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Caregivers' Skills Program


Even though the Caregivers' Skills Program is highly effective, some target behaviours may resist change. Two of the most resistant behaviours are aggression and lying. To deal with these tenacious behaviours, a powerful technique called Reinforcement Removal (RR) was developed. If RR is added to the CSP, even these difficult behaviours can be quickly brought under control,


Reinforcement Removal is the technique of taking away material reinforcers for a long period of time. For younger children the loss may be a week; for older children the loss is for longer periods of time - a month or even a year.

For example,

Alison has been told that her favourite doll will be taken away for a month if she tells a lie again. Her mother notices Alison playing outside with her brother and beginning to argue with him over who's to play with the ball. Billy grabs it from her hands and Alison runs in the house yelling, "Billy hit me."

The correct response is, "Alison, you just lied. I was watching and Billy took the ball away from you, which is his in the first place. He didn't hit you. You know the consequences. Please bring me your doll now. How long did I tell you you'd lose it?" It is a powerful technique that should be reserved for more difficult behaviour problems, such as Alison's lying.

Using RR Correctly

Time periods that work best for RR depend on age: a week for three- and four-year-olds, a month for five- to seven-year-olds, and a year above the age of eight. It must be used precisely. The pattern of behaviour that will occur following this loss is similar to ignoring, that is, the target behaviour will get worse, new target behaviours will appear, and eventually the target behaviour will return for a brief period. RR is an extremely strong approach and for that reason is best reserved for times when everything else has failed.

Here's how to implement RR:

1.    Make a list of at least seven objects and activities that are most important to your son or daughter. Examples are using the telephone to talk to friends, riding a bicycle, playing video games, listening to favourite CD's, watching a favourite TV show, going to the movies, or going camping. Do not choose things that are impractical to take away, such as reading.

2.    Prioritize the list, with number (1) being the most important to the child and number (7) also being very important but the least important on the list. Remember, if an item is not important to the child, this won't work.

3.    Explain to the child that if he engages in a serious act such as aggression, he will lose an item for a long period of time. For example, "Ricky, if you hit your sister, or anyone, you'll lose your bicycle for a month. If you do it again remember the other items on our list." This may be strict, but remember a behaviour such as aggression is so dangerous that it calls for strong measures.

This method has been successfully used with aggressive teenagers - some referred because their aggression had reached very dangerous levels.

4.    Begin with the loss of item (7) and for each act move up the list. Each aggressive act serves as an increasingly uncomfortable loss. Keep a record for yourself of the starting date as a reminder. This method has worked overwhelmingly well, even with extremely difficult cases - Greg, for example, whom we'll meet shortly.

5.    It's also important to have a backup if your child uses an item while it is confiscated. The back-up must be particularly strong and thus very meaningful. Two methods that work well are (1) to be permitted no contact with friends for a week and (2) to give away or sell the item. Use this only after the first method has failed twice and warn your child ahead of time that this will be the consequence.

Example: Greg

Greg was an eleven-year-old whose mother was feeling extremely guilty and desperate. She loved her child, but at the same time she "hated" him. Her boyfriend had also tried, in vain, to control the child.

Greg's mother was struggling financially, working extremely hard as a janitor, raising two younger children, trying to spend time with her boyfriend, and dealing with an HM-aggressive child. The stress was taking its toll on her.

We followed the Caregivers' Skills Program and in less than two months, without medication, brought all target behaviours under control except aggression. On a daily basis Greg's behaviours at home improved. He readily did as he was told, his poor-mes and whining stopped, he no longer nagged, and he stopped interrupting his mother's conversations. His schoolwork improved. He paid attention in class, completed all his work, stopped acting like the class clown, and was polite to his teacher.

However, Greg continued to lose his temper on rare occasions. Research with some cases of IA and HM children indicates that this pattern of controlling all behaviours except aggression does happen. There are several reasons for this. Other target behaviours occur frequently, allowing lots of chances for training new behaviours. Aggression typically occurs only on rare occasions, thus allowing few opportunities for training. In addition, loss of temper and violent rage are such powerful emotions that they are more difficult for a child to contain. This is why these stronger techniques are needed.

Aggression is actually very resistant to almost all forms of traditional treatment, which is why David Stein developed and researched the use of RR to deal with it.

Greg's aggression occurred only about twice a month. He would use his fist to hit other children or even his mother, sometimes with an object in his hand. Once he broke a pool cue over another boy's head.

Reasoning with Greg about his aggressiveness failed. He promised repeatedly to do better but did not. Promises to behave better with aggressive IA or HM children are quite common and indeed the children are sincere when they promise. However, for the reasons just given, they often do not succeed and need the help of RR to add more incentive. With Greg they started the RR program. Each aggressive act meant the loss of an item for one year; dates were recorded in a notebook. His mother listed the following seven items:

1. Dungeons and Dragons game

2. Guitar playing

3. Watching television

4. Riding his bicycle

5. Calling his friends

6. Going to the movies

7. Eating candy

If he was found using an item when it had been taken away, he would then not be permitted contact with his friends for one week. This is a strong backup technique.

Stein knew this would be a difficult case because Greg's mother had a history of inconsistency. Greg expected his mother not to follow through with her threats. (Her inconsistency had already bred persistency.)

The aggression persisted through the first six items. His mother managed to carry out the contingencies to the letter. Finally at item (1), the aggression halted. Now, most children stop the aggression after the loss of three items.

Several weeks later in a follow-up session, Greg was crying happy tears. His mother's boyfriend had bought him an expensive pocket-knife as a gift, and they had started going fishing together. Greg had never been treated this way.

Generally, for children below the age of five, the CSP - the combination and judicious use of time out and social reinforcement - control aggression extremely well. From the age of five through age twelve, the CSP alone works less well for aggression, so RR may have to be added at that point.

Whether the method of discipline is ignoring, time out or RR, do not forget to actively reinforce your child when he is behaving well. If you want to keep your IA or HM child away from Ritalin, this point cannot be emphasized enough. Discipline suppresses the target behaviours, but learning new and more appropriate behaviours requires very active social reinforcement. Be a bona fide hugger and kisser.















Acknowledgement: The content of this program is based on Ritalin Is Not The Answer: A Drug-Free, Practical Program for Children Diagnosed with ADD or ADHD by David B. Stein, PhD (Jossey-Bass, 1999 paperback)