The relation of patients' treatment preferences to outcome in a randomized clinical trial

Randomization procedures are performed in order to maximize the internal validity of treatment outcome studies. Objections have been made that this practice undermines the external validity of these studies because it ignores patients' treatment preferences, thereby precluding the self-selection of treatment that can occur in the community. This study used data from a multisite, double-blind, randomized, placebo-controlled trial comparing antidepressant medication to cognitive therapy for moderately to severely depressed outpatients. It compared the treatment outcomes of patients who, via randomization, received their preferred treatment versus those who did not. Although the majority of patients stated a preference for one treatment over the other, there was no significant difference in the magnitude of reduction in symptoms of depression between those who received their treatment of choice versus those who did not. These results do not provide support for the claim that the external validity of randomized controlled trials suffers from this aspect of the randomization procedure.     

Treatment preference, engagement, and clinical improvement in pharmacotherapy versus psychotherapy for depression

Pharmacotherapy and psychotherapy are generally effective treatments for major depressive disorder (MDD); however, research suggests that patient preferences may influence outcomes. We examined the effects of treatment preference on attrition, therapeutic alliance, and change in depressive severity in a longitudinal randomized clinical trial comparing pharmacotherapy and psychotherapy. Prior to randomization, 106 individuals with MDD reported whether they preferred psychotherapy, antidepressant medication, or had no preference. A mismatch between preferred and actual treatment was associated with greater likelihood of attrition, fewer expected visits attended, and a less positive working alliance at session 2. There was a significant indirect effect of preference match on depression outcomes, primarily via effects of attendance. These findings highlight the importance of addressing patient preferences, particularly in regard to patient engagement, in the treatment of MDD.     

Further examination of factors that influence preference for positive versus negative reinforcement

Factors that influence choice between qualitatively different reinforcers (e.g., a food item or a break from work) are important to consider when arranging treatments for problem behavior. Previous findings indicate that children who engage in problem behavior maintained by escape from demands may choose a food item over the functional reinforcer during treatment (DeLeon, Neidert, Anders, & Rodriguez-Catter, 2001; Lalli et al., 1999). However, a number of variables may influence choice between concurrently available forms of reinforcement. An analogue for treatment situations in which positive reinforcement for compliance is in direct competition with negative reinforcement for problem behavior was used in the current study to evaluate several variables that may influence choice. Participants were 5 children who had been diagnosed with developmental disabilities and who engaged in problem behavior maintained by escape from demands. In the first phase, the effects of task preference and schedule of reinforcement on choice between a 30-s break and a high-preference food item were evaluated. The food item was preferred over the break, regardless of the preference level of the task or the reinforcement schedule, for all but 1 participant. In the second phase, the quality of the break was manipulated by combining escape with toys, attention, or both. Only 1 participant showed preference for the enriched break. In the third phase, choice of a medium- or low-preference food item versus the enriched break was evaluated. Three of 4 participants showed preference for the break over the less preferred food item. Results extend previous research by identifying some of the conditions under which individuals who engage in escape-maintained behavior will prefer a food reinforcer over the functional one.     

Cluster randomized trials with treatment noncompliance

Cluster randomized trials (CRTs) have been widely used in field experiments treating a cluster of individuals as the unit of randomization. This study focused particularly on situations where CRTs are accompanied by a common complication, namely, treatment noncompliance or, more generally, intervention nonadherence. In CRTs, compliance may be related not only to individual characteristics but also to the environment of clusters individuals belong to. Therefore, analyses ignoring the connection between compliance and clustering may not provide valid results. Although randomized field experiments often suffer from both noncompliance and clustering of the data, these features have been studied as separate rather than concurrent problems. On the basis of Monte Carlo simulations, this study demonstrated how clustering and noncompliance may affect statistical inferences and how these two complications can be accounted for simultaneously. In particular, the effect of the intervention on individuals who not only were assigned to active intervention but also abided by this intervention assignment (complier average causal effect) was the focus. For estimation of intervention effects considering noncompliance and data clustering, an ML-EM estimation method was employed.     

