod et al. 2008; Roane 2008;Trosclair-Lasserre et al. 2008).] Furthermore, PR schedules of reinforcement havebeen implemented in an effort to increase desired responding. For example, DeLeonet al. (2009) reported that under a PR schedule individuals will produce a greaternumber of responses when a more highly preferred stimulus is delivered as areinforcer, suggesting the items identified in reinforcer and preference assessmentsmay be delivered to increase the rate of desired responding in behavioral interventions.

A second type of reinforcement schedule commonly used in reinforcer assessments isa concurrent schedule. A concurrent schedule of reinforcement involves two or moreschedules of reinforcement operating simultaneously and independently, for two ormore behaviors. When both the concurrent schedules are variable interval schedules, aquantitative relationship, known as the matching law, is found between relative responserates, the two schedules, and the relative reinforcement rates they produce (Sutton et al.2008). This was first observed by Herrnstein (1961, 1970). For a comprehensiveoverview, Catania published several studies in the 1960’s examining the parametersof concurrent schedules of reinforcement (Catania 1961, 1962, 1963a, b).

In addition to being more commonly used in reinforcer assessments compared to PRschedules, concurrent schedules of reinforcement have been used more predominatelyin behavioral interventions as well (e.g., Borrero et al. 2010; Lindauer et al. 2002).Specifically, choice procedures that have utilized concurrent fixed-duration (small)/fixed-duration (large)/progressive-duration delays to reinforcement have previouslybeen useful in promoting self-control for persons with varying disabilities (i.e., Dixonand Falcomata 2004; Dixon and Holcoumb 2000; Dixon et al. 2003; Dixon andTibbetts 2009). Furthermore, concurrent schedules of reinforcement have been shownto provide additional information than is provided from analogue functional analysisalone. For example, in a study by Adelinis et al. (2001) the initial functional analysisresults determined that the problem behavior of a boy with intellectual disability(ID) was maintained by both escape from demands and access to attention. However,subsequent assessments utilizing concurrent schedules of reinforcement (food ornonfood reinforcers paired with appropriate communication or problem behavior)demonstrated that the responding predominately associated with food occurred mostoften, suggesting that concurrent schedules may be a better way to identify the mostefficacious reinforcers when behavior appears to be under the control of multiplereinforcement contingencies. Because reinforcement is often available for more thanone response class, or from more than one source, or both, concurrent schedules ofreinforcement seem to provide a better analog for real-life situations.

Motivating Operations

As previously described, research has explored the way different schedules ofreinforcement can function as motivating operations. Motivating operations (MOs)have two defining effects. They alter (a) the effectiveness of reinforcers or punishers

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(the value-altering effect) and (b) the frequency of operant response classes related tothose consequences (the behavior altering effect). Laraway et al. (2003) present aconceptual scheme useful in identifying and categorizing this important class ofantecedent variables. In terms of function, MOs can be abolishing or establishingoperations. An establishing operation refers to an environmental event that increasesthe effectiveness of a consequence (reinforcer or punisher), whereas abolishingoperations refer to environmental events that reduce the effectiveness of aconsequence.

A variety of stimuli may act as establishing or abolishing operations, including theenvironment within which contingencies exist. For example, individual caregiversand preference for them can function as an MO. Jerome and Sturmey (2008), using aPR schedule, reported that an individual had higher break points when working forpositive social interaction with their preferred staff member than with a non-preferredstaff member. Ringdahl et al. (1997) evaluated relative preferences for stereotypicself-injurious behavior (SIB) and alternative activities. Their results suggested thatthe free-operant preference assessment predicted the efficacy or inefficacy of anenvironmental enrichment procedure and suggested possible treatment alternativeswhen environmental enrichment was ineffective. In this case, the use of environmen-tal enrichment may be viewed as the changing of the MO effects preceding theproblem behavior.

