Discipline is an extremely controversial topic in pediatrics. Often we have families coming to us concerned about their child’s behavior. Many times, parents have done their due diligence and have read up on discipline ahead of time, but even then parent are still confused on what is the best approach to many behavioral problems. “Doc, I have read 5 different books about discipline and I have been told 5 different way to treat my child!!! What do I do???” is not an uncommon statement at our 3-4 year old physical exams.
The truth is that there is not a single universal way, or a cookbook approach to discipline. Every child has a unique temperament. In addition, every family has its own distinctive dynamics and challenges that can complicate what works and what doesn’t work when it comes to discipline. With the explosion of the print media and online blogs and the many ‘experts’ on various topics there are now hundreds of books and websites you can refer to for discipline guidance, and we recommend parents to educate themselves as much as possible. However, in the following segment we will try to educate you, the mother and father, about the main principles and techniques that parents can routinely use in interacting with their children.
Techniques to Teach or Improve Behaviors
Time-in and verbal praise:
- Time-in refers to brief, nonverbal, physical contact provided to a child when a parent notices that the child is displaying appropriate or acceptable behavior. Examples include a pat on the back or a tussle of the hair. Time-In should be a two-handed approach. One hand is on the child. The other is over the parent’s mouth. This description points to the importance of providing physical contact as an encouragement to the child to continue the current behavior. The non-verbal nature of the communication decreases the chances of distracting the child from the behavior. If a child is sitting quietly while working on puzzles with her sibling and a mother “interrupts” the appropriate play and interaction by providing a verbal comment, even verbal praise, the child is less likely to continue the activity. The physical contact of Time-In provides the child with knowledge that the behavior was noticed, without distracting the child from acceptable activity. Parents should be encouraged and educated to provide their children with Time-In whenever their children are engaging in acceptable behavior. They should not wait for good behavior.
- Verbal praise is provided when a child has done something “good.” The best time to use verbal praise is during natural breaks is an activity. For example, when a child is engaged in a coloring activity, the parent should provide lots of brief, non-verbal physical contact (Time-In). Once the child has finished coloring or stops coloring to show it to a parent, verbal praise is appropriate.
- Advantages. Time-Inand verbal praise encourage children to continue to engage in acceptable behaviors. When applied correctly, these techniques take no additional parent time and do not distract children.
Children learn behaviors by being around individuals who engage in those behaviors. This is called incidental learning. For example, if both parents smoke cigarettes, their child is significantly more likely to become a smoker than if neither parent smokes. A surprising number and variety of children’s behaviors appear to have been learned incidentally, including language, gestures, and anger management strategies.
Advantages and disadvantages: incidental learning can be achieved without any additional effort on the part of the parents. They need only be aware that such learning occurs naturally and be cognizant of incidental learning during the time they spend with their children. The negative side is that the children also learn behaviors the parents never intended for them to learn (e.g., swearing, “white lies”).
Two basic modeling techniques exist: live and video recordings. Most modeling procedures work best if the model is approximately the same age as the target child. For example, a 6-year-old boy who has previously had his teeth cleansed by the dentist and who behaved appropriately during the procedure could be observed live or on video recordings while being examined. A second child who observes the dental procedures being performed on the model can learn both what to expect of dental procedures and how to react to those procedures.
Advantages and Disadvantages: children are more likely to believe what they see a peer doing than what their parents tell them, particularly if the two messages are contradictory (e.g., one a verbal message that the child should relax, and the other the anxiety that a child feels in the dental chair), however, modeling can teach maladaptive behaviors as well as adaptive behaviors. For example, if a child is observing a peer model in the dentist’s office and the peer model becomes very upset, the target child will probably have a more difficult time when it is his turn for the procedure.
No other topic in the behavioral literature has been more misunderstood than reinforcement. An item or activity can be said to have reinforcing properties for an individual child if and only if that child has previously worked to obtain access to that item or activity. For example, although candy is reinforcing for the vast majority of children, it cannot be referred to as a reinforcer until it has been demonstrated that the child will either work to obtain the candy or stop a behavior that prevents him from receiving it. Under the right circumstances, reinforcement, by definition, will work with virtually any age group and with many different behaviors. HOWEVER, the manner in which the reinforce is made accessible to a child, are extremely important and here are a few tips:
- Small rewards offered frequently are better than large rewards offered infrequently. A physical hug offered several times during a household chore will usually be more effective than a big reward at the end of a chore. Small rewards during the chore and a reward at the end will also work nicely.
- Repetition, with feedback, enhances a child’s learning. A child will learn more from performing the same task repeatedly, with help from his parent, than from performing it once. Although parents will often expect their child to perform a task correctly the first time, the child will actually learn the task better if he has many opportunities to practice. For example, a child who helps one of his parents to do the laundry several times each week for two years will probably be able to do the laundry for the rest of his life.