Effects of Interspersing Additional Brief Math Problems on Student Performance and Perception of Math Assignments: Getting Students to Prefer to Do More Work

Three experiments were conducted to assess the effects of the interspersing procedure on students' mathematics performance, perceptions of mathematics assignments, and preference for mathematics assignments when more work was added. In Experiment I, college students worked computation problems from two assignments. The control assignment contained 15 three-digit by two-digit problems (3 × 2) and the experimental assignments contained 18 3 × 2 problems and 6 additional interspersed one-digit by one-digit problems (1 × 1). Students then rated the assignments and chose one for homework. Results showed significantly more students preferred (i.e., chose it for homework) the experimental assignment with the additional target (i.e., 3 × 2) and interspersed problems. Furthermore, significantly more students rated this experiment as requiring less effort and being less difficult. Moreover, students' mathematics performance was not affected by the procedure. Experiment II strengthened the internal validity by showing that students did not prefer the experimental assignment because it contained more target problems. Experiment III showed that the interspersing procedure was not powerful enough to extend findings beyond the 20% level (i.e., 40 and 60% more conditions). Results showed how the interspersing procedure could be used to encourage students to choose to do more target computation tasks. Discussion focuses on the applied value of the interspersing procedure and plausible causal mechanisms that may account for current and past findings related to student choice and interspersing brief tasks.     

Improving assignment preference through interspersing additional problems: Brief versus easy problems

College students were exposed to a control mathematics assignment containing 16 three-digit by two-digit multiplication (3×2) problems and two experimental assignments that contained 16 equivalent 3×2 problems and six additional interspersed problems. On one experimental assignment, 4-digit plus 4-digit problems (4+4) were interspersed. On the other experimental assignment, 2-digit divided by 1-digit with whole number answers problems (2/1) were interspersed. When given a choice, significantly more students choose the 2/1 assignment over the control and 1+4 assignment. Students also ranked the 2/1 sheet as requiring less time to complete than the control or 4+4 assignment but no differences were found on assignment difficulty rankings between the 4+4 and 2/1 assignments. No differences were found on accuracy levels or rates of responding on the target 3×2 problems across assignments. Results showed that interspersing additional problems that take relatively less time to complete may be more important for altering student preference for assignments than interspersing easier problems. Discussion focuses on schedules of reinforcement and resource efficient procedures for increasing student preference for assignment without compromising curricula integrity.     

Alternatives to Randomized Experiments

ABSTRACT— Randomized experiments are preferred for making inferences about causality when they can be implemented and their assumptions are met. Yet assumptions can fail (e.g., attrition, treatment noncompliance) or randomization may be unethical or infeasible. I describe alternative design and statistical approaches that permit testing causal hypotheses and present current empirical evidence related to alternative designs. Alternative designs permit a wider range of research questions to be answered and permit more direct generalization of causal effects; however, when using such designs, estimates of the magnitude of the causal effect may be more uncertain.     

Reinforcement uncertainty enhances preference for choice in humans

Under concurrent‐chains schedules of reinforcement, participants often prefer situations that allow selection among alternatives (free choice) to situations that do not (forced choice). The present experiment examined the effects of reinforcement probability on choice preferences. Preferences for free versus forced choice were measured under a condition in which participants' choices were always reinforced (reinforcement probability of 1.0) and a condition in which outcomes were uncertain (reinforcement probability of 0.5). Forty‐four college students participated and preferences were examined under a concurrent‐chains schedule of reinforcement. Participants preferred free choice under uncertain reinforcement, but a bias toward free choice was not observed when reinforcement was certain. These results align with previous findings of preference for free choice under conditions of uncertainty, but suggest that preference may be dependent upon probabilistic reinforcement contingencies in the terminal links of the concurrent‐chains arrangement. Thus, reinforcement probability is an important variable to consider when conducting similar studies on the value of choice.     

A pragmatic trial evaluating the effectiveness of web versus live training in functional behavior assessment and interventions among special educators

This study adopted a pragmatic trial with randomization to investigate the relative effectiveness of web versus live training on special educators' competence and perceived skills in functional behavior assessments (FBA) and behavior interventions. Pragmatic trials seek to determine the effectiveness of an intervention in a real-world setting to ensure better application and generalizability in routine practice conditions. The live training group received an in-person workshop delivered in a lecture format via powerpoint slides. The web training group received asynchronous online instruction via a secure website. The same training content was delivered to both groups. Participants were randomly assigned across both instructional modalities and completed two pre- and post-test measures. Results indicated that participants (N = 104) in both groups showed a significant increase in theoretical competence of FBA and behavior interventions post training. Only participants in the live workshop group reported a significant increase in perceived skill scores. When comparing outcomes across groups, the live training group gained significantly more theoretical competence in FBA and behavior interventions than that in the web training group. These results shed light on the practical implications of online platforms for professional development among in-service teachers in behavior management for schools with children having disabilities and challenging behavior.     

