— TOKEN ECONOMY —

1. Token economies
Some behavioral classes (disruptive behavior) are displayed in a wide variety of ways.
Identifying specific functions to a functional class may prove difficult with children.
Systematically reinforcing alternative and non compatible behaviors, to those found
problematic or undesired can be quite complicated. However, reinforcing functional classes is
key to treatment success, so it cannot be left to be done at random. Token economies make it
easier for children and the parents or teachers to keep track of changes and explicitly and
systematically reinforce targeted behavior. It helps generate self-control in children. Applied
in almost every setting, from family’s home to schools. They have proven to be useful in
changing behaviors that were resistant to change in therapy. They help “bridge the gap”
between task completion and reinforcement.
A behavioral change system with three elements:
● A list of target behaviors.
● Tokens (points).
● A menu of backup reinforcers (preferred items, activities, or privileges).

2. The tokens
Tangible symbols that can be given immediately. These tokens will be exchanged for known
reinforcers previously specified and listed as back-up reinforcers. They have immediate
reinforcing transferred function:
● We transfer the reinforcing function of those known reinforcing stimuli to the tokens
by applying a certain set of verbal rules.

Characteristics:
● They should not be harmful, obviously.
● They must be hard to forge. The child should not be able to produce his or her own.
● Durable and easy to carry.
● Accessible in the moment.
● Inexpensive.
● The token itself should not be a desirable object. Its only value must come from what
can be purchased with it.
 3. Rules and target behavior
Participants must possess the prerequisite skills necessary to perform the behavior. Token
economies can’t be used to teach behaviors related to skill or performance. Behaviors must
be measurable and observable. Task completion criteria must be clearly specified. The set of
targeted behavior must start with a small number of behaviors, some of which must be easy
for the individual to accomplish. That way, we are easily transferring reinforcing functions to
the tokens. Token economies must be individualized. The rules should be always clearly
visible and for everyone. Mind that individuals who are in a setting in which a token
economy is being used but are nor participating in it should still receive other forms of
reinforcement. Rules for obtaining a token should be short, clear and easy to understand.
Convoluted or complicated set of rules as to how to obtain a token may distract children from
the purpose of the token economy.

4. The menu of back-up reinforcers

The back-up reinforcers need to naturally occur in the child’s environment. They must be
activities and reinforcers that the child already finds reinforcing in some way. Usually, TV or
videogame time, permission to go downtown, etc., are good reinforcers. Generally, it is
preferable to use things that are naturally present in the child’s environment. Unusual
reinforcers may be used if this criteria cannot be met. General comforts associated with basic
rights are NEVER to be used as back-up reinforcer (e.g. heating, clean clothes, etc.).

The use of back-up reinforcers is usually explained by Premack’s Principle:

● Given a pair of behaviors, the most likely behavior can function as a reinforcer for the
least likely, e.g.: using gaming time as a reinforcer for studying.
● Do not forget that in order for the token economy to work, reinforcing functions must
be transferred to the tokens themselves.
● If receiving tokens is not seen as reinforcing, the token economy Will fail, even if the
back-up reinforcers are rightly chosen.

5. Ratio of exchange
● Tokens should be easy to earn so that reinforcement happens very soon.
● Then, the ratio should be adjusted to keep an adequate responsiveness in participants.
 ● Guidelines:
○ Keep initial ratios low.
○ As token-earning behaviors and income increase, increase the cost of back-up
items, devalue tokens, and increase the number of back-up items.
○ With increased earnings, increase the number of luxury back-up items.
○ Increase the prices of necessary back-up items more than those of luxury
items.

Adjusting ratios should never be seen as punishment

● Clearly specified rules regarding the ratio of exchange and how it may be modified
should be stated at the beginning of the economy.
● That way, we may avoid children feeling we are cheating or changing the economy
rules to our advantage.
● If parents are responsible of keeping track of the children's behavior these points must
be properly addressed.
● Parents should NEVER use the token economy as direct punishment.

6. Response cost
Response cost can be used as a balancing factor for undesired behaviors. It is generally a
good idea to include a response cost procedure for undesirable behaviors. However,
participants should never be in debt: that is, their total token count cannot be allowed to be
negative. Nonetheless, the more incorrect the behavior, the greater the cost should be. This
should be clearly specified at the beginning of the token economy procedure. Proper rules
must be stated in regard response cost and how it may increase or decrease. Response cost is
a negative punishment, which properly addressed can help decreasing undesired behaviors.
Keep in mind that positive punishment should never be used during a token economy
procedure.

