The POWER of Clinical History in Goal Setting | Counseling Secrets

Hi, and welcome to another presentation by allce.com this is, as you can see, another one of our live interactive presentations. So in the next few minutes, I'm going to ask for your name and your email address. Those won't go public. That's just so that we can send you an email when this is done in case you want to sign up for CEUs. All right, so today we're going to talk about behavior modification and treatment planning, looking at motivation and reinforcement. Now, since we only have an hour, I really focused on one case instead of focusing on multiple cases. And we're going to open up to a roundtable discussion probably next week or the week after. Anyone who wants to participate using their own case studies and really examine things that you're working on in context. So I'll talk about that more at the end of the presentation, but for now, let's move on. Whoops. I think I went too fast. There you go. Okay, so what is your name? Those of you who've been here before know that you just type in your first name and your last name. Pretty simple. That way, when we keep the logs and if your board ever questions who was participating when and whether they were actively participating live, we can pull up the log showing your responses and linking to your name and email address and all that happy stuff so we can prove to them that you were live and you were here. All right, next one is that email address. And like I said, this doesn't go out to anyone but us. So this isn't being published somewhere where people can. The general public can see your name and email address. All right, while you're finishing those, I'm going to move on to the objectives because we've got a lot to cover today. So we're going to review case examples to identify potential reinforcers and discriminative stimuli that motivate behavior. We're going to examine events in a chain leading up to the behavior, and we're going to identify alternative reinforcers and discriminative stimuli to alter the chain. So, for example, you know, we'll just give you a real easy example. Most days, Jim Bob gets up, he eats breakfast, he goes to work, he has an adequate day. Whatever happens, he drives home, he eats dinner, watches some tv, and goes to sleep. But every once in a while, he gets up, he eats breakfast, he goes to work, has a bad day, goes to the bar after work, and then comes home and passes out. So what happened in that chain? And I gave you a hint. He had a bad day. That Altered the course of events in his daily chain. So we're going to look at that more specifically in a little while because obviously we can't just say, well, Jim Bob, you can't have bad days anymore. We need to look at what's going on now. It's important to note that while a strict behaviorist would attend to external, observable, observable, measurable events, in these cases, we're also going to talk about the internal experience of the individuals. We're going to talk about how they feel and kind of what their thoughts are, maybe. So I just want you to know that there is a bit of a separation. A strict behaviorist would just deal with what is observable and measurable. So today's terms, reinforcement increases the likelihood of a behavior by adding something positive. Remember last week we talked about positive reinforcement. So you can give somebody a paycheck, you can give them a reward. Or removing something negative, taking away something they don't like, if they don't want to have to pay bills, if they want a break on their taxes, if they don't want to eat their vegetables, anything like that. Punishment decreases the likelihood of a behavior by adding something unpleasant. Can't think of anything besides spanking right now, and that's not really a good suggestion. Or taking away something positive, taking away video games, television, grounding, time out, those sorts of things. So moving on. Discriminative stimuli set the occasion for a behavior to occur. Have you ever noticed that sometimes kids behave differently at different places? My son, when he was in preschool, the child, I swear he was afraid of water. He would not wash his hands. I have him go take a bath, and I'm like, did you actually get wet? And now or then I would take him to school and I'd pick him up. And there was one day I picked him up, and I was waiting and waiting, and his teacher said, oh, he may be in the bathroom washing his hands. He could be in there all day if I don't get him. I was just like, excuse me, what? My son actually. Water and soap? Are you serious? The question was, what was different at school that we didn't do at home or we did do at home that he was just like, well, whatever, I don't need to use soap. Another example is when your children go to different places, the discriminative stimuli set the occasion for their behavior. And sometimes it's a place, sometimes it's a person. They may act the same way at grandma's house as they do when grandma comes to visit you, but you have to look for what's setting the occasion for their behavior. My daughter, when she was much younger, spontaneously got a tummy ache every time it was time to do chores or lessons or anything else she didn't want to do. She had a lot of belly aches for a while. Now, I could reward that by going, oh, you know, you poor dear. Let me take care of you. Now. She was young enough. I wasn't able to tell whether she truly did have a tummy ache or not. So I compromised. I said, okay, well, if you've got a tummy ache, why don't you go lay down in your room? We're not going to lay down and watch tv. You're going to lay down in your room for about 30 minutes, then I'll come check on you. And when you feel better, then you can do your chores. So it didn't get her out of doing chores, and it wasn't replaced by anything fun. Dogs barking. My dogs, oh, my gosh, bark all the time. So this is another one, discriminative stimuli. Dogs naturally bark when somebody comes to the door. My dogs bark when somebody comes to the door, when a leaf blows in front of the window. Sometimes I think they're just seeing things. The stimuli are setting the occasion they're trying to protect, and that's becoming generalized to anything that catches their attention. They're going to let me know about the phone ringing and we're going to move on in a minute. But I want you to realize