Discipline

DEVELOPMENT AND BEHAVIOR: OLDER CHILDREN AND ADOLESCENTS

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DISCIPLINE Edward R. Christophersen, PhD

Discipline has probably been discussed as much as any topic about children. Experts on child rearing have produced cyclic recommendations on discipline, varying from relatively firm positions to milder positions.1 5 Only recently has this cycle appeared to be leveling off to a moderate position in large part because of the amount of quality research on discipline that has been published in the last 20 years. It is the topic of discipline that is the focus of this article. The article focuses on the reasons that caregivers have for using discipline, the types of discipline that are available, and the known factors that increase or decrease the effectiveness of discipline. Recommendations for handling questions regarding discipline are made for the practicing pediatrician, bearing in mind that he or she is not consulted about discipline as often as spouses and friends are. 16 The Task Force!6 reported that approximately 65% of pediatric residency training was devoted to subspecialty training, with pediatricians devoting very little of their practice time to subspecialty care. The Task Force identified psychosocial problems as the most underemphasized area of training in pediatric education. A discussion of children's learning and the factors that are known to affect children's learning helps to lay the groundwork to understanding discipline. LEARNING

Repetition Children, like adults, learn behaviors through repetition. Just as a skier learns to ski by skiing over and over again, with a great number of falls interspersed with occasional periods of skiing, children typically make a great many "mistakes" or "falls" in the process of learning to behave as we would like them to behave. One of the most important factors in children's learning From the Behavioral Pediatrics Division, The Children's Mercy Hospital, Kansas City, Missouri

PEDIATRIC CLINICS OF NORTH AMERICA VOLUME 39 • NUMBER 3 • JUNE 1992

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is how often they have the opportunity to practice a particular behavior. A series of studies l2 that were conducted demonstrated that the average child in an inner-city school spends about 5 minutes each week reading aloud in the classroom. Students in suburban schools spent approximately 25 minutes each week reading aloud. When tested with standardized reading tests, the children from the inner-city schools tested far below their suburban counterparts. Data on the children reading aloud at home showed a similar pattern: the inner-city children had far fewer opportunities to read aloud than their suburban controls. In fact, these research studies have replicated a finding on learning from the animal research literature: one of the most important variables in learning is the length of time between opportunities for learning. If a child reads aloud, makes a mistake, is corrected, and then immediately reads aloud again, he or she learns the correct reading-aloud behaviors fairly quickly. If, in contrast, the child reads aloud, is corrected, and then does not have another opportunity to read aloud for several days, the child learns much more slowly. The inner-city youth who has little opportunity to read aloud in school learns to read at a much slower rate than the suburban counterpart. A similar pattern occurs with children's general behavior at home and at school. If a child has a caring, patient, nurturing parent or teacher who provides a multitude of opportunities for the child to learn, learning is maximized.

Feedback

In addition to opportunities to learn, the amount and type of feedback that a child receives are vital to the learning process. When a child reads without any feedback from another person, the learning process slows to almost a standstill. Certainly, there are examples of children learning to playa piano or read books without any assistance from another person, but these incidents are rare, and the details regarding how the learning process was conducted are usually missing. In a study that was conducted a number of years ago,' an "ideal" situation was created for children to learn how to read. The children sat in small, distraction-free cubicles with an adult they knew and respected from their community who was able to provide the child with immediate feedback (and rewards) based on the accuracy of their reading. As the child read material aloud, each sentence that was read correctly was "reinforced" by the adult tutor adding one or more points to a counter directly in front of the child. At the same time, a small light flashed, indicating to the child that the points had been added to the counter. Each error in reading resulted in one or more points being subtracted from the child's counter and a different colored light flashing. To activate the counter, the adult tutor held a small switch and pushed a button to add points to the counter or another button to subtract points. Thus, each child had numerous opportunities to read aloud with immediate feedback from an adult. Similar results were obtained when the child was tutored by another child. Each tutored child was then provided the opportunity to exchange the remaining points on their counter for one of a variety of treats in the "children's store" or for cash. Under these nearly ideal circumstances, the tutored children learned how to read aloud very quickly, often gaining a year in their ability to read aloud in only 2 or 3 months. These results were easily replicated in school classrooms in the same inner-city area. The more opportunities that a child has to learn, with appropriate feedback, the quicker the child learns the requisite material. How, then, can we apply this knowledge of children's learning to their

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day-to-day behavior? If children are nurtured and provided with good supervision in the form of a caring adult who monitors their behavior often and provides appropriate feedback at frequent intervals, then children's learning is maximized. In contrast, if children are only provided feedback when they have done something wrong, then the learning process is painfully slow and, not surprisingly, they come to dislike the tutoring sessions. What, then, is meant by quality time that parents spend with their children? Quality time, in the context of this discussion, refers to a child spending time with an adult who models appropriate behaviors and monitors the child's behavior frequently and provides unemotional feedback for both appropriate and inappropriate behaviors. A child learns very little from an adult who spends time with the child but provides few opportunities for the child to behave and to receive feedback on the behavior. What else do we know about children's learning that impacts how they learn to behave? The emotional state of children while they are learning seems to playa vital role in their acquisition of new behaviors. A child who is under a lot of stress learns very slowly. Learning seems to be maximized by the child being in a relaxed state. Many parents have wondered why children learn a swear word in an instant but take weeks, months, or longer to learn how to clean their rooms. Typically, if the parents were doing something that was unremarkable to the child when the swearing occurred and the parent repeated the swearing, under these circumstances, many times the child would learn to swear quickly. Conversely, if the child feels a great deal of stress when learning to clean his or her room, then the child may require a great deal of time before being able to clean the room reliably. REASONS FOR DISCIPLINE

