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What Is It to Discipline a Child: What Should It Be? A Reanalysis of Time-Out From the Perspective of Child Mental Health, Attachment, and Trauma

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Abstract

Parental discipline strategies are a necessary and critical aspect of positive child development. Their qualities confer risk versus protection for the development of mental health problems. Time-out from positive reinforcement is now one of the most common and well-researched discipline procedures across the world, with overwhelming evidence to support its efficacy and acceptability. It has also recently attracted considerable criticism from writers evoking child well-being considerations based on attachment theory. The main concern is that the removal of a child to time-out exposes the child to a break in attachment security and, for children with trauma histories, potentially causes harm. Here, we consider what a discipline strategy should be from a mental health perspective and, utilizing the best available models of developmental mental health and psychopathology, derive five axioms for judging and guiding the worth and acceptability of any particular discipline strategy. We then use these axioms to evaluate and specify how time-out can be used in a way that maximizes positive child outcomes, and then review its use with children who have experienced complex trauma. We show that time-out, when conceptualized and enacted consistently with contemporary models of learning, attachment, self-regulation, and family systems theory, is actually a positive perturbation to these systems that can rapidly remediate problems the child is experiencing, and thereby generally enhances child well-being. Clinical, research, and policy implications are briefly discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
American Psychologist
What Is It to Discipline a Child: What Should It Be? A
Reanalysis of Time-Out From the Perspective of Child
Mental Health, Attachment, and Trauma
Mark R. Dadds and Lucy A. Tully
Online First Publication, February 25, 2019. http://dx.doi.org/10.1037/amp0000449
CITATION
Dadds, M. R., & Tully, L. A. (2019, February 25). What Is It to Discipline a Child: What Should It Be?
A Reanalysis of Time-Out From the Perspective of Child Mental Health, Attachment, and Trauma.
American Psychologist. Advance online publication. http://dx.doi.org/10.1037/amp0000449
What Is It to Discipline a Child: What Should It Be? A Reanalysis of
Time-Out From the Perspective of Child Mental Health, Attachment,
and Trauma
Mark R. Dadds and Lucy A. Tully
The University of Sydney
Parental discipline strategies are a necessary and critical aspect of positive child development.
Their qualities confer risk versus protection for the development of mental health problems.
Time-out from positive reinforcement is now one of the most common and well-researched
discipline procedures across the world, with overwhelming evidence to support its efficacy
and acceptability. It has also recently attracted considerable criticism from writers evoking
child well-being considerations based on attachment theory. The main concern is that the
removal of a child to time-out exposes the child to a break in attachment security and, for
children with trauma histories, potentially causes harm. Here, we consider what a discipline
strategy should be from a mental health perspective and, utilizing the best available models
of developmental mental health and psychopathology, derive five axioms for judging and
guiding the worth and acceptability of any particular discipline strategy. We then use these
axioms to evaluate and specify how time-out can be used in a way that maximizes positive
child outcomes, and then review its use with children who have experienced complex trauma.
We show that time-out, when conceptualized and enacted consistently with contemporary
models of learning, attachment, self-regulation, and family systems theory, is actually a
positive perturbation to these systems that can rapidly remediate problems the child is
experiencing, and thereby generally enhances child well-being. Clinical, research, and policy
implications are briefly discussed.
Keywords: parent discipline, child mental health, time-out, attachment, trauma
In 2014, Time magazine published an article titled “Time-
Outs Are Hurting Your Child” by Siegel and Bryson
(2014a). The article warned parents against using time-out
with children, arguing that harmful effects were supported
by neuroplasticity research. These authors largely recanted
most of what they wrote in a later article in the Huffington
Post (Siegel & Bryson, 2014b), arguing that they were
simply cautioning against inappropriate or punitive use of
time-out. However, Time magazine followed up with an-
other article in 2016 by psychologist Vanessa Lapointe,
again specifying the reasons why time-out may be damag-
ing children (Lapointe, 2016). These articles have been
associated with a widespread and growing rejection of time-
out as an acceptable and effective parental discipline strat-
egy, especially for children who are believed to have at-
tachment problems or trauma histories. As noted by
Quetsch, Wallace, Herschell, and McNeil (2015), there is no
empirical evidence to show that time-out is ineffective or
harmful; however, Internet-based literature warning of the
harmful nature of time-out is now rife.
The aim of this article is to conduct a first analysis of
time-out from the perspective of the child’s developing
mental health. We believe that the analysis of child disci-
pline from a mental health perspective is an important yet
neglected area. The quality and effectiveness of parental
socialization, especially parental discipline, are associated
with lifelong mental and social health (Kessler et al., 2010).
At extremes, most episodes of child abuse arise in the
context of ineffective and problematic parental– child disci-
pline encounters (Chaffin et al., 2004; Straus, 2000). Each
incident of parent– child discipline has the potential to in-
vest in the building of a more socially skilled, resilient, and
self-regulating child or, on the other hand, a child who is
more vulnerable to interpersonal conflict, intense unregu-
lated emotions, and impulsive selfishness (Patterson, 1982;
Straus, 2000; United Nations Children’s Fund, 2017). In
Mark R. Dadds and Lucy A. Tully, School of Psychology, The Univer-
sity of Sydney.
Correspondence concerning this article should be addressed to Mark R.
Dadds, Child Behaviour Research Clinic, School of Psychology, Univer-
sity of Sydney, 97 Church Street, Camperdown, Sydney, Australia, 2006.
E-mail: mark.dadds@sydney.edu.au
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
American Psychologist
© 2019 American Psychological Association 2019, Vol. 1, No. 1, 000
0003-066X/19/$12.00 http://dx.doi.org/10.1037/amp0000449
1
this sense, child discipline is one of the most common,
ongoing, and critical events or processes that drives the
social and psychological development of children, and thus
society, as it invests in the next generation. As such, a
comprehensive understanding of the effects of various child
discipline techniques should be a critical priority for child
development and mental health research.
The term time-out is an abbreviation of “time out from
positive reinforcement.” It thus requires the presence of a
reinforcing environment as well as removal from access to
reinforcers for a specified period of time for some form of
misbehavior. Although the abbreviated term time-out is
widely used in scientific literature, we believe that use of
this term has led to the misunderstanding that it is a
stand-alone strategy rather than being one part of a set of
procedures in which enhancing responsive parenting and
strengthening the parent–child relationship is a critical first
step. Thus, we believe that the use of the phrase time out
from positive reinforcement is a more descriptive and accu-
rate one to use, and we adopt the acronym TOPR for the
remainder of the article. In line with its behavioral history,
we define TOPR as a parenting strategy in which a child’s
access to rewards, usually parental attention, is temporarily
removed contingent upon a problem behavior and reinstated
following a specified period of nonproblem behavior. Al-
though the removal of access to rewards can be imple-
mented at any age, we specifically focus this article on its
common usage with children 2 to 8 years of age, as speci-
fied by the major evidence-based parenting programs (see
Everett, Hupp, & Olmi, 2010). The use of the acronym
TOPR in this article refers to both nonexclusionary time-out
(or the time-out chair) and exclusionary time-out, which is
often used as a backup for nonexclusionary time-out.
The analysis of TOPR presented here is embedded in a
broader discussion of what discipline is and should be.
Specifically, in the first part of the article, we derive a set of
axioms for evaluating the worth of parental discipline strat-
egies from the perspective of emerging child mental health,
using what we believe to be the best available contemporary
theories in developmental psychopathology. We then scru-
tinize TOPR from this perspective, leading to a set of
guidelines for use of this technique that maximize its con-
tribution to the positive development and mental health of
growing children. In the second part of the article, we
review evidence on the use of TOPR with children who
have trauma histories given the recent concerns about the
appropriateness of TOPR with these children. In this sec-
tion, we revisit the axioms and guidelines set out in the first
part of the article and aim to answer the following ques-
tions: Is there any evidence that treatments that include
TOPR are harmful? How does TOPR fit within best-
practice treatments for children with trauma symptoms?
A History of Time-Out
According to Risley (2005), it was Montrose Wolf who
first focused on the reinforcing power of adult attention for
children and, based on that, invented and named the non-
violent parenting procedure “time-out” (Wolf, Risley, &
Mees, 1963). More generally, experimental research on
TOPR commenced in the 1960s, when principles of behav-
ioral analysis were first applied to a child’s home or school
environment. Behavioral analysis grew out of Skinner’s
work in the 1930s and 1940s on operant conditioning with
laboratory animals, which described the association be-
tween a particular behavior and a consequence (Skinner,
1950): Actions that are followed by reinforcers are strength-
ened and more likely to occur again in the future, whereas
punishers are an adverse event or outcomes that cause a
decrease in the behavior it follows. Applied to the parenting
context, reinforcers are parenting behaviors (such as praise,
affection, quality time with the child) that increase the
frequency of positive behaviors in a child, whereas punish-
ers (such as ignoring misbehavior, removal of toys or priv-
ileges, and TOPR) reduce or extinguish negative behaviors.
It was clear from some of the first trials close to 50 years
ago (e.g., O’Leary, O’Leary, & Becker, 1967; Patterson,
Ray, & Shaw, 1968) that TOPR was not a stand-alone
parenting strategy; rather, it was part of a stepped process,
in which effective implementation was dependent on mas-
tery of positive reinforcement of the child as a first step. In
other words, enhancing the positive relationship between
parent and child (“time-in”) was necessary for time-out to
be effective. TOPR was also not considered a singular
intervention but part of a sequence of procedural steps.