Interspersing Additional Brief, Easy Problems to Increase Assignment Preference on Mathematics Reading Problems

We extended previous research on student preference for academic assignments by presenting college students with a control assignment containing eight, two-digit × two-digit + two-digit × two-digit (2 × 2 + 2 × 2) mathematics reading problems and an experimental assignment that contained eight equivalent, 2 × 2 + 2 × 2 problems plus three additional interspersed four-digit + four-digit mathematics reading problems. After spending 9 min 15 s working on each assignment, significantly more students ranked the experimental assignment as being less difficult and requiring less effort to complete. When given a choice between the two assignments for homework, significantly more students chose the experimental assignment. No differences between assignments were found on target problem (i.e., 2 × 2 + 2 × 2) accuracy levels. Results support earlier research that showed how students' preference for assignments could be improved by interspersing additional brief tasks among more time consuming target tasks. In addition to applied implications, theoretical implications related to task completion as a reinforcing event, choice, and relative rates of reinforcement are discussed.     

Effects of response preference on resistance to change

Treatments based on differential reinforcement of alternative behavior, such as functional communication training, are widely used. Research regarding the maintenance of related treatment effects is limited. Nevin and Wacker (2013) provided a conceptual framework, rooted in behavioral momentum theory, for the study of treatment maintenance that addressed two components: (a) reemergence of problem behavior, and (b) continued expression of appropriate behavior. In the few studies on this topic, focus has been on variables impacting the reemergence of problem behavior, with fewer studies evaluating the persistence of appropriate behavior. Given the findings from applied research related to functional communication training, variables related to response topography, such as response preference, may impact this aspect of maintenance. In the current study, the impact of response preference on persistence was evaluated in the context of functional communication training for individuals who did not exhibit problem behavior (Experiment 1) and for individuals with a history of reinforcement for problem behavior (Experiment 2). High‐preferred mands were more persistent than low‐preferred mands. These findings suggest that response related variables, such as response preference, impact response persistence and further suggest that response related variables should be considered when developing interventions such as functional communication training.     

A dual‐system framework to understand preference construction processes in choice

Building on the dual-system theory of judgment, we propose an intuitive and deliberate framework for understanding the effects of preference construction in choice. We argue that while certain choice effects can be attributed primarily to rapid, unintentional, and intuitive processing, others arise from intentional and deliberate processing. We use this distinction to group choice effects previously identified in the literature, discuss evidence in support of the dual-system framework of preference construction, and propose new research directions. Since the defining property of intuitive versus deliberate mental processes is the degree to which they engage working memory, the proposed framework sheds light on how these previously identified effects will change with conditions such as the availability of cognitive resources. We conclude by calling for additional research to explore the interplay between intuitive and deliberate processing to determine which processes are implicated in generating a preference, as well as research on new moderators of choice effects based on the difference in the amount of willful information processing that underlies decision making.     

Dimensions in the perception of architecture: III. Multidimensional preference scaling

Ten subjects were presented with all possible pairs of 20 slides of buildings representing major architectural styles. On seeing each pair, the subject stated which one of the two was preferred and then, on a 7-point scale, by how much it was preferred. Subjects demonstrated considerable agreement in the number of choices for the buildings, but not in degree of preference judgements. The choice data were subjected to an MDPREF analysis, and the degree of preference data to an INDSCAL analysis. In both cases two-dimensional solutions were most appropriate. The locations of the buildings in the two preference spaces were highly similar. They also resemble two of the dimensions important i similarity judgements of the same stimuli. Relations between the preference dimensions and previously obtained verbal and non-verbal responses to the stimuli were discussed. the underlying variables of the preferences responses were suggested to be related to Hedonic Tone/Arousal and Familiarity.     

Causal Models Drive Preference between Drugs that Treat a Focal versus Multiple Symptoms

This research examines the effects of causal beliefs on drug preference. In three studies, 374 undergraduate participants imagined that they suffered from a focal symptom and then indicated their preference between a drug claiming to treat only the focal symptom (single treatment) and a drug claiming to treat the focal symptom and a nonfocal symptom (dual treatment) they thought resulted from a common‐cause or from a different cause. Participants who thought that the symptoms resulted from different causes significantly preferred the single treatment drug more and the dual treatment drug less than participants who thought the symptoms resulted from a common‐cause. Process analysis yielded a significant mediation effect. Specifically, an individual's causal model determines preference by affecting the estimates of the potential gain and loss associated with using each drug. Participants who held a common‐cause model concerning the source of the symptoms thought they would be more likely to need the nonfocal treatment provided by the dual treatment drug and less likely to suffer from side effects when taking this drug, than those with a different‐cause model. The results demonstrate the influence of causal structure on judgment and choice. © 2017 The Authors Journal of Behavioral Decision Making Published by John Wiley & Sons Ltd.     