The way establishing and abolishing operations impact response rate is situationspecific and contingency dependent. Deprivation has been found to increase thestrength of stimulus preference, while satiation has been found to have the oppositeeffect (Gottschalk et al. 2000). For example, McGinnis et al. (2010) explored howattention satiation pre-session manipulations, functioned as an abolishing operationand deprivation pre-session manipulations, functioned as an establishing operationimpacting the overall rates of problem behavior in attention conditions of an analoguefunctional analysis. During the deprivation pre-session conditions materials wereabsent and the experimenter did not interact with the participant. In the satiationpre-session condition the experimenter either delivered five-seconds of attention on afixed-time (FT) 120-second schedule or on an FT fifteen- second schedule. Aspredicted the results demonstrated that deprivation pre-session increased problembehavior and satiation pre-session decreased problem behavior during the functionalanalysis.

Whereas some research has explored preference among reinforcers (Penrod et al.2008), there has been little research regarding the variability in preferences andreinforcers, and what factors account for changes in preferences. As noted, bothdeprivation and satiation have differing effects on reinforcer magnitude and avail-ability of certain stimuli prior to behavior intervention sessions may impact theeffectiveness of a reinforcer and cause variability among preferences. This effect alsoholds for preference assessments. For example, Chappell et al. (2009) examined theeffects of a period of free access to preferred items on the results of a preferenceassessment in three individuals with autism. Preference assessments were conductedimmediately or following a ten-minute or a twenty-minute delay after a free accessperiod to the preferred items. For two participants (out of three), access to a preferreditem ten minutes or immediately prior to a preference assessment decreased the prob-ability of selecting the preferred item. This study demonstrates how preferences, and



potentially what stimuli function as reinforcers, are subject to change, thus emphasizingthe need to consider what additional factors may impact these changes.

Practical Implications of Doing Reinforcer and Preference Assessmentsto Determine Motivating Operation Effects

Conducting reinforcer assessments and preference assessments may be useful in supply-ing information regarding the contingencies controlling behavior which might not bereadily identified when conducting analogue functional analysis. For example, Lalli andKates (1998) conducted an analogue functional analysis with three children withdevelopmental delays. Their results suggested that problem behavior, which occurredduring toy play or in presence of an adult, may have had different functions.However, subsequent concurrent-schedule assessments identified preferences be-tween these reinforcers. Lindauer et al. (2002) extended these findings. In their study,an analogue functional analysis was initially conducted to determine the reinforcersmaintaining the problem behavior (SIB and aggression) of a twenty-five-year-oldman diagnosed with profound ID, Lennox Gastaut syndrome, and autism. The resultsindicated that problem behavior was maintained by attention from caregivers and to alesser degree, access to tangible reinforcers. However, subsequent concurrent-schedulesassessments were conducted in which one topography of behavior (aggression or SIB)was paired with one type of reinforcer (tangible or attention) and these pairings wereswitched in subsequent conditions. The results indicated that rates of aggression and SIBdiffered depending on the reinforcer type each was paired with and preference forattention compared to tangible reinforcers varied across conditions.

Additionally, the variability of preference assessments was demonstrated by DeL-eon et al. (1997). They conducted a preference assessment and determined that fooditems were preferred over leisure items. However, when non-food items were pre-sented following adaptive behavior, the rate of adaptive behavior increased, suggest-ing that preference assessment may not always identify all items that may function asreinforcers. Furthermore, recent research suggests that reinforcers may be differen-tially effective as response requirements increase. Extending this line of thought,Roane et al. (2001) conducted reinforcer assessments within a PR schedule and theirresults indicated that one of two stimuli was associated with more responding for allparticipants. These collective findings confirm that variations in reinforcer magnitudeexist and are evident in differential response rates and break points for differentreinforcers.

Mason et al. (1989) demonstrated that daily reinforcer assessments, in whichreinforcer presentation was contingent on correct responding, nearly eliminatedmaladaptive behavior in three children with autism. Additionally, ongoing pre-session preference assessments for different items within reinforcement categoriesimproved assessment accuracy by controlling for satiation and changes over time.This was of particular importance because across 49 pre-session preference assess-ments, children selected the same combination of items across only two consecutivepre-session assessments. Thus, this study demonstrates the utility of ongoing assess-ments and suggests that the passage of time may serve as an MO resulting in changesin preference and reinforcer effectiveness. Adding to this research was extended by



DeLeon et al. (2001) reported that preferences can change from day-to-day andthat changes in stimuli preference were generally associated with correspondingchanges in response allocation.

