I. Out-of-Session Behavioral Change
Working with ADHD or oppositional children, do you work out a behavior management regime and send clients home to work the protocol?
Or do you develop the regime collaboratively and then practice it in-session? Let’s take a look at these two strategies.
Let’s assume the therapist helps the family work out a new, well-crafted behavior therapy contingency program to change a child’s behavior. You also include cognitive-behavioral strategies in the program.
You recognize the internal and external problems in the child’s world. Internally, the child is poor at self-monitoring of behavior. The child is self-critical (negative self-statements) after disappointing parents or poor performance in school. The child seldom gives positive self-reinforcement. Working memory is poor. Other executive functions, such as attention and emotional self-control are impaired.
In the environment, the child is deficient in positive reinforcement. Parents and teachers call the child out for poor performance, so the child receives and internalizes criticism. The result is low self-efficacy.
You might include these elements in a well-crafted contingency program.
- You worked with the family to define a clearly-stated, simple, specific statement of the desired behavior. The behaviors are measurable and are achievable within the capacities of this child.
- The behavior can be quantified – its frequency and/or duration.
We will be working with the example of completing homework, which can have a frequency, such as, the child does homework right after school 5 days a week, and a duration, such as, the child does the homework until it is completed or at least works for one hour.
- We determined the baseline – how much of the behavior is happening now.
For example, at present, the child completes homework about once per week. Most often the child forgets to bring home materials, does not know the assignments, or claims there is no homework. Through the principle of negative reinforcement, forgetting and misleading parents leads to relief of anxiety over poor performance or avoidance of conflict. So those dysfunctional behaviors increase. When parent and child work on the homework, it is usually after dinner when the child’s medication is ebbing and when both are fatigued. A ‘battle’ often ensues in which both are frustrated. The evening ends with shouting and frustration. The parents rate the intensity of these conflicts at an 8 on a 0-10 scale. The battle may lead to abandoning the process; that reinforces further ineffectiveness. Then, even if the child completed all or part of the homework, the child turns it in the next day only half the time. He or she might claim to have lost it or simply to have forgotten. That behavior is negatively reinforced. So, the baseline is that homework is done to completion and turned in the next day once per week or less on average.
- We determined a short-term goal – how much of the change to expect soon, and a longer-term goal – the ultimate standard for the behavior.
In this example, the desired behavior is completion of the homework before dinner and the parent-child interaction is conflict-free. For a short-term standard, the first week the child will complete the homework before dinner three times a week. When that target is met for four weeks, we move to the long-term target of five times per week. This outcome is doable; the child AND the family are capable of executing the goal. If the child can do the homework once or twice per week, then he or she is capable of more. Let’s assume the family is capable of taking part in changes to their routines.
- We determined an immediate positive reinforcement, which is preferred by the child and has a likelihood of increasing the performance of the behavior.
- We determined a short-term positive reinforcement, which the child receives after meeting a reasonable standard of performance (e.g., completion of homework before dinner three days out of five).
- We might set a long-term positive reinforcement. For instance, the child receives a credit (i.e., points or tokens) toward that reinforcement for each day the homework is completed before dinner and turned in the next day.
- We determined a double response cost, the loss of the immediate reinforcement and the loss of an existing privilege (e.g., use of a game, access to television, use of a cell phone, texting privileges, loss of points in a token economy).
- We help the parents to develop prompts to remind the child of the expected behavior.
- We help the parents to develop cues, which will signal the child to stay focused on the behavior.
- Thinking further out, we might build into the contingency a way to fade the reinforcements so that the child eventually performs the behavior without continuous reinforcement. We have three goals here. 1) We shift to intermittent reinforcement so that the behavior is more resistant to extinction. 2) We also want eventually for the child and the parents to achieve self-efficacy, namely, a belief in his or her ability and skills for accomplishing tasks and responsibilities. 3) We want to highlight and strengthen the self-regulatory, self-control, and self-monitoring skills needed for this goal so they can eventually be independent skills.
In this example, after completing the homework and showing it to a parent, the child earns praise, high fives, hugs (in contrast to all that conflict), and an hour of television viewing of the child’s choice. When the criterion of three times per week is achieved, the child earns an activity of choice with father on the weekend. If the child does not complete the homework before dinner or if the child expresses frustration in the form of hostile behavior, throwing pencils, or rejection of the work, the day’s television watching is withdrawn.
In addition, the child loses some previously earned credits toward the long-term reinforcement. The family agrees that each day the homework is done according to the agreement the child receives one point. After 15 points within 4 weeks, the child can select a video game to be purchased. The cost for not doing the behavior is the loss of a previously earned point.