Mark R. Dadds
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2DADDS AND TULLY
From the earliest trials, TOPR was considered a temporary
strategy that was inherently self-limiting in its use. That is,
effective implementation of TOPR resulted in rapid im-
provements in behavior, and thus the need to use the strat-
egy subsequently decreased (e.g., see O’Leary et al., 1967).
Early trials of applied behavioral analysis in the home and
school contexts were formalized into a two-stage model of
parenting skill delivery by Hanf (1969). The first stage
involved differential reinforcement of appropriate child be-
havior (via praise for positive behavior and ignoring of
misbehavior) and strengthening the parent– child relation-
ship. The second stage involved delivering calm and con-
sistent behavioral management skills in the form of effec-
tive instructions and providing appropriate consequences
for misbehavior via TOPR and other consequences.
During the 1970s and 1980s, research on TOPR largely
focused on the effectiveness of different procedural parameters
for TOPR. For example, research examined effects of differing
procedural variables such as duration of TOPR (e.g., Hobbs,
Forehand, & Murray, 1978), provision of warnings before
TOPR (e.g., Roberts, 1982), and escape prevention strategies
(e.g., Bean & Roberts, 1981). From the 1990s, research com-
menced on contemporary evidence-based parenting interven-
tions, which included TOPR, with randomized controlled trials
examining the effectiveness of these interventions as a preven-
tion or treatment for child mental health problems. These new
manualized and evidence-based parenting interventions—
including Triple P (Sanders, Kirby, Tellegen, & Day, 2014),
Parent Child Interaction Therapy (PCIT; Querido, Bearss, &
Eyberg, 2002), The Incredible Years (Webster-Stratton, 2001),
Helping the Noncompliant Child (McMahon, Long, & Fore-
hand, 2011), and Parent Management Training Oregon Model
(Patterson, Reid, & Eddy, 2002)—moved beyond simple use
of reinforcers and punishers, and integrated elements of social
interaction theory, cognitive– behavioral theory, and attach-
ment theory. In these interventions, TOPR was delivered as
one discipline strategy within a suite of positive parenting
strategies. That is, the behavioral approach saw discipline as
embedded within a context of positive nurturing parent– child
relationship.
There have now been hundreds of randomized controlled
trials of parenting interventions that include TOPR. These
parenting programs are now considered one of the most
significant achievements of clinical psychology (Brestan &
Eyberg, 1998), having clearly established effectiveness for
preventing or treating a range of child behavioral and emo-
tional problems (Kaminski & Claussen, 2017; Sanders et
al., 2014). Importantly, a meta-analytic review of studies of
parenting interventions examined program components as-
sociated with larger interventions effects and found that
TOPR was a key strategy associated with larger effects in
improving child behavioral adjustment (Kaminski, Valle,
Filene, & Boyle, 2008).
TOPR is now one of the most common discipline proce-
dures used by parents, second only to verbal explanations,
as the most common parental discipline technique in the
United States (Regalado, Sareen, Inkelas, Wissow, & Hal-
fon, 2004). Its use has accelerated over the last few decades
(Ryan, Kalil, Ziol-Guest, & Padilla, 2016). Despite this,
however, other aversive forms of discipline, such as spank-
ing, have continued, such that worldwide as many as three
in four young children are subjected to physical discipline
by their caregivers on a regular basis (United Nations Chil-
dren’s Fund, 2017). In addition, a recent survey found that
although a majority of parents reported using TOPR, many
procedural elements were implemented incorrectly, and this
was associated with parents’ perception that TOPR was
ineffective (Riley, Wagner, Tudor, Zuckerman, & Freeman,
2017). When parents view TOPR as ineffective, it is likely
to be replaced with more harsh or coercive strategies (Dray-
ton et al., 2014) or permissive parenting strategies. Thus, the
effective implementation of TOPR by parents appears to be
hampered by a lack of accurate information regarding ef-
fective procedural elements, along with inaccurate and mis-
leading information about the potential harmful effects of
the strategy.
The Theoretical Basis of Time-Out
Throughout the recent widespread adoption of TOPR, the
conceptual definition has remained largely unexplored, non-
controversial, and firmly grounded in operant theory. That is,
TOPR is defined as any procedure that reduces unacceptable
child behavior by the child experiencing an enforced reduction
in available reinforcement for a brief defined period contingent
upon an unacceptable behavior. Enacted procedures range
Lucy A. Tully
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3
TIME-OUT IN THE AGE OF ATTACHMENT AND TRAUMA
from a caregiver briefly withdrawing attention from a child, to
placing a child on a specified chair or corner of the room, to the
use of a specially designed segregated TOPR area (see Cor-
ralejo, Jensen, Greathouse, & Ward, 2018). There is a distinc-
tion between nonexclusionary and exclusionary TOPR: In non-
exclusionary TOPR, the child remains in the environment
where the problem occurred, whereas in exclusionary TOPR,
the child is removed to another location (Scarboro & Forehand,
1975). Exclusionary versions are typically reserved for
younger children, commonly 2 to 8 years of age, who at first
struggle to regulate their behavior and may need to be physi-
cally removed in order to achieve an effective time-out from
reinforcers. Exclusionary TOPR is usually used as a backup to
nonexclusionary TOPR if a child does not follow the rules
(such as remaining on the chair or staying quiet).
Given its widely accepted operant base, few writers have
addressed the adequacy of its conceptual underpinnings,
and attention has largely focused on the procedural tech-
niques defining TOPR. For example, MacDonough and
Forehand (1973) outlined and reviewed available research
on eight parameters of the TOPR procedure: location,
schedule, warning, signal, form of administration (which we
elected to call instructional vs. physical administration),
verbalized reason, contingent release, and duration. A num-
ber of updates of these procedures have taken place since
(Corralejo et al., 2018; Everett et al., 2010; Harris, 1985;
Hobbs & Forehand, 1977). As we will see, subtle variations
in procedure are critical to how TOPR functions when it is
scrutinized from a contemporary mental health perspective.
Researchers and practitioners have occasionally presented
innovative ideas about the underlying goals and meaning of
TOPR as a general discipline and child mental health strat-
egy. For example, Dadds and Hawes (2006) described a
parenting program in which TOPR is conceptualized within
a behavioral, attachment, and systems perspective (see also
Scott & Dadds, 2009). Johns and Levy (2013) presented a
case study in which TOPR and time-in are used within both
behavioral and attachment frameworks to treat a child with
severe emotional and behavioral problems. Although not
focusing on TOPR per se, a number of authors have pointed
to the compatibility of learning and attachment theories in
the processes and outcomes associated with behavioral par-
ent training interventions for child behavior problems (e.g.,
Allen, Timmer, & Urquiza, 2014; O’Connor, Matias, Futh,
Tantam, & Scott, 2013; Troutman, 2015).
What is missing, however, is a thorough analysis of what
TOPR is and should be in consideration of emerging child
mental health. In the nearly 60 years since TOPR was first
used in the scientific and health literature, there has never
been a thorough reanalysis of the full set of parent– child
dynamics that ensue when a parent implements TOPR with
a child. We argue here that a parent placing a child in TOPR
represents a dynamic far greater than a mere “operant”
punishment. It speaks to issues of power, attachment, self-
versus other- behavioral/emotional regulation, and contex-
tual family dynamics.
The following section presents an analysis of parental
discipline strategies, and TOPR specifically, in terms of
four contemporary pillars of child development theory: so-
cial learning theory, attachment theory, self- and emotion
regulation theory, and ecological/family systems theory. We
use these models to derive a set of axioms to guide how any
discipline strategy should be evaluated in terms of its impact
on child mental health. We then apply these axioms to
TOPR in order to clarify how it should be used. We show
that when conceptualized and enacted according to the joint
considerations and indications of these highly compatible
models, TOPR is a positive perturbation across these be-
havioral, attachment, self-regulatory and ecological/family
systems that can rapidly remediate problems the child has in
these systems, and thereby generally enhance child devel-
opment.
Parental Discipline and Child Mental Health
Discipline From the Perspective of Learning Theory
In terms of learning theory, broadly sampled here from
early operant to later social and cognitive learning theory,
we take the core criterion of effectiveness—that is, parental
discipline should work. Unfortunately, judging effective-
ness can be somewhat complicated, especially for parents
and many social commentators in society, as the worth of a
discipline strategy may be judged according to visible ef-
fects on the child (that is, it might be assumed that effec-
tiveness is indicated by the distress it causes in the person
being disciplined). In formal learning terms, the effects on
the emotion of the child is not the criterion for effectiveness;
discipline— or “punishment,” in formal learning terms—is
effective if it reduces the frequency or intensity of the
problematic child behavior it is contingent upon. That is,
discipline reduces the likelihood of the behavior it follows.
Discipline strategies such as TOPR can also be thought of as
extinction procedures or “response costs,” in that they re-
move a positive reinforcer from the behavior that previously
elicited this reward. Thus, in the instance of a child being
placed in TOPR for kicking a parent, TOPR is both a
punisher that may reduce the likelihood of future kicking
and an extinction event that removes parental attention that
may have previously rewarded the kicking behavior.
