Using a Behavioral Plan as Motivation for Youth in Chronic Pain
When children with chronic pain stop doing their normal activities, returning to them can feel challenging, scary, and anxiety-provoking. While we want to encourage intrinsic reinforcement for returning to normal activities like attending school—i.e., accomplishing the task is reward enough to the child—sometimes anxiety or fear is so great that motivation helps get over the initial hump.
That’s where behavioral charts or incentive plans can be helpful. The behavioral chart is a motivational tool to give your child an incentive to behave better or to engage in activities that usually cause him anxiety or fear. (It should never be used as punishment.)
There are infinite ways to create incentive plans for kids and teens based on the individual child’s motivations, parents’ ability/desire to have simple or complex plans, the child’s age, the desired behaviors, and so on. Working with a behaviorist or behavioral therapist is often helpful to help make the plan as successful as possible.
For kids with pain, incentives should be taken in baby steps, such as requiring one school period at a time or longer and longer periods of time walking without crutches.
Although it is unusual, sometimes we are surprised by how sudden the change can be. Chris came to me as an 8-year-old with headaches and school refusal. He had not been in school for 3 months. I told his parents we would create a behavioral plan for him to start going gradually to school. The next week, he told me he had been at school full-time for the entire previous week!
Stunned, I asked how he did that. He said he wanted these athletic socks for $14, and his dad told him he would get them once he went to school full-time. So, he went full-time the first day and stayed at school every day. He got the socks and continued to go every day with no problem because he had conquered his fear.
Behavioral Chart Guidelines
Often, there is a negative atmosphere in the home, and parents are frustrated with the child. The child feels the parents’ irritation and acts more anxious, fearful, or dysregulated, and then it becomes a vicious cycle.
The goal is for the family environment to be more positive because the behavioral chart will determine the parenting of these issues. The chart is planned and explained to the child in advance so that the parents’ reactions are not knee-jerk or expressed out of aggravation. The chart sets the rules. The parent does not have to get frustrated with the child, and the interactions become less contentious. Typically, the atmosphere at home becomes one of encouragement instead of disappointment.
The child earns checks or points for accomplishing agreed-upon desired behaviors or goals, which the chart keeps track of. Younger children should receive checks on the chart and something tangible to represent the checks, such as poker chips.
Common target behaviors or goals for kids with chronic pain are sitting in the sun for 15 minutes per day, eating one meal at the table, getting out of bed for a certain period of time per day, taking a shower, taking a walk, going to school for an agreed upon amount of time, etc.
Target behaviors should be precise and clear. Example: “No clothes on your bedroom floor” instead of “Keep your room clean.” This prevents areas for negotiation, such as what defines “clean.”
Target behaviors also need to be in active terms: do something instead of don’t do something. For example, “Keep hands and feet to yourself” instead of “Don’t hit or kick.” It is easier and clearer to focus on what to do instead of what not to do, and it is also less negative-sounding.
When choosing target behaviors, choose one to five behaviors. Once a target behavior becomes second nature and is internally reinforced, it will be swapped out for another target behavior.
Pick the most important goals. For example, a child not attending school has more important initial goals than emptying the dishwasher.
You may break the day into multiple periods to curb difficult behaviors that occur often (talking rudely, hitting, etc.). For example, if your child tends to hit numerous times per day, break the day into segments and reward each time period in which there is no hitting. There should be multiple times per day—and multiple chances—to receive the checks/points. Otherwise, once the child initially messes up, there is no incentive to keep trying for the rest of the day.
Earning Privileges and Rewards
After a certain number of points or checks, the child earns privileges, rewards, or both. Privileges are things like screen time or using the car (for teens). Rewards are special things, such as receiving a gift (for example, something that the child collects), going out alone with one parent, staying up a little later, choosing what is served for dinner, choosing the movie that the family watches, going on a special outing, getting nails painted, or picking from a basket of little toys.
Examples of how to earn privileges and rewards:
- For those children motivated by money, each check can correspond to an amount of money.
- Have your child make a poster of everything they want (monetary and non-monetary), from small to large items. Parents then assign the number of points needed to earn each item, and exchanges are made whenever the child wants to exchange points for an item (like the prize tent at a carnival).
