Transcript Contingency Management with Adolescents and Their Families

Contingency Management (CM)
with Adolescents & Their Families
Ashli J. Sheidow, Ph.D.
Family Services Research Center
Department of Psychiatry & Behavioral Sciences
Medical University of South Carolina
The presenter’s research has been supported by
National Institute on Drug Abuse awards
R01DA017487 (PI: Henggeler) & K23DA015658 (PI: Sheidow)
Background for Today’s Training
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Strong empirical evidence for the use of CM in
adolescents
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Cognitive Behavioral Strategies
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e.g., Azrin & colleagues, 1996, 1994, 2001
Identify triggers of drug use
Manage triggers
Develop drug refusal skills
Behavioral Strategies
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Monitored drug use
Incentivize abstinence
Point-and-Level System
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Incentives for abstinence and disincentives for use
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Clean tests (no drug use) = rewarded with points
Dirty tests (drug use) = no or loss of points + loss of valued
privilege
Other desired behaviorsa = bonus points
Points can be exchanged for various rewardsb
 aOther desired behaviors
 Examples: aggression, arguing, school attendance, homework
completion, household rule breaking, chore completion
 bEffective Reward Menu
 Effective incentives & disincentives
 Associated points determined strategically
 Steps for tracking points and incentives
Start with the Carrot
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Step 1: Identifying Motivational Items
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Potential rewards that are motivating for THIS youth
Items
Activities
Privileges
Do not necessarily have to cost money
Rewards list:
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Generated by the youth
Edited by caregiver & therapist
Procedure:
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Provide examples
Generate list
Rank order
List of Potential Rewards
Type of Reward
Transportation
(most valued privilege)
Driving Practice
Clothing
Favorite Dessert/Meal
Meals
Lunch/Dinner Out
What I Get
What I Want
What Parent Provides
Ride to recreation
center once a week
Borrow the car on
Saturday
I usually give him rides 3-4 times
a week to places.
None
Daily
I haven’t let him try practicing
even though he has a practice
permit.
One outfit at the
start of the school
year
At least one new
outfit a month
I buy him new clothes or shoes
once a month or so.
Never
Every day
3-4 times per week I usually fix
him spaghetti, fried fish, pound
cake, and chocolate chip cookies.
She cooks dinner,
sometimes makes
breakfast and
packs my lunch
Nothing
I cook everyday. I make him
breakfast and pack his lunch or
give him lunch money.
1-2 times per
month
1-2 times per
month
We all go out 1-2 times per
month.
List of Potential Rewards (p.2)
Type of Reward
Laundry
What I Get
Once a week
What I Want
What Parent Provides
Once a week
Once a week and sometimes I
will wash something he wants to
wear. I also iron his clothes when
he asks.
TV Use
Daily
Daily
Daily. I also bought him X-Box
which he plays every day. I buy
him at least one game a month.
Curfew
7:30 during the
week and 9:00 on
weekends
9:00 during the
week and midnight
on weekends
I am following probation orders.
Every day
Nothing
His friends are always here.
About once a week
2-3 times per week
I don’t like all his friends so I
don’t allow him to go to their
homes.
Invite Friend SleepOver
Never
1-2 times per
month
I have not allowed this.
Non-Drug/Alcohol
Party/Get-Together
Never
At least for my
birthday
I have not done this.
Have a Friend Visit
Go To a Friend’s House
List of Potential Rewards (p.3)
Type of Reward
What I Get
What I Want
What Parent Provides
A cell phone
Has a cell phone
We gave him a cell phone.
Low-end cell phone
Razor cell phone
Basic phone.
Never
Hang out 1-2 times
per month
He sometimes gets to watch
sports with his dad 1 time a
month.
Share room with
little brother
Move into the office
We use the office, but could
maybe move computer to
kitchen.
Stuff for Room
Nothing – looks like
a kids room
Posters, bedspread,
lamp, rug, paint
We could provide some of those.
Trips With
Family/Friends
No
Wants to go to local
amusement park
We have not done this.
Movie Theater with
Family/Friends
No
1-2 times per
month
We could sometimes afford.
Own Car (Registration,
Insurance, Payments)
No
Wants a car
We cannot afford.