Further, discipline functions in at least four ways in terms
of broader social learning theory. First, effective discipline
should prevent the likely escalation of parent– child conflict
that is fundamental to social learning models of antisocial
behavior, family violence, and associated psychopathology.
Patterson’s (1982) classic coercive family process remains
the best explanatory model of how reinforcement traps, in
which parent and child are simultaneously reinforced for
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4DADDS AND TULLY
mutual attack and capitulation, move from the innocuous to
the pathological as small struggles over daily life escalate
into chronic and frequent aggression and abuse. When no
effective discipline strategy is available to parents, mundane
events like getting a child ready for school can escalate into
severe conflict (Straus, 2000). In this sense, effective disci-
pline procedures prevent escalating coercion cycles and
give families a sense of predictable control over otherwise
uncontainable escalations.
Second, learning theory specifies modeling and imitation
as core mechanisms for learning behavior. Effective disci-
pline should present parents as positive mental health mod-
els to the child. The use of a brief calm parenting discipline
procedure models to the child that conflict can be dealt with
calmly without resorting to physical and verbal aggression.
It thus minimizes the modeling of aggression that often
ensues when parents are unable to contain escalating coer-
cion cycles.
Third, a core component of social learning theory is
self-efficacy, defined as the expectation caregivers hold
about their ability to parent successfully (Johnston & Mash,
1989). The evidence is clear that the use of escalating
coercive discipline strategies is associated with low parental
self-efficacy (Johnston & Mash, 1989; Jones & Prinz, 2005)
and poor child mental health (Regalado et al., 2004). An
effective discipline procedure provides parents with a
method that enhances self-efficacy and reduces the likeli-
hood of the use of aversive coercive parenting borne of
frustration and anger. For the child, it is critical that disci-
pline strategies are consistent, predictable, and controllable.
As such, the child clearly understands parental expectations
for child behavior, that discipline is not random or emotion-
ally driven, and, thus, that it can be successfully avoided
through self-regulation. Fourth, programs based on social
learning theory are not designed to simply remove a nega-
tive behavior without consideration of a replacement behav-
ior; some of the most successful programs show reductions
in problematic behavior by the establishment or strengthen-
ing of an alternative, often incompatible, positive behavior
(Baldwin & Baldwin, 1986).
Finally, the issue of the causes of the particular child
behavior is an important point that is addressed in social
learning theory. TOPR was designed as a response to an
operant child behavior, that is, an inappropriate behavior
that is purposeful or goal directed, and thus influenced by a
reinforcement contingency, often parental attention. The
operant specifies that the child’s behavior is occurring to
achieve some goal. Thus, TOPR is a punisher or extinction
event applied to a child “operant.” It was not designed to be
used with child behaviors that are “elicited” by powerful
environmental stimuli and are not under the child’s control,
such as fear and panic and distress reactions in the absence
of behavioral problems.
Thus, from the perspective of learning theory, successful
parental discipline is that which satisfies six criteria. Disci-
pline should (a) reduce the likelihood of the inappropriate
behavior recurring; (b) prevent the ongoing escalation of
coercive aggressive cycles; (c) model calm, positive inter-
personal processes; (d) strengthen an alternative positive
behavior; (e) increase self-efficacy that one is an effective
agent; and (f) limit active discipline strategies to operant
child behavior, not elicited or accidental behavior like fear
or making mistakes.
Discipline From the Perspective of Attachment Theory
From Bowlby through Ainsworth to contemporary mod-
els of attachment and parent– child processes, attachment
theory has provided a rich framework for understanding
developmental psychopathology (Cassidy & Shaver, 1999).
At its core is the idea of secure attachment as a fundamental
element of well-being. It is conceptualized and operation-
alized in terms of separation and rapprochement. A young
child who is securely attached to a caregiver is able to
separate in order to explore the environment, and develop
creative independence, self-soothing, and regulation, due to
the availability of rapprochement with a secure base in the
form of a predictable nurturing relationship with the care-
giver. Although attachment theory has developed broadly to
include several corollaries of child and adult relationships
(see Cassidy & Shaver, 1999), the core idea remains that
children require a secure caregiving relationship that allows
them to effectively separate, explore, reunite, and seek
comfort in order to successfully negotiate and master the
changing demands of their social environment and devel-
opment.
From an attachment perspective, a discipline strategy
should, at a minimum, not threaten or break the attachment
bond; at its best, it should enhance the bond. Attachment
bonds are threatened when a caregiver is abusive, unpre-
dictable, unreliable, or unavailable, such as associated with
death, separation, and rejection. Insecure attachments are
characterized by the inability to separate and reunite suc-
cessfully (Ainsworth & Bell, 1970); hence, the clingy child
and/or parent who struggle with anxiety and anger at sepa-
ration and reunite with avoidance and hostility. Avoiding
separation or reunification does not solve these attachment
threats; rather, attachment theory specifies that a secure
attachment is marked by the ability to successfully separate
and reunite without threats to the bond (Ainsworth & Bell,
1970; Cassidy & Shaver, 1999). Thus, discipline is effective
from an attachment perspective when it provides a clear
message to the child that the attachment bond is maintained
solidly throughout the discipline event. That is, the strategy
used provides the message that the caregiver cares about the
child, does not approve of the behavior, and believes in their
capacity to demonstrate self-control and positive behavior.
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5
TIME-OUT IN THE AGE OF ATTACHMENT AND TRAUMA
This core process of successful separation and rapproche-
ment is enacted precisely in many common discipline strat-
egies when delivered effectively. TOPR, for example, by
definition, involves a temporary separation in which access
to parental attention is reduced and is contingent upon the
child regulating their emotions and behavior, at which time
rapprochement is enacted. The essential ingredient that
makes a discipline strategy compatible with attachment
theory is that the “separation” inherent in the strategy is not
a threat to the attachment bond—rather, it is a temporary
and predictable separation solely based on the need for an
operant disciplinary event—and that the basic parent– child
relationship, its attachment security, remains unchanged by
this temporary separation.
The major concern of writers criticizing TOPR and other
forms of discipline from an attachment perspective (e.g.,
Siegel & Bryson, 2014a) is that the separation damages or
breaks the attachment bond by communicating to the child
that the parent is not available to the child to help them
manage and soothe difficult emotions and interpersonal
conflicts. This is a worthy concern and should be axiomatic
to how discipline should be used, but it also misunderstands
the underlying message that contemporary discipline strat-
egies such as TOPR have been designed to communicate,
that is, that discipline is about a brief predictable response to
a specific problem behavior; it is not about isolating and
abandoning a child. It effectively says, for example, “You
are loved, you are my child, you are safe, this is not about
you or us, it is just about this instance of aggression.”
This provides a stark contrast to the experience of many
parent– child dyads who are not able to use discipline tech-
niques without getting upset and impacting the attachment
relationship. As noted above, from a social learning per-
spective, effective discipline provides a preventative mea-
sure against escalating coercive cycles. These escalations
frequently drift into dark areas of attachment threat and
abuse as parents and children grow increasingly emotional
and frustrated with each other and say and do things they
might not wish to resort to. When this happens, discipline
procedures become “attachment rich”—they stray into is-
sues of attachment (e.g., “I am sick of you, I’m fed up, why
are you like this? Get out of my sight”). These are unsuc-
cessful separations from an attachment perspective, as they
damage the secure base and make rapprochement difficult.
Thus, from an attachment perspective, successful disci-
pline does not threaten, and preferably strengthens, the
parent– child bond, thereby increasing each person’s capac-
ity for successful attachments more generally. By success-
fully negotiating the symbolic “separation and rapproche-
ment” that is represented by the initiation and resolution of
a discipline event, especially TOPR, successful discipline
thus normalizes and reinforces the daily manifestations of a
secure attachment bond.
Discipline From the Perspective of Self- and
Emotion Regulation Theory
Here, we draw upon the rich and overlapping areas of
self-control, behavioral regulation, and emotion regulation in
the science of child development. Although these are diverse
fields each with their own methods and issues, they share a
common focus on the individual’s ability to regulate self-
processes in order to achieve a desired outcome, and we refer
to this commonality of self-regulation in what follows. The
ability to successfully regulate across domains of behavior,
emotions, cognition, and attention has been shown to promote
positive child development and mental health (Gross, 1998,
2015). That is, there is a huge literature showing that skill in
these regulatory processes is associated with, and predictive of,
a diverse range of physical, social, and health outcomes (Al-
dao, Nolen-Hoeksema, & Schweizer, 2010; Fergusson, Boden,
& Horwood, 2013; Gross, 1998; Moffitt et al., 2011; Southam-
Gerow & Kendall, 2002). Further, there is an impressive lit-
erature that formally links parental discipline with self-
regulation in children. The child’s regulatory abilities develop
early in life and in the context of parent– child relationships and
interactions, before generalizing to school and peer settings
(Fabes, Eisenberg, & Miller, 1990). A wealth of evidence
suggests a clear link between coercive, dysregulated parenting
styles and deficits in a child’s own capacity for emotion reg-
ulation (Chang, Schwartz, Dodge, & McBride-Chang, 2003;
Gottman, Katz, & Hooven, 1997).
