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The Role of TimeOut in Trauma-Informed Treatment for Young Children

Cite This Article

Quetsch, L.B., Lieneman, C., & McNeil, C.B. (2017, May). The role of time-out in trauma-informed treatment for young children. [Web article]. Retrieved from: http://www.societyforpsychotherapy.org/role-time-trauma-informed-treatment-young-children

 

Ms. Lauren Borduin Quetsch

Childhood trauma is a national concern as approximately one-half of children in the United States experience at least one traumatic event (National Survey of Children’s Health, 2012). Although staggering, help in the form of evidence-based treatments is available for pre-school-aged children exposed to trauma. Recommended treatments include Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and Parent-Child Interaction Therapy (PCIT; see Chadwick Center, 2004; Saunders, Berliner, and Hanson, 2004). While these treatments effectively reduce trauma-related symptoms, concerns about disciplinary strategies like time-out with this population may linger. A review of these concerns and the evidence base supporting time-out are highlighted below.

Ms. Corey Lieneman

Can’t We Just Avoid Discipline Altogether?

Naturally, when a child experiences trauma, caregivers offer comfort. This normal, healthy instinct to provide a traumatized child with a sense of safety and security can be taken to an extreme, however, when protecting a child from all negative emotions becomes the goal. Research has shown that effective parenting includes both warmth and consistent parental control. Failing to provide structure does these children a disservice by depriving them of clear limits and predictable environments.

Dr. Cheryl McNeil

This concept is well illustrated by Baumrind’s three parenting styles—authoritative, authoritarian, and permissive—which combine differing levels of parental responsiveness and control (for reviews, see Baumrind, 1967; Baumrind & Black, 1967). The parenting style associated with the best child outcomes, authoritative parenting, balances high responsiveness with consistent control. Children of authoritative parents tend to have fewer behavior problems, more academic success, better social development, better mental health, and higher self-esteem (Alizadeh, Talib, Abdullah, & Mansor, 2011; Dornbusch, Ritter, Leiderman, & Roberts, 1987; Lamborn, Mounts, Steinberg, & Dornbusch, 1991; Maccoby & Martin, 1983).

Alternatively, permissive parenting includes high responsiveness but little to no control. Well-intentioned caregivers may be inclined to parent traumatized children more permissively than other children, but this lack of limit-setting is associated with child behavior problems, substance abuse, and emotion dysregulation (Driscoll, Russell, & Crockett, 2008; Jabeen, Anis-ul-Haque, & Riaz, 2013; Patock-Peckham & Morgan-Lopez, 2006).

On the other hand, although discipline is essential for effective parenting and healthy child development, pairing high control with low parental warmth results in authoritarian parenting which is also associated with negative outcomes (e.g., problematic child self-regulation, alcohol-related problems, depressive symptoms; Hartman et al., 2015; LeCuyer & Swanson, 2017; Rothrauff, Cooney, & An, 2009).

For these reasons, evidence-based behavioral parent training programs like PCIT begin by enhancing warmth and responsiveness in the caregiver-child relationship (Eyberg, Nelson, & Boggs, 2008; McNeil & Hembree-Kigin, 2010). Only later are caregivers trained to provide calm, consistent discipline including the use of a time-out chair. In addition, caregivers’ and children’s abuse histories are carefully considered. In high-risk cases with long histories of caregiver-child physical aggression, some therapists modify treatment, for example, using a “hands-off” approach (e.g., a warning statement followed by a restriction of privilege; Timmer, Urquiza, Zebell, & McGrath, 2005). Initially, caregiver-child dyads with histories of physically abusive discipline may experience additional emotional distress during the time-out procedure. But, this new method becomes a corrective experience as children learn that discipline and their caregivers can be safe and predictable. Ultimately, positive parenting strategies like time-out can prevent the use of more extreme disciplinary measures.

Does Time-out Retraumatize Children?

General concerns.

Some fear that time-out and those treatments that use it (e.g., PCIT) could retraumatize children (for an overview, see McNeil, Costello, Travers, & Norman, 2013). Retraumatization is defined as “… stress reactions, responses, and symptoms that occur consequent to multiple exposures to traumatic events that are physical, psychological, or both in nature” (Duckworth & Follette, 2012, p. 2). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) describes a trauma response as “fear-based re-experiencing, emotional, and behavioral symptoms… [an] anhedonic or dysphoric mood state and negative cognitions [and/or] arousal and reactive-externalizing symptoms [and/or] dissociative symptoms” (5th ed., text rev.; DSM–5; American Psychiatric Association, 2013, p. 274).

So, negative outcomes like dissociation might occur with repeated exposures to traumatic situations; however, it is unlikely that having to sit in a time-out chair constitutes a trauma experience. There is no evidence that the short-term arousal experienced during time-out constitutes “repeated” stress, a core feature of trauma experience. In fact, PCIT has been shown to reduce internalizing symptoms in children (Carpenter, Puliafico, Kurtz, Pincus, & Comer, 2014). In treatments such as PCIT, caregivers learn to calmly follow a detailed decision tree which removes the burden of decision-making in emotionally charged situations. The result is a safe procedure for deescalating children’s aggressive, defiant behavior. While children may experience anger and emotional distress during time-out, positive caregiver interaction immediately follows. This follow-up interaction promotes bonding and emotion regulation.