- Making the choice to participate in acceptable behavior is a learning process. Children learn more quickly and retain the learning better if they are relaxed while they are learning. While helping children to acquire the skills to make appropriate choices can be very frustrating, the parent who becomes angry or impatient only exacerbates the situation. Similarly, an upset child does not learn as rapidly or as permanently as a calm child. Parents should be reminded that the children learn a significant amount about what behaviors are “appropriate” by watching how their parents respond when presented with frustrating or otherwise challenging situations.
- Warnings only make behavior worse. Although parents have a natural tendency to warn their children, it is far more effective to discipline the child (provide a consequence) for not performing the task after the first time requested is ignored and then give the child another opportunity to fulfill the command, rather than frequent warnings that the task must be done. In fact, children who receive warnings prior to consequences, often learn that they may continue to disobey their parents several times before they will either be forced to complete the request or receive a consequence. This “ planned ignoring” on the part of the child often becomes increasingly frustrating to the parent. If you want to give warning, make sure the warning is clearly stated, give your child proper time to gather himself, parents can give one more clear warning and allow a bit of time for the child to learn to stop the warned behavior. After the second warning and if the behavior continue, parents need to be consistent and persistent to implement the consequence.
- A behavior must already be learned before it can be reinforced. If the child doesn’t know how to perform the expected behavior, offering a reward, in lieu of teaching the child how to perform the behavior, is ineffective. For example, if a child has never tied his own shoes, offering him a new bicycle if he ties his shoes is not likely to be effective.
Advantages and disadvantages: “reinforcing items” and activities frequently can become part of normal, everyday life without substantial planning on the parents’ part. Examples may include 10 minutes of one-on-one time playing catch with a parent or an extra story at bedtime. It should also be noted that “reinforcing items” and activities might sometimes be inadvertent. For example, when a parent waits until their child has been crying for several minutes in the morning, the parent may be reinforcing that child for crying. If the same parent had picked their child up BEFORE he has started crying, however, he would be reinforcing the child for playing quietly in his crib instead of waiting until he was crying.
In addition, the child’s behavior may return to its pre-reinforcement level as soon as the reinforcers are no longer available. For example, in research on the use of reinforcers for automobile seat belt use, many children stopped wearing their seatbelts as soon as the reinforcers were no longer available. Procedures that have been shown to be successful in maintaining desired behaviors after reinforcement ceases include gradually making the reinforcer available less often (e.g., on the average, every second behavior is reinforced, then every third behavior, then every fourth behavior). Once a behavior becomes habitual, the individual will engage in it whether it is reinforced or not.
Many items and activities that have no intrinsic reinforcing properties can take on reinforcing properties. Money, for example, is not usually a reinforcer to a small child. When the child learns what he can purchase with the money, it begins to take reinforcing properties. As another example, to a distressed child in the middle of the night, even the sound of the bedroom door opening can take on reinforcing properties, as the child associates the sound of the door opening with receiving attention from a caregiver.
Advantages: Conditioned reinforcers are usually more readily available than the actual reinforcer, and most children will work just as hard for a conditioned reinforcer than they will for an actual one. Conditioned reinforcers, such as money also have the advantage that they can be traded for a wide variety of items or activities as the child’s tastes and preference change.
The Token Economy
Conditioned reinforcers work best if there is a consistent method of exchange. In the case of money, the exchange system is already in place, and the money becomes a “token” of what can be purchased. Entire “ token economies” have been devise as treatment programs for children from age 4 to adulthood. The term token economy refers to the organized manner in which tokens are gained and lost, as well as what can be purchased with them. The success or failure of a token economy depends almost entirely on how it is implemented and how many reinforcing activities are realistically available to the individual who must earn, lose, and spend tokens. The mere use of tokens does not make a token economy.
Token economies are most effective when they are used as motivational systems to encourage children to engage in socially appropriate behaviors. Three different types of token economies are widely used with common behavioral problems:
- A simple exchange system provides a means of keeping track of the child’s appropriate behaviors. A list of behaviors can be posted on the door of the refrigerator. As the child completes assigned or volunteered task or chores, he marks these on the “positive side” of the exchange chart. Similarly, as the child engages in inappropriate behaviors, he marks these on the “negative side”. When the child wants a special privilege or activity, there must be more positive marks than negative marks to “afford” the special privilege. The simple exchange system is appropriate for children aged 5-12 years.
- Under the chip systems, the child ears a token, such as a poker chip, for positive behaviors. Each time poker chips are earned, the parent acknowledges the child’s appropriate behavior while offering chips. The child is then expected to take the chips from the parent’s hand, look at the parent in the eye, and say “thank you.” In this way, the child not only receives the tokens for the appropriate behavior, but also practices appropriate social behaviors. Similarly, when the child engages in a behavior that loses chips, he is expected to hand the chips to the parent politely and may receive one chip back for “taking the fine so nicely.” The chip system is useful for children 3-7 years old.