So the child has much to lose as well as much to gain. The desired outcome has more salience than the old behaviors of avoidance, dramatic expression of frustration, misleading, and forgetting.
After the child earns 15 points in 4 weeks or less, the criterion will be increased to 20 points in 4 weeks which means the child is doing the homework daily.
Each morning, one of the parents prompts the child to repeat the contingency and reminds the child to complete the homework right after school. The child re-states the expected behavior and the entire protocol. During the doing of the homework, a parent cues the child to stay focused, to work steadily, to save the hardest problems so parent and child can go over those together. The person doing the prompts can prompt himself or herself as well, remembering that all this will be accomplished without conflict, yelling, or frustration, but rather peacefully. Usually, the homework will be done with a parent in the same room issuing encouragement and reinforcing focused attention repeatedly while the child works.
- Later, we consider how to generalize the behavior (e.g., perform other responsibilities at the first opportunity and to completion) and to bring in intrinsic reinforcers.
- To extend the gains and to internalize the protocol as a set of skills, we add cognitive strategies. 1) Self-reinforcement – Every time the child succeeds in earning positive reinforcement, he or she is prompted to verbalize a positive self-reinforcement, such as, “I did a good job three days in a row.” “I am pleased with my success on the homework today.” “I earned a special treat today.” To strengthen this cognitive skill, a parent can agree or even amplify the statement. When the child self-reinforces with some consistency, this skill itself can be the focus of external and internal reinforcement. 2) Self-monitoring – Since ADHD children may not be keen observers of behavior, we could ask the child to rate the quality or accuracy of the homework and to compare to an adult’s evaluation. This is rated on a 0-10 scale. If the two scores are within a point of one another, the child can receive an extra positive reinforcement. The child needs to learn accurate observation and evaluation of self.
So, now the family has a system for changing the behavior.
Assuming the program is well-crafted, how is it taught to the family?
Most of the time, therapists tell the family the details they have all agreed upon or the therapist writes out the details. The family is expected to go home and to execute the program.
These six questions focus on some problems with this approach.
1. Are you certain the family remembers and understands the details? What training did the therapist use to make sure the family understands? Most often, they did not take Psych 101 and did not learn all these principles. A contingency protocol may make a lot of sense to the therapist. But its tenets may make little sense to the family. How well did you explain it?
2. Are you certain the family committed to the protocol? What motivational interviewing and behavioral training was used to make sure the family is committed and determined? Often, the family appears to be committed, but other problems interfere.
A. The family may be driven by a belief in punishment and criticism as the way to increase compliance. We see this approach in an overwhelming percentage of families with behavior-disordered children. But punishment does not work well with behavior disorders; it is often as if gasoline were added to fire! It also encourages the child to act to reduce the punishment, to learn the skills for doing that rather than to master the desired behaviors.
B. Furthermore, one of the parents may have a history of AD/HD or behavioral problems. That parent may have difficulty following through. Often, that parent will rationalize the child’s problems, saying, “I was just like that at his age.”
C. Or the parents may disagree on the means to achieve the desired behavior. One may favor strong punishments. The other may prefer a softer approach. The child may see these differences as the parents negating one another; that leaves a power vacuum. This is a common constellation in behavior disorders.
D. Often, one or both parents play hardball and then relent. In a pique, the parent issues a harsh punishment. Later, the parent withdraws it or allows the child a privilege that negates the punishment. For the child, this is an indicator that punishment can be avoided.
E. Many families have become high in emotional reactivity. Frustrations, helplessness, and ineffectiveness have left them with hair-triggers for negative, conflictual, critical, or punitive responses. They escalate the emotional climate. But a child with behavior problems becomes dis-regulated; he or she is unable to focus on goals and self-control at that point.
F. Lastly, some families adamantly refuse to reward the child for improving or for achieving a desired behavior. These families view high-level performance as the child’s responsibility. Responsibilities are performed because one has to perform them. Rewards do not enter into it.
So, we repeat the question. Are you certain the family remembers and understands the details and also commits to the protocol? Do they demonstrate treatment acceptability – the treatment seems reasonable, appropriate, and within the family’s frame of reference.
3. Do you measure how often families complete the assignment? Notice the question is not how often the child completes it. The locus of intervention in most treatment for behavior disorders is the family. From the discussion in question #2, we see that the family may have various reasons – beliefs, knowledge, skills, ambivalence – for not carrying out the assignment adequately.