7. Implementation
It should be carried out in two phases:
- Token training:
- Participants must be introduced to what a token is and how it is going to be
used.
 - This step includes explaining the rules of the token economy (what are the
specific behaviors through which they will earn tokens, how and when can
they exchange them, etc.).
- Modeling token reception and/or exchange can be necessary in certain
circumstances.
- Token earn and exchange phase:
- Tokens must be exchanged, not hoarded.
- The exchange for back-up reinforcers must be encouraged.
- They must be readily accessible, but out of the way so that they don’t interfere
in every day's tasks.
- Participants should never be allowed to buy back-up reinforcers on credit.

8. Withdrawal
Withdrawal of the token economy must be one of the economy’s targets. So, it must be
planned beforehand. Withdrawing the economy is as important as implementing it. As
back-up reinforcers are chosen, withdrawing the economy should always be mind in this
process. Withdrawal should always be caried out slowly and gradually. As withdrawal
happens, tokens should become less and less easily earned and the naturally reinforcing
activities should be more and more naturally accessed.

Some guidelines for withdrawing:

● Always pair verbal reinforcement with token presentation.
● Gradually increase the number of responses that are needed to earn a token.
● The duration of the time in which the token economy is in effect should be gradually
decreased.
Natural backup reinforcers should be increased in the shop at the expense of reinforcers from
outside of the setting.
● The price of the most desirable items should be constantly increased while keeping a
very low price on less desirable items.
● The physical evidence of the token should be faded over time (tokens are substituted
by pieces of paper, then tally marks, then marks are not visible, etc.).
 — ADOLESCENCE AND TREATMENT STRATEGIES —

1. Disruptive behavior
As a general guideline, disruptive behavior will need professional attention if:
● The teenager is putting themselves in danger.
● They are putting other people in danger.
● They are breaking the law or causing significant trouble for other people.
● They are compromising their future well-being.

It is easier for a child that engaged in disruptive behavior to keep doing so in adolescence.
This behavior is often increased in its importance, and can clash with law and with their own
safety. The fact that teenagers tend to engage in provocative behaviors must not lead us to
classify everything they do with this intention as “disruptive behavior”.

It is essential for all the members of the household to participate in the treatment. This
includes siblings. Very often, when changes are implemented, they will affect their lives too.
Their opinion needs to be taken into account because, among other things, it can compromise
the treatment. Parents should receive as much attention as the teenager, especially if the
disruptive behaviour happens primarily at home.

Communication with the adolescent has to be fluid. Even if it takes a little longer than it
would in other cases, creating an adequate therapeutic alliance is essential. Therapists must
walk a thin line between making themselves “worthy” of both the teen’s and the parents’
trust; often, this will seem impossible at the beginning. Remember: if the teen is a minor,
professional secrecy does not apply to them. However, it is advisable to warn the parents
beforehand that the best course of action for them is to allow their daughter/son the space and
privacy that the therapy requires.

Although all the previous kinds of disruptive behavior can and do occur, there are some that
are very infrequent in children but happen often in adolescence:
- Excessive alcohol consumption, Substance abuse, Risk-seeking behavior.
The world changes very fast for teenagers, and becomes broader and broader for them. New
people, new social roles, new opportunities and, of course, new risks appear. One of the
reasons why these behaviors happen is because they need to adjust to this.
 2. Drinking behavior
It is usually associated with specific settings, moments and people: 50.8% of teenagers drink
alcohol with friends during the weekend, 26.9 in parties, and 10.8% in family meetings.
Alcohol intake begins early in adolescence: current data have it beginning when teens are 11
to 15 years old.

The cultural relationship with alcohol is perverse. On the one hand, most kinds of alcohol are
consumed without any kind of social punishment. It is customary to drink in social occasions
and it is freely sold everywhere. On the other hand, millions of euros are devoted by the
States in the fight against alcoholism in teenagers, right in the same moment in life in which
they are introduced to alcohol consumption.