- The point systems is similar to the chip system but can be much more sophisticated. Points can be used to motivate children and teenagers to practice the behaviors they are lacking, such as taking feedback well and sharing their feelings appropriately. Each time they engage in these types of behaviors, they earn points that can be used to purchase items and activities they want. The point system is useful for children aged 6-16 years.
Fading refers to changing something gradually instead of abruptly changing it. For example:
- For a toddler who is drinking too much juice, a cup can be provided with juice, which is gradually diluted from 100% juice to 90% juice:10% water, then 80% juice:20% water, and so on, until the toddler is drinking pure water from the cup.
- Raising training wheels on a bicycle 1/8 in. every two weeks until they are about 3 inches off the ground and no longer necessary.
- Changing a child’s bedtime 15 min each night at daylight savings time instead of abruptly changing the entire hour in one night.
- Teaching a child how to swallow pills by starting out with very small cake sprinkles to wash down with a favorite beverage, then moving to a slightly larger piece of candy. Typically using six to eight steps sizes is very effective.
Advantages and disadvantages: Fading often helps to avoid confrontations with a child. It can be used to accomplish something without incident that otherwise may have been difficult to accomplish. The disadvantage of fading is that parents have to spend more time than they would if their child could abruptly make the desired changes.
Procedures to Decrease or Discourage Behaviors
Probably the most frequently recommended disciplinary technique is time-out. As initially used, time-out was actually referred to as “time-out from positive reinforcement.” Over the past three decades or so the term has been shortened to “time-out”, and, in doing so, the idea of removing a pleasant interaction has been ignored or forgotten. Time-in and time-out are effective from the age below 1 to early adolescence. It is very important for parents to realize that in absence of good “time-in”, there really is no such thing as “time-out”. There is often confusion regarding how long a time-out should last. This question can be answered by discussing with parents the purpose of time-out. The purpose is two-fold. The first is to stop the undesired behavior (noncompliance, tantrum, etc.) The second is to encourage the development of self-quieting (calming) skills. Once a child is able to sit silently with quiet hands and feet, the child has accomplished both of these goals.
The following variables have the most impact on the effectiveness of time-out:
- It must be presented immediately after an inappropriate behavior.
- It must be presented every time the inappropriate behavior occurs.
- The time-out must remove or make unavailable an otherwise pleasant state of affairs (i.e. time-in), most cases ALL interaction with the parent must cease.
- The time-out should not be considered “over” or “finished” until the child has quieted down.
- All warnings about using time-out should be carried out.
- The child should be completely ignored during the time-out, regardless of how outrageous the behavior might become.
- One study demonstrated that time-out becomes more effective when the time-in is “enriched” (more fun, more enjoyable) and becomes less effective when the time-in is “impoverished”.
Advantages: Time-in and time-out provide parents with an effective alternative to nagging, yelling, or spanking. Their consistent use also encourages children to develop self-quieting skills (a child’s ability to calm himself without the assistance of a parent). It encourages these skills because the parents are modeling the ability to cope with an unpleasant situation and because the child is learning how to cope with feelings he experiences when he does not like something his parents have done. The one problem that parents run into with time-out is that it works great, then parents want to “time-out” everything single negative behavior and by overusing it, it loses its efficacy.
Extinction is defined as the withdrawal of all attention after a child engages in undesirable behaviors. One of the most common examples of extinction is not paying attention to a child’s whining. When used properly, extinction involves completely ignoring a child’s whining.
A major problem with using extinction is an initial sharp increase in the child’s inappropriate behavior, called an extinction burst. For example, when a child is ignored during a temper tantrum or when whining, these behaviors usually increase in intensity and duration at first, perhaps discouraging the parents from continuing the extinction procedure. If the parents continue with the extinction procedure, however, the change in the child’s behavior will usually be forthcoming.
Although extinction procedures are often successful, parents may sometimes not be able to tolerate the technique. Sometimes modifications need to be done for extinction to be more manageable. For example, if a parent is trying to help their child to sleep easier at night with out much winning and crying, it helps to first try the method for whining and fussing during the day. The parent then feel more confidence in their ability to use it properly, and the child learns that the parents will follow through with the use of extinction once they start it. Sometimes, only after the parents and the child are familiar with the use of extinction during the day are the parents more encouraged to use it at bedtime and follow all the way through.
Disadvantages: The main disadvantage is the extinction burst and the parent’s inability to tolerate their child’s initial distress at being ignored.