Causal models frame interpretation of mathematical equations

We offer evidence that people can construe mathematical relations as causal. The studies show that people can select the causal versions of equations and that their selections predict both what they consider most understandable and how they expect variables to influence one another. When asked to write down equations, people have a strong preference for the version that matches their causal model. Causal models serve to structure equations by determining the preferred order of variables: Causes should be on one side of an equality, and a single effect should appear on the other.     

Relative preference for distinct reinforcers maintaining destructive behavior

The literature offers few recommendations for sequencing exposure to treatment conditions with individuals with multiply maintained destructive behavior. Identifying relative preference for the functional reinforcers maintaining destructive behavior may be one means of guiding that decision. The present study presents a preliminary attempt at developing a robust relative preference and reinforcer assessment for individuals with multiply maintained destructive behavior. Guided and free-choice trials were implemented in which participants chose between two multiple-schedule arrangements, each of which programmed signaled periods of isolated reinforcer availability and unavailability. Consistent participant choice and responding during free-choice trials was then used to thin the corresponding schedule of reinforcement. The results demonstrated a strong preference for one of the two functional reinforcers for all four participants, yet preferences differed across participants and were not well predicted by responding in prior analyses.     

Arousal, changeover responses, and preference in concurrent schedules

Pigeons were trained on multiple schedules that provided concurrent reinforcement in each of two components. In Experiment 1, one component consisted of a variable-interval (VI) 40-s schedule presented with a VI 20-s schedule, and the other a VI 40-s schedule presented with a VI 80-s schedule. After extended training, probe tests measured preference between the stimuli associated with the two 40-s schedules. Probe tests replicated the results of Belke (1992) that showed preference for the 40-s schedule that had been paired with the 80-s schedule. In a second condition, the overall reinforcer rate provided by the two components was equated by adding a signaled VI schedule to the component with the lower reinforcer rate. Probe results were unchanged. In Experiment 2, pigeons were trained on alternating concurrent VI 30-s VI 60-s schedules. One schedule provided 2-s access to food and the other provided 6-s access. The larger reinforcer magnitude produced higher response rates and was preferred on probe trials. Rate of changeover responding, however, did not differ as a function of reinforcer magnitude. The present results demonstrate that preference on probe trials is not a simple reflection of the pattern of changeover behavior established during training.     

The acceptability and preference for the psychological treatment of PTSD

The acceptability and preference of psychological treatments is important in understanding patient treatment seeking, choice, engagement and attrition and possibly treatment response in health care. The acceptability of, and preference for, 14 different types of psychological treatment for posttraumatic stress disorder (PTSD) were investigated in a student population through invitation to participate in a web-based survey. Respondents were asked to rate each treatment on 10 scales and to rank the treatments in order of preference. Respondents were also asked whether they would seek treatment themselves, recommend treatment to friends and family, feel stigmatised by suffering from PTSD, had any prior knowledge of the treatments and if this had been positive or negative and whether they had a history of psychological problems or treatment. A total of 330 respondents completed the survey. A past or current history of psychological problems and treatment was surprisingly high. Almost all respondents indicated that they would seek or recommend treatment in spite of high levels of stigmatisation. Factor analysis of the 10 scales indicated two factors: Endorsement and Discomfort. Rank ordering on preference and Endorsement scores was highly consistent. The highly preferred and endorsed treatments involved cognitive therapy, exposure or psycho-education in spite of high levels of discomfort anticipated with exposure. Treatments involving new technologies, EMDR and psychodynamic psychotherapy received the lowest Endorsement and preference. There was a modest influence of prior knowledge of a treatment.     

A replication of preference displacement research in children with autism spectrum disorder

The purpose of this paper was to replicate previous research on preference displacement with edible and leisure stimuli. In the present study, the experimenters evaluated preference displacement in 25 children with autism spectrum disorder using combined multiple stimulus without replacement preference assessments that consisted of highly preferred edible and leisure stimuli. In addition, the experimenters used a block randomization procedure to evaluate if assessment order influenced displacement outcomes. The experimenters observed patterns of complete displacement by edible stimuli for four participants and complete displacement by leisure stimuli for two participants; assessment order did not influence outcomes. The results and implications are discussed.     

A post hoc analysis of multiple‐stimulus preference assessment results

Fifteen individuals with developmental disabilities participated in multiple‐stimulus without replacement preference assessments (seven assessment sessions, seven trials each). Twelve of 15 individuals completed a second set of preference assessments 6 months later. Post hoc analyses indicated that in 25 of 27 cases, the same most preferred stimulus was identified in the first three trials as the full seven trials. Additionally, five sessions of three trials each were sufficient to identify the most highly preferred stimulus in 22 of 27 instances. Copyright © 2002 John Wiley & Sons, Ltd.