Thus, parental behavior and parent– child interactions can
promote the positive development and mental health of
children by promoting the child’s ability to effectively reg-
ulate their emotions, attention, and behavior. In relation to
parental discipline strategies, then, self-regulation theory
would regard an effective discipline strategy as one that, at
a minimum, does not challenge or reduce, but preferably
enhances, a child’s ability to self-regulate their behavioral,
emotional, and attentional/cognitive processes. This is chal-
lenging to achieve with many discipline strategies, espe-
cially with young children, as discipline inherently contains
elements of control, whereby the child is, by definition and
necessity, being regulated by the parent. A common element
of broad models of child development (e.g., Vygotsky,
1978) is the idea that healthy child development entails
some form of transfer of control from parents to the child,
such that the child gradually internalizes disciplinary con-
trol into skills for autonomous regulation.
For discipline in general, then, and TOPR in particular,
the development of self-regulation should be a broad goal.
Although TOPR typically involves parental control, there
are multiple opportunities in the process whereby the child
can be empowered to learn self-regulatory skills. By under-
standing that a predictable, nonemotional consequence will
reliably follow a problematic behavior, a child is given
maximum opportunity to regulate in advance to avoid the
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6DADDS AND TULLY
discipline. Similarly, a calm instruction given before TOPR
maximizes the likelihood of self-regulation. Explaining to a
child how TOPR works in advance of implementation max-
imizes the chances that the child can stay calm and regulate.
By making removal from TOPR contingent upon the child
successfully regulating behavior and emotions, autonomous
regulation and a sense of self-agency and control can be
strengthened in the child.
This approach to discipline overlaps with the previous
comments on self-efficacy, such that self-regulation refers
to actual regulatory processes, and self-efficacy refers to an
individual’s beliefs about their ability to successfully per-
form a behavior, in this case, self-regulatory processes, in
order to achieve a desired goal. Developmental psychopa-
thology has identified self-regulatory processes at the core
of various models of vulnerability and resilience to mental
health problems (e.g., Gross, 2015), as well as models of
specific disorders, including cognitive and behavioral reg-
ulation in ADHD, attention control in anxiety disorders and
psychopathy, and emotion regulation in conduct problems
(Cavanagh, Quinn, Duncan, Graham, & Balbuena, 2017).
Thus, from the perspective of self-regulation theory, an
effective discipline strategy will be a positive force in the
development of mental health by enhancing, over time, the
child’s ability to regulate behavior, emotion, arousal, and
attention without the need for external, disciplinary con-
straints. The development of autonomous self-regulation
skills is a core aspect of early child development. Thus,
disciplinary strategies should be sensitive to and promote
development such that external control inherent in disci-
pline should be gradually relinquished as the child learns to
internalize the regulatory skills.
Discipline From the Perspective of Ecological/
Family Systems Models
Children develop in a complex social field. Huge con-
tributions to understanding developmental psychopathol-
ogy have come from models that focus on the ecological
system in which development is embedded. This covers a
range of diverse models that have in common the core
idea that the development of mental health is in part
determined by the relationship of the child to functional
and structural properties of the social context. This con-
text includes the family, neighborhood, school, sporting
and other activity groups, religion, and larger cultural
groupings. Some of the most influential ideas come from
Bronfenbrenner (1979) and the ecology of child devel-
opment; the 1970s family therapy thinkers such as
Minuchin et al. (1975), who detailed how healthy child
development is in part dependent on structural hierar-
chies and groupings with clear boundaries within the
family; and a wealth of empirical work showing that
effective parent– child and family communication pat-
terns are a clear predictor of developmental health versus
disorder (Davies & Cummings, 2006).
For the purposes of evaluating discipline from the
ecological perspective, we propose a general tenet
emerging from the core of these models, especially Bron-
fenbrenner’s (1979) ecological model, that can be sum-
marized as follows: Child development and mental health
is in part determined by both how the child interacts with
his or her immediate family and social systems, and how
these systems interact with each other to promote child
development. This, then, includes the child’s interactions
with individual parents and other family members,
school, and broader social groups, as well as how these
individuals and groups interact with each other with
regard to the child. The latter is determined by how well
the broader social ecology holds compatible and positive
values about child development, moral and cultural sys-
tems, and meaning in general.
Thus, discipline, both in terms of its procedures and the
behavior it is applied to, should be consistent with a
larger set of shared values held by the child and parent’s
social ecology. Discipline is thus not erratic, impulsively
emotional, random, or applied differentially; it is based
on higher goals of moral and social behavior. This fit
between the discipline and its social and moral context is
a critical principle for understanding the worth of any
discipline strategy. As argued by Grusec, Danyliuk, Kil,
and O’Neill (2017), discipline is effective when it is
perceived by the child to be fair, reasonable, and clearly
embedded in explicit community moral values of right
and wrong. That is, the discipline event has meaning
clearly embedded in a family and ecological system of
shared perceptions of what is right; it is not arbitrary, out
of scale to the problem behavior, unfair, and based on
parental emotion or impulse. We also note that the con-
struct of how well individual behavioral events are em-
bedded in, and consistent with, larger cultural and spiri-
tual meaning is emerging as one of the most robust
predictors of mental health and resilience in the “happi-
ness” literature (see Ryan & Deci, 2001).
This literature indicates that to understand the value and
acceptability of TOPR, there must be consideration of the
social context in which it is implemented. Primarily, this
refers to the child’s family and how fairly and explicitly its
moral and social principles are used to guide the various
child behaviors that are selected for discipline. From the
perspective of ecological and family systems thinking, ef-
fective discipline is one that responds to a behavior that is
wrong or inappropriate according to broader system and
cultural mores, and enacts a corrective process that is fair,
reasonable, acceptable, and aligned with the general cultural
mores and meaning of the system.
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7
TIME-OUT IN THE AGE OF ATTACHMENT AND TRAUMA
Integrating the Prescriptions of Major Mental
Health Models Into a Set of Working Axioms
The above leads us to propose a set of working axioms by
which to guide and evaluate the worth of specific parental
discipline strategies. It should be noted that elements of
these recommendations are specified in existing evidence-
based interventions that employ TOPR, such as Triple P
(Sanders et al., 2014), PCIT (Querido et al., 2002), and the
Incredible Years (Webster-Stratton, 2001). This is the first
time, we believe, that these axioms have been brought
together into an expanded, integrated set. Thus, in terms of
the development of mental health in children, discipline
strategies should be (a) effective in terms of their success in
reducing recurrence of the problem behavior, preventing
escalation of further coercive aggression, providing effec-
tive modeling of interpersonal process, and developing and
strengthening alternative behaviors to the problem behavior;
(b) attachment secure, as in not a threat to, and preferably
facilitative of, ongoing secure attachment relationship
between the parent and child; (c) promoting of the child’s
self-efficacy and skills for behavioral, emotional, and
cognitive/attentional self-regulation; and (d) fair and
meaningful, not arbitrary and personal, and be clearly
embedded in, and consistent with, an explicit set of
shared family, social, and cultural mores about what is
right and meaningful.
Guidelines for Implementation of TOPR From a
Mental Health Perspective
These axioms about how discipline should be conceptu-
alized and implemented to enhance positive child develop-
ment and mental health can now be used to inform the
appropriate use of TOPR, our main focus in this article.
Thus, in response to the question “How then should TOPR
be implemented in terms of promoting the ongoing mental
health of children?” we propose the following specific
guidelines:
1. TOPR should only be used for inappropriate child
behavior that has an operant or deliberate quality or
component, that is, behavior over which the child
has some control and that is functional in producing
some desired outcome for the child. It should not be
used for behavior that represents an inability to
perform an action, lack of understanding, mistakes,
fear or other overwhelming emotions. These behav-
iors warrant supportive teaching responses from par-
ents, not discipline. TOPR can be used for inappro-
priate child behavior such as aggression that
accompanies distress reactions but not for the dis-
tress reactions themselves.
2. The effectiveness of TOPR implementation should
be judged in terms of observable and timely reduc-
tions in the problem behavior and. thus, in the rap-
idly diminishing need to use TOPR.
3. Parental behavior during the TOPR procedure should
provide a positive role model of calm, attachment-
secure interpersonal process.
4. The use of TOPR must be a part of a broader behav-
ioral program that promotes a warm and rewarding
relationship, and explicitly teaches alternative positive
child behaviors to replace the problem behavior to
improve the child’s self-efficacy in meeting their own
needs.
5. TOPR should be seen as a microcosm of the funda-
mental attachment process of separation and reunion. It
must not carry any parental communication of aban-
donment, isolation, and rejection during the TOPR and
return to time-in phases. Implemented appropriately,
TOPR can be seen as microtheater for enacting and
repairing attachment problems, conveying the explicit
message that this discipline event is focused on a
specific problem behavior, and throughout, the child
remains safe, valued, and loved.
6. The child should have an active role in influencing the
unfolding of TOPR such that their self-regulatory ca-
pacities are enhanced rather than externally controlled
and diminished. Thus, TOPR should end in a way that
is contingent upon the child’s self-regulation, not an
arbitrary time period. For example, return to time-in
can be contingent upon the child showing a brief but
stable period of regulated emotions and behavior.