that discriminative stimuli are pretty varied in what they can be. Temperamentally, I am very structured. I'm a J on the Myers Briggs. I'm, like, pegged out J. So I don't deal well with changes in schedule or changes in routine. So when the phone rings, it's a little stressful for me because it's like I didn't plan on somebody calling. Yeah, I know. Why do you even have a phone? I question that sometimes, but I digress. When I volunteered at the crisis center when I was in college, this was, you know, way long time ago. I would do the overnight shift. And number one, it was stressful being there overnight because you were there all by yourself, but you would be there all night long trying to stay awake. And then you knew that whenever somebody would call, it was 99% of the time going to be somebody that was in crisis or suicidal. So you knew you had to be on. Well, over time, that got to be a little bit stressful. So whenever I would be anywhere Where a phone would ring and it would sound like the phones at the crisis center. My stomach would jump up into my throat. I remember distinctly walking through Penny's one day and one of their phones rang and I was just like, oh no. So we want to look at people's temperament and what causes them stress. And you know, again, a true behaviorist would be like, yeah, let's look at observable and measurable and we could break it down, but that would take way too long for today. And spiders, spiders for some people, I don't like the. Really? I don't like the ones that have the red dot on them, you know, obviously, because they're generally poisonous. I love jumping spiders though. That's a discriminative stimuli for me. If I see a little spider that looks like a jumping spider, he's walking like one and kind of furry and black, I think he's really cute. If I see one that's kind of brown and long and lanky and I think brown recluse. Now those of you who know anything about spiders, you're going, there's like a bazillion long lanky brown spiders out there. I know that, but I can't discriminate between the non harmful ones and the harmful ones. So for me, any big brown lanky spider gonna be something I'm not gonna go near except for maybe to help it outside because it's not his fault he got in my house. Oh wow. You're just going to have to go on these trips with me today. So the first question, what discriminative stimuli might cue an anxiety reaction in a person? Now remember, anxiety you can generally think of as fight or flight. So you're going to have something of an adrenaline dump. A police siren, when we're working with people who are new cops, they get this huge adrenaline dump when they get to run code and it's like, woo hoo. Over time they desensitize to that. Desensitize to the police siren. Now if you have a habit of getting into trouble, then a police siren might indicate to you that, oh crap, I'm going to jail again. Okay, I'm getting a lot of people a knock on the door. If the people who are knocking on your door are bill collectors, or if you're a child and you're home alone and somebody knocks on the door, or you're a child and you're home alone and you see a spider, you might have an anxiety reaction. And that's your body saying prior learning tells me that this is not good. So we want to look at what causes anxiety for that person and why. And is it the same in all situations? If you're at your Grandma Susie's house and somebody knocks on the door, do you care? Probably not, because they're there to bother Grandma Susie, not you. If you're a child and there are other people in the house and somebody knocks on the door, you may be like, well, the grown ups will get it. Whatever the. Let's see the phone ringing. A spider. Okay, children, front and center. Yeah, generally, especially in my house, if you hear that, you should have a little anxiety because that means I'm not happy. That's a discriminative stimuli that indicates that mommy's either not happy or we're in a rush and I need you to be present. So there are a lot of those things. Last page of terms. Vulnerabilities. They may intensify a reaction. And in dialectical behavior therapy, they talk a lot about vulnerabilities. So let's think about things that make your anxiety reactions worse or depressive reactions, or just reactions in general. Not enough sleep. If you're sleep deprived, if you have had a lot of stress, at a certain point, you just can't take no more. If you're sick, if you're in pain, if you just get up on the wrong side of the bed. And you know, it happens sometimes. So some people may be more irritable, some things may predefine, predispose you to being more irritable. Now, on the flip side of it, vulnerabilities don't always just make you more irritable. They may make you more vulnerable. We all know about the rebound relationship. You see something in someone and you're like, oh, you know, the person I just left was such an idiot. And this person is just the cat's meow. You're overlooking things or you're focusing on the good things and really blowing them up. Just like sometimes you focus on the bad things and really blow them up. So vulnerabilities are those things that alter the way we perceive and react to discriminative stimuli. Now we talk about generalization. And I said earlier, some people, they get bit by a spider once or they hear about somebody who's bit by a spider, and then every spider they see after that is bad news and they become arachnophobic because they're terrified of all spiders. Children can generalize a lot of things. And one of the things that we also know is that people generalize things about children. If you've ever been in a family that has multiple children and gone through the same school system or been a teacher, you may know that sometimes, not always, people expect behaviors out of you based on the behaviors of your siblings. Oh, here comes those Smith kids again. Or Johnny, I'm surprised you're not getting this. Your sister and your older brother took to it right away. What's wrong with you? So generalizing expectations based on family, based on hair color, based on where they live, based on how they dress, based on what school they go to, whatever. Those are discriminative stimuli that say, okay, this person fits in this group. So I'm going to think these things. And we have to really watch that because as we well know, that it doesn't usually work