Ricky demonstrated increasing depression and isolation from family and friends as attendance problems persisted, leading to significant academic problems. Significant family conflict resulted from alternating attempts by the family to exert “tough love” and accommodation (Ricky’s SR was one reason his mother did not seek employment). Ricky and his mother first appeared highly motivated for treatment. The “devil’s advocate” strategy was used to elicit a strong

commitment to treatment by posing questions like, “This program is asking a lot from you and it’s going to be hard to follow through with all of it. Why would it make sense to commit to all of this?” Ricky answered stating, “Because I have nothing to lose. I can do anything for 16 weeks and if I feel the same, I haven’t lost anything.” Ricky completed daily diary cards and parents completed youth-parent interaction trackers.

Ricky completed diary find more cards consistently but had difficulty remembering to bring them sessions. One consistent pattern reflected the relation between refusal behaviors and high intensity selleck screening library emotions (usually distress or sadness). Positive emotions were associated with socializing after school or on weekends. Contingency management was introduced, and a re-entry plan was drafted that included the hierarchical goals of: getting out of bed by 6:45 a.m., not returning to bed once out of bed, limiting bathroom time to 30 minutes, driving to school, staying

in school for one class period, and concluding with staying in school for the whole day. These steps were brainstormed and developed early in treatment and flexibly applied Pyruvate dehydrogenase lipoamide kinase isozyme 1 as new behavioral patterns emerged. For instance, multiple chain analyses (see Rizvi & Ritschel, 2014) revealed that Ricky stayed in school once he was there, but getting out of bed and into the car was most challenging. Graded steps focused on approaching school (e.g., going to school but staying in the counselor’s office; going to school for just one class) with many morning routine sub-steps (e.g., engaging in something active when he gets out of bed; taking a short bath to self soothe stomach pains). A reward plan was developed for Ricky, so that each target behavior was reinforced with desirables (time spent on the computer and other electronics, time with friends, and driving the family car). Once this plan was in place (session 4), the majority of Ricky’s individual sessions focused on identifying behavioral patterns that maintained SR behavior and ways to maintain treatment engagement and practice effective behaviors. Chain analyses identified Ricky’s personal vulnerabilities included failure to take medication on time/as prescribed which affected his routine, irregular sleep patterns, and eating foods that upset his stomach. Ricky’s intestinal disorder meant that he would experience extreme constipation and discomfort.