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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

February 2019
American Psychologist 74(7)

DOI:10.1037/amp0000449

Authors:

Mark R Dadds

The University of Sydney

Lucy 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.

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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

0003-066X/19/$12.00 http://dx.doi.org/10.1037/amp0000449

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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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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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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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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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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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

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Accepted January 2, 2019 䡲

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Dec 2024
BRIT J PSYCHIAT

Background Discipline is a crucial aspect of parenting, shaping child development and behaviour. Time-out, a widely used disciplinary strategy with a strong evidence-base, has recently come under scrutiny with concerns about potential adverse effects on children's emotional development and attachment, particularly for those with a history of adversity. Aims To contribute critical empirical insights to the current controversy surrounding time-out by exploring the associations among time-out implementation, parent–child attachment and child mental health, and whether adversity exposure moderated these associations. Method This cross-sectional study utilised a nationally representative sample of 474 primary caregivers in Australia, with children aged 6–8 years, who completed an online survey. Measures included the Implementation of Time-out Scale, Adverse Life Experiences Scale, Primary Attachment Style Questionnaire, Strengths and Difficulties Questionnaire and Spence Child Anxiety Scale. Results Appropriately implemented time-out was associated with enhanced mental health and attachment, while inappropriate time-out correlated with adverse child outcomes. Exposure to adversity moderated the relationship between time-out implementation and child well-being, such that children exposed to adversity were most likely to experience attachment enhancement from appropriately implemented time-out. Conclusions Despite recent concerns of harm caused by time-out, particularly for children with a history of adversity, findings support the beneficial impact of time-out on child well-being and attachment when implemented in accordance with evidence-based parameters. Combatting misinformation and disseminating evidence-based time-out guidelines is crucial for promoting child well-being and attachment, especially for children who have experienced adversity.

Therapist Anxious Distress and Avoidance of Implementing Time-Out

Article

Full-text available

May 2024
CHILD PSYCHIAT HUM D

Therapist anxious distress when delivering child mental health treatment has been understudied as a factor that contributes to the underuse of some evidence-based interventions (EBIs), such as time-out for children with disruptive behaviors. This study investigated therapist anxious avoidance of time-out using a three-part, vignette-based survey design. Therapists (n = 198) read a vignette of an in-session time-out and reported on their personal anxious distress and likelihood of discontinuing the implementation of time-out. Therapists also provided open-ended descriptions of challenges to delivering time-out. Therapists reported moderate anxious distress at time points 1 and 2 and lower anxious distress at time 3 when the time-out had resolved. Most therapists endorsed some avoidance of time-out. Binomial logistic regression analyses indicated that increased anxious distress corresponded with an increased probability of avoiding time-out delivery in the future. Qualitative reports expanded on challenges to implementing time-out. Findings suggest the importance of addressing therapist anxious distress when implementing children’s mental health treatments.

The Positive Discipline in Everyday Parenting Questionnaire: Psychometric Characteristics of a Revised Version

Article

Full-text available

Apr 2024
J Child Fam Stud

This study describes the development of the Positive Discipline in Everyday Parenting Questionnaire (PDEPQ), which assesses key parental cognitions underlying punitive parental behaviours, namely 1) Approval of Physical Punishment; 2) Approval of Non-Physical Punishment; 3) Subjective Norms; and 4) Parenting Self-Efficacy. In Study 1, two samples (parents, professionals) were recruited to assess the content validity of the four scales, following which a revised version was created. In Study 2, the revised PDEPQ was administered to 400 Canadian parents to examine the factor structure as well its reliability and validity. Results indicated a good factor structure of the scales, but several items were removed to achieve a better fit. Internal consistency of the four scales ranged from acceptable to excellent. Correlations between the scale scores at the two time points were large in magnitude and significant, indicating excellent test-retest reliability. Furthermore, correlations between the PDEPQ scales and measures of similar constructs were significant and in the expected direction, indicating a strong alignment of each scale with its respective construct of interest. In conclusion, findings from these various studies indicate good psychometric properties of the PDEPQ scales, as well as strong evidence of construct validity, internal consistency, and test-retest reliability.