very well. Desensitization. We know about how people work to desensitize themselves to spiders. First they think about a spider and learn to calm themselves down. And then they experience a spider from across the room in a glass jar. And then they learn to calm themselves down, and gradually they work up to maybe holding a spider. Dogs. If dogs stress you out, then you may have to do the same thing. Now, if you're working with dogs who have generalized behavior, you have to help them understand what's appropriate to bark at and what's not, so they know to discriminate. Oh, the lady running down the street every morning is going to happen every morning, and she ain't going to bother me. For me, the phone, you know, I only generalized that one phone sound, but it was when I heard it any different place. Now, over time, I've gotten used to it, and when I hear that phone sound anymore, thank goodness most phones don't make it. I'm like, oh, yeah, I remember that sound, but it doesn't elicit the same reaction in me. So you need to look at what's causing the reaction. Is there a legitimate reason for the reaction, and is there a way to sort of hone it down? So, like, for me, snakes, and I'll move on past this in a minute, but I don't mind black snakes because they keep away the rattlesnakes. And, you know, I'm not going to go up and pick one up and be its best friend or anything, but that's just because I don't know about snakes very much, but I can discriminate when I see them in the wild, and I can be like, oh, that's a garter snake. No big deal. You know, you look for the diamond head, and if you see that, then you back away sometimes really quickly. Help people discriminate what things are worth getting upset about and what things aren't. And for those things that aren't, they need to learn to control their reaction. Because after you've experienced for me the snake a few times, now I see it and it's no big deal because my learning has taught me, oh, the little green thing stunning itself in the middle of the path, not a big deal. He doesn't care about me and I'll just leave him be. So what does this mean to anything? We're getting there. What vulnerabilities might intensify a reaction in one of your patients? Detoxification is one. And I will tell you that in the first week or two weeks of residential treatment after somebody got out of detox, people are often in a fog. So we want to help them see that they may not be learning to make the right connections and they need to be conscious of what choices that they are making. If they're experiencing lots of other stressors, then certainly they're going to at a certain point, run out of energy. You can only deal with so much if you're sleep deprived, whether it's because the neighbors downstairs had a party last night or you've got a new baby at home, or the neighbor's dog down the street was barking all night long. It, it doesn't matter why you're sleep deprived. If you are, just know that you might react differently or more intensely one way or another to different discriminative stimuli. Lack of social supports. It's a whole lot easier to deal with things if you can call up your friend or walk to the next cubicle and go, okay, this is bugging me. Am I crazy? Social supports help. They help us bounce ideas off and really get a more three dimensional picture of what's going on. And they help us relieve stress. That's one of the biggest things that helps people relieve stress and buffers them against stress related illnesses. So you really need, when you're talking to people, you want to look for commonalities between situations in which the behavior occurs. You always lose your temper when and virtually no behavior occurs. Always. But as you'll see in the example, people like that word. So let's look at the discriminative stimuli. You always start drinking when you use cocaine. You always get upset when your husband doesn't call and let you know that he's not going to be there for dinner. You always, okay, you see how it goes. So let's look at some commonalities where they know they get upset. And then we're going to look at some of the situations about when they don't get upset. Has it ever happened that you've been planning dinner and somebody hasn't called and you didn't get upset? Has it ever happened that you used cocaine and you didn't end up drinking? Let's look for exceptions and see what was different for a lot of people. They'll say, well, I don't drink in front of my children. Well, okay, guess what? You're going to spend a whole lot more time with your kids now. You want to increase the exceptions. One of the other things that you can do that provides people a sense of forward movement is start looking at those vulnerabilities. You always react more strongly when you're overtired. Okay, so that's an easy one. We need to figure out how to get you more rest. You may not have more time to get rest, but let's see if we can improve the quality. Even giving people something to do, even if it's something small, gives them hope that things might change. And we know that 90% of change is perception. What vulnerabilities for anxiety could you easily address in a treatment plan? So we're talking about vulnerabilities. Sally says she's anxious all the time. So we talked about what some vulnerabilities might be. So what are some things she could easily address to give herself some buffers? Avoiding stimulants would be one too much caffeine, decongestants, anything that might tend to just naturally hype her up and make her feel a little bit more anxious is going to be something that we can look at. Making sure that she's eating. Thank you. Good nutrition. Making sure that she's eating frequently and well so her blood sugar's not doing this. Because we know when people get low blood sugar, a lot of people get the shakes and they get confused and it's hard to make decisions. Well, what happens when we get anxious? Sometimes we get the shakes and we get confused and it's hard to make decisions. So your brain's going, blood sugar, anxiety, blood sugar, anxiety, I'm going to be safe. And we'll go with anxiety. And if it's blood sugar, you know, no harm, no foul. So we want to make sure that our body can interpret what's going on and that we interpret what's going on. Exercising regularly, exercise is a wonderful way to help people get rid of some of that pent up frustration