What are some of the reasons why parents discipline their children? Parents Use Discipline to Stop an Inappropriate or Undesirable Behavior

Probably the most frequent reason that parents resort to discipline is in an attempt to stop an inappropriate or undesirable behavior. Parents usually make the assumption, with the best of intentions, that stopping an inappropriate or undesirable behavior automatically results in the child engaging in more appropriate behaviors. Unfortunately, just like a snow skier falling does not automatically make the skier a good skier, the disciplined child does not automatically behave better. Rather, such use of discipline typically results in a temporary suppression of the child's inappropriate or undesirable behaviors, only to have the child return to them again. In children with high outputs, such as those diagnosed with attention deficit disorder, this return to the status quo probably takes place much faster than the parents would like. In order for diScipline to be effective, children must have two alternate behaviors from which to choose. This suggests that discipline is only effective at bringing about behavior change when children already know what behavior the adult is trying to get them to exhibit. Thus, in order to be effective, children must already know what behavior parents are trying to teach them. ' ° This, in turn, would be an impossible situation were it not for the fact that children do learn and they usually do it without much diScipline-such as the learning that takes place in the typical school classroom.

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Parents Use Discipline to Teach Children a Lesson and Make Them Think Twice Before They Do It Again

Getting children to think twice about their behavior is of little value if they do not already have the appropriate behavior in their repertoire. Rather, thinking twice about their behavior often only causes them more stress, which results in their learning more slowly. Parents often are mislead by the fact that their children are able to carryon discussions about their behavior with them. This only demonstrates that the children have good verbal skills, not that they can or will behave in a particular way. The parents, however, after carrying on a conversation with the child about the child's behavior, often assume that they have "taught" the child the appropriate behavior and that no further activity is necessary on the parent's part. Parents Use Discipline to Teach Children Appropriate Behaviors

Society has hundreds of years of formal experience teaching almost every conceivable skill to almost every conceivable type of individual. No place in society is corporal punishment used under the guise of being an educational experience except in homes and prisons. Again, if parents want to teach children appropriate behaviors, they must do exactly that: teach them appropriate behaviors. Parents Use Discipline to Help Children to Internalize Society's Values

I have often heard parents say that they want their child to behave a certain way because the child "wants to." Yet we as adults often behave the way we do because we do not like what happens when we get caught misbehaving. Witness the 55 mph speed limit. Many adults drive several miles over the speed limit and admit that the only reason that they do not drive faster is that they do not want to get a ticket. They do not drive the speed limit because they are good Americans or because it is the right thing to do; they drive the speed limit because they do not want a ticket. There are many different reasons that parents and other caregivers give for using discipline. If discipline fits what has come to be a classic position, then its sole purpose is to stop a child from performing a particular behavior. Unfortunately, this is a rather short-sighted position because the caregivers, in reality, usually use discipline in an effort to teach a child appropriate behaviors. Thus, if parents are upset with a child for bothering them while they are on the telephone, practically no form of diScipline teaches the child how to behave while they are on the phone. Rather, discipline may temporarily discourage the child from bothering the parents. It is this temporary nature of the effects of discipline that leads to parents getting frustrated and angry. In order for discipline to be effective, the child must have two separate and discrete sets of skills from which to choose. 6 The disciplinary procedure, under the right circumstances, should encourage the child to choose one set of skills over the other set. Thus, if parents talk on the phone a lot and their child bothers them most of the time, the use of a disciplinary procedure usually only serves to frustrate the parents and hurt the child's feelings, not to mention it

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increases the child's annoying behaviors. There is little chance that the child learns anything productive or useful from the entire experience. If, however, the parent works at teaching the child a set of skills that are incompatible with bothering the parent, such as reading, watching television, or coloring in a coloring book, then the parent has a much better chance of being able to encourage the child to choose coloring over bothering the parent. LEARNING NEW BEHAVIORS

How, then, does a parent teach a child a new behavior? Let us use the example of riding a bicycle. The parent begins by putting training wheels on the bike so that the child can ride, initially, without having to think about keeping the bike upright and so that the child is less likely to be hurt while in the process of learning how to ride the bike. The parent places the child on the bike, holds the bike steady, and gently pushes the child around on the bike while the child pedals the bike. As the child develops more and more confidence, the parent provides less and less support, and gradually, the child builds up confidence until that point at which he or she asks to be allowed to pedal alone. At that point, the adult usually gives the bike a gentle push and lets the child pedal for a short distance. As the child develops more and more confidence, he or she pedals with less and less assistance. Then, when the child has learned how to ride a bike with the training wheels in place, the parent gradually begins to raise the training wheels, perhaps one quarter inch at a time, so that the child still has the support of the training wheels but only needs them occasionally. How does learning to ride a bike differ from learning to clean one's rooms? Not by much. The parent begins by cleaning the room alone. Then, ideally, the parent cleans the room with the child providing a little help. Over time, the parent cleans less and less and the child cleans more and more. It is through the parent modelling how to clean the room and gradually expecting more and more of the child that the child learns how to clean the room. Once the child has demonstrated repeatedly that he or she is capable of cleaning the room, then and only then can discipline be expected to effect the room-cleaning behavior. In fact, many children learn to clean their rooms with very little need for discipline. What about the child who knows how to clean his or her room and refuses to clean it? Then, and only then, does discipline begin to take on an important role. The mistake that many parents make is that they expect far too much to come from disciplining a child. They expect that the child will not break the rules again, although most adults, knowing what the rules are in most situations, typically break the rules over and over again. DISCIPLINE TECHNIQUES

Probably the most frequently recommended form of discipline over the past two decades is a procedure called time-out. There are a number of factors related to the use of time-out that have been carefully researched in terms of promoting the effectiveness of the use of time-out. These include how the timeout is initiated, how the time-out is terminated, what the child does during the time-out, and what the parent does after the time-out is over. Let us review these each now. The most important issue in any discussion about time-out is

time-in.