4. Does the family complete the program as outlined? The protocol contains all the elements we know are necessary and sufficient to produce improvement. Deviation from the protocol could undermine its success.
5. Do you observe them carrying it out? Do you know the fidelity of the family’s performance? Given questions #1-4, it’s surprising that therapists tell rather than show families how to carry out the protocol. Too much can and will go wrong. The gist of this paper is that it is more effective to show and coach rather than to tell.
6. Do you ask the child to repeat the program until he or she has it memorized reliably? Unless the protocol is uppermost in the child’s mind, how will the child remember it?
We assume much when we expect the child to be able to achieve the desired behavior.
- The child is physically and intellectually able to complete it.
- The child has sufficient attachment to the adults such that their interests and the rewards and costs matter to the child.
- The child recalls the protocol easily.
- The child has the self-control, restraint, inhibition, judgment of consequences, and foresight to remember what will happen when the goal behavior is not performed.
- The desired behaviors, such as the homework protocol in our example, are often complex, requiring multiple steps, materials, family cooperation, and, often, teacher input. Often, families want to change behaviors, which involve too many steps or complexities for a given child. So, the child has to perform a sequence of behaviors, remembering the importance of each one. Often, we have to start with more basic skills and behaviors than the ones the family wants changed most immediately.
- When the child is emotional or dis-regulated, the child must remember the protocol and must activate the inhibitions and self-controls that are implicitly built into the protocol.
Indeed, we are assuming a lot!
I suggest that when we send the family home to carry out such a complicated protocol, which we have not rehearsed, we lower the probability of the program working.
II. In-Session Change versus Out-of-Session Change
Advantages. The example above is one in which the performance of the change takes place entirely outside of the consulting room. We are assuming two complex sets of behavior. 1) The family can remember and carry out the protocol. 2) The child will remember and carry it out.
When therapists assign homework, they check how it went. So, if the child does not improve in the completion of homework, the therapist wants to determine if the problem lies in the protocol or in how the family executed it. Then the therapist problems-solves with the family to determine what could be improved.
This is inefficient. The likelihood is something will go wrong and the therapist will help correct it. A few sessions can pass while the family becomes more proficient.
On the other hand, the therapist could co-create the entire contingency in the session with the family. Doing so has the advantage of ensuring the family knows the protocol, the child has memorized it, the family can execute it faithfully, and the family has practiced it. In addition, the family experiences shaping of effective patterns. That is, the therapist shapes the behavior of all the family members until each is carrying out his or her role in the protocol.
Below is an example of in-session change. The first line of in-session therapeutic change is to observe and to coach the family in the effective creation of the protocol. Then the family learns to use the prompts and cues and to deliver the reinforcements.
Practice makes perfect. When we use in-session change, we get to observe how the family negotiates developing the contingency. The therapist also gets to observe how the family carries it out. The therapist is constantly reinforcing successive approximations to the improved behavior – the parents for skills in developing and using the contingencies and the child for learning it. High fives all around!
When we strive for in-session change, the therapist prospectively corrects the family’s negotiation of the steps in the protocol. The therapist prospectively corrects the family’s execution of the protocol.
Enactment. In Minuchin’s Structural Family Therapy, enactment is a technique of asking the family to perform a task that causes them difficulty and recapitulates the system’s problem. The therapist coaches or intervenes in order to produce immediate in-session improvement.
For in-session application of a contingency protocol, the therapist sets up an enactment. We get to see how the family ‘enacts’ the common errors and to see what strengths may be present. The enactment for a family with an ADHD child could begin with “Tell your child what the rule is for the change you want.” We could say, “Let’s see what happens at home. Your child could behave better right now. Instruct your child on what to do.” From there, we observe how the family members interact and we coach them to be more effective. The changes are produced in the session.
Common Errors. Experience shows families make a variety of predictable mistakes in developing the protocol and in carrying it out. These mistakes are endemic to the problems the family is having! Why should we expect anything else.
Here are some of the most common mistakes we observe in session.
- Asking rather than telling the child what the behavior change must be
- Using too many words so the child has trouble attending and processing the instructions
- Failing to make sure the child is attending
- Striving to change too many behaviors all at once
- Pleading with the child rather than telling the child the expected behavior in specific terms
- Choosing reinforcements which are not strongly desirable to the child
- Choosing reinforcements which are too far in the future or require too much behavior on the part of the child before reinforcement is given
- Failing to check if the child knows the protocol
- Expecting the contingencies to work without prompts and cues
- Giving up without making sure the protocol is being properly executed for a long enough period of time
- Failing to reduce emotional reactivity
Other Advantages of In-Session Change. The therapist not only gets to observe and to correct these mistakes, in addition, the therapist gives a large amount of positive reinforcement and encouragement to the family for effectively negotiating and practicing the protocol in the session.
