Counseling Parents of Children With Behavior Problems: The Use of Extinction and Time-Out Techniques

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Counseling

Parents

of Children

With Behavior

Problems:

The

Use of Extinction

and Time-Out

Techniques

Ronald S. Drabman, Ph.D., and Greg Jarvie, B.A.

From the University of Mississippi Medical Center, Jackson

ABSTRACT. The pediatrician is the professional most frequently sought out for advice concerning disciplinary

problems with children in the home. Behavioral

psycholo-gists have advocated the use of contingent ignoring and time-out procedures to help reduce problem behaviors; however,

practicing pediatricians have found that these two procedures are often not successful. In fact, sometimes the two procedures seem to exacerbate inappropriate behavior.

This paper documents the difficulties found in using the ignoring and/or time-out procedures in the home setting. Potential pitfalls in the use of ignoring, including not specify-ing the target behavior, not taking a baseline, inadvertently,

intermittently reinforcing the inappropriate behavior,

response bursts, spontaneous recovery, and not reinforcing an appropriate alternative behavior, are described. In addi-tion, several pitfalls in the use of the time-out procedure, including selection of isolation area, inappropriate selection

of time intervals, interference from others in the family, and escape attempts on the part of the child are discussed. For each potential problem a remedy is suggested. Pediatrics,

59:78-85, 1977, DISCIPLINE, BEHAVIOR MODIFICATION, COUN-SELING.

The professional most likely to be consulted

regarding problems of discipline with young

chil-dren is the pediatrician. The pediatrician’s

rela-tionship with families is a special one, although it

must be limited by the practical considerations of

practice. He/she frequently hears complaints

from concerned and often distraught parents

seeking advice on how to deal with their

“problem children.” “How can I make Johnny

obey me?” “My child is a brat and won’t leave me

alone for a minute.” “Sally picks on her brothers

and

I can’t seem to make her stop.” These are all

familiar examples of complaints to which the

pediatrician must listen from parents who feel that discipline has slipped away from them. In

order to help the parents improve discipline in

the home, the pediatrician may enlist the aid of

behavioral psychologists who have suggested a

variety of procedures designed to reduce unwanted behaviors. The two behavioral pro-cedures which can be most practically handled within the pediatric relationship are “ignoring” and “time-out.”

Ignoring is among the simplest of the methods

currently advocated, and there is now

consid-erable evidence that many kinds of troublesome behaviors are easily eliminated by the systematic withdrawal of attention.’ Although there is a

growing body of successful research involving the

use of ignoring in the home situation, few authors

have described the potential problems parents are

likely to meet when attempting the ignoring

procedure. Often parents are told to “simply

(Received January 26; revision accepted for publication

April 21, 1976.)

Supported in part by grant 1 ROl 28367-01 from the National Institute of Mental Health (Dr. Drabman).

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ignore the behavior and it will disappear.” As

IiianV parents have found out, this simple advice sometimes works. At other times it may have no effect or may actually exacerbate unwanted

behaviors.

Another method of controlling a young child’s probleni behavior(s) without the use of yelling, pleading, scolding, continued spanking, etc., on

the part of the parent(s) is the “time-out”

proce-dure. Upon initiation of a disruptive behavior, the child is removed to a very nonstimulating,

uneventful, dull place (often the child’s room or a bathroom) and is forced to stay there for prede-termined lengths of time. There is a growing amount of successful research involving the use of

the time-out procedure65; however, as with the

use of the ignoring procedure, there are certain problems that may arise with its implementation in the home situation.

What seems initially like a “straightforward”

approach to the parents can easily become a

complex nightmare unless they are properly

warned and advised on how to deal with the

problems and complications which may arise when using either an ignoring or a time-out procedure.

What can go wrong when using these two procedures and, more importantly, how can the

pediatrician prepare the parents to be ready? We

hope to help bridge the gap between the

practic-ing pediatrician and researchers regarding the proper use of ignoring and social isolation

(time-out) in the home setting.

EXTINCTION

Advice to ignore disniptive behavior is usually

based on the principle of extinction. Extinction is the removal of reinforcement from a situation in which it formerly occurred, with the consequence

that the probability of the previously reinforced response is decreased. For example, a child screams at the mother (the undesired response) in

an effort to get the mother’s attention (the rein-forcer). This behavior can be reduced or elimi-nated (decreased in probability) by the mother

ignoring it (removing the reinforcer).

