Contingency Management (CM) with Adolescents & Their Families
Ashli J. Sheidow, Ph.D.Family Services Research CenterDepartment of Psychiatry & Behavioral SciencesMedical University of South Carolina
The presenter’s research has been supported by National Institute on Drug Abuse awards
R01DA017487 (PI: Henggeler) & K23DA015658 (PI: Sheidow)
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
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
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
List of Potential Rewards
Type of Reward What I Get What I Want What Parent Provides
Transportation(most valued privilege)
Ride to recreation
center once a week
Borrow the car on Saturday
I usually give him rides 3-4 times a week to places.
Driving Practice None DailyI haven’t let him try
practicing even though he has a practice permit.
Clothing
One outfit at the start of the school
year
At least one new outfit a
month
I buy him new clothes or shoes once a month or
so.
Favorite Dessert/Meal
Never Every day
3-4 times per week I usually fix him spaghetti,
fried fish, pound cake, and chocolate chip
cookies.
Meals
She cooks dinner,
sometimes makes
breakfast and packs my
lunch
Nothing
I cook everyday. I make him breakfast and pack
his lunch or give him lunch money.
Lunch/Dinner Out
1-2 times per month
1-2 times per month
We all go out 1-2 times per month.
List of Potential Rewards (p.2)
Type of Reward What I Get What I Want What Parent Provides
Laundry Once a week Once a week
Once a week and sometimes I will wash something he wants to
wear. I also iron his clothes when he asks.
TV Use Daily Daily
Daily. I also bought him X-Box which he plays
every day. I buy him at least one game a month.
Curfew
7:30 during the week and
9:00 on weekends
9:00 during the week and midnight on weekends
I am following probation orders.
Have a Friend Visit
Every day NothingHis friends are always
here.
Go To a Friend’s House
About once a week
2-3 times per week
I don’t like all his friends so I don’t allow him to go
to their homes.
Invite Friend Sleep-Over
Never1-2 times per
monthI have not allowed this.
Non-Drug/Alcohol Party/Get-Together
NeverAt least for my
birthdayI have not done this.
List of Potential Rewards (p.3)
Type of Reward What I Get What I Want What Parent Provides
Own Phone A cell phoneHas a cell
phoneWe gave him a cell
phone.
Upgrade PhoneLow-end cell
phoneRazor cell
phoneBasic phone.
1-on-1 Time with Dad
NeverHang out 1-2
times per month
He sometimes gets to watch sports with his dad
1 time a month.
Own RoomShare room with little brother
Move into the office
We use the office, but could maybe move
computer to kitchen.
Stuff for RoomNothing –
looks like a kids room
Posters, bedspread, lamp, rug,
paint
We could provide some of those.
Trips With Family/Friends
No
Wants to go to local
amusement park
We have not done this.
Movie Theater with Family/Friends
No1-2 times per
monthWe could sometimes
afford.
Own Car (Registration, Insurance, Payments)
No Wants a car We cannot afford.
List of Potential Rewards (p.4)
Type of Reward What I Get What I Want What Parent Provides
Computer NoWants a
computerWe cannot afford.
Weights, Sports Equipment
Some weightsMore
equipmentHe wants a
bench/weights.
Music Player/i-Pod
DailyHave stereo –
daily use; wants i-Pod
He uses stereo daily. May get i-Pod.
Play Football Weekly in fallWant to stay
on teamHe plays, I try and
support.
Pet/Pet Supplies None A pit bull We cannot afford.
Other Item: Jewelry
Ring last fallBracelets,
rings, necklaceI bought him ring for his
birthday.
Other Item:Good report to my probation
officerOnce a month
I tell the truth – bad reports.
Other Item:
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.
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"
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
Take It to the Bank
Step 5: Track points Checkbook System
Graphing System Run “what ifs” on the plan
It’s Showtime!
Step 6: Sign the Contract
Step 7: Implement the Contract
Step 8: Revise the Contract
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.
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.
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.
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
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).
Drug Urine Detection Time
Amphetamines6 2-5 days
Barbituates (Short-Acting) 2 days
Barbituates (Long-Acting) 3-4 weeks
Benzodiazepines6 Varies by type of drug, many are 7-10 days
Cannabinoids (THC, Marijuana)3, 6
1x only = 5-8 days; 2-4x/month = 11-18 days;
2-4x/week = 23-35 days; 5-6x/ week = 30+ days; Daily=30+ days
Clenbuterol (illegal weight loss drug)
4-6 days
Cocaine3, 6 1-4 days
Codeine 5-7 days
Euphorics (Ecstasy, Shrooms) 5-7 days
Ketamine (Special K) 5-7 days
LSD - ACID 7-10 days
Methamphetamines3, 6 5-7 days
Nicotine (Cigarettes) 4-10 days
Opiates6 5-7 days
Phencyclidine (PCP) 2-4 days
Phenobarbital 10-20 days
Propoxyphene 6 hours to 2 days
Steroids (anabolic oral) 14-28 days
Steroids (anabolic injection) 1-3 months
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)
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).
Ashli J. Sheidow, Ph.D.Family Services Research CenterDepartment of Psychiatry & Behavioral SciencesMedical University of South Carolinaemail: [email protected]
Contact Information