Assessment:
● Self reports are HIGHLY IMPORTANT.
● They need to give information about when, where, with whom and how much does
the person drink.
● We specifically need to determine which are the stimuli that discriminate the drinking
behaviour.
● Verbal rules about alcohol use should be explored:
○ Ideas about alcohol and its effects:
■ Why does the person drink?
■ Do they find it easier to interact with other people that way?
■ Do they dare to do or say things they wouldn’t normally?
■ Is alcohol the only way in which they perceive they can reach desirable
things, like friendship, fun, sex…?
● Alcohol-related customs in their family or closest context should also be explored.
● Alcohol in small to medium doses is a dispositional variable that is usually associated
with fun and social contexts. That transfers reinforcing function to the drinking
behavior and lowers the natural reinforcement of others.
● Transforming the reinforcing fucntion of drinking must be the top priority.
Treatment: Transforming the function of drinking
● Information about alcohol and how it works must be provided.
● Pointing out the effect of certain verbal rules regarding alcohol and drinking on
current drinking behaviors.
● Alcohol has certain unconditioned effects in the organism and these effects cannot be
prevented, but they can be modulated. Behaviours that are incompatible with drinking
alcohol are to be reinforced.
● Training social skills and emotional management techniques.

3. Substance abuse
Assesment:
● Assessment should be done primarily through self-reports.
● Again, the most pressing concern is to know precisely when, where, and with whom
this behaviour takes place.
● Ideas about drugs and their effects should be explored. The “natural phallacy” can be
very common here.
● Family customs regarding drugs have to be explored too, obviously.
● The reasons why drugs are consumed have to be thoroughly assessed and used in the
treatment.
● In many ways it is similar to excessive drinking.
● Peer pressure, availability, and a low perception of risk are usually key in these cases.
● The culture that surrounds certain kinds of drugs associated with entire subcultures
might be very attractive for teenagers.
● In much the same way that it is with alcohol, the relationship with drugs is perverse,
both telling adolescents to never ever try drugs and at the same time painting them in
a very attractive light.

Treatment:
● With some drugs, complete abstinence has to be the objective. With some others,
conscious and chosen use could be reinforced.
● Training in assertiveness is key if drug abuse is related to peer pressure and social
circumstances.
 ● Identifying and changing verbal rules regarding the effects and uses of drugs is key to
treatment.
● Identify and treat underlying problems taht may be explaining the use of drugs:
usually drugs are used as a way of avoiding unwanted private experiences
(experiential avoindance).
● Do not patronize: do not appear to know better.
● If you appear to be absolutely hostile to drugs, you might not be well accepted by
some teenagers that want to reduce but not eliminate their drug consumption.
● Information should be relayed to the parents if the teenager is in danger, so that they
can help.

4. Risk seeking behavior

Although both drug abuse and excessive alcohol intake can be risky, they should only be
considered as such when they are done as ways to facilitate risk-seeking behaviour.
Purposefully breaking the law (from shoplifting to breaking and entering), actively looking
for or creating fights, risky sexual behaviour that is done for the sake of risk, could be some
examples of what we refer to as risk-seeking behaviors.

Some theories propose that the slow maduration of the cognitive-control system is to blame.
Their pereception of risk and their vulnerability to it is comparable to that of adults.
According to Steinberg (2004), attempts at reducing risk-seeking behaviour in adolescents
through interventions that aimed to alter knowledge, attitudes or beliefs have proven to be
“remarkably disappointing”. It is in social contexts where this risk takes place, and it seems
that adolescents are more vulnerable to antisocial peer influence

Aseessment
● First of all, the specific behavior that is to be changed has to be delimited:
○ what is it, when, where and with whom does it happen.
● Self-reports and the reports of others are very informative.
● There are useful questionnaires aimed at gathering information about what activities
are considered to be desirable by the client.
● As always, explore the reasons why and what risky behavior happens. It is key for the
treatment.
Treatment
● Transferring an undesirable function to the consequences of the risk-seeking behavior
is key to change it.
● Assessing and changing verbal rules in regard the behaviors and their reinfrocing
consequences should be carried pout.
● If risk is undertook as a way of seeking sensations, alternative, safer ways to get the
same reinforcing functions should be found and reinforced.
● As always, social skills training and assertiveness are key if peer pressure is involved.