Time-out rooms.

In addition to general concerns about time-out, it is also important to address concerns about time-out rooms. Some treatments involve a short period (e.g., one-minute in PCIT) in a “back-up room” as a consequence for escape from the time-out chair. Back-rooms must be spacious enough for children to calm down safely, have windows or other openings allowing visual contact between the child and caregiver, and be well-lit. Back-up rooms must not contain potentially dangerous objects (e.g., chairs, outlets) or entertaining items (e.g., toys). A back-up room is meant to create a safe environment that lacks stimulating activities and attention, to increase child motivation to comply. Once the child complies, he or she is allowed to return to the excitement of positive caregiver-child interactions. Following one-minute in the back-up room, a caregiver carefully transports the child back to the time-out chair, located in an open family/play room. The child quickly learns to remain in the time-out chair in the clinic setting and usually does not need to return to the back-up space after one or two treatment sessions. In the home, caregivers typically childproof the child’s bedroom, which serves as the back-up space (McNeil & Hembree-Kigin, 2010).

The use of a back-up space for escape from the time-out chair is crucial to the time-out sequence for three reasons: 1) It prevents the caregiver from attempting to hold the child on the chair, 2) It provides a safe space for the child to calm down, and 3) It allows the caregiver to remain in control. Specific concerns for children with histories of abuse or neglect are also taken into consideration. If the use of a back-up room would represent an intense exposure to a previous trauma (e.g., being locked in a room), alternatives are used. Accommodations, like having a therapist or caregiver go into the back-up space with the child or using a restriction of privilege instead of a back-up space, maintain the efficacy of the time-out while decreasing the emotional intensity of the procedure for certain trauma cases.

Finally, it is important to remember that without effective disciplinary tools like time-out, many families resort to harsh, inappropriate methods because they do not know how to effectively manage misbehavior. This is especially likely when families become entangled in the coercive process. Patterson (2002) delineates this process:

  1. A caregiver sets a limit on his or her child.
  2. The child becomes frustrated and does not comply.
  3. The caregiver is angry with the child’s misbehavior.
  4. The child increases his or her defiance.
  5. The interaction continues to escalate.

As discussed previously, evidence-based treatments build positive relationships between caregivers and children to break the coercive cycle (Urquiza & McNeil, 1996). When misbehavior cannot be avoided, the time-out sequence creates a structured procedure in which a caregiver abides by a script to calmly address behavior problems. This allows predictability for a child who may feel stress from never knowing how a caregiver will respond and trust in the caregiver to be consistent and fair. It also reduces caregiver stress since the caregiver now has been taught a clear, reasonable, and effective solution to extreme child misbehaviors.

What’s Good About Time-Out?

  • When effective discipline strategies like time-out are combined with caregiver-child relationship building skills, children’s trauma symptoms actually decrease (Pearl et al., 2012).
  • Caregivers with histories of physical abuse who learn to implement consistent, safe disciplinary strategies like time-out reduce their use of physical punishments (Chaffin, Funderburk, Bard, Valle, & Gurwitch, 2011).
  • Time-out teaches children to self-soothe, an especially important skill for abused or neglected children who often experience behavioral and emotional extremes (e.g., somatic concerns, anxiety, aggression).
  • Research shows that time-out can bring problematic externalizing and internalizing behaviors to within normal limits, help children show greater self-control, and improve prosocial emotion regulation capabilities (Graziano, Bagner, Sheinkopf, Vohr, & Lester, 2012; Johns & Levy, 2013; Webster-Stratton, Reid, & Stool-Miller, 2008). These skill increases have been linked to more self-control and better life outcomes (Moffitt et al., 2011).
  • Similar to treating trauma by constructing a trauma-narrative as part of TF-CBT, a well-executed time-out sequence serves as an exposure intervention. Exposure is the primary treatment for people who have experienced a trauma. The process involves either imaginal or in-person exposure to triggers associated with the original traumatic event all within a safe environment. Through repetition, trauma-related anxiety decreases as previous triggers are paired with a predictably calm sequence of events (PCIT International, 2016).
  • For children with histories of abuse, consistently calm time-out procedures extinguish the fear and pain once associated with discipline. The results are feelings of safety, the comfort of a predictable environment, and a sense of control (PCIT International, 2016).

Summary

Overall, time-out is a safe, developmentally- and psychologically-appropriate procedure for young children including those exposed to trauma. Although discipline strategies may need to be modified in certain extreme cases, delivering time-out consistently and calmly allows children to learn how to manage their emotions and trust their caregivers.

For a full review of the evidence-base behind time-out, refer to the article by Quetsch, Wallace, Herschell, and McNeil (2015). For more details on implementing Parent-Child Interaction Therapy with trauma-exposed children, please see the chapter by McNeil, Costello, Travers, and Norman (2013) or the book by McNeil and Hembree-Kigin (2010).

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References

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