In the home setting, the typical behavior modification procedure has two phases: a baseline

phase and then the extinction phase itself. During

the baseline phase parents are instructed to keep a record of how often the undesirable behavior

occurs and also the consequences that follow each occurrence. For example, the parents may complain that their child is “always bothering

them.” It is important that the parents define the

problem behaviorally. Does bothering mean that the child clings to the mother? Does it mean that

the child screams at them? Does the child ask them questions constantly? The parents must focus on an exact behavior rather than obscure

descriptions like “bothering us.” Then the parents must record the consequences of the behavior

(

e.g., does the mother interrupt her housework to

reprimand or give attention to her child when the child exhibits the behavior?). This recording of

responses (both the child’s and the parent’s) serves two useful purposes. First, it tells the pediatrician

if the behavior is actually occurring as often as the parents report, that is, whether it warrants the time and effort involved in implementing the intervention procedure. Secondly, it provides a reference for the parents by which to determine if

the extinction procedure is working.

During the extinction phase, the parents arrange things so that the disruptive behavior is

systematically ignored while continuing to count

the frequency of disruptive behaviors. The

treat-ment data are then compared with the data obtained during the baseline phase as a check on the effectiveness of the program. Although, from a theoretical viewpoint, the procedure seems

straightforward, considerable difficulties are

fre-quently encountered in its application in the

home setting.

PROBLEMS WITH THE USE OF THE

EXTINCTION PROCEDURE

Probably the main reason there are frequent problems with the use of the ignoring technique is

its apparent simplicity. Because it is a relatively

uncomplicated procedure, parents tend to assume

that it will be easy, thereby causing their own

mdoing.

Because of the simplicity of initiating the

extinction procedure, it is tempting to the parents to skip the baseline phase of the program. This is

often fatal to the procedure, because without the baseline data the parents and pediatrician cannot

know if the program was needed in the first place and what the reinforcers maintaining the disrup-tive behavior(s) actually are. Furthermore,

with-out pretreatment data it is difficult to determine

whether the procedure is successful. This is most crucial where the improvement is gradual.

Occa-sionally, systematic observation alone will result in a decrease of the disruptive behavior,

rendering further efforts unnecessary.

Often parents’ perceptions of the severity of a

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Extinction Baseline

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35

30

25

20

0

5

I 5 10 15 20 25

DAYS

FIG. 1. Number of “I hate you” responses across days observed in baseline and extinction phases. Extinction procedure is carried out correctly.

pediatrician how often the target behavior actually occurs. In some cases, education of the parents as to the behavioral norms of children of

their progeny’s age may be the appropriate

ther-apy. Baseline data are also important when the

parents falsely assume that their attention is the maintaining factor of the child’s disruptive

behav-ior(s). Unfortunately, sometimes parents forget

that they are but one of several possible

rein-forcers available in the home atmosphere.

Siblings and other adults in the home may play an important part in providing reinforcement for disruptive behavior. It is essential that the parents determine from examination of the consequences of the behavior what is, in fact, the source of the reinforcement maintaining the behavior.

Other-wise, the parent’s attempts to ignore the child may prove futile. In this case successful treatment will involve both of the parents and even siblings.

Behavior modification procedures require work

from the parents. It is not easy for parents to

change their child-rearing practices and their relationships with their children. The pediatri-cian should keep this in mind both when selecting

appropriate parents and when explaining the

procedures.

Once the parents have determined the

rein-forcer of the inappropriate behavior, they must

understand that that behavior must be ignored each and every time it occurs. It must be stressed

that no compromise can be made if the extinction

procedure is to succeed. Should the parents forget and inadvertently reinforce the target behavior

with their attention, this thinning of the schedule of reinforcement may lead to increased resistance

to extinction. Experimental studies dealing with the properties of reinforcement schedules have shown that intermittent reinforcement is more resistant to extinction than continuous

reinforce-ment.2 Thinning the schedule inadvertently

teaches the child that, although it takes longer to get attention, eventually persistence pays off.