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Time-in

The normal state of affairs when a child is not being placed in time-out is called time-in. A child who is sitting on the floor playing near his or her mother while she talks on the telephone is experiencing time-in. If the mother periodically strokes the child's hair, rubs the child's back, or maintains some kind of frequent, brief, nonverbal physical contact, then the child is much more likely to continue what he or she is doing and, therefore, is much less likely to bother the mother. The same is also true when either parent is reading, doing housework, entertaining friends, or getting ready to leave the home. If an effort is made on the parent's part to sprinkle these activities with frequent, nonverbal, physical contact, then the child is much more likely to continue with the appropriate activity. One study showed that parents were much more successful in disciplining their children if the children were encouraged to engage in "solitary toy play."" There is an important distinction between simply praising a child and teaching a child solitary toy play. Solitary toy play actually teaches children how to spend some of their time, which is often much more satisfying to a parent than having a child engaged in a play activity that requires that the parent provide the child with frequent praises or rewards. Children who learn solitary toy play are much better able to spend their time alone in an enjoyable activity. Time-out

If parents already are engaging in "time-in" with their child, then simply removing the time-in or using time-out is all that is necessary to discipline the child. The most effective way to introduce time-out is to begin with very brief time-outs, preferably of only 2- to 3-second duration. For example, a parent can be reading a story to his or her daughter up until about 30 minutes before he or she wants her to go to bed. The parent stops reading the story and asks the daughter to put on her pajamas. If the daughter pauses or stalls for even 5 seconds, the parent says "time-out" and then refuses to interact with her again until she is quiet and calm. This quiet and calm serves the primary purpose of making sure that the child is relaxed and unstressed so as to maximize the effectiveness of any learning that might be taking place. Once the daughter is quiet and calm, the parent again asks her to put on her pajamas. If she pauses or stalls again, the parent says "time-out" again and waits until she is quiet and then asks her again to please put on her pajamas. Thus, the parent sets up a situation in which the daughter is able to practice the skill that the parent wants to work on over and over again, with feedback from her parent and with interspersed periods of calm. Within a relatively brief period of time, the daughter would probably put on her pajamas and the parent would then sit down with her to resume reading with her. Thus, the daughter is given two choices: (1) she can repeat the time-outs over and over again, or (2) she can do what her parent has asked her to do and return to reading with her parent. This same scenario can be repeated over and over again, night after night, until the daughter learns to put on her pajamas when asked. Similar scenarios also can be played out with a wide variety of other behaviors. The only requirements are that the parents must be certain, based on having seen her do the activity many times before, that she knows how to do it and that the time-outs that follow each request to engage in a particular, parent-selected activity must only be ended when the child exhibits quiet, calm behavior.

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Solnick et al14 conducted a study on the effects of impoverished versus enriched time-in. Enriched time-in consists of routine activities that the child enjoys, whereas impoverished time-in consists of activities that the child would just as soon stay away from. Thus, parents who go out of their way to make their time with their child pleasant enrich the child's time-in. Parents who ignore their child make the time-in unenjoyable for the child. Whenever parents state that time-out does not work with their child, the first issue to address with them is to ask what they are doing during time-in. Sometimes it helps to address the issue of what time-out really is. When the time-out procedure was first introduced to the research literature, it was referred to as "time-out from positive reinforcement."" In this early study, the researchers did not even begin to use a time-out procedure until they had initiated a regular program of positive reinforcement for appropriate behaviors. Thus, when they did introduce the use of time-out, they had enriched time-in to withdraw. In Etzel and Gewirtz's study 9 on operant crying in infants (the term operant crying refers to crying in a child who has been rewarded with parental attention), the first procedure that they taught the parents to use was smiling at their baby whenever their baby was making eye contact with the parent. It was only after the parents had the smiling well established that the researchers talked to the parents about withdrawing that positive interaction from their child. Perhaps one of the best features about time-in is that the health care provider can model or demonstrate it for the parents during a routine office visit. When a health care provider begins talking to a parent during a wellchild visit, he or she should start by having a lot of brief, nonverbal, physical contact with the child-gentle back rubs, touches on the shoulders and neck, touching that conveys a sense of calmness to the child and lets that child know that the health care provider likes the child. It works well to begin using timein during the parent interview before even telling the parent about time-in. One can start right out by demonstrating it for the parents. I am reminded of a Fellow in our program several years ago who used to enjoy using brief phYSical touching to get the child to stay right next to her. Then, after about 5 minutes, she would begin ignoring the child and when the child got near me, I would begin the brief physical touching. Within 20 minutes or so, we would be to the point where we could actually move the child back and forth across the room by just using the physical touching contrasted with the ignoring. After doing this successfully while the parents watched, we would point out to the parent what we had been doing and the child's favorable reaction to it. It was interesting to note how few parents ever noticed what we had been doing. Table 1 is a copy of the written handout given to parents to describe time-in. As children age, with enough nurturing from one or both of their parents typically their independent play skills improve, both in terms of the duration of time that they can play without any assistance from an adult and in terms of the complexity of the tasks that they can engage in while they are playing independently. Thus, whereas a 2-year-old may only be able to play for 5 or 10 minutes alone, a 4-year-old should be able to play for an hour or more alone. The more a child plays alone, the better he or she usually gets at this independent play, which means that like a child's language development, the independent play becomes generative. With language development, a child soon begins to say things to the people around him or her that they have never heard. The child begins to generate his or her own intelligent speech. In the same fashion, independent play becomes generative. A child who has been taught how to work with simple house tools (a saw, a hammer, glue) soon

