by Jan Hittelman | Jan 23, 2014 | Parenting Difficulties, Communication, Transitions, Stress, Anger, Early Childhood, School Issues, Social Issues
By Dr. Jan Hittelman
When I first introduce the idea of using a type of behavior modification, parents often dismiss it by saying, “We’ve already tried that and it doesn’t work; what else have you got?” This is because there are several common pitfalls that will effectively sabotage a behavior modification approach with children. These pitfalls include: using an overly complicated system (usually including grids and charts), choosing unmotivating “rewards”, not including the child in the creation of the plan, no plan for phasing out the system, lack of clarity regarding the behaviors themselves, expecting perfection, bribing versus reinforcing and poor parental follow through.
The Structured Activity Reward techniques used here are both simple and effective. In fact, the results are often immediate and dramatic. Chronic negative behaviors often improve within weeks! In addition, the technique can be used with a wide variety of undesirable behaviors. It is a structured approach that focuses the child on the desired behavior and provides fun activity rewards that are motivating to the child. As a result, the child is also taught how to get parental attention in a more appropriate, positive fashion. This is very important, as most undesirable child behaviors are actually fueled by the parent’s negative attention to those behaviors. To better illustrate this approach, consider the following case examples.
Alex, Age 6
Alex was a feisty, highly intelligent boy who was diagnosed with Attention-Deficit Hyperactivity Disorder (ADHD) and was on related medication. Children with ADHD display unusually high levels of inattention, impulsiveness, and hyperactivity for their age. As is often the case with very bright children, Alex was very manipulative. He had a history of aggressive behaviors which included biting others, as well as himself. What better way to get immediate and consistent negative attention! Alex’s parents were seeking assistance for his increasingly unmanageable behaviors in school. His most recent exploit involved running out of the school building and climbing up a tree. When the school staff attempted to talk him down, he growled loudly!
During my first session with Alex, he explained to me that he liked biting himself when he was “bored and hungry”. He smilingly reported behaving well in school “unless someone antagonizes me. Like if you antagonized me, I’ll bite you!” Needless to say, I made every effort to stay on Alex’s good side, as I’m sure others in his life felt compelled to do.
The next week, I met with Alex and his father, who informed me that the school began a point system to provide the parents with daily feedback regarding Alex’s behavior. He could earn up to four points a day. We integrated this into our Structured Activity Rewards Contract (see Figure 1). As soon as Alex accumulated eight good behavior points, he earned a fun activity with Mom or Dad. To maximize motivation, we also included a “bonus for perfection”. If Alex obtained four points every day in a school week, he got to choose an additional activity. The next week, parent reports indicated a good week in school, earning three points most days. This continued the following week and by the third week, Alex got his bonus for perfection. Because structured activity rewards allow highly manipulative children to be manipulative in a positive way, it is often quite effective. After five weeks, we increased the number of points required to twelve and eventually phased out the system completely.
Contract for Alex
When Alex gets 8 Good behavior points
Then he can choose a reward activity
Bonus!
If Alex has a perfect week
Then he can pick an extra activity.
Reward Activities
- Go to the lake
- Play a board game
- Play a card game
- Play Wiggle Bridge
- Play math games
Monica, Age 8
Monica was a socially sensitive, needy child who easily got into conflicts with her mother. Mom reported that Monica would experience anxieties/frustrations, take it out on her mother, who would then get angry at Monica. Later, her mother would feel guilty and try to make up. This scenario occurred repeatedly within their relationship. Consider how this behavioral sequence would result in and was being reinforced by so much negative attention.
One area of specific difficulty common to so many families is getting homework done. When it was homework time, Monica would engage in a variety of avoidant behaviors including: eating, fooling around, playing with her younger sister, etc. Her mother indicated that Monica would procrastinate until or through dinner and all the way up to and often past bedtime, requiring “hundreds” of reminders (or “yelling” according to Monica) to no avail. Mom tried “everything” including rewards like playing video games, which Monica loved, but then she would just rush through her homework in a haphazard fashion. Consequently, for the last year, Monica was not allowed to play video games during the week. In addition, Monica wanted to play with her friends after school, but couldn’t due to this time consuming negative homework ritual. This only compounded her social problems, by reducing her opportunities for needed socialization experiences.