5. Internet, video games, social network use

● The use of social networks in adolescence has modified the way in which teens
interact; since sharing contents can be a way of expressing private events freely.
● It can distort the concept of value of the self, and cause self-esteem problems.
● In more serious cases, it can affect school performance and relationships.
● Online interaction has its own problems (bullying, exposure to inadequate contents…)

Assessment:
● Self-reports.
● Interview.
● Apps or extensions that log the time you spend online and where.
● Games they play, what for, how much, online vs offline experiences, if they spend
money or not, explore the loot box effect.
● Loot boxes have been defined as “features in video games which may be accessed
through gameplay, or purchased with in-game items, virtual currencies, or directly
with real-world money”. They often appear as chests, crates, or card packs.

Treatment:
● Enrich the environment from the first moment: one of the basic problems of the
excessive use of the internet is stimulus poverty and the effect it has on mood.
● Apps or extensions that control the time online and even block certain sites.
● Behavioral contracts.
● Video Games: total withdrawal is not advised. Conscious gaming should be
encouraged. Making gaming behavior a chosen and conscious behavior.
 — TRAUMA AND ABUSE —

● Children Abuse: Any behavior made by an adult or other child with the express
intention of causing harm or suffering.
● Physical abuse: punching, beating, burning, kicking, biting, shaking,
throwing,choking, hitting etc. “Spanking or paddling, is not considered abuse as long
as it is reasonable” Child welfare Organization. (As we can see, even institutions have
difficulty drawing generalizable lines.)
● Psychological abuse: a consistent pattern of behavior that impairs a child’s emotional
development or sense of self-worth. Including, excessively harsh criticism,
contingencies that are insufficiently clear or keep changing, emotional blackmail…
Emotional abuse is often difficult to prove, and, therefore, child protective services
may not be able to intervene.
● Sexual abuse: includes activities by a parent or other caregiver such as fondling a
child’s genitals, penetration, incest, rape, sodomy, indecent exposure, and exploitation
through prostitution or the production of pornographic materials. It is harder to
integrate in the child self and narrative the closer the abuser is.
● Negligent abuse: an abandonment of the needs of someone who is dependent, to the
point of physical or physiological harm. Contributing in this way to a future
maladjustment.

○ Physical (food or shelter) ○ Educational

○ Medical (medical and ○ Emotional
mental health)

Difficulties in therapeutic treatment of abuse

One of the hardest problems is the hardship children go through when reporting and
verbalizing traumatic experiences (only 38% disclose), especially in the family context.
Sometimes, abuse is not perceived as such, due to dissociation or context compliance.
Psychological and legal definitions often do not coincide (Sexual abuse requires legally a
difference in age of 5 years if the victim is younger than 15 or 10, if older). Many
consequences are deferred in time (they either happen or become truly problematic after
years), complicating therapeutic approaches.
Happens in all social classes. Increased Vulnerability factors:
- Victim has psychological or developmental disability.
- Households in which physical abuse or violence towards other members already
exists.
- Substance abuse is present in the environment of the victim.
- Regarding sexual abuse, women are more vulnerable to it than men, and tend to
develop more serious psychological consequences.
Generally, victims of physical abuse are believed to be more prone to commit it; this doesn’t
happen with sexual abuse, though.

Abuser profile
● More than 90% of abusers are people children know, love and trust.
○ 30-40% of victims are abused by a family member.
○ 50% are abused by someone outside of the family whom they know and trust,
and in consequence he is usually integrated in the family circle and has time
with the victim.
○ The younger the victim, the more likely it is that the abuser is a family
member. Of those molesting a child under six, 50% were family members
● Most sexual abuse of children occurs in a residence, typically that of the victim or
perpetrator – 84% for children under age 12, and 71% for children aged 12 to 18.
● Studies have found that 80-90% of the abusers are men.

Psychosomatic Symptoms
Adult survivors of child sexual abuse are at greater risk of a wide range of conditions that are
non-life threatening and are potentially psychosomatic in nature. Adults with a history of
child sexual abuse are 30% more likely than their non-abused peers to have a serious medical
condition such as diabetes, cancer, heart problems, stroke or hypertension.
Other higher risk relevant medical conditions include:
- Fibromialgia. - Excessive intercourse bleeding.
- Severe premenstrual syndrome. - Amenorrhea.
- Chronic headaches. - Pain during intercourse
- Irritable bowel syndrome - Menstrual irregularity.
Distortion of relationship patterns: since the abuser is almost always someone very close to
the victim, this may have a lasting effect on how the victim relates to others. A number of
studies have found that adolescents with a history of child sexual abuse demonstrate a three
to fourfold increase in rates of substance abuse/dependence. Depression. Anxiety. Sexual
maladjustment.