With the initiation of the ignoring phase, an

unexpected, although somewhat predictable, event may take place and the parents need to be

alerted to it. The child will likely “test the parents’ stamina” to see if they will be persistent. This “testing of the system,” or response burst, will be seen as an increase in the frequency of the

inappropriate behavior immediately following

the onset of the extinction procedure. Figure 1, a graph depicting a child’s “I hate you” response behavior, illustrates a response burst. During the

baseline phase, the child’s problem behavior was approximately 22 “I hate you” remarks to his mother per day. The mother initiated the ignor-ing procedure, and the graph shows the initial increase from the baseline rate of behaviors. The child began to yell the “I hate you” remarks and yelled them with greater frequency until, at the peak of the burst, the “I hate you” rate was 33 times per day. Fortunately, the mother continued to ignore the accelerated response rate, and later the rate of unreinforced behavior decelerated

until it was well below the baseline.

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Reinfoitement During Response

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FIG. 2. Number of “I hate you” responses across days observed. The extinction procedure which

was unsuccessful is reintroduced. However, the response burst is again reinforced, beginning a chain reaction.

50

mother successfully “weather” the response burst.

Had the mother capitulated and given attention

to the accelerated response burst, then a higher rate of responding would have been reinforced.

The child would have learned to yell “I hate you” remarks louder and with more frequency. The average rate would then have approached 31 responses per day as the graph illustrates. Later, should the mother again attempt to ignore the child’s “I hate you” responses, she would have to

deal with a more accelerated and annoying

behavior. If, during the second attempt to ignore,

the mother had again capitulated to the response

burst, a behavior pattern of even more intense “I hate you” responses would have been reinforced and thus established. Variations of the problem

behavior such as swearing or hitting the mother,

may also have emerged during the response burst. They, too, would have been reinforced by the mother’s capitulation and thus become estab-lished as part of the already accelerated

reper-toire.

The problem of response bursts is perhaps the

most critical in the administration of the

extinc-tion program. They do not always occur;

occa-sionally the behavior decreases immediately upon

the initiation of the procedure. However, when the data indicate that a response burst is

occurring, parents should be advised to be “stoic

and weather the burst,” however difficult that

may seem. Mishandling of this crucial phase of the procedure may perpetuate the problem

behaviors rather than reduce them. In explaining the intricacies of the response burst to parents, it

is often helpful to use visual displays like Figures 1

and

2.

Although it may seem obvious to the

pediatri-cian, often it is not easy for parents to understand

that the ignoring technique does not teach the

child to

do

anything, but rather simply teaches him or her what

not to do.

It is hardly in the best

interests of the child to merely suppress his/her

inappropriate modes of interaction without al-lowing the child legitimate access to the attention

and

reinforcement currently obtained through

maladaptive behaviors. Ignoring the child’s

maladaptive behavior may eventually reduce it; however, the child will be left to his/her own

means for arriving at new methods of gaining attention. He/she may or may not choose appro-priate ones. It is, therefore, important that the pediatrician advise parents to provide alternative modes by which the child can learn to interact more appropriately. These alternative ways of

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and family. The parents then should make a

special effort to reinforce the child with

imme-diate attention for the appropriate behavior. This will greatly increase the chances that the child

will switch to the appropriate behavior when the ignoring procedure begins. When the parents reinforce the appropriate behaviors, they should

describe it to the child. For example, they might say, “You didn’t say ‘I hate you’ this time; instead

you asked me very nicely if I could play with you and build puzzles. That’s very good. Now we can make them together.” This procedure allows the

child to become increasingly aware of what the

desired, expected behavior is and what the

conse-quences of it will be. Later, after it is clear to the child what is expected and he/she demonstrates

the appropriate behavior continually, the men-tion of the specific behavior need not be included

with every praise. Still later the schedule of praise can be thinned so that the child must behave appropriately several times before praise is given.

Jtist

as thinning the schedule makes maladaptive behaviors resistant to extinction, it works with

appropriate behaviors.

Should the child demonstrate the appropriate behavior and the parent is too busy at the

moment to interact with the child, then the parent should praise him/her for the appropriate behavior and explain the situation to the child. The parent should tell the child when he/she will be able to interact and assure the child at that time he/she will do so. It is important that parents do not make promises to the child and then not fulfill their part of the agreement. This might call for the parents to reassess their home

situation and allow more opportunities to interact with their children. Children usually have

diffi-culty understanding “rainchecks,” and such

situa-tions should be avoided to prevent the additional

complications that unfulfilled agreements would

bring.