and stress that they've just kind of sucked in all day long. Give them things to do to help them relieve their anxiety. When you get anxious, try combat breathing, mindfulness meditation, journaling, Calling a friend. Oh, calling a friend. Hey, let's talk about those social supports that you mentioned on the last slide. Okay, so all of these are not miracles, but they're all things the person can start putting in place in order to feel better. So we're going to talk about some examples in the animal kingdom. Rabbits and other prey animals. I fostered rabbits for a while, and bunny rabbits will not appear injured. They pretty much look healthy until they kick off. And it makes sense because in the animal kingdom, they've learned kind of through evolution, if they look like they're injured, then the predators go, oh, there's an easy mark. So the predators will go after the slower, sicker, older animal. Killdeer. Adorable little animal when it's not constantly in your backyard. But one of the things it does to protect its nest is it will pretend it's got a broken wing and it will walk away from the nest to lure the predator away. So it takes that stuff that the rabbit learned. He said, oh, if I look injured, then it's going to chase me. And it says if I look injured, it's going to chase me and it's going to leave where my babies are. So it acts injured and then lures the animal away and flies off and everybody's happy and the predator didn't get a meal. That's how I like to see it. Chickens and eggs. Oh, my gosh. For the longest time, I thought they were just announcing that they did a good thing because when my chickens and my ducks would lay an egg, they just, they cock a doodle doo like crazy. Well, they don't cock a doodle do because that's a rooster. But when I ended up reading about it, what I found out was in the wild, back in the BC times, when there were wild chickens, the flock would look for food and everything away from the nesting area for the same reason that the killdeer acts injured. They don't want predators going near the eggs and the nesting area. So when the chicken would get finished laying an egg, she would get off. And what she's doing when she sounds off is she's calling to her flock, saying, where you at? I'm done. Where you at? We figured out that's how we find our ducks eggs now, because for some reason she doesn't want to lay in the nesting box. She just lays arbitrarily in the yard. But whenever a teenster starts running through the yard going, wah, wah, wah, wah, wah, wah, we know that there's going to be an egg out there somewhere. It's just finding it. And then Kenny, my dog, learned that when I would get irritable if he jumped around like crazy, guess what? It would stop. Now, it took me a whole lot longer to learn this. So I would come home and I'd be stressed out or something and Kenny would bounce off the frickin walls and it would make me so angry. And I'd be like, kenny, stop it. And I'd pay attention to him to get him to calm down, and he'd calm down. Well, lo and behold, he learned that since I am the pack leader, he doesn't want me to get upset. And he also doesn't like it when there's tension in the house because he's a very receptive little lab. So he would jump around and act crazy. We finally figured it out to the point where as soon as he started jumping around, one of my kids or my husband would be like, kenny thinks you're stressed. Tell him it's okay. And all I had to do was tell him, kenny, it's okay, buddy, come here. And he'd be fine. Yeah, I told you, I'm a little high strung. Anyhow, so we see it in all levels of animals, even below humans on the evolutionary ladder. So case one, Johnny is 4 years old and his mother comes in and she says he is acting out all of the time lately. Okay, well, yeah, we'll talk about that. What questions? Now think back to last week. What questions do you need to ask to better identify what your goal is for treatment or the treatment plan? Remember, good goals are what? Observable, measurable. Observable, measurable. Time, limited and achievable. So where do you want to be in a day? And how will you know if you made it? Okay, that's a good where do we want to go? Statement. So tell me a little bit more about what in particular, about Johnny's behavior is causing you the most distress. Okay, so in terms of Johnny, we might say, what and when do you see are his strongest reactions? Can you identify for me specifically what you need or want to change? Okay, those are all some great suggestions, so let's move on. So I ask, in order for me to understand what makes Johnny tick, I need to get a little bit more information. So he was born eight weeks premature. I'm going to file that back in my memory because that means there could be Some developmental stuff or some sensory stuff that needs to be dealt with? Maybe, maybe not. Overall development has been adequate. He's doing fine in school. On a typical day, he goes to preschool, comes home, has dinner, a bath and goes to bed. He interacts with his dad, his mom and the kids at school. Mom says those relationships are fine, although he says he hates me, but. Okay, so again, file that back there. She just threw in the he hates me. Is there a family history of mental health or addiction issues? No. Okay. Not that we can rule out ADD or bipolar or depression or anxiety or anything like that, developmental delays, but we know that there's really not a family history that we're looking at right now. So let's move on. When did it start? About a month ago. Okay, what are some recent changes? Oh, he had a new baby sister. She's two months old now. That might give you a clue. There's a huge change for grown ups and for children when you have a new child added to the mix. So what do you do when he acts out? And mom says, I either ignore it or I go try to talk to him, but he just tells me he hates me and goes away and to go away. So let's look at it. If you ignore it. Well, one would say eventually it'll be too much trouble for him to act out. But ignoring it may still not be meeting whatever that need is because that behavior keeps coming back. So. All right, that's not working. I go to try to talk to him, but he just tells me he hates me and to go away. What's the reward there? He's got control, he got parental attention and then he was able to say, oh, but I don't want it now. Now a four year old