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3-1 CHADD Parent to Parent © 2008 Revised 9-2010 Parent to Parent: Family Training on AD/HD ® Session 3 Developing Parenting Strategies and Positive Behavior Interventions Behavior Management - Part I CHADD Parent to Parent © 2008 3-2 Revised 9-2010 Questions We Will Answer What are two management strategies for behavior problems? What are six types of proactive strategies? What are the most important house rules in your home? What are tips for using reinforcement effectively? What are the 10 steps to designing a token program? How do you design a response cost program? How do you know when to use what intervention? CHADD Parent to Parent © 2008 3-3 Revised 9-2010 Deficits in Executive Functioning Deficits in Executive Functioning (EF) undermine the child’s ability to use internal control to regulate behavior. Therefore, the behavior of children with AD/HD is more externally controlled than children without AD/HD. Children with AD/HD are strongly influenced by the: Conditions of the immediate environment Availability of immediate rewards

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Page 1: Parent to Parent: Family Training on AD/HD Session 3 · Parent to Parent: Family Training on AD/HD ... effective parenting strategies/interventions. ... • Set and clarify behavioral

3-1CHADD Parent to Parent © 2008

Revised 9-2010

Parent to Parent:Family Training on AD/HD®

Session 3

Developing Parenting Strategies and Positive Behavior Interventions

Behavior Management - Part I

CHADD Parent to Parent © 2008 3-2

Revised 9-2010

Questions We Will Answer

• What are two management strategies for behavior problems?

• What are six types of proactive strategies?

• What are the most important house rules in your home?

• What are tips for using reinforcement effectively?

• What are the 10 steps to designing a token program?

• How do you design a response cost program?

• How do you know when to use what intervention?

CHADD Parent to Parent © 2008 3-3

Revised 9-2010

Deficits in Executive Functioning

• Deficits in Executive Functioning (EF) undermine the child’s ability to use internalcontrol to regulate behavior.

• Therefore, the behavior of children with AD/HD is more externally controlled than children without AD/HD.

• Children with AD/HD are strongly influenced by the:– Conditions of the immediate environment

– Availability of immediate rewards

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3-2CHADD Parent to Parent © 2008

Revised 9-2010

CHADD Parent to Parent © 2008 3-4

Revised 9-2010

CHADD Parent to Parent © 2008 3-5

Revised 9-2010

Common Behavior Problems

• Failure to think prior to acting

• Noncompliance to rules

• Repeats past mistakes

• Verbal and/or physical aggression

• Lack of concern or sensitivity for others

• Needs immediate gratification - doesn’t work for long-term incentives

• Poor problem-solving skills and internalization of the rules

• Easily frustrated - poor anger control

• Disorganized - poor response to time

CHADD Parent to Parent © 2008 3-6

Revised 9-2010

Two Management Strategies for Behavior Problems

Proactive Strategies

• These interventions are implemented prior to the onset of a behavior.

• Proactive interventions are designed to minimize the occurrence of an inappropriate behavior.

Reactive Strategies

• These are interventions that are implemented afterthe onset of a behavior.

• Reactive interventions use rewards to encourage appropriate behavior or punishment to discourage inappropriate behavior.

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3-3CHADD Parent to Parent © 2008

Revised 9-2010

CHADD Parent to Parent © 2008 3-7

Revised 9-2010

Creating an AD/HD Friendly Environment within the Home

The following Proactive Strategies can help create an AD/HD friendly environment at home:

• Establish a parental division of labor– Both parents must work together and be consistent!

• Form daily routines/schedules

• Provide space to be AD/HD

• Organize the environment

• Maintain a disability perspective

• Establish house rules

CHADD Parent to Parent © 2008 3-8

Revised 9-2010

Creating an AD/HD Friendly Environment within the Home

Kids with AD/HD NOT Welcome!

Parenting Style Does Not Cause AD/HD, but It Can Influence the Characteristics!