7. Discipline strategies should function to improve the
child’s ability to effectively regulate emotions and be-
havior. Thus, the child should be taught, at a positive
time outside of conflict and prior to TOPR being used,
some basic rules for TOPR and skills for regulating
their emotions and behavior that can be used in TOPR
and elsewhere.
8. TOPR should be used for behaviors that are prespeci-
fied and explicitly explained to the child as being
problematic and inappropriate in terms of generally
accepted mores to the child, the family, the school, and
so on. These should be open to discussion at positive
times outside of discipline events.
9. TOPR implementation should be embedded in a family
and ecological system of shared perceptions of what is
right; it is not arbitrary, out of scale to the problem
behavior, unfair, and based on parental emotion or
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8DADDS AND TULLY
impulse. Children should be encouraged to be active
participants in understanding the cultural, moral, and
pragmatic context of family discipline.
10. TOPR should be applied democratically. That is, in
order to embed the discipline process firmly within
accepted ideas of fairness, time-out should be applied
equally and fairly across children in a family, depend-
ing on developmental levels.
Conceptualized and enacted within these guidelines for
promoting mental health, we propose that TOPR is not only
an acceptable parental discipline strategy—it is a positive
perturbation of the parent– child system that can enhance
and repair behavioral problems as well as broader problems
of self- and emotion regulation and parent– child attachment
problems. Studies show that behavioral parenting programs
that include TOPR have clear benefits for these broader
aspects of child development, including attachment pro-
cesses (O’Connor et al., 2013). We thus propose that the
widespread use of TOPR is warranted, and when concep-
tualized and implemented appropriately, as described
above, is a positive force for the mental health of children
and families.
Negative Information About TOPR
What, then, drives the recent flurry of criticism of TOPR
as a harmful procedure for children? It would be easy to
dismiss this as based on inaccurate ideas of what TOPR is.
We think it better to look carefully at these criticisms for
ideas of worth, as there is no doubt that they are motivated
by a positive concern for children. From reviewing the
literature on the Internet about TOPR (e.g., Australian As-
sociation for Infant Mental Health [AAIMH], 2009; Coul-
son, 2016; Lapointe, 2016; Siegel & Bryson, 2014a), it
would seem that the criticisms can be summarized into three
categories: (a) TOPR produces an attachment threat, for
example, “it deliberately cuts off the child from the rela-
tionship with parent or carer so that the child feels power-
less to connect with the adult” (AAIMH, 2009); (b) TOPR
does not teach new behaviors; and (c) TOPR fails to address
the underlying causes of the problem behavior. These are
reasonable concerns and they should be carefully consid-
ered rather than dismissed by proponents of TOPR. These
are the same concerns noted by Quetsch et al. (2015) in their
analysis of the literature that claims TOPR to be harmful for
children. Importantly, the analysis we presented above
about how parent– child discipline should be conceptualized
and implemented, and thus specifically how TOPR should
be used, converged on the same issues. Further, the analysis
showed that when implemented in terms of current knowl-
edge of child development and mental health, TOPR is
actually a positive discipline strategy that addresses each of
these concerns and can be a positive perturbation for attach-
ment problems and the development of self-regulation
skills. There is a further concern, however, about the use of
TOPR in relation to children with trauma histories and the
potential of TOPR to harm these children, and this will be
addressed in the following section.
Is TOPR Safe and Effective for Children With
Trauma Histories?
Exposure to traumatic or adverse events is unfortunately
common in childhood and adolescence, and is associated
with the onset of a broad range of mental health disorders
(e.g., McLaughlin et al., 2012) as well as behavioral symp-
toms of “trauma,” such as reexperiencing, avoidance, and
hyperarousal, which may lead to a diagnosis of posttrau-
matic stress disorder (PTSD). Concerns about the harmful
effects of TOPR for children with trauma histories are
prolific on the Internet, although these concerns have not
been documented in the published scientific literature, and it
is not clear how widespread these concerns are among
practitioners and caregivers. For the sake of this analysis, it
is important to distinguish between acute trauma, which
results from exposure to a discrete traumatic event, and
complex trauma, which results from the experiences of
multiple, chronic, and prolonged developmentally adverse
events, often of an interpersonal nature and with early life
onset (van der Kolk, 2005). Exposure to child abuse and
neglect is considered a complex trauma and can result in
difficulties in emotion perception, processing and regula-
tion, and long-lasting physical, emotional, and psychologi-
cal problems as well as changes in structural and functional
brain development (Jedd et al., 2015).
We believe it is important to focus on the appropriateness
and effectiveness of TOPR as a discipline procedure for
children who have experienced complex trauma in the form
of abuse and neglect specifically, as it is for these children
that concerns about potential harmful effects of TOPR are
paramount. Additionally, because the trauma is often expe-
rienced within the context of a dysfunctional caregiving
system, it is important to explore the potential of TOPR to
reduce trauma-related mental health problems. Thus, we
address two key questions in relation to use of TOPR with
children with abuse and neglect histories: Is there any
evidence that treatments that include TOPR are harmful,
and how does TOPR fit within current best-practice treat-
ments for children with trauma symptoms? We also revisit
the axioms and guidelines for implementation of TOPR
covered earlier in relation to children with trauma histories.
Regarding the first question about whether interventions
that include TOPR are harmful for children with abuse and
neglect histories, there is considerable research that has
examined the efficacy of parenting interventions that in-
clude TOPR within child welfare populations, and this
research has found no evidence of adverse effects. For
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9
TIME-OUT IN THE AGE OF ATTACHMENT AND TRAUMA
children who have experienced physical abuse and remain
with their parents, parenting interventions have been found
to significantly reduce rereports of physical abuse; ineffec-
tive, harsh, and dysfunctional parenting practices; and neg-
ative parenting attitudes, and to enhance positive parenting
practices, attitudes, and attributions (see reviews by Chen &
Chan, 2016; Vlahovicova, Melendez-Torres, Leijten, Knerr,
& Gardner, 2017). Many of these interventions include
TOPR as part of a focus on teaching effective parental
discipline, along with enhancing the parent– child affective
bond. PCIT includes TOPR, and a review of 11 PCIT
studies targeting maltreating families found significant re-
ductions in child welfare rereferrals, negative parenting
practices, and child externalizing behaviors (Batzer, Berg,
Godinet, & Stotzer, 2018). There is much less research for
children who have experienced parental neglect, but there is
some evidence that interventions including TOPR are also
effective in reducing neglect recidivism (Chaffin, Funder-
burk, Bard, Valle, & Gurwitch, 2011). We could find no
evidence of iatrogenic effects stemming from the use of
parenting programs that include TOPR with these popula-
tions of children.
Use of TOPR for children who have been removed from
their parents and placed with foster or kinship carers war-
rants a particular focus. Not only have these children expe-
rienced abuse and/or neglect severe enough to result in
removal from their parents—they have also experienced
separation from parents and other attachment figures. For
these children, there is evidence that parenting interventions
are effective in improving child mental health and parenting
(see reviews by Hambrick, Oppenheim-Weller, N=zi, &
Taussig, 2016; Uretsky & Hoffman, 2017), and TOPR is
often included as a key discipline procedure in these inter-
ventions (e.g., Mersky, Topitzes, Grant-Savela, Brondino,
& McNeil, 2016; Price et al., 2008). Thus, there appears to
be evidence that interventions involving TOPR improve
parenting and child adjustment for children in the welfare
system, and there is no evidence to date of harmful effects.
A few evidence-based parenting interventions have also
been adapted to be appropriate for children with trauma
symptoms (Akin, Lang, McDonald, Yan, & Little, 2019;
Gurwitch, Messer, & Funderburk, 2017). For example, Par-
ent Management Training Oregon Model was adapted to
include trauma content and a focus on emotion regulation
and mindfulness techniques for children in foster care with
serious emotional disturbance (Akin et al., 2019). This
intervention was found to be effective in improving child
socioemotional well-being in an randomized controlled trial
when compared with services as usual (Akin et al., 2019).
Importantly, the adaptations to this program did not include
changes to core parenting strategies such as TOPR.
There have been concerns among practitioners and par-
ents that the use of TOPR with children with abuse and
neglect histories may retraumatize children, which is de-
fined as “traumatic stress reactions, responses and symp-
toms that occur consequent to multiple exposures to trau-
matic events that are physical, psychological, or both in
nature” (Duckworth & Follette, 2012, p. 2). It is argued that
retraumatization can occur through discipline practices that
are distressing for a child and may cause reexperiencing of
the traumatic event (McNeil, Costello, Travers, & Norman,
2013). For example, TOPR may serve as a reminder of a
previous traumatic event and cause intense distress (see
McNeil et al., 2013, and Quetsch et al., 2015, for detailed
discussions about retraumatizaton in relation to TOPR).
However, in the unlikely event that TOPR should remind a
child of a previous traumatic event (e.g., limit setting by
parents reminding a child of previous physical abuse) and
trigger temporary arousal or fear, repeated use of the pro-
cedure as part of a calm, consistent response to misbehavior
may potentially serve as psychological exposure (McNeil et
al., 2013; Quetsch, Lieneman, & McNeil, 2017; Quetsch et
al., 2015). Gradual exposure to trauma reminders is a key
component of interventions for child trauma symptoms. In
this context, exposure to TOPR has the potential to reduce
a child’s arousal or fear of the trauma reminder (McNeil et
al., 2013). Through the implementation of TOPR as a calm
and predictable discipline strategy—and one that does not
disrupt secure attachment— children may learn to replace
feelings of fear and pain with feelings of control and safety
(see Quetsch et al., 2015, 2017).