is not planning that out in his mind, but that's him saying, I am really angry right now and I needed your attention, but I don't have the words to tell you what's going on. Is there anything that seems to make it worse or better? I don't know. Okay, that's fair. A lot of times when you're in the mix of something, ferreting out what makes it better and what makes it worse is really difficult. So that's fine. If she doesn't know, let it go. So, okay, let's look specifically at Johnny's behavior. What exactly does he do when he acts out? Does he run around and bang into walls? Does he do somersaults through the living room? Okay, so he started throwing tantrums, which we talk about and learn that Means he sits on the floor and screams and pounds his fists into the floor. Fine. We can call that throwing tantrums. Now that, now that I know what it looks like, I can see Johnny doing it. He breaks his toys. Okay. And he cries. Okay, I know what crying looks like. So I'm like, okay. So I'm looking through this and I'm not seeing anything that's jumping out at me except for maybe the recent changes in the family situation. But a lot of kids get new baby brothers and sisters and this doesn't happen. So, you know, I just file this all in my head and I say, help me get a better picture of what was going on the last time this happened. Walk me through the entire day from the time Johnny got up until his tantrum. Why do I care about the entire day if his tantrum occurred at 8 o' clock at night? Because I'm looking for those vulnerabilities and I'm also looking for the differences. If he was fine at 2 in the afternoon, what changed? So she says his father got him up and made his lunch while he ate cereal and watched cartoons. His dad dropped him off at preschool on his way to work. He stayed at school all day and the teacher said he took a good nap. So in my mind I'm thinking, okay, sounds like a good day so far. Jenny, his baby sister and I picked him up and we went home. Okay, that's what probably going to happen. Jenny was hungry so I told him to go play with his toys while I fed her. Alright, not the first time I've heard that. His dad got home about 6:30 and I had not gotten dinner ready yet, so he went back out and got Kentucky Fried Chicken. Johnny wouldn't come down to eat, so I told Tom to go up and get him. Then bam. Johnny lost it. Tom is just over it with this stuff, so. So I went up and talked to Johnny and he calmed down some. So let's look at this a little bit from a behavior standpoint. His father got him up and made his lunch while he ate cereal and watched cartoons. What did we hear earlier in the assessment? He started telling mom, I hate you. Hmm. Okay, so I might ask there, is this what usually happens or is this different since Jenny was born? And she says it's different since Jenny was born because I'm up three times a night feeding her. And so Tom pitches in and helps out in the morning. Kudos to dad, however little. Johnny doesn't really understand what's going on and mom's not paying attention. Anymore. Dad dropped him off at preschool on his way to work. Okay, that's fine. He, he stayed at school all day and took a good nap. So we can rule out the vulnerability of being necessarily overtired. Now remember, children developmentally will go through phases where they need more sleep and they tend to be crankier. I know my children before they get sick. You know, real sick, not just a fake tummy ache will tend to get more disorganized and irritable. So that's one of the things you want to file away for exploration later. But right now it sounds normal. We're just going to move on. Jenny and I picked him up. There's that daggone sister again. Not only did mom not get up to help him get ready for school in the morning, but he can't even have her by himself when she picks him up from school. He was an only child. Now he's having to share. We know four year olds don't like to share toys, let alone mommies. So I'm starting to see a pattern here. They went home. Jenny was hungry, so I told him to go play with his toys while I fed her. So they got home, he hadn't seen her all day long. The little rugrat started to cry and he was sent to go play with his toys. He was kicked out. I don't know what word I'm looking for. And she paid attention to Jenny again. Okay, from his point of view, I can see where this is really starting to suck. Dad got home at 6:30. I had not gotten dinner ready yet, so he went back out and got kfc. Well, Kentucky Fried Chicken is pretty good. However, I might ask how Tom reacted to dinner not being ready because the dad gets irritable because he pitched in all day long and he came home, worked hard and then he still has to go back out into traffic to get the kfc. Not to play in traffic, that is. That might contribute to Johnny's reaction. We want to look at the whole picture, not just Johnny because there's a lot of other stuff. If he sees Dad's getting irritable, he can feed off that and go, well Dad's not happy because Jenny's doing all this. He's four, let's remember that. And then bam. Johnny lost it. So when Johnny wouldn't come down to eat, he got parental attention because dad went up to bring him down. He said no. And my guess is in prior events, and I would ask about it, this has happened before. He tells dad no and guess what happens? Mom comes Up. Jenny's still down at the table. Dad's left the room. He's got mom all to himself finally. But you know, he's angry. So what does he say? I hate you. Okay, so she talked to him, he calmed down a little bit and they moved on. So my first thought, now, remember I said not all of this stuff is observable and measurable developmentally. Looking at what's going on in this situation from Johnny, as much as I can get into a four year old's head, this seems pretty frustrating because his little world is turned upside down and he doesn't know how to control it. And a four year old generally doesn't have the words. And a four year old isn't able to see things in shades of gray. He sees it as mommy hates me or Mommy loves me. There's no gray in between. There's not. Well, Jenny's here, so now I have enough love for both of you. So we've got to figure out what to do because Johnny's feeling insecure. So what do you think? You ask mom, what do you think is causing this behavior? She says he's having difficulty adjusting to the new baby. Okay, she