After a successful extinction program has reduced or eliminated the undesirable behavior, there is still the possibility of a spontaneous recovery. That is, the child may, at a later date, attempt to gain attention via “old tricks.” As with the response burst problem, it is important that parents be aware of this phenomenon in order to refrain from reinforcing such “recovered” behav-iors should they occur.

In summary, ignoring has been found to be a viable and useful technique for the control of disniptive behavior(s) in a variety of situations. However, frequently the procedure fails because

its users are either not aware of the problems

inherent in such a “simple” procedure or are

imable to effectively confront and/or avoid these pitfalls.

TIME-OUT

The time-out or social isolation is another

method of eliminating maladaptive behaviors. It

is usually used in situations where the behavior(s)

cannot easily be reduced by using the ignoring procedure. Examples of such situations would involve those where the child harms others or

property, or situations where the child does not

obey appropriate parental requests.

Basically, the procedure entails placing the

child, after initiation of the target behavior, in a

nonstimulating, uneventful, dull place for a

pre-determined length of time. After the time limit

expires, if the child behaves appropriately, then

the child is allowed to leave the time-out room or area. This procedure is reminiscent of “sending the child to his/her room,” a disciplinary method frequently used by many parents. However, unlike this common procedure, social isolation is more systematic and much more controlled.

As with all behavioral techniques, it is initially

important that the parents define the target

behavior operationally. Data should be collected

by the parents as to the frequency of the target

behavior (baseline phase). Upon reviewing the baseline data and deeming the situation serious enough to require intervention, the parents must then prepare for the initiation of the time-out

procedure.

First, the area or room to be used in the time-out procedure must meet special considerations.

“Sending a child to his/her room” may or may not be effective. If there are toys, television sets, etc., in the child’s room, then the child might be

able to entertain her/himself and not mind at all

being sent to his/her room. Therefore, an area,

preferably a room, devoid of objects should be sought. The child’s room (sans toys, etc.) or an

extra room, laundry room, garage, or any area that is free fron’ outside or inside stimulation will do. Also, the time-out area should have limited avenues of escape for the child.

The object is not to make the time-out area formidable, but to make it very bland so that the

child quickly gets bored with it. The main effec-tiveness of time-out is derived not from

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engage in pleasurable activity combine to render time-out a painless, yet potent, punisher.

If an adequate room is not available, then

tle

parents can place the child in a chair facing the wall in a nonstimulating area such as the parent’s bedroom, the dining room, the hall (if other family members can be restricted from using the hallway), or even the bathroom.

The answer to the question of how long the

child should remain in the time-out area varies

with the age of the child. Usually with a child

from 2 to 5 years of age, it is best to begin by placing him in time-out for five minutes; with a child over 5 years of age, ten minutes is more appropriate. If these do not seem effective, they can be slightly lengthened without problems.

However, care should be taken to instruct the

parents that the time-out room is not a dumping area for the child. Once the time span has been decided upon, the child must be instructed to stay there until the time is up. Importantly, if the

pediatrician does not trust the parents to appro-priately use the time-out procedure, it should not

be suggested. Instead, the family should be

referred to someone who can more directly

supervise their child-rearing procedures.

PROBLEMS WITH THE USE OF THE

TIME.OUT PROCEDURE

There are a number of situations and problems which are bound to arise when parents begin to

use the time-out procedure. One of the problems the parents are confronted with initially is how to

easily keep track of the time the child is supposed to stay in time-out. One easy way to ensure accuracy without having

the

parents constantly

“watch the clock” is to instruct them to use a

COlilniOli kitchen timer with a built-in bell or

buzzer. Thus, the parents can easily set the timer for the allotted time, and when it is up they will be cued by the bell or buzzer. This allows the parents freedom from remaining in the

imme-diate vicinity of a clock. In addition, this method guards against forgetting to “check one’s watch”

and leaving the child in time-out longer than

required. Also, this prevents the child from cajoling the parents into shortening the

punish-ment.

It is important in the beginning of the

proce-dure that the parents explain the time-out system to the child. In other words, the child must be informed about what behaviors the parents want

the child to do or stop doing. Then the child must be told, in detail, the consequences of

noncom-pliance (which in this case would be placement in

the time-out room). It is important that the child

understand what the undesirable behavior is as

well as its consequences.