CHADD Parent to Parent © 2008 3-9

Revised 9-2010

Disability Perspective

• Adopting a disability perspective provides the foundation for parenting a child with AD/HD.

• A disability perspective shapes

a parent’s responses to the

child’s symptoms of AD/HD.

• A disability perspective encourages the parent to be supportive, positive and sensitive to their child with AD/HD.

“Look, Mommy! I let the sunlight in.”

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CHADD Parent to Parent © 2008 3-10

Revised 9-2010

Principles of a Disability Perspective

Children with AD/HD…• Have a legitimate medical condition that

undermines the ability to regulate their behavior.• Have the same need/desire as other children to

gain acceptance from others.• Can improve their conduct with the assistance of

effective parenting strategies/interventions.• Should be expected to make gradual rather than

rapid behavior progress.• Will respond more favorably to supportive/positive

discipline strategies than to rejecting/punitive discipline strategies.

CHADD Parent to Parent © 2008 3-11

11-2008CHADD Parent to Parent © 2008 3-11

Revised 9-2010

CHADD Parent to Parent © 2008 3-12

Revised 9-2010

Establishing House Rules

House rules provide clear behavioral expectations for the child with AD/HD.

The house rules help to:

• Set and clarify behavioral limits/boundaries.

• Emphasize the importance of specific parental expectations.

• Maintain the awareness of the specific parental expectations.

• Make sure that there is consensus in the family about the house rules.

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CHADD Parent to Parent © 2008 3-13

Revised 9-2010

How to Form House Rules

• Hold a family meeting to brainstorm a list of potential House Rules.

• Select three to five of the rules from the list to be the House Rules that are non-negotiable. Parents retain the right to determine the final list.

• State the House Rules in specific, objective language. (i.e., do not say “be responsible” – say “put your dishes in the dishwasher”.)

• Establish rewards and punishments for compliance or violation of the House Rules.

• Post the House Rules on charts that can be easily read.Remember to explain the rules to the child – do not just “post” the rules.

(cont’d.)

CHADD Parent to Parent © 2008 3-14

Revised 9-2010

How to Form House Rules

• Each week, target a House Rule for emphasis. Highlight or circle this House Rule on the chart and pay added attention to compliance / violations of this rule.

• Each night, review examples of instances in which your child complied or violated a House Rule.

CHADD Parent to Parent © 2008 3-15

Revised 9-2010

Reactive Strategies

• Reactive strategies are evidence-based behavioral interventions.

• Reactive strategies use positive/negative incentives called reinforcement or punishment to encourage or discourage appropriate or inappropriate behaviors.

• The behavioral consequences are applied after the occurrence of a behavior and thus are reactive rather than proactive.

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CHADD Parent to Parent © 2008 3-16

11-2008

CHADD Parent to Parent © 2008 3-16

Revised 9-2010

CHADD Parent to Parent © 2008 3-17

Revised 9-2010

A Changing Behavior ToolToken Economies

Token economies are one of the most effective behavioral interventions for children with AD/HD.

• These strategies use a symbolic token to provide immediate reinforcement.

• The child earns a token for each occurrence of the appropriate behavior.

• The child may exchange the tokens for a valued reward when a predetermined number of tokens is collected.

CHADD Parent to Parent © 2008 3-18

Revised 9-2010

Types of Tokens

Effective token programs use high-interest and novel tokens that maintain the child’s interest and motivation.

Suggestions include:

• Stickers

• Dot-to-dot charts

• Magic Grid

• Commercial programs

• Tangible objects – poker chips, peg boards

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CHADD Parent to Parent © 2008 3-19

Revised 9-2010

Reinforcement (Reward)

Guidelines

The value of reactive interventions depends on the effective use of reinforcement.

Guidelines are:

• Immediacy - apply right after the “good” behavior

• Frequency – use often to encourage repetition of “good” behavior

• Novelty – maintain interest in the reinforcement

• Enthusiasm – communicate the importance of the “good” behavior

• Description – specify the connection between the action and the consequences

CHADD Parent to Parent © 2008 3-20

Revised 9-2010

Limitations of Rewards

• The change is generally gradual rather than dramatic.