Conclusion
The dissociative and evitative response to abuse makes it harder to detect, and in many cases
deferred consequences are usually overseen. Deferred consequences are very hard to study,
because causality cannot be assured. Estimates are that 33% of male victims suffer them,
while 75% of female victims do.
- Eating disorders. - Difficulties to bond with daughters
- Sleep disorders. and sons.
- Hypochondria. - Dissociative disorders.
- PTSD - Social Alterations.

Possible alarm sings

➔ Children:
◆ Excessive shyness, withdrawal.
◆ Regression in verbal or cognitive skills.
◆ Alteration in normal patterns of development (sphincter control).
◆ Sleep pattern disorders.
◆ Lack of hygiene.
◆ Prolonged or unexplained absences in school.
◆ Eating problems, refusing to eat, or trouble swallowing.
◆ Inappropriate attachment behaviors.
◆ Irritabilidad.
◆ Physical Injuries.
◆ Genital irritation or discomfort.
◆ Self genital stimulation.
◆ Sexual knowledge that is infrequent in children of that age.
◆ Sexual games.
◆ References to body image or body parts as repulsive, dirty or bad.
 ➔ Adolescents:
◆ Withdrawal.
◆ Low self-esteem.
◆ Sleep patterns alterations.
◆ Prolonged or unexplained absence in school.
◆ Extreme guilt or shame.
◆ Compulsive masturbation.
◆ Sexual games that imply excessive force or unwanted asymmetric dynamics.
◆ Infrequent sexual affiliations.
◆ Drug abuse.
◆ Suicide attempts.
◆ Self harm, specially those close or in the genital structures.
◆ Low expectations for the future.
◆ Exposure to sexually related dangerous situations: relations with unknown
people or people older that them, prostitution, risk situations.

Assessment
● Being delicate but at the same time not reinforcing the evitative/fearful behavior
towards memories and abuse related content is critical.
● We must avoid fast conclusions especially when we believe the age or development of
the minor may not let him include into a comprehensible narrative the full extent of
the situation.
● Interprofessional is a must in these interventions, as one of the main problems with
abuse is that it frequently happens in a context with absence of involved/responsive
social and health networks.
● Interviewing both children and family is necessary.

Treatment
- Children:
- Relation with body image, intimacy and self-care behaviours.
- Psychoeducation (how and why what happened was wrong).
- Strengthen the support net around them.
- Rebuild trust, and a narrative that includes adults and kids relation.
 - Reinforce behaviors that are appropriate for the child’s age.
- Prevent victimization, re-traumatization. SAFE SPACE
- Adolescents:
- Relation with body image, intimacy and self-care behaviors.
- Psychoeducation (how and why what happened was wrong), a deeper
narrative can be supported by the self.
If dissociation is present, work around exposure to fragmented memories,
reducing avoidance and increasing the sense of control over the memories.
- Prevention of repetition under other similar contexts.
- Cognitive and emotional work with guilt, understanding the situation and
context under which the abuse took place.
- Self esteem.
- Assertiveness, how to legitimize defending his/her rights, being able to see
oneself as a victim and not others.
- If the abuse is perpetrated by a family or trusted adult, shame and conflict
between idealization and devaluation of the perpetrator and oneself must be
integrated.
- Working with family and social networks is crucial, as withdrawal is a
common symptom.
- Listen and validate the story.
- Don’t express doubts about its veracity.
- Explicitly reinforce the decision of telling it.
- Act with serenity. What’s important now is to contain and support the person.
- Manage accordingly between asking for detail, to enable exposure and
avoiding being too invasive.