At this point, it is also important that the

parents communicate to the child an alternate, appropriate method of dealing with the problem

situation. As with any program which reduces a

maladaptive behavior, it is crucial that one supply the child with an appropriate alternative so that the child can learn an approved method of dealing with the situation in the future. Although

most children know which behaviors are appro-priate and which are not, such knowledge should

not be assumed by the pediatrician or parent. Occasionally, children will seemingly forget what they were told and react to a situation with an inappropriate behavior pattern even though

they understand the consequences. They have for

so long reacted to the situation in an unapproved

way that it is difficult for them to behave

appro-priately in that situation. This is why a warning system has been developed into the time-out

procedure. Parents are required to provide a

warning to the child before initiating the

proce-dure. After the warning the child has the option

of continuing to noncomply or choosing the

alternative, approved behavior. It is important that the parents not scream, yell, beg, physically threaten, etc., the child; rather, the consequences should be stated nonemotionally but firmly. If the

child does not comply, then the parents need to inform him/her that he/she must go to the time-out area. The child should be placed in the time-out room and the timer set. Again, this is all to be done unemotionally and with little verbal interac-tion between parents and child.

The parents will find that upon placing the child in the time-out area the child will probably protest, whine, cry, or have a tantrum. This is the

usual response and should be expected. In this situation the parent should be instructed to reply

to the child’s protest, “The longer you cry and whine, the longer you will have to remain in time-out. I am setting the timer back to the

begin-ning.” This is stated once firmly to the child, after which the child’s protests are ignored. Once the

child has stopped crying, the parent then waits

the standard duration (five minutes or ten

minutes). When the timer rings, the child is informed that he/she can leave the time-out area

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adult’s voice coming from near the door may

indicate to the child that he/she has control of his/her parents. Thechild might begin increased

misbehavior in order to manipulate his/her parents into giving the child their complete

attention while outside the door.

Another probleni the parents should expect is that of escape on the part of the child in an

attempt to flee the time-out situation. The child

may try to leave the room or may jump up. from

the chair and run away. This must be prevented

Each time the child leaves the time-out area, or even makes an effort to do so (opening the door,

for example, or standing by the chair), the child ii-iust be immediately and firmly returned. It is

important that the parents catch the escape as it

begins and not after the chjld is in full flight

through the house. It is hoped that if the parents

can be consistent in the beginning of the

proce-dure, the child will eventually realize he/she cannot escape the time-out room and will cease efforts to do so. Should a child become violently determined to leave the time-out room or contin-ually invent methods to sabotage the procedure, consultation and therapy with a behavior

thera-pist are indicated.

It is important that as few objects as possible be in the time-out room. However, there may be occasions where it is impossible to remove all

manipulatable items from the child’s reach. The

child may in some fashion make a mess or damage the time-out area. The parent should inform the child of what he/she has done and that he/she has

earned another ten minutes in time-out which will not start until the mess is picked up. It is important that the parent stress to the child that he/she will remain in the time-out room until lie/she has cleaned up the mess and the full time

has elapsed. If the child persists in destroying

articles in the time-out area, therapy is mdi-cated.

The child should not be allowed to leave the

time-out area until the tinier has rung. This may mean postponing meals or cold food. If the child needs to go the the toilet, the parent must insure that the child is returned immediately to time-out

for the full duration of his/her time. This prevents the #{235}hildusing “the need to toilet” as a ploy to avoid time-out. The mother should be instructed never to bring water to the child nor allow the child to drink or snack while in time-out, as this will interfere with the unpleasantness of the time-out situation. For the same reason, no reading objects, play things, or other stimulations should

be allowed while time-out is in progress.

Interferences from other siblings must never

become a problem. At no time should the child in time-out be allowed to interact with a brother or sister and vice versa. Siblings should be told that

the child is being punished and to leave the time-out area immediately. Also, when the child

emerges from time-out, he/she may be teased by

siblings. This should be prevented by giving strict

instructions to the brothers and sisters. Teasing upon release will only anger the child and

promote further complications in the use of the

procedure.