• The change may not persist after the reinforcement is discontinued.

• The reinforcement does not directly weaken the inappropriate behavior.

CHADD Parent to Parent © 2008 3-21

Revised 9-2010

Benefits of Rewards

• Sustains motivation and effort during low interest tasks.

• Highlights the connection – the cause/effect link between the appropriate behavior and the positive outcome – a reward.

• Directs attention to the outcome of a behavior.

• Enhances the child’s sense of competency.

• Fosters a positive parent-child relationship.

• Builds the strength of good habits.

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CHADD Parent to Parent © 2008 3-22

Revised 9-2010

Three Types of Reinforcement (Rewards)

• Edible – treats, favorite dinner

• Material – toys, CDs, video games, clothing

• Activities or Privileges –playing a board game, wrestling time with dad, bike ride with parents, later curfew, money for gas

CHADD Parent to Parent © 2008 3-23

Revised 9-2010

Ten Steps to Designing a Token Program

• Step 1: Select one specific behavior to target.

– Non example: Clean your room

– Example: Put your dirty clothes in the clothes basket.

• Step 2: Model the appropriate behavior for your child.

• Step 3: Select the tokens (or chart) to be used.

• Step 4: Select the reinforcement to be used.

• Step 5: Determine how many tokens must be acquired to earn a reinforcement.

(cont’d.)

CHADD Parent to Parent © 2008 3-24

Revised 9-2010

Designing a Token Program

• Step 6: Determine the time period in which the target behavior will be monitored.

• Step 7: Put the terms of the program in writing.

• Step 8: Display the contract in a visible location.

• Step 9: Start the token program and monitor progress.

• Step 10: Identify obstacles to progress and make adjustments in the program as necessary.

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CHADD Parent to Parent © 2008 3-25

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Example: Justin’s Token ProgramKeep Hands to Self Chart

Time of Day Kept Hands To Self

6:00 to 6:30 ���� Yes ���� No

6:30 to 7:00 ���� Yes ���� No

7:00 to 7:30 ���� Yes ���� No

7:30 to 8:00 ���� Yes ���� No

8:00 to 8:30 ���� Yes ���� No

Rules: For each “yes”, a sticker is earned. When Justin has earned four stickers, he may select an item from his reward menu.

CHADD Parent to Parent © 2008 3-26

Revised 9-2010

Justin’s Daily Reward Menu

• 30 minutes extra TV time with Mom/Dad before bedtime

• Wrestling with Dad before bedtime

• Favorite dessert for dinner the next night

• $1.00

• Board game with Mom or Dad before bedtime or on the weekend with a set time with mom or dad

CHADD Parent to Parent © 2008 3-27

Revised 9-2010

Developing Token Programs:Cautions

• Begin with modest goals. Don’t overreach.• Target a behavior that you believe will be

easy for your child to alter.• Start slowly. Implement the program for a brief

period of time each day and slowly extend its length as you feel more competent.

• Give reinforcement a chance to work. Do not rush into the use of punishment.

• Be consistent and stick to the agreed terms of the contract.

• Be fair. Do not withhold reinforcement that your child has earned because he/she has done something else that is inappropriate.

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CHADD Parent to Parent © 2008 3-28

Revised 9-2010

Benefits of a Token Program

• The token program clearly specifies the behavioral expectation(s).

• Tokens provide the child with the incentive needed to sustain the effort to make a change in behavior.

• Tokens help a child make the link between what they did right and a favorable outcome.

• The tokens cue the onset of the appropriate behavior.

CHADD Parent to Parent © 2008 3-29

Revised 9-2010

Example: Jake’s Cell Phone Chart

TIME OF DAY STAYED OFF THE CELL PHONE

6:00 to 6:30 p.m. ���� Yes ���� No

6:30 to 7:00 p.m. ���� Yes ���� No

7:00 to 7:30 p.m. ���� Yes ���� No

7:30 to 8:00 p.m. ���� Yes ���� No

Rules: If Jake earns at least three “yes” marks between 6:00 and 8:00 p.m., he may select a privilege from his reward menu.