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Table 1. TIME-IN By their very dependent nature, newborns and young infants require a lot of physical contact from their parents. As they get older and their demand characteristics change, parents usually touch their children much less. By the time children are four years old, they are usually toilet trained, can get dressed and undressed themselves, can feed themselves, and can bathe themselves. Thus, if parents don't conscientiously put forth an effort to maintain a great deal of physical contact with their child, he or she will be touched much less than they did at earlier ages. There are several things that parents can do to help offset these natural changes. 1. Physical proximity. During boring or distracting activities, place your child close to you where it is easy to reach him. At dinner, in the car, in a restaurant, when you have company, or when you are in a shopping mall, keep your child near you so that physical contact requires little, if any, additional effort on your part. 2. Physical contact. Frequent and brief (one or two seconds) nonverbal physical contact will do more to teach your child that you love him than anything else that you can do. Discipline yourself to touch your child at least fifty times each day for one or two seconds-touch him anytime that he is not doing something wrong or something that you disapprove of. 3. Verbal reprimands. Children don't have the verbal skills that adults do. Adults often send messages that are misunderstood by children, who may interpret verbal reprimands, nagging, pleading, and yelling as signs that their parents do not like them. Always keep in mind the old expression, "If you don't have anything nice to say, don't say anything at all." 4. Nonverbal contact. Try to make most of your physical contact with children nonverbal. With young children, physical contact usually has a calming effect, whereas verbal praise, questioning, or general comments may only interrupt what your child was doing. 5. Independent play. Children need to have time to themselves-time when they can play, put things into their mOl!ths, or stare into space. Generally, children don't do nearly as well when their parents carry them around much of the time and constantly try to entertain them. Keep in mind that, although your baby may fuss when frustrated, she will never learn to deal with frustration if you are always there to help her out. Give children enough freedom to explore the environment on their own, and they will learn skills that they can use the rest of their lives. Remember:

Children need lots of brief, non-verbal physical contact. If you don't have anything nice to say, don't say anything at all. From Christophersen ER: Little People: A Commonsense Guide to Child Rearing, ed 3. Kansas City, MO, Westport Publishers, Inc, 1988; with permission.

learns to make objects that neither parents have ever made. Similarly, a child who learns to read can read materials that neither parents have ever read, either to the child or to themselves. As the independent play skills continue to develop, the child gets more inner satisfaction from them as well as more external rewards from them. For a child with poorly developed independent play skills, the parents need to begin teaching these skills by playing with the child. The parents should watch for times when their child is appropriately engaged in an activity and provide a lot of brief, nonverbal, physical contact with the child. When the parents observe the child engaging in the play activity, they should quietly excuse themselves for a minute. Initially such an interruption should be for only a period of 2 or 3 seconds, just long enough for the parent to walk about 5 feet away and return. With many repetitions, the child becomes less disrupted by these brief interruptions and continues playing throughout them. Then the parents begin to take longer and longer breaks from playing with the child.

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Although it usually takes 4 to 6 months for a child to learn independent play skills, the average parent should be able to see an improvement in independent play skills within 1 to 2 weeks. Table 2 describes how to teach independent play to a child. If the parents are providing their child with a lot of "quality" time-in, then they can remove that time-in, that is, they can "time the child out." All that time-out refers to, then, is stopping an activity that the child normally enjoys. Without this normally enjoyable activity, there is nothing to take away from the child, nothing to use to time-out the child. Initiating a Time-out