Parents concerned with disciplinary problems

in the home often consult their pediatricians for advice. Although the pediatrician may give them

correct information, the intervention procedures frequently do not work, and sometimes the prob-lems become worse. Much of the fault lies in the implementation of the procedures. Therefore, it is important that the pediatrician not only advise the parents but also prepare them to effectively identify and deal with problems that may arise when using such intervention techniques as

ignor-ing and time-out. The successful use of these

procedures will not only change the child’s

behavior, but parents often report that as the amount of yelling and spanking necessary to

maintain discipline decreases, there is a

corre-sponding increase in positive feelings towards the

child as a result of his/her new behavior.

CAUTIONARY NOTE

Extinction and time-out are only two of the

myriad of techniques used by behavior therapists.

Also, behavior modification is not a series of techniques but a treatment philosophy based

upon ascertaining the environmental conditions currently maintaining problem behavior and then

changing those conditions. The advantage of

ignoring and time-out procedures for the

pediatri-cian lies in the fact that they are especially

appropriate for young children and, if they are

properly explained, many parents can implement

them without the close supervision necessary with other behavioral techniques. Whether

behavioral techniques will be effective depends less on the problems of the child (assuming the

medical or pharmaceutical intervention is not required) than on the stability and maturity of the parents. Indeed, behavioral approaches have been demonstratively successful with children carrying

varying diagnostic labels.”’4 However, if the

parents are unwilling or unable to change their behavior-even under the close supervision of a

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cases where the child’s inappropriate acts are

actually appropriate reactions . to refractory

stressful home situations, and the pediatrician should be especially alerted to this possibility. In

these cases when the behavior therapist discovers the futility of helping the parents change their

child-rearing behavior, therapy is recommended

for the parents.

REFERENCES

1. Allen KE, Hart BM, Buell JS, et al: Effects of social

reinforcement on isolate behavior of a nursery school child. Child Dev 35:511, 1964.

2. Brown P, Elliott R: Control of aggression in a nursery school class. J Exp Child Psychol 2: 103, 1965.

3. Carlson CS, Arnold CR, Becker WC, Madsen CH: The

elimination of tantrum behavior of a child in an

elementary classroom. Behav Res Ther 6:117,

1968.

4. Williams .C: The elimination of tantrum behavior by

extinction procedure. J Abnorm Soc Psychol

59:269, 1959.

5. Wolf MM, Risley T, Mees H: Application of operant

conditioning procedures to the behavior problems of an autistic child. BehaV Res Ther 2:305, 1964. 6. Drabman RS, Spitalnik R: Social isolation as a

punish-ment procedure: A controlled study. J Exp Child Psychol 16:236, 1973.

7. Patterson G, Ray R, Shaw D: Direct intervention in families of deviant children. Oregon Res Inst Bull

8:1, 1968.

8. Wasik B, Senn K, Welch R, Cooper B: Behavior modification with culturally deprived school chil-dren: Two case studies. J Appl Behav Anal 2:181, 1969.

9. Cowan PA, Walter RH: Studies of reinforcement of aggression: I. Effects of scheduling. Child DeV

34:543, 1963.

10. Crum J, Brown WL, Bitterman ME: The effect of partial and delayed reinforcement on resistance to extinction. Am J Psychol 64:228, 1951.

11. Ferster GB, Skinner BF: Schedules of Reinforcement.

New York, Appleton-Centuiy-Crofts, 1957.

12. Peterson LR: Variable delayed reinforcements. J Comp

Physiol Psychol 49:232, 1956.

13. Bandura A: Principles of Behavior Modification. New York, Holt Rinehart & Winston, 1969.

14. Gelfand DM, Hartmann DP: Child Behavior: Analysis and Therapy. New York, Pergamon Press, 1975.

THE QUALITY OF LIFE

In many industrialized countries, the attainment of health has proved somewhat of an illusion. Many acute diseases of major public health

impor-tance have certainly disappeared, but only to be replaced by chronic

debilitating physical andmental disease. Longevity has not brought the bliss and blessings many thought it would do. Long life without improvement in the

quality of life is one of the tragic sequels of technological development in many countries. It is therefore clear to me that virtually every society needs a

redefinition of its health goals today.

H. MAHLER

(WHO Chron 30:259, 1976)

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1977;59;78

Pediatrics

Ronald S. Drabman and Greg Jarvie

Time-Out Techniques