CHADD Parent to Parent © 2008 3-30

Revised 9-2010

Jake’s Reward Menu

• May use the cell phone from 8:00 p.m. to 10:00 p.m.

• Have “screen” time from 8:00 p.m. to 10:00 p.m.

• $5.00 worth of gas

• Permitted to go to a friend’s home until 10:00 p.m.

• Money for a car wash

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Activity 1: A Token of My Affection

Behavior of Concern:

Meg is an eight-year old child that often tattles on her older brother. The tattling creates frequent conflicts between Meg and her brother. Use the blank chart found on the next slide to design a token program to reward “no tattling”.

CHADD Parent to Parent © 2008 3-32

Revised 9-2010

Meg’s No Tattle Tale Chart

MONITORING SESSIONS MEG REMEMBERED NOT TO TATTLE

Rules:

CHADD Parent to Parent © 2008 3-33

Revised 9-2010

Advanced Token Programs

Advanced token programs target more than one behavior at a time or break a complex behavior into smaller, sequential steps.

For example, performing homework might be divided into four separate behaviors:

• Recording the homework

• Bringing appropriate materials home

• Completing the homework

• Turning the homework in to the teacher

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Behavior Reward ChartMorning Routine

Week of 9-12 thru 9-16PAYOUT

Get out of bed within 2 requests 4 Tickets

Put on your clothes that are laid out 4 Tickets

Brush Teeth 4 Tickets

Come to breakfast within 2 requests 2 Tickets

Take your backpack to school with you 2 Tickets

Go out and wait for the school bus by 8:15 a.m. 6 Tickets

TOTAL that can be earned daily 24 Tickets

Monday Tuesday Wednesday Thursday Friday

CHADD Parent to Parent © 2008 3-35

Revised 9-2010

Behavior Chart

What can I purchase with my tickets?

1. One hour TV time in evening on school days 6 Tickets

2. Ice cream cone after dinner 6 Tickets

3. Half hour of dad’s time to help me with homework

6 Tickets

4. One hour of computer games before bedtime 10 Tickets

5. A toy valued at $10 to be purchased with mom or dad at a time specified by mom or dad

150 Tickets

CHADD Parent to Parent © 2008 3-36

Revised 9-2010

Evaluating the Success of the Program

Parents sometimes incorrectly decide that the token program is ineffective when it is providing benefits.

Keep these considerations in mind when determining the effectiveness of your program:

• Expect gradual rather than rapid progress.

• Ask yourself the following questions:

– Is the behavior occurring less often?

– Is the behavior lasting for a shorter duration?

– Is the behavior less intense or severe than

before?

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Free Response Cost:Do It or Lose It!!!

In a free response cost program, the tokens are freely provided at the onset of the program.

These programs have several advantages:• It is very useful to reduce the rate of high

frequency inappropriate behaviors.• The loss of a token is less frustrating because the

child is not losing something that was previously earned.

• The programs are easy to design and implement.• The tokens provide a firm and visible behavioral

boundary.• The programs are adaptable to public settings.

CHADD Parent to Parent © 2008 3-38

Revised 9-2010

Designing a Free Response Cost Program

• Select the target inappropriate behavior (e.g. swearing)

• Collect data. How often does it occur within a certain period of time?

• Give tokens to the child on a scale that reflects the behavior. (Swearing – 10 times per hour, give seven tokens.)

• Determine when and how long the behavior will be monitored.

• Remove a token for each occurrence of an inappropriate behavior.

• If the child has at least one token remaining at the end of the monitoring session, provide the incentive.

CHADD Parent to Parent © 2008 3-39

Revised 9-2010

Example: Connie’s Swearing Free Response Cost Program

Target Behavior Number of Tokens

Swearing 1 2 3 4

Rules: Connie will be monitored for swearing between 7:00 p.m. and 9:00 p.m. each week night. Connie will lose one token each time she says a swear word as defined by her parents. If Connie has at least one token remaining at 9:00 p.m., she may stay up until 9:30 to watch TV.