We negotiated a Structured Activity Rewards Contract which addressed these issues (see Figure 2). If Monica did her homework well after dinner and before bedtime with no more than 3 reminders, she could play video games and be with her friends the next day. In addition, these good homework days would result in a fun activity with her mother or father. A week later, her mother reported that the contract was working “really well”, and Monica indicated that Mom was yelling less. While we addressed other therapeutic issues, homework continued to go well over the next 6 weeks at which time we were able to phase the contract out, as Monica had developed appropriate homework skills.
Contract for Monica
When Monica does her homework well after dinner and before 8:15pm (no more than 3 reminders)
Then the next day Monica can play video games (1/2 hour) and play with her friends after school
Also 3 good homework day results in one of these fun activities:
Reward Activities
- Going out to ice cream
- Going bowling with Dad
- Dinner with Mom
- Playing video games with Mom
- Coffeehouse for tea and a muffin with Mom
- Softball with Dad
- Sleep over
____________________ ___________________
Monica’s signature Mom’s signature
Omar, Age 10
In our initial session, Omar presented as a respectful, well-mannered adolescent who was eager to please. He was referred for a very common problem that had manifested into a variety of unusual behaviors. His mother indicated that Omar was, “Scared of being alone and darkness. He needs to have somebody with him at all times when it’s dark”. Until age 3, Omar shared a room with his sister, who is one year older. “Then he became scared to sleep by himself.” This developed into a pattern of behavior in which Omar would initially fall asleep in his room and during the night, go into either his sister’s or parents’ room where he would remain until morning. Another set of behaviors also developed around the fear of being alone. Whenever Omar went to the bathroom or showered, one of his parents had to stand outside the door. In addition, Omar was fearful of going upstairs alone or washing the dishes downstairs alone. Keep in mind that these behaviors continued for many years. What precipitated their finally seeking treatment was Omar’s recent desire to go on sleepovers. It would have been awkward for Omar to ask his friend’s parents to stand outside the bathroom door! Despite his being highly motivated to conquer his fears, he was unable to break these behavioral patterns.
In our second session we discussed some basic cognitive-behavioral strategies to help cope with these fears. Omar learned a deep breathing technique to foster relaxation and created a calming statement of reassurance that he could repeat to himself. The following week we constructed a Structured Activity Rewards Contract (see Figure 3). We were able to move quickly in large part due to Omar’s motivational level. At his suggestion, we set a fairly challenging goal of 5 out of 7 “good” days. In addition, we added a “bonus for perfection”. Again, we utilized basic activity rewards with Mom or Dad. Two weeks later we met again and to my amazement, Omar proudly reported being successful every day! We revised the contract to 6 out of 7 days and one month later phased it out. Each subsequent week resulted in 6 or 7 good days. Once again consider the behavioral sequence. Consider the inordinate amount of parental time and attention that Omar’s problem behaviors resulted in. While it’s possible that the cognitive-behavioral techniques alone could have eventually gotten the same results, providing Omar with a way to earn positive parental attention insured rapid success.
Contract for Omar
When Omar
- showers on his own (going upstairs with the door closed) 5 out of 7 days
- bathroom on his own (again with the door shut) 5 out of 7 days
- sleeps on his own (in own room and doesn’t call anyone) 5 out of 7 days
Then Omar can choose one activity on Sunday
***Activity***
-Lake with Mom -Go to mall with Mom
-Craft with Mom -Gardening with Mom
-Build model with Dad -Fishing with Dad
-Lake with Dad -Bike ride with Dad
-Play catch with Dad -Play a sport with Dad
***Bonus*** For a perfect week, Omar picks another activity
I have read and agree with this contract.
______________ _____________ _____________
Omar’s signature Mom’s signature Dad’s signature
Ryan, Age 5
Initial parent reports indicated that Ryan was a, “Perfect child for the first five years.” Four weeks earlier he had begun a new pre-kindergarten program. Since the first day of school, Ryan had been having increasing difficulties adjusting. It began with his dislike of a forty-five minute “sleepytime” toward the end of the school day. Ryan was not a napper and probably found sleepytime to be tedious and boring. His mother attempted to solve the problem by picking him up earlier, thus avoiding sleepytime altogether. To the parents’ dismay, his adjustment problems worsened. At this point Ryan resisted going to school at all, wanting only to be with his mother. Despite a prior history of positive and frequent socialization experiences, Ryan was having tantrums every morning before being forced to go to school.