gets that. So tell me more about that. What's changed since Jenny came along? And then you have a discussion about how the routine has changed. She can't spend any time alone with him anymore. He's having to fend for himself more, those sorts of things. And then you start to find places where you might be able to intervene because it wasn't happening before Jenny. We know Jenny's not going away. So let's see what parts of pre Jenny we can put into the present. What other things have worked to help calm him down? We put him in time out or just told him to go to his room and play for a while. Does that help? Yeah, because eventually he just gets tired of being angry, but it doesn't solve the problem. So we're still going to have the outbursts. What is he like Curious George, reading books? All right, we can even read books about Curious George. So you see where my mind's going with this? I hope so. Ultimately, the consequences they give him that are maintaining this behavior. If I act out, the only way I get attention is if I act out, I throw a hissy. And again, this is a four year old. He's not thinking this, he's learning. If I do this, this happens. I remember when my son was about 18 months old, he, bless his heart, he was a little scientist and he knew good and well, not to touch grandma's tv, but he toddled right up there in his diaper and he looked at and he said, no touch. And I said, that's right, no touch. And he touched anyway, alright. And he says, time out. I said, yep, time out. So we walked over and he sat in the timeout chair and he got up and we were fine. After that he just had to make sure that the rules still applied at grandma's house that you didn't touch the tv. So earlier I said he knew good and well he probably didn't. So he was learning. He was generalizing that, okay, I don't touch the TV at home. Let me check here. Do I touch the tv? You said, no, but let me just double check. Let me touch it anyway. All right. So he got parental attention. That's the only way he knew how to get it. At that point he couldn't say, well, maybe he did say, mom, I want you to read me a book. And mom said, I'll do it after I finish giving the baby a bath. I'll do it after blah. I'll do it after blah. So he feels like he's getting pushed off. He needed attention. So at this point, negative attention is better than no attention. And he's trying to communicate something without words. Four year olds don't have the same vocabulary we do. So we need to look and ask ourselves, what was the benefit to Johnny of this behavior? Time out sometimes works. Why? Because it reduces the stimulation, gets him away from his sister. He has time to let that adrenaline go away, but his needs are still not being met. So likely in this particular instance, the time out is not going to be a good long term solution. We can modify that. And if he throws a tantrum, have him put in timeout and then process it with him and then try to move on from there. If he's sent to go play again, he'll probably just break his toys and get his aggression out some other way. So I send mom home and I say, you've got two things to do for homework. I want you to chart his outbursts, the frequency, how often. So I want you to write down the date and time it happens. I want to know the intensity. And I'm probably not going to tell her all these formal words. I'm going to say, write down the date and time he does it. Exactly what he does and how long it lasts. Are we talking two or three minutes or are we talking 20 or 30 minutes? I want to know where it happened. Is this just at home? That gives me some clues. Is this anywhere? If it's after 3 o', clock. A lot of kids have that post school meltdown. They've been good all day and they can't take anymore and they're just like, ah, four o'. Clock. How was the behavior handled? What did you do? Because then we're going to look and see if we're still rewarding that behavior and discriminative stimuli. What seemed to set him off so. So each time he acts out, she's going to fill in a worksheet with all these things and then I'll chart it when she brings it back to me, the other thing I want her to do. And because I found that generally if somebody comes to you and asks for help and you just send them off to gather data, they feel very disempowered. So this is not a true baseline because we are implementing an intervention. But you know we're going to. So I have her start working on a star chart and she gets a piece of poster board and writes down the things that Johnny would do every day anyway. Eating breakfast, getting ready for school, behaving at school, taking a good nap, helping with feeding his sister and reading a book, eating dinner, taking a bath. Those are all things he has to do anyway. But you know what? If you're going over them with them, it shows you're interested. If you're asking about them, it shows you're interested. If he's getting stars for them, he feels like he's doing a good thing because he is. So let's reward the good things because the more rewards he gets for the good things, the less time he's going to have to do the bad things. Maybe when you're feeding Jenny, you can have him playing on the floor in front of you and tell you about what he's doing and you can talk to him or maybe you can read a book together or watch a movie while you're feeding the baby. Something that might help him during that period right after school when he hasn't seen mom all day long, just to connect again, to see kind of where he's at. So this star chart again is really not putting anything more on mom because she's already pretty tired and dad's already pretty over it and pretty exhausted himself. So I don't want to put more stuff on them. We're just going to chart what's already happening and give praise where praise is due. It's amazing how much it helps. So why does this work? And I think I cut My nose off to spite my face. And I already answered this. Why does it work to give them homework when they walk out of your office? Even if we're not changing huge things and looking at the developmental issues that Johnny may be dealing with. Blah, blah, blah, blah, psychobabble. If we're just saying make a star chart and give him a gold star if he has a good day at school, It gives him the positive attention that he's craving and a sense of responsibility. I can do this. And then you can talk about how proud