Time-outs should occur as soon after the inappropriate behavior as is practica1. 6 Thus, if a child is playing on the floor near where the mother is talking on the phone, and he or she abruptly stops what he or she is doing and climbs up on the mother's lap and starts to push the touch-tone buttons on the phone, the mother should immediately time the child out. A good rule of thumb is that any time-out should be started with only three words: "time out interrupting," "time-out sassing," or "time-out hitting." Saying more than three words will more than likely engage the child in a conversation and, in time, will more likely frustrate the parent. The three-word rule should be inviolate in the sense that there really should not be any circumstances under which the parent uses more than three words. Table 3 summarizes rules about time-out. Table 2. TEACHING INDEPENDENT PLAY SKILLSTODDLER To encourage independent play activities: 1. Begin an activity with your toddler that you think they will enjoy. Play with them the whole time the first couple of times that you do it. 2. Provide many "love pats" during the play activity. 3. Pick an isolated play activity. An isolated play activity is an activity that is best performed by one person. For example, building Legos is something that children do well alone. A social play activity is an activity that requires two people in order to do it. An example would be playing catch with a ball. 4. Begin to excuse yourself from the activity at times when you can tell that your child is actively engaged. Excuse yourself for a very brief period of time, perhaps for only five seconds while you walk over to the kitchen counter and return directly to the activity. After about two days of excusing yourself for only 5 seconds, if your child can play for that 5 seconds, plan to be gone for 7 or 8 seconds. In this fashion gradually increase how long you are gone based upon your child continuing with his play while you are gone. What you are aiming for is to be able to leave without interrupting the activity that your toddler is doing. 5. Over time, perhaps two to three months, gradually stay away from your toddler for longer and longer periods of time, until you notice that you can be gone for extended periods of time. As you are able to excuse yourself for increasingly longer periods of time, don't forget to provide your toddler with periodic, brief, nonverbal, physical contact. In this way your toddler will get the enjoyment out of playing and the affection from you from the same activity. 6. With time and practice, your toddler will learn how to entertain himself without the need for assistance from you. The more they play alone, the more they can accomplish on their own, and the more sense of satisfaction they will derive from their play activities. From Christophersen ER: Beyond Discipline: Parenting that Lasts a Lifetime. Kansas City, MO, Westport Publishers, Inc, 1990: with permission.

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Table 3. USING TIME-OUT FOR BEHAVIOR PROBLEMS Preparations 1. Purchase a small portable kitchen timer. 2. Select a place for time-out. This could be a chair in the hallway, kitchen, or corner of a room. It needs to be a dull place (not your child's bedroom) where your child cannot view the TV or play with toys. It should not be a dark, scary, or dangerous place-the aim is to remove your child to a place where not much is happening, not to make him feel afraid. 3. Discuss with your spouse which behaviors will result in time-out. Consistency is very important. Practicing (if your child is three or older) 1. Before using time-out for discipline, you should practice using it with your child at a pleasant time. 2. Tell your child there are two rules when in time-out: a. The timer will start only after he is quiet. Ask your child what would happen if he or she talks or makes noises when in time-out. Your child should say the timer will be reset or something similar. If they do not say this, remind them of the rule. 3. After explaining the rules and checking out your child's understanding of the rules, go through the steps under "Procedures" below. Tell your child you are "pretending" this time. 4. Mention to your child you will be using this technique instead of spanking, yelling, or threatening. Procedures 1. Following an inappropriate behavior, describe what your child did in as few words as possible. For example, say "Time-out for hitting." Say this calmly and only once. Do not lose your temper or begin nagging. If your child has problems getting to the chair quickly, guide them with as little effort as needed. This can range from leading them part way by the hand to carrying them all the way to the chair. If you have to carry him, hold them facing away from you. 2. Practice with two-second time-outs initially, until you are certain the child understands they must be quiet in order to get up. Gradually increase the length of time they must sit. After you are using time-outs that are at least a minute long, begin to use the timer to signal the end of time-out. 3. The rule of thumb is a maximum of one minute of quiet time-out for each year of age. A two-year-old would have two minutes; a three-year-old, three minutes; and a five yearold, five minutes. For children five years and above, five minutes remains the maximum amount of time. If your child makes noises, screams, or cries, reset the timer. Do this each time the child makes any annoying noises. If your child gets off the chair before the time is up, replace them on the chair, and reset the timer. Do this each time the child gets off the chair. 4. After your child has been quiet and seated for the required amount of time, the timer will ring. Walk over to him, place your hand on his back and simply say "okay." Apply gentle pressure to their back with your hand for a second to let them know it's all right to get up now. Do not even comment on the time-out. 5. After a time-out period, your child should start with a "clean slate." Do not discuss, remind, or nag about what the child did wrong. Within five minutes after time-out, look for and praise good behavior. It's wise to take your child to a different part of the house and start them in a new activity. Table continued on opposite page

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Table 3. USING TIME-OUT FOR BEHAVIOR PROBLEMS Continued Things to Check When Time-out Doesn't Work 1. Be sure you are not warning your child one (or more) times before sending them to the time-out chair. Warnings only teach your child that they can misbehave at least once (or more) before you'll use time-out. Warnings make children's behavior worse, not better. 2. All adults who are responsible for disciplining your child at home should be using the time-out chair. You should agree when and for what behaviors to send your child to time-out. (You will want new sitters, visiting friends, and relatives to read and discuss the time-out guidelines.) 3. To maximize the effectiveness of time-out, you must make the rest of the day ("timein") pleasant for your child. Remember to let your child know when they are well behaved rather than taking good behavior for granted. Most children would prefer to have you put them in time-out than ignore them completely. 4. Your child may say "Going to the chair doesn't bother me," or "I like time-out." Don't fall for this trick. Many children try to convince their parents that time-out is fun and therefore not working. You should notice over time that the problem behaviors for which you use time-out occur less often. 5. When you first begin using time-out, your child may act like time-out is a "game." They may put themselves in time-out or ask to go there. If this happens, give your child what they want-that is, put them in time-out and require them to sit quietly for the required amount of time. They will soon learn that time-out is not a game. Your child may also laugh or giggle when being placed in time-out or while in time-out. Although this may aggravate you, it is important for you to ignore them completely when they are in timeout. 6. TV, radio, or a nice view out the window can make time-out more tolerable and prolong the length of time your child must stay in the chair by encouraging them to talk. Try to minimize such distractions. 7. You must use time-out for major as well as minor behavior problems. Parents have a tendency to feel that time-out is not enough of a punishment for big things. Consistency is most important for time-out to work for big and small problems. 8. Be certain that your child is aware of the rules that, if broken, result in time-out. Frequently, parents will establish a new rule ("Don't touch the new stereo") without telling their children. When children unwittingly break the new rule they don't understand why they are being put in time-out. 9. Review the time-out guidelines to make certain you are following the recommendations. When Your Child is in Time-out: a. Don't look at him or her. b. Don't talk to him or her. c. Don't talk about him or her. d. Don't act angry. e. Do remain calm. f. Do follow the written guidelines. g. Do find something to do (read magazine, phone someone) when your child is crying and talking in time-out. h. They should be able to see you. i. They should be able to tell you're not mad. j. They should be able to see what they are missing. From Christophersen ER: Beyond Discipline: Parenting that Lasts a Lifetime. Kansas City, MO, Westport Publishers, Inc, 1990; with permission.