Bullying & cyber bullying

According to the last statistics, in Spain school bullying can be suffered by children as young
as 7 years old. 7 out of 10 of the children who are victims of bullying suffer it daily.
Alert signs:
- Difficulty in their interactions with family and parents.
- Continued sadness. Withdrawal.
- Low self-esteem (constant verbalizations of worthlessness).
 - Doesn’t want to go to school.
- Suicidal thoughts.
- Bruises, torn clothes, etc.
- Self-inflicted injuries.
All bullying that takes place primarily or in part through electronic media, such as social
networks or instant messaging apps. It eliminates safe spaces: the child or adolescent can be
verbally abused even when they are at home, on weekends and vacation. The traditional tactic
of changing school is rendered ineffective, since physical proximity is not necessary.
Anonymity in social networks is one of the things that makes this kind of abuse more
appealing to potential bullies.

Treatment
The first and most important step is to eliminate the possibility of the abuse happening again;
physically removing the child or adolescent from the environment can be considered as an
option.The school or relevant institution must make sure that the abuse is dealt with. Not
always an option. The child needs to know that they are not alone, and that other people are
going to help them. Training assertiveness can be helpful in mild abuse situations. Some
situations are bound to have been conditioned as aversive: social contact, school context,
mobile phones or devices… Exposure to them should be a priority. Coping strategies (rational
thought, self cognitive-restructuring, self-instructions) have to be taught. Family support is
essential and should be guided, as the anxiety induced by the helplessness felt by parents
usually deteriorates the relationship with parents.

Prevention
Training empathy in schools. Clear policies regarding bullying, cyberbullying and abuse have
to be enforced in schools and other vulnerable contexts; children and adolescents need to
have resources and trained personnel with whom they can speak. All teachers should be
trained to react appropriately when they see potential bullying. Parents should develop and
work around the delicate line between knowing what their children are up to and respecting
their privacy, especially when they are teenagers. Trust is something we build on actions not
words with children, “ You know you can tell me anything”, will not automatically work.
Bereavement
Mentalizing death
Very often, people avoid speaking to children about death. While death might not be the most
fun subject to discuss, when the opportunity arises it should be discussed (e.g., seeing plants
or flowers die, the death of a pet, etc.). Until the age of 8-9, approximately, children have a
hard time understanding that death is something definitive. They should also not be kept
away from old or terminally ill relatives, provided they are given information about what is
happening in ways that they can process and understand (e.g., emotionally neutral and
adapted to their age). The way kids see what emotions are validated and accepted in their
parents while dealing with bereavement is the model children will incorporate (what is
accepted and what not). For children it can be difficult to understand the difference between
being upset and being angry; they might be afraid of approaching their parents for fear of
them being angry at them. They need to be told that feeling that way is natural and means that
the person who died was important for you.

Situations or rituals that are commonly accepted (burial), can be adapted to kids' ages, but
family activities that encourage emotional relief are deeply recommended. Children
sometimes ask brutally blunt questions, like “when are you going to die?”. These questions
should be treated as an opportunity to offer consolation. Expressions that should be avoided.
“She’s resting now”, “she’s gone away”, etc., are to be avoided: they can make the child
afraid when their parents leave for work.
“eternal rest” or “rest in peace” can be complicated too, and the child might develop a fear of
going to bed or of his loved ones going to bed.
“Aunt Jane died because she was old” or “only old people die” can be problematic when they
see young people die too.

Emotional Reactions
● Guilt: it is common for children to think that the death of a loved one had something
to do with something they did or said (or even thought), that they “left” because he
was “naughty” or a natural response to someone´s suffering. Unspoken aspects or
situations with the loved one must be verbalized.
● Anger: we all might feel anger at the death of a loved one. Children might express it
in a more blunt, seemingly selfish way. They should not be scolded for that. Instead,
they should be allowed to express their feelings, and carefully and warmly corrected
(if they are old enough). Anger is incentivised by situations where the child believes
the loved one didn’t take care of him/herself (addictions). Or they hid the truth to the
kids.
● Regressions: children might go back to behaviors or patterns of which they had grown
out before, like sucking on their thumbs or not wanting to sleep alone. This should be
tolerated, by working on the underlying vulnerability and the need for care.
● Depression and other behavior problems: if they persist beyond approximately six
months, professional help might be needed, sadness is not a problem, but a
requirement to grief correctly.
● Isolation of affect: One of the most common ways of coping with the death of a loved
one is avoiding any conversations or stimuli that may be associated with either the
loss or the desire of sharing more time with the loved one.