The therapist gets to ensure the behavior will be under the control of positive reinforcement rather than negative reinforcement and avoidance.
One more step is essential to in-session change. Namely, the therapist generalizes the protocol from the session to the home environment. We do this by two strategies. First, we ask the family to imagine going through their environment and their routine and to tell where the protocol will fit in. Where in the residence will they carry it out? Which parent will be responsible for the prompts? How will the television, phone, video game, or other reinforcers be controlled? What time will the child be given medication? What times will the child be given prompts?
Second, we ask the parents and the child separately to rate the level of confidence each has that they will be successful. We could use 1-10, A-B-C-D-F, or percentages. The object is to get a level, then problem-solve in advance any doubts they may have.
Therapist: (Arranges a chair facing mother so Johnny and mother face one another with their feet about 12″ apart.) Johnny, sit over here facing your mother. (Johnny comes over to the chair the therapist has arranged.) Great. Good work complying right away. (High five) Now, Abby, tell your son exactly what behavior you want him to do. (Johnny shifts in the chair, facing away from mother.)
Abby: I want you to get your homework done every night.
T: Do you have his attention?
A: No. Johnny, look at me. (Johnny faces mother.)
T: Good complying, the first time, too.
A. I want you to get your homework done every night.
T: You want him to? Or he has to?
A. He has to.
T: Say it that way.
A. You will do your homework every night.
T: Just a minute. Have you said this before?
A: Yes. And it didn’t work.
T: Okay. Does he bring all of the assignments home and remember them?
T: Johnny, do you write down all the assignments?
J: I try to remember.
T: You try? So you don’t remember them all? Abby, we may have to change the desired behavior to writing down all the assignments, bringing home all the materials, and getting all the homework done by a certain time.
A: I agree. Johnny, you write down all your assignments in your notebook and you get all the assignments done. Okay?
T: Whoa. ‘Okay?’ That implies he has a choice. Does he? (She shakes her head.) Try again.
A: Johnny, you write down all your assignments in your notebook and you get all the assignments done.
T: Better. But that leaves room for doing the work late at night or even ‘forgetting’ and then having a little panic in the morning as you have mentioned. Try again.
A: Johnny, you write down all your assignments in your notebook and you get all the assignments done before dinner. And without shouting.
T: Much better. Johnny, what’s the rule?
J: I wasn’t listening. Do my work?
T: Abby, please get his attention and say it again. (She does.) Johnny, please repeat that.
J: Write down all my assignments and get them all done.
J: Before dinner.
T: Great. Please say the whole thing.
J: Write down all my assignments and get the work done before dinner.
T: (High five) Did you do a good job of remembering?
T: Repeat the rule. (J does.) Abby, if he did well, ask him to complement himself.
A: You did it just right. Give yourself an atta-boy.
J: I did it. I know the rule. (Self-reinforcement)
A. Very good. (High five) Now I also want you to do your chores and clean your room.
T: If you try to change too many things at once, Johnny will have a hard time succeeding and could get discouraged. Then you may think the program is not working. Let’s stick to one behavior at a time.
A: There are so many things I want him to do!
T: You have a lot of important changes that you want. And need. Absolutely. It can be frustrating to have problems for such a long time. But his working memory is poor and asking him to hold onto too many changes is likely to cause some disappointments. Do you suppose if we succeed at this system for the homework, we could apply it to other behaviors one at a time?
A: Okay. I guess what I have done isn’t working. So let’s try this.
T: Good thinking. Now let’s decide on what will happen when Johnny writes down his homework assignments and does his homework before dinner. Johnny, you’ve been really hearing what Mom is saying today. When you finish your homework before dinner, what would make you feel very pleased, like a reward?
J: A treat.
T: Abby, a treat? Is that an okay positive?
A: He could have dessert.
T: So no dessert with or after dinner unless it’s done, a dessert if it’s done?
J: (Smiling) That’s what I want.
T: Abby, do we have to discuss what desserts? (J lists several.) Good choosing. Let’s picture the homework done three times out of five. What could happen on the weekend?
T: Abby, could you hold off any pizza except on the weekend he meets this standard?
T: Every day he gets dessert, he gets a point. Let’s say he gets 15 points. What would you like to earn?
J: I know. I want a game for my xbox.
A: Sure. That works.