you are of him growing up and you know, how he's your little man or whatever, but it gives him a sense of responsibility, a sense of pride, a sense that you really still care. Thank you. Shows mom's paying attention. A sense that you still care what's going on in his little four year old life because it's still important and it gives mom hope. If you take mom and she's less stressed or dad, you know, I don't want it to just be on mom. But if parents are less stressed, the children tend to be less stressed and less reactive. That vulnerability there, if the tension in the household goes down, the reactivity goes down. He's happy when he does a good thing. Aren't we all? Even if it's something we know we should have done anyway. He feels like he can do something right because for the past two months all he's heard is, Johnny, don't do that, Johnny, don't do that, Johnny. I'll get to it later. Johnny, Johnny, Johnny. Lots of negative attention and shuffling off. So yeah, this works for both. It's rewarding. And again, it's important to remember you want to look at the entire system. So she comes home and she says, or comes back. And I forgot to change that. There were only three tantrums during the week, not two. But that's okay. Three is not bad because he was doing it all the time. So we say specific or generalized location. Two nights at home after dinner. So I'll say, all right, what was different about those two nights as opposed to the other five? Were you more tired? Was Jenny fussier? Let's talk about what might have been different and see what might be a vulnerability here. Not focusing on the person because we know Mom's a good mom. She's there. She wants Johnny to be happy. She just doesn't know why he's doing this. So, okay, let's solve the problem together. And one day when we were leaving, place group at 2:30pm so my question might be all right. Does he usually do this when you leave playgroup? Mom says, no. I said, okay, what was different this time? Mom says, well, it was Jenny's nap time and she was starting to get fussy, so we needed to leave early. Aha. Jenny's ruling the situation again. No, this is something again. When you're integrating families, whether it's a new baby or a step family, we need to make sure that the children don't feel like they're being pushed aside for another child. So we want to make sure that Johnny learns to love his sister and learns how to deal with her. We look at the time of day, it's occurring mid afternoon, evening and weekdays. Okay, so what's different about these three days? She said on those days, Johnny's dad and I were more stressed and tired. Jenny's going through that period where she's not sure if she wants to sleep through the night or not. So it's just exhausting. We feel like we're up all the time. Okay. It's exhausting and it's frustrating. Got it. But that makes mom more reactive to anything Johnny does, which makes Johnny feel more reactive often. Anything different in verbal behavior? Was anybody screaming, being condescending? No. Okay. The activities were somewhat governed by what Jenny wanted and what mom had energy to do. I get it. You gotta meet Jenny's basic needs. How can we do this and involve Johnny? He's four. Is there something that he can do to help you? Because I'm sure he would love to be able to be a helper. So we want to identify, normalize, and protect against vulnerabilities. State again, and I stated it several times today so far. He's four. He's not doing this intentionally. He's not going, you know, I want to be a brat because I'm angry at her. He's four. So how do we deal with a four year old? Not the same way we deal with a 14 year old. Developmental issues. He was premature, but by all accounts he's developing just fine. He was the firstborn, and as we've talked about, it seems like he's internalizing a rejection because Jenny's finally taken front stage and he's not getting any stage time, time of day. This didn't seem to really account in here. It wasn't first thing in the morning, but it was in the afternoons. So Johnny went through the day, got through things, said okay, going with the flow, and then he reaches his boiling point about the time most of us do, you know, 2pm and each time he acted out. It was after that 2:00 clock cutoff. So we say, okay. We know he may be more sensitive in the evenings and afternoons, so we'll just file that away to see if that continues to hold true. We want mom to continue charting because everything we do is going to have a kind of reciprocal fold in effect. It's worse on school days. Hmm, that's interesting. I wonder, and this is something to hypothesize and test, I wonder if it's because on the weekends he sees you all day long and on the school days he gets up and he goes to preschool and he doesn't come home until the afternoon. So he only feels like he gets this little window with you. Family functioning is stressed. It's a new baby in the house. It's a change. She's up and down and sleeping and crying and colicking. Who knows? Okay, that's a vulnerability. How can we protect against it? Is there a time where maybe Tom can take care of Jenny and you and Johnny can go out and do something? Is there something that you can set that will help Johnny feel less stressed? Is there something you and Tom can do so both of you feel less stressed? And look at other stressors, physical, social, emotional, environmental, anything that might be going on. Maybe grandma came to live to help take care of the new baby. That'll throw a whole new other kink in the works. Possibly. So just keep asking questions. There are multiple paths to Johnny having a meltdown. And most likely, unless you're really lucky, you're not going to choose the right path right away. But you can start putting little interventions in along the chain and saying, okay, let's see if we can make sure he feels like he's getting attention. If he will at least reduce the frequency and intensity of the meltdown. He may still have a tantrum in the evening, but can we reduce it a little bit? Can we head in the right direction? So the treatment plan, we want to reduce tantrums as we defined them earlier to less than one per week lasting less than 10 minutes. We're going to create structure that involves positive rewards for positive behaviors throughout the day. Johnny's four, so you don't want to wait until bedtime to go through the whole chart. Preferably you go through it before he goes to school. Everything up until that point, what happened at school, go through it after school and then right before bed. That puts less behavior strain. He's getting those positive rewards periodically. Spend at least 30 minutes with Johnny each day doing something positive, ideally just you and Johnny. But if it's you and Johnny and Jenny, wow, that's a lot of Js. Then make sure the focus is still on Johnny and maybe he's teaching his sister something. Talk to Johnny about what anger is again. 