These studies collectively support that satiation, deprivation, or time affect anindividual's reinforcement preferences. Changes in preferences may reflect a changein contextual variables, reinforcement magnitude, or the number of responses requiredfor reinforcement. Although MOs can be controlled and manipulated experimentallyas in analogue functional analyses (McGinnis et al. 2010), there is tremendousvariability inherent to the natural environment. One potential source of variability ispsychotropic medication.

Demonstrations of Psychotropic Medication as Motivating Operations

Research has demonstrated that psychotropic medications can change the reinforcingor punishing value of stimuli. For example, Northup et al. (1997) discovered that astimulant drug can serve as an MO. Prior to medication administration, tokensredeemable for food functioned as reinforcers; however, when children were admin-istered a stimulant, those same tokens no longer functioned as effective reinforcers.Psychotropic medications often have the potential for various side effects, therebyproviding one method by which their administration may serve as MO’s. By con-ducting reinforcer assessments when medication changes occur, one should be able tomonitor the effects of medication on reinforcers (and by extension develop moreeffective behavioral interventions).

Basic research has elucidated how neurotransmitters can mediate the reinforcingqualities of stimuli and how their release can further serve as reinforcers themselvesas in the case of dopaminergic activity in the nucleus accumbens. For example,Couppis and Kennedy (2008) found that when mice were required to perform anoperant task (nose pokes) to gain access to another mouse in which then aggressionensued, mice engaged in high rates of nose poking. However, when a dopamineantagonist was administered, rates of nose poking decreased in a dose-dependentfashion (movement was not impacted so decreases in nose poking were not attributedto an inability to engage in the response). This finding suggests that psychotropicdrugs, brain activity, and behavior function are interrelated.

To determine the impact that psychotropic drugs have on behavior, basic researchemploys various schedules of reinforcement (e.g., differential reinforcement of lowrates, interval and ratio schedules). Research has demonstrated that various drugclasses can differentially impact behavior, however, even within the same class ofmedication, disparate effects on responding can also be observed. For example,Varvel and colleagues (2002) examined the impact of acute dosing of several typicaland atypical antipsychotics (e.g., haloperidol, risperidone, olanzapine, clozapine,thioridazine) on responding within fixed ratio and interval schedules. They foundthat these drugs produced dose-dependent decreases in responding while increasingresponse duration with the exception of haloperidol (typical antipsychotic) andrisperidone (atypical antipsychotic). What accounts for these contrasting effects isunclear. Nonetheless, even within the applied literature, varied effects of medicationon behavior are also observed.



In one of the first studies conducted, Garcia and Smith (1999) found that eventhough topographies of behavior may be similar (in this study SIB was targeted), thefunction of behavior may influence therapeutic response. Using analogue functionalanalysis as a means to assess behavior function and the relative impact of naltrexone,their results revealed differential responses to naltrexone which, interestingly, werenot the same for each participant. For one participant her SIB decreased afternaltrexone administration in the alone condition of an analogue functional analysis.However, for their other participant, naltrexone only decreased SIB in the demandcondition of an analogue functional analysis.

Although differential patterns of responding to psychotropic medication havecontinued to be reported across individuals, some general response patterns tomedication classes have been reported across studies as well, specifically the abolish-ing effects of antipsychotic and stimulant medication. For example, Crosland et al.(2003) conducted an analogue functional analysis and reported decreases in rate ofbehavior during the demand condition of the assessment for participants when onrisperidone while rates remained elevated in other conditions. Furthermore, results byZarcone and colleagues (2004) revealed that problem behaviors maintained bynegative reinforcement were more likely to decrease when participants were onrisperidone than placebo rather than problem behaviors maintained by positivereinforcement. Thus, risperidone use seems to function as an abolishing operation(i.e., demands were less aversive as stimulus events).

