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Behavior modification is a psychotherapeutic intervention primarily used to eliminate or reduce maladaptive behavior in children or adults. While some therapies focus on changing thought processes that can affect behavior, behavior modification focuses on changing specific behaviors with little consideration of a person’s thoughts or feelings. The progress and outcome of the intervention can be measured and evaluated. First, a functional analysis of the antecedents and consequences of the problem behavior(s) must be identified. This allows for the determination of specific target behaviors that will become the focus of treatment. Then, certain variables can be manipulated via reinforcers and punishments to change problem behavior(s). The goal is to eliminate or reduce maladaptive behavior. This activity reviews the indications and contraindications for behavior modification and highlights the role of the interprofessional team in the management of patients with behavioral disorders. Objectives: Identify the indications for behavioral modification therapy. Describe the contraindications to behavior modification therapy. Outline the clinical utility of behavioral modification therapy. Explain interprofessional team strategies for improving care coordination and communication to advance the use of behavioral modification therapy and improve patient outcomes. Access free multiple choice questions on this topic.

Behavior modification is a psychotherapeutic intervention primarily used to eliminate or reduce maladaptive behavior in children or adults. While some therapies focus on changing thought processes that can affect behavior, for example, cognitive behavioral therapy, behavior modification focuses on changing specific behaviors with little consideration of a person’s thoughts or feelings. The progress and outcome of the intervention can be measured and evaluated. Functional analysis of the antecedents and consequences of the problem behavior(s) must be identified. This leads to the creation of specific target behaviors that will become the focus of change. Then, certain variables can be manipulated via reinforcers and punishments to change problem behavior(s). The goal is to eliminate or reduce maladaptive behavior.[1][2][3] Behavior modification is a type of behavior therapy. B. F. Skinner demonstrated that behavior could be shaped through reinforcement and/or punishment. Skinner noted that a reinforcer is a consequence that increases the likelihood of behavior to recur, while punishment is a consequence that decreases the chance. Positive and negative are used in mathematical terms. Positive indicates that something is added, and negative indicates something is subtracted or taken away. Thus, positive reinforcement occurs when a behavior is encouraged by rewards. If a child enjoys candy and cleaning the room is the desired behavior, the candy is a positive reinforcer (reward) because it is something that is given or added when the behavior occurs. This makes the behavior more likely to recur. Negative reinforcement is removing a stimulus as the consequence of behavior but results in a positive outcome for the individual. For example, a fine is dropped, and a person no longer has to go to jail. The removal of the negative stimulus (the fine) results in a positive outcome for the individual, no jail time.

Behavior modification is a type of behavior therapy. B. F. Skinner demonstrated that behavior could be shaped through reinforcement and/or punishment. Skinner noted that a reinforcer is a consequence that increases the likelihood of behavior to recur, while punishment is a consequence that decreases the chance. Positive and negative are used in mathematical terms. Positive indicates that something is added, and negative indicates something is subtracted or taken away. Thus, positive reinforcement occurs when a behavior is encouraged by rewards. If a child enjoys candy and cleaning the room is the desired behavior, the candy is a positive reinforcer (reward) because it is something that is given or added when the behavior occurs. This makes the behavior more likely to recur. Negative reinforcement is removing a stimulus as the consequence of behavior but results in a positive outcome for the individual. For example, a fine is dropped, and a person no longer has to go to jail. The removal of the negative stimulus (the fine) results in a positive outcome for the individual, no jail time. Conversely, positive punishment is the addition of an adverse consequence. For example, a child gets spanked when he crosses the street without holding his mother’s hand. He then no longer crosses the street alone. Spanking is positive punishment because it is a consequence added to the situation that decreases the likelihood of the child crossing the street alone. Negative punishment is taking away favorable consequences to reduce unwanted behavior. For example, if Emily doesn’t finish her homework on time, her cell phone gets taken away. She makes it a priority to finish her homework immediately after school before she does anything else. Removal of the cell phone would be a “negative” because it takes something away, decreasing the chance that she won’t finish her homework the next time.

Conversely, positive punishment is the addition of an adverse consequence. For example, a child gets spanked when he crosses the street without holding his mother’s hand. He then no longer crosses the street alone. Spanking is positive punishment because it is a consequence added to the situation that decreases the likelihood of the child crossing the street alone. Negative punishment is taking away favorable consequences to reduce unwanted behavior. For example, if Emily doesn’t finish her homework on time, her cell phone gets taken away. She makes it a priority to finish her homework immediately after school before she does anything else. Removal of the cell phone would be a “negative” because it takes something away, decreasing the chance that she won’t finish her homework the next time. Reinforcement and punishment both work independently, as well as together, as part of a behavior plan. Positive reinforcement works exceedingly better and faster than punishment. In child psychiatry, parents often come to the office angry and frustrated with their child because “nothing works.” They have tried multiple types of punishments when bad behavior has occurred using the removal of toys or privileges away or placing a child in time out. Often positive types are not being reinforced. One immediate benefit of behavior modification plans is the shift away from solely punishing unwanted behavior to also rewarding good behavior. (Table 1, Scott and Cogburn, 2017) In table 1, note that punishment and reinforcement have nothing to do with good or bad behavior, only if it increases or decreases the likelihood of the behavior to recur. There are several schedules of reinforcement that can impact behavior. When a behavior plan is initially set up, continuous two is used to establish and reinforce the behavior. Once the behavior has been established, continuous reinforcement can change to intermittent reinforcement which is termed thinning. There are four types of intermittent reinforcement. They are: Fixed interval where the person is reinforced by a set number of responses Variable interval where the person is reinforced by a variable number of responses Fixed ratio where the person is reinforced after a certain number of responses

There are several schedules of reinforcement that can impact behavior. When a behavior plan is initially set up, continuous two is used to establish and reinforce the behavior. Once the behavior has been established, continuous reinforcement can change to intermittent reinforcement which is termed thinning. There are four types of intermittent reinforcement. They are: Fixed interval where the person is reinforced by a set number of responses Variable interval where the person is reinforced by a variable number of responses Fixed ratio where the person is reinforced after a certain number of responses Variable ratio where the person is reinforced after a variable number of responses. Variable ratio intermittent reinforcement is the most effective schedule to reinforce a behavior. Examples Fixed interval: rewarding a person at the end of each day Variable interval: rewarding a person sometimes at the end of the day, sometimes at the end of the week, sometimes every few days Fixed ratio: rewarding a person after completing the desired behavior four times Variable ratio: rewarding a person after completing the desired behavior after three times, then after six times, then after two times. Gambling is a real-world example of a variable ratio of reinforcement.

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.

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.