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Self-quieting Skills

One major advantage of the use of time-out is that parents can use it to teach their children self-quieting skills. 6 Self-quieting skills refer to an individual's ability to calm oneself down when upset or when something happens that one does not like. Examples would be anything from a child having to cope with building blocks falling down to not being able to find a missing piece of a puzzle to being coerced to share something with a sibling when the child does not feel like it. Self-quieting skills allow an individual to cope with many of life's events without getting unduly upset or angry. It appears that the sooner we begin to teach children these self-quieting skills, the easier it is for children to learn these skills. Once learned, if the parents continue to allow the child to experience situations in which he or she can use self-quieting skills, the child can use these skills virtually all of his or her life. The use of brief time-outs are an excellent way to encourage a child to use self-quieting skills. If the child is timed-out for an inappropriate behavior and is required to calm down prior to being in time-in again, the child has many opportunities to use self-quieting skills. Researchers and clinicians have known for a long time that when first exposed to the use of time-out as a disciplinary procedure, children often fuss significantly more than they had been doing. 8 This is to be expected because children do not like the fact that their parents have changed what they are doing and because they typically lack the selfquieting skills that are necessary to quiet easily. Over an extended period of time, children begin to incorporate these skills into everyday activities, resulting in excellent coping skills during adolescence and adulthood. Table 4 summarizes rules for encouraging children to use their self-quieting skills. Warnings

There is good research to show that children's behavior gets worse with warnings, not better. Research has shown that children behave less appropriTable 4. TEACHING SELF-QUIETING SKILLS TO TODDLERS You should discipline yourself to take advantage of every naturally occurring opportunity to teach your child self-quieting skills. If your child comes up to you with their feelings hurt, or after falling off their tricycle, try to refrain from saying anything. Rather, hold them against you, without saying a word, while you rub their back and pat them. In this way, they will learn that you are a great source of comfort when they need you. But, they will also learn that you don't quiet them down-they are responsible for quieting themselves down. Using time-outs for discipline is another way of teaching toddlers self-quieting skills. Every time that you send your toddler to time-out and they quiet down, they are learning self-quieting skills. While there may only be one or two opportunities in a day to let a child naturally quiet himself down, using time-outs can create many opportunities for the same skills to be practiced. If you keep reminding your toddler that they must be quiet when they are in time-out. they will never have the opportunity to self-quiet. They must learn to quiet down without any help from you whatsoever. That means that. if they are having a horrendous tantrumyou must let them quiet down. To comfort a child who is having a tantrum only encourages them to have more. Remember, the more opportunities, and the closer the opportunities are to each other, the quicker your toddler will learn self-quieting. From Christophersen ER: Beyond Discipline: Parenting that lasts a Lifetime. Kansas City. MO. Westport Publishers, Inc, 1990; with permission.

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ately when they are warned frequently. 13 The more warnings, the worse the behavior gets. Of What Does a Time-out Consist?

During a time-out, the child should be completely ignored, independent of what he or she is doing or saying. Our rule with time-out is that a child should be allowed to urinate, defecate, vomit, bleed, spit, scream, kick, or swear and the parent still should make no attempt to interact with the child until the time-out is over. Passive Time-outs

With some children, particularly children who are very oppositional, it becomes almost a contest when the parent tries to incorporate time-out. The children fight the parents verbally, physically, or both. In these situations, a child really is not in time-out because although it is unpleasant, the child is continuing to interact with the parent. With a passive time-out, the parent tells the child that he or she is in time-out and then completely ignores the child until the child has self-quieted. Although the child may yell, beg, or run, the parent continues to ignore the child no matter what he or she is doing. The instant that the child does calm down for even 2 seconds, the parent says, "time-in" or "OK," and that time-out is over. The Importance of Contrast

The contrast between time-in and time-out does more to enhance the learning of it than anything else that the parent can do. If children get a lot of attention while they are playing nicely, are completely ignored when they behave obnoxiously, and then get a lot of attention when they behave appropriately, they quickly learn that they prefer the nice interaction to being ignored. Whether this contrasting of two situations takes 10 times or 100 times does not and should not matter to the parents. It is the fact that the parents ultimately accomplish their goal of teaching the child something that is of the utmost importance. Ending a Time-out

Time-out is generally more effective if it is terminated when the child is quiet. Thus, if a child is upset when told that he or she is in time-out and is ignored as long as he or she is fussing, the parent should tell the child that the time-out is over immediately upon calming down. Except for telling the child that the time-out is over, either by saying time-in or OK, nothing else should be said to the child. There should be no attempt to discuss why the child was "timed-out." Nor should there be any attempt to make certain that the child knows why he or she was put in time-out. Rather, the time-out should be completely over immediately after the child is quiet. This ignoring of a child who may be acting out during a time-out may require good coping skills on the part of the parent. Nagging, Threatening, and Warnings