Own Phone
Upgrade Phone
1-on-1 Time with Dad
Own Room
List of Potential Rewards (p.4)
Type of Reward
Computer
Weights, Sports
Equipment
Music Player/i-Pod
Play Football
Pet/Pet Supplies
Other Item: Jewelry
Other Item:
Other Item:
What I Get
What I Want
What Parent Provides
No
Wants a computer
We cannot afford.
Some weights
More equipment
He wants a bench/weights.
Daily
Have stereo – daily
use; wants i-Pod
He uses stereo daily. May get iPod.
Weekly in fall
Want to stay on
team
He plays, I try and support.
None
A pit bull
We cannot afford.
Ring last fall
Bracelets, rings,
necklace
I bought him ring for his birthday.
Good report to my
probation officer
Once a month
I tell the truth – bad reports.
Reward Menu
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Step 2: Edit the List of Potential Rewards
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Caregiver determines final list of rewards
Each reward must meet 4 criteria:
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It does not contribute to irresponsible behavior.
It is non-essential.
Caregiver is willing & able to withhold the
privilege if it’s not earned.
It’s reasonable given the context in which the
youth & caregiver live.
Monetizing Rewards
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Step 3: Assign Points to Rewards
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Less valuable rewards = fewer points
More valuable rewards = more points
Rewards able to be given daily = fewer points
Weekly/Monthly Rewards = more points
Points can be equated to a $ value
Review rewards to see if any
monetary rewards should have
an added "tax"
Make It Personal
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Step 4: Personalize the Contract
Contract clearly outlines what the youth can earn in
return for doing good behaviors
Points awarded and deducted for the youth’s behaviors
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Possibly use “Base Points”
Assign points to each desired behavior
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Points can be earned
Points can be lost
Bonus points can be awarded
Level System: Escalating Reinforcers
Moving up levels and down levels: Rapid Reset
Rewards and the rewards’ associated points
Disincentives and associated points
Take It to the Bank
Step 5: Track points
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Checkbook System
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Graphing System
Run “what ifs” on the plan
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It’s Showtime!
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Step 6: Sign the Contract
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Step 7: Implement the Contract
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Step 8: Revise the Contract
The Proof is in the Pudding
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Drug screens ensure we are accurate
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We usually can’t observe the youth’s drug use
Screens ensure
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Drug screens ensure contingencies are provided consistently
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i. good behavior (abstinence) is always rewarded
ii. while bad behavior (drug use) is always consequented
Use can receive a consequence right away
Abstinence can be rewarded right away
Drug screens alleviate caregivers having to make judgments of
youth’s truthfulness
Note on Adulterants: Products are readily available on the market and are constantly
being produced and modified to mask the presence of drugs in urine. To find out more
about these agents, consult the National Institute on Drug Abuse website
(http://www.nida.nih.gov) or a local laboratory.
Teaching Caregivers to Test
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Before collecting the sample:
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1. Take everything out of the bathroom that the youth
could potentially use to alter the urine specimen
(cleaning solutions, any containers, medications, etc).
2. Place dye in the toilet bowl and in the top of the tank.
3. Tape water faucets so that they cannot be turned on
without breaking the tape.
4. Place youth’s name and date on the cup.
5. Ask the youth to remove jacket or bulky clothes that
can conceal objects, as well as turn pockets inside-out.
6. Put on disposable gloves.
Teaching Caregivers to Test
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Obtaining the urine specimen:
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1. Ask youth to provide the specimen with appropriate
supervision (stand at the doorway facing out – close
enough to be able to hear any suspicious activity).
2. When youth has provided the specimen, have him or
her replace the cap.
3. Take the specimen from youth and place on a flat
surface; make sure the cap is on tightly.
4. Read the temperature strip on the cup and ensure
that the urine is between 90 and 100 degrees.