The parents gradually ignore their child’s behavior for longer and longer periods of time (as opposed to introducing complete extinction abruptly). Planned ignoring may result in less of an extinction burst, but it takes longer to be effective. Probably the most common use of planned ignoring is for bedtime resistance.
With spanking, caregivers can vent their own frustration at the same time they are discouraging a child from engaging in the behavior that resulted in the spanking. In addition, spanking will often produce an immediate decrease in the child’s behavior.
Advantages and disadvantages. Spanking can teach a child that hitting is an acceptable way to express frustration or anger. The child, after being spanked, is likely to avoid or try to escape from the caregiver who administered the spanking. To maintain its effect, the magnitude of spanking often must increase over time (harder spanking), this may lead to injury or abuse. Thus, a child who is frequently spanked at home is less likely to be responsive to the use of extinction at daycare. Since time-in and time-out can produce virtually the same effects as spanking but without the side effects, spanking is not recommended at all.
This is a form of grounding whereby the child has control over how long the grounding is in effect. When a child has broken a major rule (e.g., gone to a shopping center by a bike without telling the parents), he is “grounded.” The child loses all privileges (including television, telephone, having a friend over, playing with games, snacks and desserts) until he has completed one job properly. The jobs, which can each be written on a 3″ x 5″ card, should be agreed upon by both parent and child during a quiet, peaceful time, should not be one of the child’s typical household chores, and should take 5-10 minutes to complete (washing the windows of the family car, picking up pet waste from the yard). The child, upon being grounded, is asked to pick from a stack of cards that are held face down by the parent. Once the job is chosen, the child is restricted from all activities, with the exception of family meals and homework, until the job is completed. Parents are instructed to refrain from nagging, prodding, and reminding. As soon as the child has completed the job (most jobs should take only 5-10 minutes to complete and be tasks that the child has done many times before), he is “off grounding.” Job grounding differs from traditional time-based grounding in that the child determines how long the grounding lasts and, under most circumstances, the child has the option of getting the job done without missing valued social activities.
Advantages and disadvantages. Job grounding is usually effective, it lets the child practice a job that he probably did not want to do in the first place, and it gives him the opportunity to avoid losing a valued activity. The disadvantages are that if the child has no planned activities, he may stall on completing the job until some external motivation is present.
Positive practice is the procedure of having a child practice an appropriate behavior after each inappropriate behavior. For example, when a previously toilet trained child wets his pants, he is required to practice “going to the bathroom” 10 times; five times from the place where the accident was discovered and five times from such alternative sites as the front yard, the backyard, the kitchen, and the bedroom. When used correctly, with no nagging or unpleasant behavior on the part of caregivers, positive practice can produce dramatic results.
Advantages and disadvantages. Positive practice gives a child many opportunities to practice appropriate behaviors. This technique is typically effective quickly. The disadvantages include the length of time necessary to implement the practice, as well as the fact that the practice should be done immediately after the inappropriate behavior, which is not always convenient.
Practice, Praise, Point out, and Prompt
Several of these procedures can be combined into very effective teaching tool. For example, when a child’s interruption is a problem they can be taught an alternative to interrupting. Parents are encouraged to practice having their child gently place her hand on the parent’s forearm, and the parent immediately place his or her hand on the child’s hand and ask her what they would like to say. This should be practiced daily with a reward for practicing. The parents should “point out” to their child when the parents wait instead of interrupting, or when a character in a book is seen to be waiting. The parents can also “prompt” their child to place her hand, for example, on Daddy’s arm when she wants to get his attention. This strategy combines incidental learning, modeling, reinforcement, and praise.
In addition, there are many more and perhaps more effective techniques discipline techniques, but it is out of the scope of this newsletter to cover them all. The purpose of this section was to give our parents some general ideas abut various discipline techniques as discussed by Pediatric Developmental specialists. The area of discipline is fairly controversial and there is definitely more than one way to do the right thing with your child. Try to educate your self as much as you can and use the technique that works best for each of your children (different children may respond to different styles of discipline). Here are a few last general recommendations we have for you.
- Discipline is important. You can’t just ignore bad behavior, but be careful not to over do it!
- If you have to choose between “over-doing” or “under-doing” it, we would like you to under do it.
- When it comes to negative consequences, we suggest you pick only 2 or 3 behaviors and mainly work on those, once you fix one negative behavior (i.e. biting), then you can add another behavior to your list of 2 or 3.
- When it comes to discipline, when you say something, you have to mean it!! Your child needs to know that you will follow through.
- Although discipline seems to always be synonymous with negative consequences, the main emphasis and the majority of your effort should be on teaching your children appropriate behaviors, rather than on reducing inappropriate behaviors.
Adapted directly from The Zukerman Parker Handbook of Development and Behavioral Pediatrics for Primary Care