Let’s stop for a moment and consider the behavioral sequence. Ryan’s initial adjustment difficulties result in leaving school early, to be with his mom. In addition, there were certainly countless talks with Ryan regarding his concerns, trying to soothe his fears. Not only do his adjustment problems increase, they now are unrelated to the initial issue of sleepytime. All of the adjustment difficulties do, however, have one thing in common. They all resulted in parental attention. While the parents may not be yelling or punishing, it is still negative attention in that it fuels and even escalates the undesirable behaviors.
After sharing my negative attention theory, Ryan’s parents were doubtful that this could apply to their son based upon his very well adjusted first five years. Despite this, they agreed to try utilizing structured activity rewards and we created a contract for Ryan (see below). Ryan’s parents telephoned me prior to our two-week follow-up appointment. They were pleasantly surprised to report that Ryan’s difficulties had dramatically improved and they would call back to reschedule if problems reoccurred. I spoke with them sometime later on a different issue and was told that their son’s school adjustment problems were much more infrequent (i.e., normal).
Contract for Ryan
When Ryan has a good school morning (crying only in room, no grabbing Mom before school)
Then Ryan gets a Happy Point
2 Happy Points = 1 Reward Activity
Reward Activities
- Go out for pizza with Dad
- Go to grocery store with Dad
- Play a game with Dad
- Bike ride with Mom
- Go out with Mom/Dad for ice cream
- Go out with Mom/Dad for Chinese food
Bonus 5 Good Mornings = Clock
Jason, Age 11
Jason was also diagnosed with Attention-Deficit Hyperactivity Disorder. Through prior therapeutic contacts and a good response to medication, his symptoms were kept under control. Jason’s father had a variety of medical conditions that he had suffered with and, to his credit, learned to cope with fairly well. Approximately three months earlier, Jason’s father had a sudden mysterious attack which left him temporarily paralyzed and seemingly, catatonic. His family, who was with him at the time, feared he was dead. While he completely recovered hours later, it was certainly a traumatic experience for everyone. This was particularly true for Jason. Ever since this incident, Jason insisted on constantly being with his father to make sure that he was all right. As his father put it, “He just won’t leave me alone!” It had gotten to the point where Jason insisted his dad sleep with him in his room every night. Even the garage, which used to be Dad’s private sanctuary was now always shared with Jason. While Jason and his dad previously always had a close relationship, he was driving his dad crazy!
This case is a good example of a very common behavioral process. Jason’s initial concerns and behaviors were completely appropriate and understandable. The unanticipated consequence, however, of a significant increase in parental attention inadvertently fueled the behavior to a more dysfunctional level.
We agreed to utilize a Structured Activity Rewards Contract, but given the dynamics of the case, all of the reward activities were with his father (see below). In our two-week follow-up, his father was ecstatic to report eight good days. One month after initiating the contract, their relationship was returning to normal and both were forgetting to monitor the contract. In this case the system was successfully phased out “naturally”.
Contract for Jason
When Jason gives Dad his space for a day
- Not bother Dad in Garage after 8:00pm
- Dad sleeps in his own room
One warning per day for first week only!
Then Jason earns 1 Point
3 Points = 1 Activity Reward
Activity Rewards
-Buy a model -Work on a model
-Go fishing -Rent a video game
-Go mineral mining -Play a board game
-Work on a project in garage
-Go to park, throw ball around
-Fly/work on a model plane
I read and agree with this contract
_____________________ __________________________
Dad’s signature Jason’s signature
Taylor, Age 8
According to Taylor’s parents, he “always” had a problem complying with their requests. They described him as, “very impulsive”, “overemotional” and stated that he “tantrums whenever we discipline him”. Even when he did comply it usually required at least 6 reminders and often, endless debates.
A review of Taylor’s school records and early developmental history indicate that at age three he was diagnosed with speech/language delays and had a history of frequent ear infections. A pre-kindergarten screening noted specific weaknesses in auditory memory (remembering what you hear) and receptive language (understanding what is said to you). Taylor benefited from ongoing speech/language therapy and was reported to currently be within the normal range for his age. While “not listening” is easily one of the most common child disciplinary issues, it is quite possible that Taylor’s noncompliance was initially a function, at least in part, of his real language difficulties. I hoped that an effective structured activity rewards contract would give him the extra motivation needed to break these very early habits and foster new skill development.