T: So before, he got dessert, pizza, and games without earning them. No more. Johnny, repeat the rule and all the things that happen when you get it all done right.
J: (Has trouble starting. T says it’s something about before dinner.) Oh, yeah. I’ll do my homework after school. (Notice the working memory problem – missing elements to the rule.)
T: Abby, is there more?
A: How do we know you brought home all the homework?
J: Oh, I will write down all the work and do it all before dinner. Then I get dessert, right?
T: What else?
T: Abby, please state the entire rule.
A: You write down all the assignments. Then you do all the homework right after school. You finish before dinner. Without getting loud and frustrated. Then you get desert. Otherwise no dessert. If you do it 3 days that week, you get a pizza. Each day you get a point and 15 points in a month get you an xbox game. (T asks her to repeat it and she does.)
T: Abby, show what you say to yourself when you do a great job like that.
A: I am proud of myself. (Example of self-reinforcement.)
T: (High five) Johnny, your turn.
J: I write all the work and do it after school and get dessert. Then pizza if I do it 3 days. Xbox!
T: (Shaping) You are getting it pretty close. Let’s do it again. When do you get the game?
J: Uh, if I do good for a month. (T helps J state this correctly.)
T: Pretty good. Repeat the whole thing. (J gets it approximately right.) Good job. (High five) How do you feel about getting it right?
J: I’m happy. (Self-reinforcement)
T: One more time, the whole thing. (J repeats it.) Now, in addition to no dessert and no pizza, what’s going to happen if Johnny doesn’t get the homework done before dinner?
Abby: He loses a point, too.
T: And if he doesn’t get it done three times in a week?
A: I think he should lose his xbox for the whole weekend.
T: I’ll repeat the entire rule. (Writes it down as it is repeated.) He writes down the assignments every day. He does them all before dinner. Then he gets dessert and a point. After three days in a week, he gets pizza. After 15 points in a month, he gets a game. If he doesn’t do the homework before dinner, no dessert and one point is taken away. If he doesn’t get it done three times that week, no pizza and he loses his xbox on the weekend. If he doesn’t get 15 points, no game. Abby, please state it. (She does.) Outstanding. Give yourself a positive.
A: I am pleased I got it right. Johnny, your turn.
J: (Johnny has difficulty remembering the details. It takes several prompts to get him to remember the details. For each segment he gets right, he is praised and cued for the next part. Eventually, he gets the whole thing. He is told to repeat it one more time.)
T: Abby, did he get it right.
T: One more time, Johnny.
J: (Again, it is not easy for him to get all the details just right. T reads the entire protocol and hands it to J to read, which he does twice.) I did a good job.
T: You really did. How confident are you that you can do this and earn a pizza every week?
J: I’ll do it.
T: Really, how many pizzas will you earn in the next two weeks?
T: So, Johnny thinks he can do it more than you do. Let’s see who is right and if he can evaluate himself right. I will send you home with the entire rule I wrote out and a form to use to keep track. Abby, the last question is how confident you are that you can follow your part of the rule to a “T.” Zero to 100%?
T: Why 80 and not 70?
A: I know the rule and I want this to work.
T: Then why not 100%?
A: It’s been so frustrating. Sometimes I get upset.
T: One more thing. Who is going to remind Johnny every morning of the whole rule? And how and when? (Prompting)
A: I’ll put in on the fridge and read it to him before breakfast. How’s that?
T: Perfect. Oh, and let’s say he is working on the homework. Where will he do that?
A: In the kitchen while I get dinner ready. Then I can help.
T: What if you notice his mind wandering or off-task behavior? (Cuing)
A: “Johnny, put your nose back in the book. Stay focused.”
T: Perfect. We have more work to do since we want to see him get that xbox and then increase the standard to five nights out of five. And to see if he can get to be pretty good at estimating the quality of his work. Plus getting an accurate accounting from his teachers that he writes it all down and turns it all in. We don’t always realize how complicated this is for a child with memory problems. So let’s do this first part. So let’s go with 80%; that’s realistic.
In summary, an enactment is an opportunity to co-create the behavioral and cognitive-behavioral treatment protocol. The skills for more effective parenting are incorporated into the procedure. The procedure helps compensate for the child’s deficits in working memory and attention. The therapist demonstrates a process in which the family learns a new, non-reactive approach with massive positive reinforcement given for improvement within the session. The therapist gets to coach more functional behavior, elicit that behavior, and reinforce it. Also, the therapist looks ahead to the performance of the behavior in the environment. Corrections are made before the family goes home to perform the protocol rather than after they attempt it.
Give it a try!
© Don Rosenberg