Behavior Modification

Indications

The indications for developing a behavior modification plan can be for any unwanted, maladaptive, or aberrant behavior. It can also be used to teach and reinforce new, desired behaviors. In clinical settings, the treatment team utilizes the concept of operant conditioning to reinforce prosocial behaviors through positive consequences as seen in token economy, shaping, differential reinforcement of desired behaviors, and extinguish the undesired behaviors through negative consequences like an overcorrection, response costs, time outs. 

In child psychiatry, behavior modification is often part of treatment planning when a child is diagnosed with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder, conduct disorder, intermittent explosive disorder, or other externalizing disorders (as opposed to internalizing disorders like major depression). While behavior therapy is not limited to externalizing behavior disorders, it is often a key part of the treatment plan because the presenting problem is behavior-related.[4][5][6][7].

Applied Behavioral Analysis (ABA) is one of the common therapeutic techniques used in behavior modification. It has been proven very effective in those diagnosed with autism spectrum disorders and other similar developmental disorders.

Behavior modification is also a component of Parent-Child Interaction Therapy (PCIT), which teaches specific skills to the parents that they can use to help improve physical and verbal exchanges with their children. PCIT is an evidence-based intervention for preventing child abuse & neglect, helpful for children who exhibit disruptive behavior and/or have experienced trauma, those on the autism spectrum, and has been shown to decrease child’s risk of antisocial and criminal behavior later in life.

The Triple P – Positive Parenting Program draws on social learning, cognitive therapy, behavioral modification, and developmental theory as well as an exploration into risk factors associated with the development of social and behavioral problems in children. It aims to empower parents with the skills and confidence they need to be self-sufficient and to be able to manage family issues without ongoing support. 

Many reviews and meta­analyses of the research literature have established that behavioral treatments—including brief intervention, marital and family therapy, behavioral couples therapy, relapse prevention, and other cognitive-behavioral treatments in addition to community reinforcement and contingency management approaches—are among the most effective treatments for AUDs[8][9]

Contraindications

A behavior plan should not be started if it cannot be appropriately executed with consistency and longevity. Often, shaping, which is reinforcing and rewarding behavior as it approaches the desired behavior, is needed before the desired behavior is fully reached. Perfection cannot be the expectation from a behavior plan. Mistakes and setbacks are common when a change in behavior is expected, so consistency and patience are important from the caretakers and the clinician. If a behavior plan is only partially enforced, then this can lead to worsening behavior.

Equipment

A behavior modification chart is frequently used when implementing a behavior modification plan. Behavior charts require specific, objective, quantifiable tasks that are rewarded in a previously agreed upon way, be it points, stickers, or tally marks.

(Table 2, Scott and Cogburn, 2017)

• 3 points per day equal 30 min of screen time
• 6 points per day equal 1 hour of screen time
• 20 points per week equal picking a toy worth $5 to $10 at the store
• 25 points per week equal the toy plus getting to stay up 2 hours later on Saturday night.

(The above behavior chart with the subsequent rewards would be appropriate for a five to ten-year-old)

A “token economy” is synonymous with a behavior modification plan. A token (sticker, chip, point, tally) is anything that can be earned by exhibiting the desired behavior that can then be exchanged for reinforcers.

Reinforcers or rewards are a key part of a behavior plan but are unique to each child. The reinforcement has to be of value to the child for the program to be effective. A child may be motivated to make her bed every day if she gets a sucker every time she does it, but she may not make her bed if she gets extra reading time. She has to value the reward for the reward to be valued.

Reinforcers and punishments must happen at the time of the behavior to increase the likelihood of success of a behavior modification plan. The more immediate to the behavior the better. For example, praising a child for using the toilet while he is using it versus later that day. The reinforcer must be appropriate, e.g., giving a child a sticker every time he says please, or giving a teenager extra screen time for a good attitude. And lastly, the reinforcer must be consistent where the behavior is rewarded by all caretakers as previously agreed upon and not to avoid punishment due to caretaker guilt or inconvenience.

Personnel

A behavior modification plan can be started and implemented with an individual or by a team of people. A parent, teacher, or childcare provider can start a plan. Often, the behavior plan can be implemented in multiple settings, like at school and home (rewards for turning in homework assignments to the teacher, and rewards for cleaning your room by the parent). The broader the settings for the behavior plan, the better.

Preparation

Time is needed to define the problem behavior. Then the desired behavior has to be decided upon with appropriate rewards. If punishment is considered, specific punishments should go along with specific aberrant behavior.

Technique or Treatment

The mainstay of behavior modification plans is consistency.

Complications

Resistance in the beginning, from both the child and the parent or teacher, is to be expected. Children are often opposed to trying anything new because they are tired of being punished and reprimanded for their aberrant behavior. They do not want any more privileges or items taken away or banished. They may have low self-esteem or lack confidence that they can adequately fulfill the behavior plan. This is where shaping is important. If they come close to achieving the desired behavior, they can be rewarded in part or whole for their effort with the goal to one day reach the goal fully.

Parents or authority figures are sometimes resistant because they are angry or frustrated with the child and do not want to reward them for positive behavior. They may also be worried that it will not work. It may be a new way of thinking which is challenging and requires work to enforce consistently.

Clinical Significance

Behavior therapy achieves goals in therapy that medication alone may not be able to accomplish. It has long-lasting effects on the individual even after the behavior plan is no longer in place because the new behavior is already established. Behavior can change the way a person thinks and feels about themselves which in psychiatry is an ultimate goal.[10][11][12][13][11]

Enhancing Healthcare Team Outcomes

A behavior modification plan can be started and implemented with an individual or by a team of individuals that includes the mental health nurse, psychologist, social workers, primary care provider, parent, teacher, or childcare provider. Often, the behavior plan can be implemented in multiple settings, like at school and home (rewards for turning in homework assignments to the teacher, and rewards for cleaning your room by the parent). The broader the settings for the behavior plan, the better. Interprofessional involvement has been shown to improve health care quality and outcomes for patients, clients, families, and caregivers. 

Behavior therapy achieves goals in therapy that medication alone may not be able to accomplish. It has long-lasting effects on the individual even after the behavior plan is no longer in place because the new behavior is already established. Behavior can change the way a person thinks and feels about themselves which in psychiatry is an ultimate goal.