Through a series of studies Northup and colleagues determined that stimulantmedications can also serve as abolishing operations as well as establishing operations.For example, Northup et al. (1999) found that peer attention functioned as a reinforcerfor children with Attention Deficit Hyperactivity Disorder (ADHD) when on placebobut not while on methylphenidate. Conversely, in another study, Northup et al. (1997)found that tokens delivered for engagement in activities increased in reinforcing valueor became reinforcing when children were given methylphenidate rather than whengiven placebo. Hence, methylphenidate appears to function to abolish the reinforcingproperties of certain consequences or can alter reinforcer magnitude and establishsome consequences as reinforcers. Additional research has provided more evidencefor these effects. For example, Dicesare et al. (2005) found that attention served as areinforcer for disruptive behavior of an eighteen year-old male when methylphenidatewas taken but did not serve as a reinforcer when methylphenidate was not taken.Collectively, these findings suggest that stimulants may alter the reinforcing value ofsocial positive reinforcement.

Antidepressants are another psychotropic medication class prescribed to individ-uals with intellectual disabilities to treat problem behavior (Zubieta and Alessi (1993)suggested that problem behavior may result from serotonin dysregulation). Luiselli etal. (2001) reported the effects of sertraline, a selective serotonin reuptake inhibitor(SSRI), and clomipramine, a tricyclic antidepressant (TCA), on the rate of problembehavior of two individuals with ID. In one individual, a lower dose of sertraline wasassociated with an initial decrease in the rate of SIB followed by an increase in rate atthe same dose. At a higher dose of sertraline, the rate of SIB decreased dramaticallyand was maintained at a lower rate for over 6 months. In the second individual,clomipramine was associated with a decrease in rate of aggression and progressiveincreases in medication dose were associated with an increase in rate of aggression.



Although this study demonstrates that varied doses of different classes of antidepres-sants may decrease problem behavior for individuals, few studies have described theeffects of antidepressants on reinforcement contingencies. Marshall et al. (2003)described the effects of venlafaxine, a serotonin-norepinephrine reuptake inhibitor(SNRI), and the atypical antipsychotic olanzapine on negatively reinforced aggres-sion in a teenage female with autism. It appeared that when she was receiving bothvenlafaxine and olanzapine she engaged in increased rates of high intensity aggres-sion (e.g. punching, head-butting, or biting) compared to when she was receivingolanzapine alone in demand conditions. These results suggest that SNRIs mayestablish some stimuli as more aversive and subsequently the escape of these stimulias more reinforcing. Clearly more research is needed in this area.

Finally, although not as tightly controlled with regard to drug use, Valdovinos andcolleagues (2007, 2009) have evaluated the effects that medication changes have onthe rate of behavior problems observed within analogue functional analyses. InValdovinos et al. (2007), the discontinuation of a drug (quetiapine, an atypicalantipsychotic) was associated with a decrease in the rate of aggression withinanalogue functional analysis but not SIB. However, in Valdovinos et al. (2009)multiple medication changes were observed to alter problem behavior and the con-ditions within which it occurred. This study presented the results of analoguefunctional analyses for three individuals diagnosed with autism as each of theseindividuals experienced multiple medication changes. For all of the individuals therate of and conditions within which problem behavior occurred was different aftereach medication alteration. The results of these two studies suggest that any changesin medication may function as MOs subsequently producing changes in the condi-tions under which problem behaviors are likely to occur.

While, the studies reviewed suggest that psychotropic medication can have dis-criminate effects on both the conditions under which problem behavior occurs as wellas the topography of behavior affected, there are a limited number of studiesexploring the impact of psychotropic medication on behavioral interventions thatincorporate reinforcer assessments. Given that the basic literature has yieldedconflicting results on the impact of psychotropic drugs on behavior, the need forfurther characterizing the effects of medication in applied settings becomes evenclearer.