We negotiated our Structured Activity Rewards Contract (see Figure 6). For each parental request, Taylor was allowed one reminder. Three good days would earn him an activity reward. At our two week update session, Taylor had earned eleven good days out of fourteen. I was pleasantly surprised with his progress. Considering his developmental history, his parents were also very pleased with his progress, but did mention that he often waits for his one reminder. To address this issue, Taylor and his parents added a bonus reward of money, which reportedly Taylor wanted more than anything, for needing no reminders. Preferring activity over monetary rewards, I reluctantly agreed to this revision (see below). The following week Taylor had accumulated six more good days, three of which were bonus days of no reminders. Mom confided that the days without reminders took so much effort on Taylor’s part that she had succumbed to the fact that he just needs a reminder or two. His success continued and we phased out the contract after five weeks.
Contract for Taylor
When Taylor does what is parents ask him to do all day
Then Taylor will earn one (1) point
Reminders!Taylor is allowed one (1) reminder for each request
Three (3) points = one(1) activity reward
Bonus!! 1 Day no reminders = 25cents/3 in a row = $1
Activity Rewards
- Go for a drive to see a relocated friend
- Draw or paint with Mom
- Build something with Dad, like racetrack
- Go to a movie with Mom or Dad
- Play Monopoly with Dad
- Go to Blockbuster to rent a movie or game
- Go out to eat with Mom or Dad
- Go out for ice cream/frozen yogurt
I have read and agree with this contract
________________ ________________ _______________
Taylor’s signature Mom’s signature Dad’s signature
Matthew, age 6
In 1992, a significant earthquake rocked southern California at approximately 5:30 in the morning, waking most of us. Matthew, like most children (and adults!) became quite frightened. To help Matthew feel more secure, his parents allowed him to spend the remainder of the night with them in their bed. In my opinion, this was a completely appropriate response. The next night, Matthew awoke at 2:00 am and asked to sleep with his parents again due to his continuing earthquake fears. As you may have guessed, this pattern continued for days that turned into weeks. Consider the behavioral sequence that, of course, culminates in enormous parental attention. Attention which, while initially quite appropriate, was now fueling Matthew’s earthquake anxiety behaviors. Keep in mind that Matthew’s fears were also initially appropriate. Inadvertently fueled by parental contact/attention, his fears became more severe and maladaptive.
Matthew’s parents reported that he was always a worrier. He was even easily startled as an infant. Consequently, Matthew may have also been more predisposed to having anxiety difficulties.
As our initial session was ending, I began to feel somewhat anxious myself as I was going away on a two-week vacation the next day and Matthew’s parents were desperate. With great reluctance, I agreed to meet with Matthew later that day and quickly formulated a Structured Activity Rewards Contract with the family. I like to work quickly, but not that fast! We were, however, able to complete our contract later that day. The system encouraged staying in his bed, but even if he came in once, he was still rewarded (see figure 7). If he came in more than once, his parent’s would simply help him back to bed. He could not, however, stay in his parents’ room. Right before the family left, Matthew looked up at me and his eyes watered up. He then quietly said, “I don’t think this is going to work.” At that moment I was afraid that because I had moved too quickly, he would be right. At our two week follow-up session, we reviewed Matthew’s progress. During the first five days, Matthew visited his parents repeatedly on three nights and only once on two nights (thus earning two points). Then to everyone’s amazement, Matthew remained in his room the following nine nights! Matthew proudly indicated that he did wake up on some of those nights but was able to deal with it on his own. We then proceeded to revise/phase out the contract (see below).
I met with the family two years later about some compliance difficulties and was told that there was no reoccurrence of these earthquake anxiety/behaviors.
Contract for Matthew
When Matthew stays in his bed all night
Then he will get 3 smiley faces
If Matthew only gets out of bed one time
Then he will get 1 smiley face
Activity Rewards (5 Smiley faces)
- Wild Animal Park
- Sea World
- Zoo
- Ice skating
- Buy and play with bow and arrow
- Marine Museum
New Contract for Matthew
When Matthew stays in his bed all night
Then he will get 1 star
Activity Rewards (5 Stars)
- Wild Animal Park
- Sea World
- Zoo
- Ice skating
- Buy and play with bow and arrow
- Marine Museum
- Go to a movie
- Stay up ½ hour late
- Bowling
- Go to tide pool
Cindy, Age 7
Cindy presented as a sweet, friendly child whose eyes sparkled when she smiled. In reviewing her case history with her parents, she seemed to almost be the perfect child. Cindy adjusted “extremely well” to school, which she still “loves”. Her interactions with peers were observed to be “excellent”. Her parents also indicated that she was “very responsible” and she even willfully helped with chores! You may ask, “Why bring her to a psychologist?”