In support of the argument that interventions that include
TOPR do not increase trauma symptoms, a study of a
standard PCIT found significant reductions in child trauma
symptoms along with child behavior problems from pre- to
posttreatment (Pearl et al., 2012), although it should be
noted that this was not a randomized controlled trial. The
children in this study were considered high risk, with the
majority of children having experienced some form of trau-
matic event. It is important to caution that we are not
suggesting that TOPR be used as a discipline procedure
specifically for trauma symptoms (as noted earlier in Guide-
line 1), but it may be indicated as part of a parenting
intervention for inappropriate child behavior that accompa-
nies these symptoms Cohen, Berliner, & Mannarino, 2010.
The second question focuses on how TOPR fits within
current best-practice treatments for child trauma symptoms.
Recent reviews have identified that one of the most evidence-
based interventions for reducing child trauma symptoms is
trauma-focused cognitive behavioral therapy (TF-CBT; Leen-
arts, Diehle, Doreleijers, Jansma, & Lindauer, 2013). This
intervention— described by the acronym PRACTICE—
involves a focus on parenting, along with psychoeducation,
relaxation skills, affective modulation skills, cognitive cop-
ing and processing skills, trauma narrative, in vivo mastery
of trauma reminders (exposure), conjoint child–parent ses-
sions, and enhancing future safety and development (Cohen,
Berliner, et al., 2010). In the parenting component, caregiv-
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10 DADDS AND TULLY
ers learn effective parenting skills, stress management, and
skills to support gradual exposure and to correct their own
trauma-related cognitive errors (Kliethermes, Drewry, &
Wamser-Nanney, 2017). The parenting skills taught in TF-
CBT comprise standard discipline strategies, including the
use of TOPR (Cohen, Berliner, et al., 2010). However,
interventions such as TF-CBT may not feasible if child
disruptive behaviors prevent the child and parent from ef-
fectively engaging in the intervention, so in this case, a
parenting intervention may be warranted as a first-line treat-
ment (Cohen, Berliner, et al., 2010; Gurwitch et al., 2017).
Cohen, Berliner, et al. (2010) provide a detailed discussion
about treatment for comorbid behavior problems and trauma
symptoms. Thus, it would seem that TOPR is already a
standard procedure within evidence-based interventions for
child trauma symptoms such as TF-CBT.
It is also important to revisit the likely putative mecha-
nisms for how TOPR works within the context of maltreat-
ing parents and trauma-exposed children, and in doing so,
revisit the axioms set out earlier. Child physical abuse
mostly occurs within a context of an escalating coercive
parent– child interactions, and interactions may be driven by
negative parental attributions and intolerance toward the
child’s behavior as well as increasing reliance on harsh
discipline (Chaffin et al., 2004). Through successful imple-
mentation of TOPR, discipline becomes calm, controlled,
predicable, and brief, instead of being emotional, escalating,
chaotic, and prolonged, with caregivers modeling effective
emotion regulation skills (Axiom a). Use of TOPR ensures
that the positive parent– child relationship is maintained and
not damaged by discipline encounters (Axiom b). Children
practice and achieve success at emotional and behavioral
regulation in TOPR, thus improving their skills in self-
regulation (Axiom c). Through consistent and predictable
use of TOPR, which is discussed and rehearsed with chil-
dren prior to implementation, children will replace beliefs
about discipline being unsafe, unfair, and erratic with an
understanding that TOPR is safe, fair, reasonable, and
meaningful (Axiom d). Consequently, children may replace
the distress and fear that was once associated with discipline
with feelings of safety, security, and predictability (Quetsch
et al., 2017).
Implementation of TOPR should be considered with each
child’s abuse and neglect histories in mind (Quetsch et al.,
2015), along with their behavioral presentations. It is im-
portant that comprehensive assessments include standard-
ized measures about a child’s traumatic experiences, PTSD
symptoms, and behavioral problems, as well as the quality
of parenting and the parent– child relationship. A thorough
assessment is critical to determine treatment planning for
children with trauma histories in order to determine what
problems to focus on during treatment (see Cohen, Berliner,
et al., 2010, and Cohen, Bukstein, et al., 2010, for more
information about assessment and treatment). Based on
each child’s individual history and presentation, TOPR may
require modification. Such modifications may include iden-
tifying alternative strategies to exclusionary TOPR, which
is often used as a backup to nonexclusionary TOPR. The use
of exclusionary TOPR may be particularly concerning for
caregivers of children with trauma histories, and they may
be reluctant to implement it. Pearl et al. (2012) described
how the strategy was modified in response to organizational
policies preventing the use of exclusionary TOPR. In this
example, loss of privileges was implemented as a backup
procedure to nonexclusionary TOPR, and this modification
did not appear to reduce the effectiveness of the strategy.
Additionally, some strategies or procedures may require an
increased emphasis for a child with trauma histories, such as
an a more intense focus on establishing/strengthening the
positive parent– child relationship prior to introducing
TOPR. Ongoing assessment of child symptoms throughout
the duration of intervention is also critical, as this will
determine the effectiveness of TOPR, as described in
Guideline 2, and guide any modifications to the procedure.
We thus conclude that there is no evidence to show that
TOPR is contraindicated for children showing trauma symp-
toms, either as a discipline strategy or as part of a parenting
intervention to address trauma-related behavior problems, al-
though the procedure should not be used to manage trauma
symptoms specifically. TOPR is used in evidence-based inter-
ventions that show benefits for improving parenting and child
adjustment in child welfare populations. This is not to say that
these research findings constitute evidence that TOPR per se is
effective, as the intervention effects may arise primarily from
strengthening the parent– child relationship or other strate-
gies in the intervention. The type of studies that would be
needed to evaluate the independent contribution of TOPR
per se, such as dismantling studies and meta-analyses of
intervention components, have not yet been conducted.
The evidence base for making these conclusions is small
at present, and more research into the use of TOPR with
highly vulnerable populations should be a priority. We
also note that procedural variations of TOPR might aid
applicability and acceptability with traumatized children
without compromising effectiveness. This would be rec-
ommended, with an important emphasis on monitoring
implementation to ensure that caregivers adhere to its
evidence-based procedural parameters, guidelines for im-
plementation as outlined in this article, and careful mon-
itoring of changes in child behavior to determine effec-
tiveness of the strategy.
Summary and Conclusions
We reviewed contemporary theory and empirical studies
with the aim of developing a set of axioms for evaluating
the value and acceptability of parental discipline strategies
from the perspective of emerging mental health using the
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11
TIME-OUT IN THE AGE OF ATTACHMENT AND TRAUMA
best available contemporary theory in developmental psy-
chopathology. We then scrutinized TOPR, one of the most
common but increasingly controversial parental discipline
strategies from this perspective, leading to a set of guide-
lines for use of this technique that maximize its contribution
to the mental health of growing children. Given recent
concerns about the use of TOPR with children who have
experienced trauma, we also reviewed evidence on the use
of discipline with such children, especially the use of
TOPR. We conclude the following:
1. Parental discipline represents a group of common
and ongoing events in the lives of children that
contribute to their mental health, and thus society’s
health at large. Thus, its usage should be a priority
concern for the health, education. and social sec-
tors of society.
2. The quality of any particular discipline strategy as
a mental health perturbation can be evaluated using
the best contemporary models of developmental
psychopathology, that is, social learning, attach-
ment, self-regulation, and family/ecological sys-
tems theories.
3. Each of these models contributes to a set of clear
guidelines, presented in this article, about how
discipline can and should be used to facilitate pos-
itive child outcomes.
4. TOPR is an increasingly common but somewhat
controversial discipline strategy that has been
shown to be effective in reducing inappropriate
behavior and improving parent– child relations, but
that has not been comprehensively scrutinized in
terms of contemporary models of developmental
mental health.
5. The application of the guidelines we derived from
models of developmental psychopathology to the
practice of TOPR leads to specific guidelines for
its use, specified earlier in this article.
6. When implemented within these guidelines, TOPR
is an effective and positive discipline strategy that
has the potential to enhance all aspects of the
child’s development and mental health.
7. The appropriate use of TOPR is also compatible
with our best understanding of the needs of chil-
dren with a history of exposure to trauma, although
the procedure is not appropriate for trauma symp-
toms specifically.
8. Research into the use of TOPR with children with
a history of trauma exposure indicates that when
presented as part of broad parenting intervention, it
improves behavioral and emotional problems.
9. Notwithstanding Points 7 and 8 above, further re-
search is needed to confirm the effectiveness and
safety of using TOPR with children who have
experienced complex trauma.