Evaluating Psychotropic Medication Effects on Reinforcer Value

Progressive ratio schedules are commonly used in psychopharmacological research toevaluate the reinforcing efficacy of different drugs or dosages (cf. Stafford et al. 1998,for a review). However, these procedures have yet to be applied to the study oftherapeutic effects of pharmacological interventions in applied settings (see theJournal of Applied Behavior Analysis, 2008). Roane (2008) recommends that PRschedules be used to assess response to pharmacological interventions for behaviordisorders, such as response stability across different medications or doses. Certainly,there is a need for research in this area. Chelonis et al. (2011) conducted PR reinforcerassessments with children diagnosed with ADHD (the task involved a lever pressreinforced by delivery of nickels). Results showed that while receiving



methylphenidate, children’s responses reached higher break points. Additionally, whilereceiving methylphenidate, decreased mean interrepsonse times (IRT) were observed.However, methylphenidate did not appear to alter postreinforcement pause duration.

Much of the research conducted on problem behavior reduction via behavioralinterventions involve participants who are concurrently receiving psychotropic med-ications to treat the same behaviors (e.g., Day et al. 1994; Langdon et al. 2008). It isnot surprising then, that researchers want to determine the impact that these medi-cations have on reinforcers maintaining the problem behavior. Kelley et al. (2006)conducted a paired-choice reinforcer assessment for an eleven year-old boy withADHD and moderate ID. Reinforcers were presented contingent on either problembehavior (aggression, disruption, spitting, and SIB) or compliant behavior (initiationof task following a demand and completion of task). The participant also receivedeither stimulant medication, 20 mg of dextroamphetamine (Adderall), or placebo in adouble-blind fashion. Results revealed that problem behavior occurred at higher rateswhen on placebo; whereas problem behavior occurred at lower rates and compliantbehavior occurred at higher rates when on medication.

Mace et al. (2009) evaluated the evocative effects of stimulant medication in asixteen year-old boy diagnosed with ADHD and moderate ID under high and lowattention conditions and during high and low preference activities. All problembehavior (inappropriate touching, rude behaviors, and physical aggression) decreasedwhile the child was on stimulant medication; however, problem behaviors stillremained at unacceptably high levels during the divided attention condition. Thedifferential effect of stimulant medication on social reinforcer value has also beendemonstrated across participants. Conducting a reinforcer assessment with variousplay coupons (social play, alone play, or quiet time), LaRue et al. (2008) reported thatstimulant medication altered the reinforcing magnitude of coupons for some partic-ipants. Specifically one dose of methylphenidate (54 mg) appeared to decrease thevalue of social play while increasing the value of alone play for one participant, whilelower doses for this same participant had the opposite effect.

Other research, however, has found that stimulant medication (various doses ofmethylphenidate) had little impact on the rate of responding when different dimen-sions of reinforcement (i.e., immediacy, rate, quality, and response effort) werealtered (Neef et al. 2005a). The assessment involved directly comparing the effectsof reinforcer dimension manipulations (e.g., immediacy versus response effort) onimpulsivity. Reinforcer immediacy was the second most influential dimension for oneindividual and most influential dimension for the other three individuals across bothplacebo and medication conditions. Neef et al. (2005b) also found immediacy to bean influential reinforcement dimension for all participants diagnosed with ADHD,both those receiving stimulant medications (methylphenidate, amphetamine salts, ord-amphetamine) and those not receiving stimulant medications, suggesting stimulantmedications have little impact on impulsivity. These results are inconsistent with thefindings of Mace et al. (2009) and Kelley et al. (2006), suggesting that more researchis needed to evaluate the potential MO effects medications may have on the relativevalue of reinforcers.

Overall, the observed effects of stimulants on reinforcer value suggest that stimu-lants have differential effects across individuals, topographies of behavior, andmedication doses. Specifically, stimulant medications have been consistently reported



to impact the value of social reinforcers, functioning as both establishing andabolishing operations depending on the individual and doses of medication.