Cindy was referred for chronic bed-wetting. She was toilet trained at age two and had no accidents until age five. For the last two years, however, she wet her bed almost every night. Cindy’s father left very early each morning for work. Prior to leaving, he would check on Cindy. If she wet her bed he would wake her up, change her sheets, and put her back to bed. Her medical history indicated frequent urinary tract infections, which were probably a contributing factor. At age six, Cindy went to a urologist for a comprehensive medical evaluation and was even placed on medication for a year. Despite this, however, her frequent bedwetting continued. Not sure what else to do, the urologist sent her to me.
At that time the most effective treatment for bedwetting was a device called a “Pad and Bell”. To use the device, the pad is placed under the bed sheet and is attached to a bell next to the bed. Any moisture that touches the pad completes a circuit, which activates a loud bell. The theory is that this trains children who are usually heavy sleepers, to be more aware of the body sensations that wake us up when we have to go to the bathroom at night. (I’ve always wondered how this classical conditioning tool affects its subjects later in life. When they hear a door bell, do they get the urge to go to the bathroom?) I discussed this approach with Cindy’s parents and located a pharmacy, which sold the pad and bell device.
Prior to purchasing the pad and bell, I suggested that we assess motivational factors by setting up a Structured Activity Rewards Contract. I explained to Cindy’s parents that I didn’t expect the contract to help much, but I wanted to see if increasing her motivation would have any effect at all. We also explained to Cindy that we’d try it and if it didn’t work, it was no big deal. We constructed a contract that included daily rewards and bonus rewards for multiple dry nights (see below). We met a week later and to everyone’s surprise, Cindy was dry five out of seven nights! The following week she was dry seven nights straight! During the next week, Cindy only had one wet night. At this point we began phasing out by modifying the contract (see Figure 10). Cindy was also required now to change her own sheets. Approximately six weeks after initiating the contract, we phased it out completely. One month later, Cindy continued to have all dry nights. I couldn’t help but wonder if the daily one-on-one attention from Dad each morning inadvertently fueled the behavior. Interestingly enough, her parents began to notice an increase in attention seeking /defiant behaviors from this seemingly “perfect” child. While she was staying dry at night, she was getting more “pissed-off” during the day! We addressed these issues in subsequent family therapy sessions.
Contract for Cindy
If Cindy has a dry night
Then she can choose 1 daily reward
Daily Rewards
-Lunch at school -Time alone with Mom or Dad
-Later bedtime -15 minutes in parents’ bed
-Dad’s seat for dinner -Sleeping on the floor
Bonus! 2 Dry nights = 1 Bonus
3 Dry nights = 2 Bonuses
4 Dry nights = 3 Bonuses
Bonus Rewards
-Nails with Mom -New notebook
-Mom cleans her room -New markers
-Front car seat on weekend -New book
-Bath with Mom -Mermaid cards
-Ice cream with Dad -Having a friend over
I have read and agree to this contract
_____________________ _______________________
Parents’ signatures Cindy’s signature
New Contract for Cindy
When Cindy has two dry nights
Then she can choose 1 special reward
Special Rewards
-Lunch at school -Time alone with Mom or Dad
-Later bedtime -15 minutes in parents’ bed
-Dad’s seat for dinner -Sleeping on the floor
Bonus! 3 Dry nights = 1 Bonus
4 Dry nights = 2 Bonuses
5 Dry nights = 3 Bonuses
Bonus Rewards
-Nails with Mom -New notebook
-Mom cleans her room -New markers
-Front car seat on weekend -New book
-Bath with Mom -Mermaid cards
-Ice cream with Dad -Having a friend over
I have read and agree to this contract
_____________________ _______________________
Paarent’s signatures Cindy’s signature
These case histories attest to the powerful impact of systematically shifting parental attention from negative to positive. It is important to point out, however, that these seemingly simple contracts were carefully constructed to maximize their chances of success. The next chapter will provide you with everything you need to know to construct an effective Activity Rewards Contract for your child. The key element to this system is the use of parental attention that fuels the child’s motivation to practice the desirable behavior(s). To get your own step-by-step instructions on creating your own Structured Activity Rewards Contract, download Dr. Hittelman’s free report: “Change Your Child’s Behavior in 30 Days” by clicking HERE .