These conclusions have important implications for clini-
cal practice and policy. The evidence presented here indi-
cates that the adoption of policies that prohibit the use of
TOPR with children may be ill-considered and deny access
of children in need to an effective evidence-based proce-
dure. Given the wealth of evidence showing that TOPR is a
positive perturbation in child mental health, and the absence
of evidence showing it is harmful after five decades of
research, clinical, and common usage, claims that it is
harmful should be considered extraordinary, and thus re-
quire an extraordinary level of evidence to back them up. A
clear parallel is claims that vaccinations cause autism. The
evidence showing this to be false is so strong that claims to
the contrary require an extraordinary quality and quantity of
evidence to back them up. When TOPR is used, however, it
is crucial that its underlying theory, therapeutic mecha-
nisms, and procedural subtleties are well understood and
explicit to all parties concerned. The evidence is clear that
inappropriate parental discipline strategies have been, and
continue to be, implemented in the name of TOPR and these
are widespread, ineffective, and potentially harmful. Thus, a
priority for improving child mental health literacy is to
disseminate accurate information about the mechanisms and
procedures of this and other forms of discipline.
Finally, we have clearly seen that the use of TOPR is
synergistic with attachment theory and, in fact, offers a
concrete way of preventing and addressing attachment prob-
lems in everyday life. Similarly, the use of TOPR is com-
patible with the needs of children who have been exposed to
complex trauma and appears to be effective for treating
behavioral and emotional problems in these children. The
literature on this latter conclusion is tentative, however, and
should be a priority for future research.
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Received July 17, 2018
Revision received December 18, 2018
Accepted January 2, 2019
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15
TIME-OUT IN THE AGE OF ATTACHMENT AND TRAUMA
... We expanded on this rebuttal in our initial piece (Larzelere, Gunnoe, Roberts, & Ferguson, 2017) by articulating four methodological fallacies that pervade the correlational research typically cited to oppose disciplinary consequences, and by questioning the effectiveness of parenting devoid of such consequences. More recently, Dadds and Tully (2019) published an excellent defense of timeout, in which they argued for timeout's compatibility with many standard psychological theories (learning, attachment, emotion regulation, family systems) and specified how best to use timeout, in response to legitimate concerns cited by its critics. ...
... The evidence for the effectiveness of timeout in reducing child noncompliance is very consistent, and effect sizes are large. Not a single study suggested harm, validating the perspective of Dadds and Tully (2019) who argued: ...
Article
In our initial article we raised concerns about a paradigm we called “Exclusively Positive Parenting” (EPP). This paradigm opposes all negative disciplinary consequences, including timeout and privilege removal. We argued that the empirical support for EPP was insufficient. Researchers should not rely on insufficient causal evidence to replace well-established parenting perspectives that combine positive parenting with appropriate firm control. In reply, Holden et al. defended EPP. In this rejoinder to them we do two things. First, we use their citations to evaluate the limited causal evidence (four randomized studies) for what EPP supports. Second, we summarize the evidence for timeout, which EPP opposes. To do that, we offer the first known meta-analysis of the overall effectiveness of timeout, based on 24 studies with strong causal evidence for its effectiveness with young oppositional defiant children (6 randomized clinical studies; 18 small-N experimental designs). We call for parenting researchers to synthesize positive parenting techniques and disciplinary consequences based on adequate causal evidence.
... After having completed a five-day training in PCIT, therapists continued to hold concerns about the use of time out, and the impact of time out on the attachment relationship between parent and child. This perception of time out is not unique to the NZ context (Dadds and Tully, 2019). Given these concerns, it may be that those therapists who reported using only components of PCIT are teaching and coaching parents in CDI skills alone. ...
... It is possible that there is a role for an adjunct training moduleperhaps via online delivery to enhance uptakeor further post-training supervision that specifically addresses therapist concerns around the use of time out. This material would usefully be informed by recent publications and existing resources on the use of time out, developed in acknowledgement of therapist and family concerns about the technique (e.g., Quetsch et al., 2015;Dadds and Tully, 2019;Larzelere et al., 2020) However it is acknowledged that one implementation intervention component is unlikely in and of itself to bring about significant change in implementation behaviour (Bauer et al., 2015). ...
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Objectives Embedding effective parent training programmes for the treatment of childhood conduct problems into routine clinical practice does not happen spontaneously. Despite the known influence of contextual factors on implementation success, and the centrality of the therapist as a key implementation stakeholder, studies into the therapist experience of receiving training in, and implementing evidence-based manualised parent training programmes are relatively rare. This study sought to understand the training and post-training implementation experiences of Parent-Child Interaction Therapy (PCIT) therapists in New Zealand, and to compare and contrast these with existing research into the experiences of PCIT trainees in the Netherlands (i.e., Niec et al., 2018) Methods Fifty-six therapists (a response rate of 67%) completed an anonymous online survey of their experiences of training in, and subsequently implementing Parent-Child Interaction Therapy (PCIT) in New Zealand. Results Qualitative and quantitative analyses indicated that therapists experienced barriers to implementation, both internal (“burdened”) and external (“blocked”) yet typically persisted with implementation efforts. Therapist (and other stakeholder) attitudes towards the use of time out with young children was a common barrier to implementation. Therapists described drawing from other - at times incompatible – treatment approaches for children with conduct problems, and in some cases reported using only components of the manualised PCIT protocol. Direct international comparison of New Zealand and Dutch PCIT therapists’ responses demonstrated remarkably similar (and positive) attitudes towards PCIT, and the experience of similar barriers internationally. Conclusions Implications for implementation success are discussed.
... Thereby, it is preoccupying that time-outs are frequent, of long durations, and mostly not used to prevent harm (MacLeish & Landau, 1989;Ryan et al., 2007). Whether time-outs are effective or harmful in traumatized children and youth remain unknown (Dadds & Tully, 2019). ...
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Background Many children and youth living in residential units have experienced multiple traumas that may result in challenging behaviors. Among a range of professional responses, staff may use restraint, seclusion and time-out to manage these behaviors. Objective To enhance our understanding of these restrictive interventions in residential units as a means of improving professional practices involving children and youth in out-of-home care. Participants and setting Administrative data were used. Restrictive intervention data for 324 children and youth (29 units) over a 6-month period were extracted. Methods : Latent profile analysis was used to identify subgroups of children and youth with distinct restrictive intervention profiles. Children and youth in these profiles were compared on individual (age, sex, ethnic group, length of stay in unit, reasons for services) and environmental characteristics (unit type, type of services, specialized designation). Results Restrictive interventions, especially time-outs, were frequent (5136 interventions; 69% time-outs), yet approximately half of the sample did not experience any. Restraints, seclusions and time-outs differed in frequency, duration and reason for use. A two-profile model was favored for children and youth who were subjected to restrictive interventions (classification accuracy = 94%). Children and youth in these two profiles differed from each other, and from those not subjected to restrictive interventions, on numerous individual and environmental characteristics. Conclusion The use of restrictive interventions is frequent, and attention should be paid to individual and environmental risk factors identified in this study (i.e., being a boy, non-Caucasian, taken into care for neglect, and having a longer stay in unit).
... The conceptualisation of, for example, Time-out or other skills for responding to misbehavior wary depending on psychological theory (Dadds & Tully, 2019) and it is important to use descriptions appropriate and acceptable to the Swedish context. ...
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Many countries seek evidence-based interventions for children who have been exposed to domestic violence, and they frequently turn to interventions developed in the US and disseminated to Europe as a solution. Societal and cultural differences may, however, pose barriers to successful implementation. Project Support (PS), piloted in this study through social services agencies in Sweden, has shown positive effects in the US for families with children who have been exposed to intimate partner violence (IPV). The aim of this study was to investigate counselors’ and caregivers’ experiences when giving/receiving PS in Sweden. The study was based on interviews conducted with 11 mothers and 13 counselors with experience in the programme. A thematic analysis showed three themes (Initial doubts, Confidence from positive change, and Flexibility- challenge for the organization) and the study adds information about obstacles for implementation of PS in Sweden. Cultural and organizational differences between Sweden and the US in practice and child-rearing attitudes are highlighted, as well as the importance of making adjustments while maintaining treatment fidelity, and promoting the dissemination of the approach.
... Similarly, parenting research has traditionally been guided by learning theory (Patterson and Stouthamer-Loeber, 1984). However, Dadds and Tully (2019) have argued that improving parenting quality requires understanding the trade-off between learning principles and the child's developing attachment bond with their parents (see also Juffer et al., 2017). Taken together, this suggests that formulating a learning theory of attachment fits with contemporary research and thinking about child development. ...
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Attachment is an inborn behavioral system that is biologically driven and essential for survival. During child development, individual differences in (in)secure attachment emerge. The development of different attachment behaviors has been traditionally explained as a process during which experiences with (lack of) responsive and supportive care are internalized into working models of attachment. However, this idea has been criticized for being vague and even untestable. With the aim of unraveling this black box, we propose to integrate evidence from conditioning research with attachment theory to formulate a Learning Theory of Attachment. In this review , we explain how the development of individual differences in attachment security at least partly follows the principles of classical and operant conditioning. We combine observed associations between attachment and neurocognitive and endocrinological (cortisol, oxytocin, and dopamine) processes with insights in conditioning dynamics to explain the development of attachment. This may contribute to the explanation of empirical observations in attachment research that are insufficiently accounted for by traditional attachment theory.