Conclusion

Although full and brief preference assessments have been shown to identify preferreditems (e.g., Lanner et al. 2009; Roane et al. 1998), reinforcer assessments have beenshown to be a more accurate method for identifying reinforcers (Northup 2000).Furthermore, reinforcer assessments have been shown to provide additional informa-tion about reinforcers than what may be learned from analogue function analysisalone (Lindauer et al. 2002). Nonetheless, both preference and reinforcer assessmentsare used to develop behavioral interventions that successfully reduce problem behav-ior. For example, Lee et al. (2010) conducted both preference and reinforcer assess-ments. Preferred items were found to also be the most reinforcing items. Interestingly,the lesser preferred items also functioned to reinforce behavior for some of theparticipants as well.

Psychotropic medication is increasingly being used to decrease problem behaviorand often in combination with behavioral interventions (Weeden et al. 2009). Withthis increase in use, it becomes even more pertinent to consider how psychotropicmedications may facilitate or inhibit the effectiveness of behavioral interventions andvice versa (Sevin et al. 2001). Although the MO effects of psychotropic medicationsare well documented, there is limited research regarding how medications impactoutcomes on reinforcer or preference assessments. The results of analogue functionalanalyses conducted before and after medication changes suggest that medication maychange the conditions under which behavior occurs by altering the reinforcingmagnitude of stimuli (Valdovinos et al. 2009).

As already reviewed, the effects of antipsychotics on reinforcement contingencieshave been examined via analogue functional analysis of problem behavior (Croslandet al. 2003; Zarcone et al. 2004), however, little research has examined how anti-psychotics alter reinforcer value using reinforcer or preference assessments. Thelimited research examining the effects of psychotropic medication using reinforcerassessments has predominately focused on stimulant medications. This research mustbe extended to other medication classes as antidepressants, anxiolytics, and moodstabilizers are other commonly prescribed psychotropic medications for people withID exhibiting problem behavior (e.g. Lott et al. 2004).

Another point to consider is that any perceived changes in reinforcer valueattributed to medication use may be subject to the influence of time (Mason et al.1989). As discussed, Mason and colleagues (1989) demonstrated that conductingdaily reinforcer assessments, in which the identified reinforcers were deliveredfollowing correct responding, nearly eliminated maladaptive behavior and also im-proved accuracy. This was accomplished by controlling for MO effects of which thepassage of time may be one. Consideration of the role of the passage of time is ofparticular importance when individuals are experiencing changes in psychotropicmedication (changes in medication class or dose or the discontinuation of medica-tion), as there is evidence that this may impact the function of behavior as well as theresponse rate to gain access to certain reinforcers (Valdovinos et al. 2007, 2009).



Given that similar topographies of behavior may have different functions, researchneeds to evaluate if some medications should be prescribed based on function/topography presentation rather than solely function or topography. Furthermore, wemay be looking at this backwards, it may be that there is some idiosyncratic nature ofreinforcer value for some individuals (i.e., people may experience temporal changesin what they find reinforcing due to other setting events) which then predicts howefficacious a medication will be for that individual. For example, if peer attentionfunctions as a stronger reinforcer at school versus at home, perhaps the effects ofstimulant medication should be evaluated with respect to peer attention and thedecision to use stimulants should be based, in part, on the outcomes of this reinforcerassessment.

Admittedly, we are posing empirical questions in this paper that need to be addressed.Progressive ratio or concurrent schedules may help to identify those potential changes inreinforcer effectiveness that may follow administration, or changes in, medications. Inlieu of evidence, we propose that any medication change should be considered apotential MO with either establishing or abolishing effects. These MOs could be theresult of the intended or unintended pharmacological effects, and in turn affect thereinforcing properties or effectiveness of any chosen behavioral intervention. Thus, themost efficacious behavioral interventions should not only include routine reinforcer(ideally) or preference assessments in addition to routine functional assessments butthese assessments should also be conducted after medication changes.

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The Use of Reinforcer Assessments in Evaluating Psychotropic Medication Effects