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Allen’s Free Response Cost Program

Time # of Tokens Tokens Remain?

5:00-5:30 1 2 3 ���� Yes ���� No

5:30-6:00 1 2 3 ���� Yes ���� No

6:00-6:30 1 2 3 ���� Yes ���� No

6:30-7:00 1 2 3 ���� Yes ���� No

Target Behavior: Breaking House RulesRules: 1. Allen will lose 1 token each time he violates 1 of the posted House

Rules.2. If Allen has at least 1 token left at the end of each half hour, he will

earn a “yes”.3. If Allen earns at least 3 “yes” marks in an evening, he may select an

item from his reward menu.

CHADD Parent to Parent © 2008 3-41

Revised 9-2010

Allen’s Reward Menu

• 30 additional minutes of screen time at night.

• Board game with Mom/Dad.

• $2.00

• Special Dessert.

• Pillow fight with Mom/Dad.

CHADD Parent to Parent © 2008 3-42

Revised 9-2010

Free Response Cost in Public Places

Free response cost is particularly useful in public locations such as:

• Restaurants

• Malls

• Car trips

• Grocery stores

• Classroom settings

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Using Free Response Cost in Public Places

Example #1: John is a seven year old child who misbehaves at the grocery store.

• His mother explains the rules of conduct while at the store.

• His mother provides him with 4 tokens.

• John loses one token for each rule violation.

• If John has at least one token remaining when his mother is finished shopping, he earns a milkshake.

CHADD Parent to Parent © 2008 3-44

Revised 9-2010

Using Free Response Cost in Public Places

Example #2: Carol acts out whenever her parents take her for a long ride in the car.

• Carol’s parents explain the “rules of the road”.

• Carol is provided with 3 tokens for a 15 minute ride.

• One token is removed for each rule violation in the 15 minute period.

• If Carol has at least one token remaining at the end of the ride, she earns 30 minutes extra screen time.

CHADD Parent to Parent © 2008 3-45

Revised 9-2010

Review: When to Use What

Token Economies – Advantages:

• Clearly specifies behavioral expectations

• Provides frequent reinforcement to sustain effort

• Tokens cue appropriate behavior

• Tokens link the appropriate behavior with the outcome

Token Economies – Limitations:

• Requires more time and effort to design and implement

• Must be cautious not to make the program too complex

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Review: When to Use What

Advanced Token Economies – Advantages:

• Use with complex behaviors that need to be broken down into smaller tasks

• Replaces frustration while learning a new skill with feelings of progress and success

Advanced Token Economies – Limitations:

• Require more planning, modeling and monitoring

CHADD Parent to Parent © 2008 3-47

Revised 9-2010

Review: When to Use What

Free Response Cost – Advantages:

• Easy to design and implement

• May easily be used in public places

• Quick way to reduce high frequency, inappropriate behaviors

• Provide a specific and visible behavioral boundary

Free Response Cost – Limitations:

• Does not teach or reinforce appropriate behavior

• Loss of token may frustrate some children

CHADD Parent to Parent © 2008 3-48

Revised 9-2010

What My Child Should Know…

• Mom and Dad are going to teach him/her how to organize his/her room and clothes.

• The family will be following a list of House Rules.

• There will be a designated space in the home for play and toys.

• Mom and Dad will be setting up a chart with incentives to earn prizes or privileges.

• Mom or Dad will discuss the rules of behavior before a long trip or outing to a store.

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CHADD Parent to Parent © 2008 3-49

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Questions We Have Answered

• What are two management strategies for behavior problems?

• What are six types of proactive strategies?

• What are the most important house rules in your home?

• What are tips for using reinforcement effectively?

• What are the 10 steps to designing a token program?

• How do you design a response cost program?

• How do you know when to use what intervention?