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Kontingenzmanagement beschreibt die Modifikation von positiven oder negativen Konsequenzen eines spezifischen Verhaltens, um dadurch die Auftretenshäufigkeit von erwünschtem oder angemessenem Verhalten zu erhöhen und von unerwünschtem oder Problemverhalten zu vermindern. Positive Verstärkung und negative Verstärkung haben eine Zunahme der Auftretenswahrscheinlichkeit eines Verhaltens zur Folge, während Verstärkerentzug und Löschung sowie Bestrafung zur Reduktion der Auftretenswahrscheinlichkeit eines Verhaltens führen. Vermutlich ist das Kontingenzmanagement die wichtigste verhaltenstherapeutische Technik, vor allem in der Behandlung von Kindern und Jugendlichen. Diese Methoden werden nicht nur eingesetzt, um problematisches Verhalten direkt zu vermindern und angemessenes Verhalten direkt aufzubauen, sondern auch, um basale Voraussetzungen für eine erfolgreiche Kinderpsychotherapie (z. B. Beziehungsaufbau, Motivationsaufbau) zu etablieren oder um die Anwendung anderer Methoden zu verstärken.
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Previously institutionalized children on average show persistent deficits in physiological and behavioral regulation, as well as a lack of normative reticence towards strangers, or disinhibited social engagement (DSE). Post-adoption parenting, specifically a combination of supportive presence and structure/limit-setting, may protect against DSE over time via better adrenocortical functioning. This study examined the impact of adrenocortical activity and post-adoption parenting on DSE across the first two years post-adoption (age at adoption: 16–36 months) and observed kindergarten social outcomes in previously institutionalized children (n = 94) compared to non-adopted children (n = 52). Path analyses indicated a developmental cascade from institutional care (operationalized as a dichotomous group variable, age at adoption, and months of institutionalization) to blunted adrenocortical activity, increased DSE, and lower kindergarten social competence. Consistent with a permissive parenting style, higher parental support was associated with increased DSE, but only when not accompanied by effective structure/limit-setting. Further, parental structure reduced the association between blunted adrenocortical activity and DSE behaviors.
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This article reviews the state of the science on psychosocial treatments for disruptive behaviors in children, as an update to Eyberg, Nelson, and Boggs (2008). We followed procedures for literature searching, study inclusion, and treatment classification as laid out in Southam-Gerow and Prinstein (2014), focusing on treatments for children 12 years of age and younger. Two treatments (group parent behavior therapy, and individual parent behavior therapy with child participation) had sufficient empirical support to be classified as well-established treatments. Thirteen other treatments were classified as probably efficacious. Substantial variability in effectiveness of different programs within the same treatment family has been previously documented; thus, a particular level of evidence might not hold true for every individual program in a treatment family. Systematic investigations of implementation, dissemination, and uptake are needed to ensure that children and families have access to effective treatments. Investigations into how to blend the strengths of the effective approaches into even more effective treatment might also lead to greater impact.
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Child physical abuse is an issue of global concern. Conservative estimates set global prevalence of this type of maltreatment at 25%, its consequences and cost to society escalating with increasing frequency and severity of episodes. Syntheses of the evidence on parenting programs for reducing rates of physical abuse recidivism have, to date, not been able to establish effectiveness. Paucity of data and inconsistent inclusion criteria in past reviews made meta-analysis often impossible or uninformative. The current systematic review updates prior reviews and overcomes some of the methodological issues they encountered by pooling trial-level data from a well-defined scope of trials of parenting interventions aimed at preventing the reabuse of children by parents with substantiated or suspected physical abuse history. Randomized controlled trials and rigorous non-randomized designs were sought via nine online databases, two trial registries, several clearinghouses and contact with experts. A total of fourteen studies of variable quality were included in this review, four of which had outcomes that enabled meta-analysis. Overall, this review presents evidence supporting the effectiveness of parenting behavioral programs based on social learning theory for reducing hard markers of child physical abuse recidivism. Meta-analysis found that the absolute risk reduction in risk of recidivism was 11 percentage points less for maltreating parents who undergo parenting programs (RD = -0.11, 95% CI [-0.22, -0.004], p = 0.043, I2 = 28.9%). However, the pooled effect size was not statistically significant when calculated as a risk ratio (0.76, 95% CI [0.54, 1.07], I2 = 38.4%). Policy makers and practitioners should be made aware that this intervention method is backed by promising evidence featuring modest yet significant reductions in hard markers of child physical abuse, even though the methodological robustness of these findings should be further explored in future research.
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Background and objectives: The prevalence of corporal punishment is high in the United States despite a 1998 American Academy of Pediatrics policy statement urging against its use. The current study tests whether the socioeconomic difference in its use by parents has changed over the past quarter century. It goes on to test whether socioeconomic differences in the use of nonphysical discipline have also changed over time. Methods: Data are drawn from 4 national studies conducted between 1988 and 2011. Each asked how often a kindergarten-aged child was spanked in the past week and what the parents would do if the child misbehaved, with physical discipline, time-out, and talking to child as possible responses. We use regression models to estimate parents' responses to these questions at the 90th, 50th, and 10th percentiles of the income and education distributions and t tests to compare estimates across cohorts. Results: The proportion of mothers at the 50th income-percentile who endorse physical discipline decreased from 46% to 21% over time. Gaps between the 90th and 10th income-percentiles were stable at 11 and 18 percentage points in 1988 and 2011. The percentage of mothers at the 10th income-percentile endorsing time-outs increased from 51% to 71%, and the 90/10 income gap decreased from 23 to 14 percentage points between 1998 and 2011. Conclusions: Decline in popular support for physical discipline reflects real changes in parents' discipline strategies. These changes have occurred at all socioeconomic levels, producing for some behaviors a significant reduction in socioeconomic differences.
Article
In reviews published more than 30 years ago, eight parameters important to the use of time-out were identified and available research was summarized. The purpose of the current paper is to provide an updated summary of existing research for each parameter of time-out. Within each parameter, we conducted a thorough review of the published literature and identified all peer-reviewed articles addressing each parameter. We identified and summarized a total of 46 articles across the eight parameters, including 32 not cited in previous reviews. Sufficient findings were available to draw conclusions regarding time-out warning, schedule of time-out, contingent versus noncontingent release, and duration. Tentative conclusions based on only a few studies could be drawn in regard to instructional versus physical administration and verbalized reason for time-out. No conclusions could be drawn regarding time-out signal and specific time-out location. While we know much more today regarding effective implementation of time-out, there is a clear need for further exploration within these identified parameters. In addition to summarizing the literature, we reviewed recommendations made by behavioral parent training programs, parenting books, and parenting Web sites, and compared how well their recommendations matched current research based on the conclusions drawn from our review. We found that parenting sources made strong and specific recommendations on several of the parameters that were either not consistent with available research or simply lacked a sufficient research base.
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Effective discipline involves the use of negative consequences, including reasoning as well as modest levels of power assertion, to discourage unacceptable behavior. A brief history of changing views of discipline is presented and recent positions outlined. Successful discipline requires the imposition of clear and consistent rules, autonomy support, perspective-taking, and acceptance rather than rejection of the child. There are different kinds of negative consequences that are evaluated differently by children as well as having different effects on their behavior. In addition, there are individual differences in how children react to a specific form of discipline, and parents need to be aware of what those differences are. Cultural research underlines the fact that the meaning children assign to specific parenting actions is crucial in determining discipline success. When discipline is seen as normative, fair, and a sign of caring its form, within limits, is less important.
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Exposure to traumatic events during childhood is relatively common and is related to a host of adverse short- and long-term outcomes. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al. Treating trauma and traumatic grief in children and adolescents. The Guildford Press, New York, 2006) is the leading intervention for childhood trauma, having amassed the most empirical support (Cohen et al. J Am Acad Child Adolesc Psychiatry 4: 414–430, 2010). TF-CBT is a conjoint child and parent therapy model that consists of nine trauma-focused components that spell the acronym PRACTICE. In this chapter, we provide a brief overview of the TF-CBT model and PRACTICE components. Next, we describe the theoretical underpinnings of TF-CBT, highlighting such concepts as stress management, gradual exposure, cognitive theory, and observational learning via caregiver involvement. We then illustrate how to implement TF-CBT using a case example. Special challenges frequently observed in TF-CBT, and how to overcome these difficulties, are then discussed. We conclude by describing the significant empirical support for TF-CBT and outlining areas for future TF-CBT research.
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Objective: To assess parents' perceptions and utilization of Time-out (TO) in contrast to empirical indications and examine the relationship between reported implementation procedures and perceived effectiveness. Methods: We surveyed parents of preschool and school-aged children (N=401, aged 15 months-10 years) at well-child visits with regards to their awareness, perception, and usage of TO. Parents were specifically surveyed regarding TO components that have been empirically evaluated or pertain directly to its underlying behavioral principles. Descriptive analyses, group comparisons, and correlational analyses were used to characterize responses and evaluate the relationship between TO administration variation and perceived effectiveness. Results: Most parents (76.8%) reported using TO in response to misbehavior, but a large majority of these parents (84.9%) reported implementing TO in a manner counter to empirical evidence. Parents who endorsed TO as effective varied significantly from those who did not on key implementation components (e.g., use of a single warning). Further, several reported implementation practices were correlated with perceived effectiveness and challenging child behavior. For example, requiring a child to be calm before ending TO was positively correlated with perceived effectiveness. Conclusions: These results cement TO as a widely disseminated practice, but cast doubt on the fidelity with which it is typically implemented. Better methods of educating parents on evidence-based discipline are needed.