Contingency Management (CM) with Adolescents & Their Families

1. 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)

2. Background for Today’s Training • Strong empirical evidence for the use of CM in adolescents • e.g., Azrin & colleagues, 1996, 1994, 2001 • Cognitive Behavioral Strategies • Identify triggers of drug use • Manage triggers • Develop drug refusal skills • Behavioral Strategies • Monitored drug use • Incentivize abstinence

3. Point-and-Level System • Incentives for abstinence and disincentives for use • 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

4. Start with the Carrot • Step 1: Identifying Motivational Items • Potential rewards that are motivating for THIS youth • Items • Activities • Privileges • Do not necessarily have to cost money • Rewards list: • Generated by the youth • Edited by caregiver & therapist • Procedure: • Provide examples • Generate list • Rank order

5. List of Potential Rewards

6. List of Potential Rewards (p.2)

7. List of Potential Rewards (p.3)

8. List of Potential Rewards (p.4)

9. Reward Menu • Step 2: Edit the List of Potential Rewards • Caregiver determines final list of rewards • Each reward must meet 4 criteria: • 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.

10. Monetizing Rewards • Step 3: Assign Points to Rewards • 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"

11. Make It Personal • 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 • Possibly use “Base Points” • Assign points to each desired behavior • 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

12. Take It to the Bank • Step 5: Track points • Checkbook System • Graphing System • Run “what ifs” on the plan

13. It’s Showtime! • Step 6: Sign the Contract • Step 7: Implement the Contract • Step 8: Revise the Contract

14. The Proof is in the Pudding • Drug screens ensure we are accurate • We usually can’t observe the youth’s drug use • Screens ensure • i. good behavior (abstinence) is always rewarded • ii. while bad behavior (drug use) is always consequented • Drug screens ensure contingencies are provided consistently • 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.

15. Teaching Caregivers to Test • Before collecting the sample: • 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.

16. Teaching Caregivers to Test • Obtaining the urine specimen: • 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.

17. Drug Testing Schedule • Determine frequency of drug testing • Individualize • Regular & Random • High risk times • Indicated • Sufficiently frequent • Average detection times • See Table on Next Slide

18. Average Detection Times 3Tested in most 3-panel urine drug screens; 6Tested in most 6-panel urine drug screens; Adapted from American Association for Clinical Chemistry (1988).

19. Additional Resources • General Resource: www.nida.nih.gov • Integrated Instant Test Cups and Alcohol Breath Scans: • 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)

20. Common Dilemmas • 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).

21. Contact Information Ashli J. Sheidow, Ph.D. Family Services Research Center Department of Psychiatry & Behavioral Sciences Medical University of South Carolina email: sheidoaj@musc.edu