Drug Testing Schedule
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Determine frequency of drug testing
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Individualize
Regular & Random
High risk times
Indicated
Sufficiently frequent
Average detection times
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See Table on Next Slide
Average Detection Times
Drug
Amphetamines6
Urine Detection Time
2-5 days
Barbituates (Short-Acting)
2 days
Barbituates (Long-Acting)
3-4 weeks
Benzodiazepines6
Cannabinoids (THC, Marijuana)3, 6
Varies by type of drug, many are 7-10 days
1x only = 5-8 days; 2-4x/month = 11-18 days;
2-4x/week = 23-35 days; 5-6x/ week = 30+ days;
Daily=30+ days
Clenbuterol (illegal weight loss drug)
4-6 days
Cocaine3, 6
1-4 days
Codeine
5-7 days
Euphorics (Ecstasy, Shrooms)
5-7 days
Ketamine (Special K)
5-7 days
LSD - ACID
7-10 days
Methamphetamines3, 6
5-7 days
Nicotine (Cigarettes)
4-10 days
Opiates6
5-7 days
Phencyclidine (PCP)
2-4 days
Phenobarbital
10-20 days
Propoxyphene
6 hours to 2 days
Steroids (anabolic oral)
14-28 days
Steroids (anabolic injection)
1-3 months
3Tested
in most 3-panel urine drug screens; 6Tested in most 6-panel urine drug screens;
Adapted from American Association for Clinical Chemistry (1988).
Additional Resources
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General Resource: www.nida.nih.gov
Integrated Instant Test Cups and Alcohol Breath Scans:
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ushealthtests.com
www.btnx.com
www.uritoxmedicaltesting.com
www.floridadrugscreening.com
www.varianinc.com
www.drugtestsystems.com
Parenting Your Out-of-Control Teenager: 7 Steps to
Reestablish Authority and Reclaim Love by Scott P.
Sells (esp. Chapter 2: Writing an Ironclad Contract)
Common Dilemmas
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Caregiver: I don’t know if I agree with giving him rewards. He has caused so many problems in the past he should just
do what he needs to do.
Therapist: That’s a common response I hear from parents who have been hurt by their teens’ behavior. One way to
look at it is this: the contract program, although it will be critical that you are involved, will actually take some
emotional pressure off of you. It will be up to him if he earns the reward, so you will not have to be the bad guy—it is
his decision. In this way, you’re teaching him that good behavior is rewarded—he needs to stay clean and follow your
rules to be rewarded—and there are immediate consequences for negative behavior—using drugs and not following
your rules. So, you are preparing him for adulthood, where he will learn to take responsibility for himself.
Caregiver: So you’re telling me that you want me to pay off my son for staying off of drugs when he just shouldn't use
in the first place?
Therapist: That’s an excellent question and is a concern many parents have. Getting off drugs is a very difficult thing
to do for adolescents because the drug use makes them feel good. So in order to overcome this "good feeling" we
have to develop an incentive that’s more rewarding than the good feelings they get from the drugs. This way, when
your son is confronted with the option to use drugs, he’ll choose to stay clean to earn the incentive, instead of using.
As you will see, we won’t reward him forever, but we need to start rewarding him for being clean so that he can get
himself off of the drugs. Also, don't think of it as paying him off because he must work very hard to earn these
incentives. So whether or not he earns them depends on if he is willing to put in the hard work.
Caregiver: Well, shouldn’t he just stay off drugs so that he’ll graduate school, not go to prison, and that sort of thing?
Therapist: Great! You’re bringing up the most common concerns right up front! We’ve found adolescents don’t seem
to be very affected by consequences that are farther into the future. Perhaps it would help to think of it like this:
imagine if my boss told me I need to do my work, but that I won’t get paid ‘til next year. Perhaps I’d stay motivated for
a few days or weeks, but I’m fairly certain I’d quit doing my work and start goofing off & having fun instead!
Caregiver: Why do we have to write this all down and have a “contract”?
Therapist: By having a contract, we will all be on the same page. That is, everyone will be aware of the expectations
for Jake and for Mom. We will all know that drug use (and other problem behaviors) will be regularly assessed and
when and how incentives will be provided. By establishing clear expectations we minimize the chances of confusion.
You can think of it like you would think of a contract for a job—the contract lists the expectations for you (such as
showing up on time and working a certain number of hours), as well as for the business (such as paying you a certain
amount, keeping you safe while you’re at work, and so forth).
Contact Information
Ashli J. Sheidow, Ph.D.
Family Services Research Center
Department of Psychiatry & Behavioral Sciences
Medical University of South Carolina
email: [email protected]