There is some research that shows that warnings and threats make children's behavior worse. The parent who is constantly giving verbal repri-

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mands makes the environment unpleasant for everyone in the house. No one actually enjoys being nagged or nagging someone else. Ginott" said that a warning just tells your child that he or she can get away with the obnoxious behavior at least one more time, whereas getting disciplined immediately tells the child exactly what is going to happen if he or she misbehaves again. Hitting and Slapping

There are numerous, well-intentioned professionals who advocate that physical force never be used to correct a child's behavior. They argue, usually incorrectly, that strong forms of punishment do not work. This often is simply not true. If children are hit on their back or their bottom every time that they engage in the same undesirable behavior, they quickly learn how to avoid getting hit. They probably learn very little about the behavior that their parents want to see from them, however. Furthermore, children who grow up with hitting or slapping as their primary form of diSCipline may have problems when they are attending a preschool, a mother's day out, or regular school because, in most states, corporal punishment is not allowed in these settings. What little research there is on this subject has shown that if a child is spanked in one setting and placed in time-out in another setting, the time-out loses its effectiveness, leaving the formal school setting with no viable options for discipline. Medication

In uncomplicated cases of oppositional or defiant behavior (that is, where there is no suspicion of attention deficit disorder, depression, or other disorder) there are no medications that are routinely recommended. 5 Even in those cases in which a child is both oppositional and is suspected of having attention deficit disorder, the use of medication may be a significant aid in managing the attention deficit but is rarely of any help in teaching the child appropriate behaviors. Even in those cases in which a child presents with both a need for more and better discipline and has attention deficit disorder, medication alone is simply not sufficient therapy.' DiSCipline with Older Children

Ironically, although most parents find out relatively early in their child's life that yelling and spanking are not effective as disciplinary procedures, for some reason (probably because they do not know what other options are available) they still attempt to use yelling and spanking with older children and adolescents. My feeling is that time-in and time-out should be used with children as well as adolescents. When a child has engaged in a behavior that is more serious than the run-of-the-mill misbehavior, however, then we recommend grounding. Grounding has been around for at least several decades. A variation of grounding, called job grounding,' has been very effective with children more than 6 years old who have engaged in a behavior that the parents think is more serious than the behaviors that they use time-out for. Table 5 summarizes rules for job grounding. Rather than ground a child for a period of time-anywhere from 1 day to

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Table 5. GROUNDING AS A METHOD OF DISCIPLINE Grounding is a method of discipline that may be used to teach your child the consequences of breaking rules (inappropriate behavior). It is not a substitute for time-out; it should be used for more serious offenses. Grounding also provides your child with an opportunity to learn how to do various jobs around your home and receive your instructive feedback. The following instructions describe how to use grounding. 1. Sit down with your child at a pleasant time and develop a list of at least ten jobs that need to be done regularly around the house. The individual jobs should be approximately equal in difficulty and amount of time required to complete. Be sure your child is physically capable of doing each job. Examples of such jobs are washing the kitchen floor, cleaning the bathroom, sweeping out the garage, or vacuuming the living room and dining room. 2. Each job should be written on a separate index card with a detailed description of what is required to complete the job correctly. For example: Wash kitchen floor. The floor should be swept clean first. Remove all movable pieces of furniture. Fill a bucket with warm soapy water, wash the floor with a clean rag, squeezed dry. Dry the floor with a clean, dry rag. Replace the furniture that was moved. 3. Explain to your child that when she has broken a rule (for example, by not returning home from school on time), one or more job cards will be assigned. The child will randomly select the assigned number of cards from the prewritten job cards. Until the aSSigned number of jobs described on the cards are completed correctly, she will be grounded. 4. Being grounded means: . a. Attending school b. Performing required chores c. Following house rules d. No television e. Staying in own room unless eating meals, working on chores, or attending school f. No telephone calls g. No record player, radio, etc. h. No video games or other games or toys i. No bike riding j. No friends over or going to friends' houses k. No snacks I. No outside social activities (movies, going out to dinner) 5. Being grounded does not mean: a. Nagging b. Reminding about jobs to be done c. Discussing the grounding d. Explaining the rules 6. When the jobs are completed, you should check to be sure that they have been done correctly. Praise your child for completing the chores correctly and, thus, ending the grounding. If a job is not completed correctly, review the job description and provide feedback on parts done correctly vs. incorrectly. Without nagging, instruct your child to redo the incorrect tasks in order to end the grounding. 7. Your child determines how long she is to be grounded. The grounding only lasts as long as it takes to complete the assigned jobs-it could last from fifteen minutes to a day or longer. 8. If the grounding seems to be lasting an excessively long time, check to be sure that your child's life is dull enough during the grounding. Make sure you are not providing a lot of attention in the form of nagging, etc. 9. Grounding is effective when your child follows the rules more often and is aware of the consequences of breaking them. 10. Be sure you have a baby-sitter available on short notice in case your child is grounded and unable to accompany you on a planned family outing. From Christophersen ER: Little People: A Commonsense Guide to Child Rearing, ed 3. Kansas City, MO, Westport Publishers, Inc, 1988; with permission.