- Set daily, weekly, and long-term goals: a small daily reward for earning a certain number of checks that day and a medium weekly reward on the weekend for earning a certain number of checks during the week. A long-term goal, such as going to Disneyland, can be the reward for a big target behavior goal met over a longer period of time. Example: tell your child they will have a trip to Disneyland when they can walk without a wheelchair for two months.
- Each check can be worth a certain number of minutes of screen time. When all checks are met in a given day, unlimited screen time is available until the parents’ normal nightly cut-off time. The unlimited time gives an extra incentive to get all tasks accomplished promptly.
No Negativity
When giving points for desired behaviors, parents’ attitudes should be either neutral (if the child did not earn their check) or positive (if the child did earn their check). No negative emotion should be associated with not earning the point, and no disappointment or negativity should be expressed.
Once it has been stated that a check was not earned, parents should proceed to cheerleading to earn the check the next day. Example of what NOT to say: “Well, if you had only gotten out of bed today, you would have earned the check.” Example of what TO say: “You didn’t get out of bed, so you did not earn a check today, but I know you can do it tomorrow! I really want you to earn that game you have wanted, and I know you can do it!”
Do not take points, checks, or poker chips away! Once they are earned, they are your child’s to keep. Taking away is negative—not neutral or positive. It will perpetuate the negative relational cycle and shame the child.
Bonus Points are Your Best Weapon!
I often ask my clients what is most motivating about the behavior plan, and inevitably, their answer is “bonus points.” Parents should give bonus points spontaneously when they “catch” the child doing something difficult and making improvements.
I believe that the magic of bonus points is that it focuses parents on what their children are doing well instead of only noticing when their children are being troublesome. It is very easy for busy parents to forget to pay attention when their children are being “easy” and to pay more attention to “difficult” behaviors.
These are examples of times to give bonus points: your child spontaneously helps with something around the house, your child starts to have a meltdown and then stops herself, your child stays calm in a situation where he would usually have trouble or something as simple such as trying a new food.
For younger kids, two colors of poker chips can be used: one corresponds to the checks on the chart, and the other is for bonus chips. Bonus chips should be worth a quarter and one-half of regular chips. Bonus chips should be distributed liberally and right at the moment of the preferred behavior.
It is sometimes fun and motivating for younger children to make a spinner that gives them bonus chips. If they have gotten all of their checks for that day, they can spin it at night and receive bonus chips.
It is important to Reward “Well” Behaviors
Often, parents have to attend so much to their child’s needs because of chronic pain that the child gets attention, mostly during times of pain or when not functioning normally. The understandably busy and tired parents leave the child to herself when she is not complaining or needing help.
The goal, though, is to attend particularly to your child when he is exhibiting “well” behaviors so that there is no secondary reinforcement for being sick or in pain. This can come in the form of eye contact, a hug, an offer to play a game, and so on.
I’ve mentioned the following story in a previous blog, but it bears repeating here as an example of successfully reinforcing “well” behavior: Jodi was an 8-year-old with headaches. She said she often went home from school early because of her headaches and that both of her parents worked full-time. I learned that her grandmother would pick her up, and when I asked what they did after she was picked up, she said they would go out to lunch! We changed the plan so that she would come home and rest if she left early. However, if she stayed all day, Grandma would bring her to do something special after school. Jodi began staying in school longer, and her headaches decreased in frequency.
Do not give a big reward for a big accomplishment until the ability is firmly set in!
Andrew was a 13-year-old boy with chronic ankle pain from CRPS. He walked with crutches and refused to try to walk on his foot. He really wanted a puppy, and his parents asked if that would be a good reward for walking. I said it would be a great motivator, as he would need to walk to care for his puppy. I suggested that he could get the puppy after walking without crutches for two to three months.
A few weeks later, his dad called me with disappointment, saying, “You were right…” Dad was so excited when his son walked for the first time that he got the puppy for him right away. A few days after getting the puppy, Andrew was no longer walking.
It Won’t Last Forever
Parents are sometimes concerned that their child will indefinitely need external motivation from a behavioral chart. In 25 years of practice, I have never seen that happen. Once the activity that is very difficult, scary, or anxiety-provoking is accomplished, it becomes intrinsically motivating, and the parents forget about the rewards. In addition, the parents can substitute a conquered task for another difficult task.
Eventually, when kids with chronic pain get back to their full functioning lives with interesting and engaging activities, they don’t need or care about a behavioral plan anymore.
