Thursday, September 4, 2014

Multifaceted plan for 9 yr old

I've had a number of questions over the years about when to use rewards and also about dual diagnosis. I've been working with a boy (with multiple issues) and his mother for the last six months in my office, and wanted to share some approaches that have been helpful.

First of all, he had psychological testing to evaluate his learning disability (LD), and we suggested modifications in school to help lessen his stress and anger in school.  Mother also recently hired a reading specialist to help him twice a week after school.  In addition, a pediatric psychiatrist was contacted, and the boy recently started on ADHD medication.

During the last six months while the evaluation was going on, we began to work on his anger overload issues. Anger would erupt around turning off a computer game, starting homework, or doing his chores.  The themes had to do with schoolwork (which activated his frustration with reading) and with tasks that he was not expecting and that he did not like having to do.  We worked on a schedule together (so he could predict when chores would occur) and also a "mantra," or saying, that he would practice repeating to himself when he was frustrated:  we chose the saying "crap happens."  We chose these words because he felt it was "cool" to use those words, and because it captured the idea that not everything is easy or predictable.  We want him to learn to expect that things will not always go the way he wants.  We also established a "chill space" in his room.  If he went there either on his own or when cued by Mom, he would later receive a lot of praise.  If he did not "chill" but continued to rage, his mother tried to ignore him the best she could until he was calmer.

When there was a conflict with the babysitter (because she made him pick up toys that he said he had not used), we empathized later with his frustration, and talked about how people sometimes look at things from different perspectives.  We talked about how the babysitter did not see who played with the toys and just wanted things picked up before everyone went home, while he felt the other children made some of the mess so should help more.  It was difficult to talk about the issue calmly, and we stopped talking about it when he started to get wound up.  We will try again to talk about different perspectives that people have when similar issues come up in the future.

Recently, the boy protested going to tutoring, and got into a heated argument that led to pushing his mother. In our therapy session, we set a firm limit about physical contact with adults and talked about a significant consequence were it to happen again.  We explained that voicing his displeasure in a loud way would not trigger the severe consequence, just pushing, hitting or kicking.  Since then there have been no further incidents of pushing.  Notice that we did not punish anger per se, just the physical expression of it.

His anger outbursts have been lessening, and we decided to add a reward for his cooperation with the reading specialist.  He earns a small amount of money each week that he can use toward a purchase of his choice in the future.  He wants an action figure, and is saving up for it.  The reward is for cooperation, and at the same time eliminates a source of anger in the past.  Rewards can work when the frequency of angry outbursts has been lowered already with other strategies, and when the target is socially appropriate behavior that prevents anger from arising.  We did not establish a reward for never exploding verbally, because this would be too difficult and would probably lead to more frustration.  Hope this gives you some idea how to apply strategies (that I  discuss in more detail in other blog posts and in my parent's manual) and when to use consequences and rewards,

David Gottlieb, Ph.D.

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