4. Remember again, my son, bless his heart, he's going to need therapy if he ever watches all my videos. He was about two and a half and he had come to work with me one day because I had to stop in for something and he was walking down the hall with me and you know, as little kids do when they've got a diaper on and everything and he just looks at me and goes, I so angry. I'm like, where in the world did that come from? Okay. But he identified a feeling inside of himself because we had been talking about it, you know, therapist kid, you got to. And he was able to verbalize, he felt a particular way. And then I was able to stop and go, okay, you're angry. Let's talk about why what happened? And you know, quite honestly, I don't remember why at the moment. I was just so proud he was able to appropriately verbalize his emotions. But you want to help him identify. This is what it feels like, this is what it is, this is why we have it and this is what you do with it. So let's figure out how to use your words when he starts to get angry. Validate his experience of anger and talk with him about what would make him feel better. So I hear you're angry. You shouldn't be angry about that. No, you don't want to invalidate him. You want to say, okay, I hear you're angry. Let's talk about why you're angry about it and what we could do to make it better. Not what I could do, what we could do. Or better yet, what you could do. Teach Johnny to identify things that make him angry so he can use his words. It makes me angry when the dog eats my food off my plate. Okay. And you know, four year old might shorten it to doggy makes me angry. But motivate him not to throw tantrums by allowing him to experience the natural consequences if safe and appropriate. If he throws a tantrum and pops the head off his favorite GI Joe and it's broken irreparably, don't fix it. That's what happens when you break the heads off your GI Joes. Now most of the time, obviously you want to keep him safe. If he's going to throw himself on the ground and beat his fists into the floor. Okay, that's a natural consequence. If he's safe and he's in the middle of your living room, you may choose to let him do that because guess what, his little fists are going to be sore the next day and it's still not going to get him anywhere. Giving him a whole lot of attention, saying, oh, come here, I don't want you to be sad. That just reinforces that behavior. So let him get it out in a safe way. If you need to give him a pillow or a blanket that he can use so he doesn't hurt himself, obviously do that. If you're in the middle of the shopping mall, probably don't want to let him do it there. I know with my son, the natural consequence when he would act out in Walmart was, okay, you can either straighten up or you can go sit outside with daddy by the wall. Now, he didn't like the heat and we lived in Florida, so most often he chose to straighten up. Find natural consequences. If you act like this, you can't stay in the store. So points to remember, there are discriminative stimuli for all behavior. And it's really easy. If you've ever written a relapse prevention plan or a treatment plan, it's really easy to overlook discriminative stimuli. So look and look and relook. If it doesn't seem like you're making progress. Anything can be conditioned to elicit a response. Pavlov had the bell. He would ring the bell, the dog would salivate. Normally, a bell is not going to make you salivate. When I was a professor at the University of Florida, I used to just mess with people and they'd come in and they'd sit down and I'd be like, okay, I want everybody to clear their desks. We're going to have a quiz. And I'd watch their eyes get big and their stomachs come up into their throats and they're like, oh, I didn't study. And then I'd say, ha ha. Just kidding. I just wanted them to see that the word quiz elicited a response. You say quiz to a two year old and they just look at you. You say quiz to a 22 year old get a very different reaction. Each living organism in the chain of events is likely to behave in a way that elicits reinforcement. So we can't just look at Johnny. We need to look at mom and dad and to a certain extent, whatever the baby's name is. Little Jenny, what is rewarding and reinforcing those behaviors and maintaining this chain. It's important that any changes in the system produce reinforcement for new behaviors for all organisms. If you're throwing a bunch more stuff on top of mom and dad to try to make things better for Johnny, guess what? It's not going to happen because it's not rewarding. So those are the things that we really want to start looking at when we're looking at reinforcers. Start with the easy things, reduce vulnerabilities, look at the discriminative stimuli, see if you can identify differences between when it does and doesn't happen, and try to make it more like the times it doesn't happen. That's where you want to start. Now, I said before. And for those of you who want CEUs, you can tune out now and we'll be sending you your email pretty soon. But for those of you who are interested in participating in a more in depth behavior modification and treatment planning workshop, I will be putting that together. So send me an email@drperiodsnipeslceus.com so that's drperiodsnipeslce.com I would love to have 8 or 10 people that could get on video chat and we could talk about different examples and try to figure out what reinforcers are maintaining the behaviors and different things that we might use different interventions to help an individual or families. And that will help us sort of flesh out some of the complicated stuff we've been talking about here. So. Okay, well, you are done and thank you for attending and I really enjoyed being here and I will see you next Friday at 2:00pm Eastern Standard Time. Thanks.