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1 week-I prefer to have them grounded until they have finished one job assigned by the parent. In this way, the child can work off the grounding in a matter of 10 to 20 minutes instead of being grounded for a much longer period of time. During the job grounding, the parents are forbidden to remind the child about the grounding, discuss the reason for the grounding, or interact with the child in any way. The child, in turn, is forbidden to have friends over, make or take phone calls, or watch television. As soon as the job is completed in a satisfactory manner (not perfect but satisfactory), the grounding is over. PARENT COPING SKILLS

One strategy that has been developed by cognitive behavior therapists has to do with "self-talking." These therapists have identified parents who engage in negative and nonproductive self-talking during stressful times with their children.· They may persevere on how unpleasant the child's behavior is and how they (the parent) cannot stand the unpleasant behavior much longer. In essence, what the parents are doing is dooming their use of time-out to fail. They are starting out immediately to tell themselves how unpleasant the timeout is and how hard it is for them to do it. Within a short time, such parents can easily convince themselves that they should not use time-out as a disciplinary procedure anymore. Examples of such negative self-talking are, "I don't know how many times I'm going to have to tell you. , . ," "If I have to tell you one more time ... ," "What's it going to take to get you to .... " Other variations are, "I can't stand it when you do that," "If you don't stop doing that, I'll lose my mind," "Don't you understand, you have to do what I tell you," "I remember the days when children did what they were told." If the parent had just substituted some helpful self-talking, they may well have found the entire experience much more pleasant. Such helpful self-talking could involve saying something to themselves such as, "I don't like it when Jason yells at me during a time-out but at least it demonstrates to me how much he dislikes time-out." Or, "Although 1 don't like it when Jason yells like this, 1 can tolerate it." CONCLUSION

Discipline is not something that can reasonably be handled on an as needed basis. Rather, parents are much better off if they choose their method of discipline carefully. Far more important than the immediate impact of the form of discipline are the effects that the discipline has on a child over the long term. If a form of discipline is chosen that is effective immediately but cannot be generalized to other caregivers and to other settings, then that form of discipline is limited. Time-out is one of the best researched methods of discipline in the history of mankind. No single procedure in child rearing has been studied more carefully. No single procedure has been subjected to a more careful and thoughtful analysis than time-out. When used correctly, with a major emphasis on the quality of the child's time-in, the use of time-out can be impressively effective. Like any other procedure, however, time-out must be used correctly, often, unemotionally, and every time a child misbehaves. As parents get better about using time-out immediately and unemotionally, their children typically get better at both self-quieting and independent play.

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As children get better at both of these skills, then the need for discipline declines. It is nice that the most effective form of discipline, when used correctly, teaches children skills that reduce the need to discipline. ACKNOWLEDGMENT The editorial assistance of Barbara Wood is gratefully acknowledged. Preparation of this article was partially supported by a grant from the Centers for Disease Control. Professionals are authorized to reproduce the tables in this article, without charge, provided that they include the attribution footnote and no fee is charged.

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Research and Application. New York, Appleton, 1966 2. Baren M: The case for Ritalin: A fresh look at the controversy. Contemporary Pediatrics 6:16-28, 1989 3. Barnard JD, Christophersen ER, Wolf MM: Supervising paraprofessional tutors in a remedial reading program. I Appl Behav Anal 7:481, 1974 4. Barrish HH, Barrish IJ: Managing and Understanding Parental Anger. Kansas City, MO, Westport, 1989 5. Cantwell DP: OppOSitional defiant disorder. In Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry, ed 5. Baltimore, Williams & Wilkins, 1989, pp 18421845 6. Christophersen ER: Beyond Discipline: Parenting that Lasts a Lifetime. Kansas City, MO, Westport, 1990 7. Christophersen ER: Little People: Guidelines for Commonsense Child Rearing. Kansas City, MO, Westport, 1988 8. Drabman RS, Jarvie G: Counselling parents of children with behavior problems: The use of extinction and time-out techniques. Pediatrics 59:78-85, 1977 9. Etzel BC, Gewirtz IL: Experimental modification of caretaker-maintained high-rate operant crying in a 6- and a 20-week-old infant: Extinction of crying with reinforcement of eye contact and smiling. J Exp Child Psychol 5:303-317, 1967 10. Gelfand DM, Hartmann DP: Child Behavior Analysis and Therapy. New York, Pergamon Press, 1984 11. Ginott HG: Between Parent and Child. New York, Macmillan, 1965 12. Greenwood CR: A longitudinal analysis of time, engagement, and achievement in at-risk versus non-risk students. Exceptional Children 57:521-534, 1991 13. Phillips EL: Achievement place: Token reinforcement procedures in a horne-style rehabilitation setting for "pre-delinquent" boys. J Appl Behav Anal 1:213-223, 1968 14. Solnick JV, Rincover A, Peterson CR: Some determinants of the reinforcing and punishing effects of timeout. J Appl Behav Anal 10:415-424, 1977 15. Stendler CB: Sixty years of child training practices. J Pediatr 36:122-134, 1950 16. Task Force Report on Pediatric Education: The Future of Pediatric Education. Denver, Hirshfield Press, 1978 17. Wahler RG, Fox JJ: Solitary toy play and time out: A family treatment package for children with aggressive and oppositional behavior. J Appl Behav Anal 13:23-39, 1980

Address reprint requests to Edward R. Christophersen, PhD Division of Behavioral Pediatrics The Children's Mercy Hospital 2401 Gillham Road Kansas City, MO 64108-9898