Tim could now earn (or "not earn") rewards twice a day, so that he could have the opportunity to "turn things around" as each day continued. Checkmarks, rather than emotionally loaded smiley faces or stars, were employed to let him know how he was progressing. We modified the plan to include "reminders" rather than "warnings" when he showed signs of inappropriate behavior. In my experience, giving a warning is a red flag to an easily aroused child, tending to escalate an already tense situation.

Each class period was broken into three blocks in which he could earn a checkmark. The "beginning" served as the initial transition period, the "middle" was the workblock itself, and the "end" was the closing time. In this way, Tim and his teachers could clearly see when he did well and when he struggled. The clarity of this structure allowed Tim to predict when he'd receive feedback on his behavior and anticipate consequences. He was bolstered by the agreement that, as much as possible, his plan would be kept confidential from his peers. Despite his brashness and aggression, he was sensitive to perceived slights, so he gained a sense of security, personal control, and self-respect from knowing exactly how the process for using the plan would unfold and that it was confidential.

Rewards, whether in school or at home, need to be clear and practical, and they must motivate initial and ongoing participation. Many children, especially those whose behavior is motivated by the need for control, prefer a menu of rewards, so they can make a choice on any particular day. A child of Tim's age might be offered computer time, a chance to draw, the opportunity to build something, access to a "grab-bag" of items (including markers, pens, and baseball cards, but no food items), or some other constructive activity that's easy to deliver and monitor. For Tim, a hands-on boy with a keen interest in computers, establishing the choices was easy: he wanted a break to work on the computer at midday and access to the grab-bag at the end of the day. This was a good arrangement for his teacher, too.

Tim made good progress, and increasingly earned the 75 percent of checkmarks needed to earn his next reward. Until then, he'd been incapable of linking his behavior to the established consequences, at least in the split second of its occurrence. This is a common trait for people with severe AD/HD and corresponding oppositional behavior. With immediate consequences in view, however, he could begin to make this connection.

At the end of the two-week trial period, he asked to continue working with the plan. It helped him greatly to know that if he proved unable to earn rewards during the morning, he could "turn it around" and earn them during the afternoon. He put energy into learning to slow down his impulsive responses and trying to appear less hostile. After he'd begun to have more success in the classroom, his father enrolled him in a social skills group. The boy's improvement in school seemed to give the father more faith and trust in the counselor's recommendations.

Tim's was a success story, but this sort of intervention doesn't always lead to such positive change, notably in children who experience ongoing trauma and whose lives are unsafe. Yet even when it doesn't work, trying it for two weeks can elicit a great deal of information about the child. We can determine, at a fundamental level, if he or she can participate in it. We can explore whether the predictable meeting time with a significant adult helps build a sense of relatedness and containment. We can discover whether there are patterns to when the child experiences success or failure. At times, the plan serves as much as an informational tool as an agent of change.

Overall, what generates an opening for children like Tim to be able to change may be the relational component of having regular, nonjudgmental assessment meetings with the teacher, along with the structure and consistency of the plan. Recurring feedback, given in a positive tone and style, helps children learn how to reflect safely on their behavior. All these features offer success to children with histories of failure.

James Levine, Ph.D., is the founder and director of James Levine & Associates, a multidisciplinary consulting and psychotherapy company in western Massachusetts. A paperback edition of his Learning from Behavior will be published in December 2008. Contact: jimlevine2@aol.com. Letters to the Editor about this department may be e-mailed to letters@psychnetworker.org.

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