Time Out as a Regulated and Specified Element of Child Care Licensing Policy: Are Policies Aligned with the Research Base?

Article

Full-text available

Jun 2024
Early Child Educ J

„Ef við náum ekki bekkjarstjórn þá getum við gleymt þessu“: Mat á námskeiði í bekkjarstjórnun fyrir starfsfólk skóla

Article

Full-text available

Apr 2024

Kennarar og starfsfólk skóla þurfa að ná til fjölbreytts hóps barna og styðja við nám, hegðun og líðan hvers og eins. Mikilvægt er að samskipti kennara og nemenda séu farsæl og þar skiptir bekkjarstjórnun miklu máli. Árangursrík bekkjarstjórnun eykur gæði kennslu og námsástundun og stuðlar auk þess að bættri líðan kennara og nemenda. Ef hún er ómarkviss getur það hins vegar valdið álagi og streitu, bæði fyrir nemendur og kennara. Þessi rannsókn fjallar um mat starfandi grunnskólakennara á námskeiði í gagnreyndum bekkjarstjórnunaraðferðum fyrir starfsfólk skóla, sem meðal annars voru sóttar í smiðju PMTO-foreldrafærni og SMT-skólafærni. Hagkvæmni og gagnsemi aðferðanna var metin; hvort það að takast markvisst á við að efla eigin bekkjarstjórnun og stuðning við félagsfærni nemenda nýttist starfandi grunnskólakennurum. Áhersla var lögð á að kanna sýn kennaranna á aðferðir sem þeir lærðu á námskeiðinu og nýttu svo á vettvangi með nemendum sínum, svo sem gagnsemi þeirra og hvort og hvaða aðferðir þeir sæju fyrir sér að nota áfram. Þátttakendur, alls ellefu talsins, voru starfandi grunnskólakennarar sem luku námskeiðinu og mátu afrakstur þess. Blönduðum rannsóknaraðferðum var beitt, meðal annars spurningalistum og mati á mætingu og þátttöku. Einnig voru tekin rýnihópaviðtöl við tvo mismunandi undirhópa þátttakenda. Samhljómur var um að það sem þátttakendur lærðu á námskeiðinu hefði borið árangur og að þeir myndu halda áfram að nýta aðferðirnar á vettvangi. Þá töldu þátttakendur þjálfun sem þessa nauðsynlega fyrir kennara, sérstaklega nýliða í stéttinni. Niðurstöður samræmast fyrri íslenskum rannsóknum á þessu sviði og benda til þess að þörf sé fyrir og áhugi á þjálfun í bekkjarstjórnun meðal kennara og starfsfólks skóla hérlendis. Fjallað er almennt um aðferðirnar og mikilvægi þeirra fyrir aðlögun nemenda og kennara.

Finding Solutions to Scaling Parenting Programs That Work: a Systems-Contextual Approach

Article

Nov 2024
PREV SCI

Prevention science has now encompassed decades of research exploring risk and protective factors and effective programs for the prevention and treatment of childhood behavioral, emotional, and developmental concerns. This paper shares our experience over the last 40 years as program developers and researchers in responding to contemporary needs and finding solutions to barriers preventing access to evidence-based parenting support. We propose a systems-contextual approach to designing and implementing programs that meet families’ needs and preferences and promote self-regulatory capacity across the lifespan. Key areas discussed are innovations to improve the reach of evidence-based parenting support (e.g., online program delivery, cultural adaptation, and tailored programs to engage vulnerable children and families), innovations to improve professional training outcomes (e.g., competency-based training, peer supervision and support, implementation support, and workforce development), and innovations to meet future needs (e.g., embracing new technology, standing by science, and considering global issues). It is incumbent on program developers, researchers, and clinicians to continue to evolve our practices and service systems in response to new evidence, societal changes, and technical advances to remain relevant and impactful in shifting prevalence rates of conduct problems and promoting child, family, and community well-being.

A Study of the Effectiveness of Camp Baker, an Adapted Summer Treatment Program for Children with ADHD

Article

Sep 2024

Affective and Behavioral Responses to Time-Out in Preschool Children With Conduct Problems and Varying Levels of Callous-Unemotional Traits

Article

Jul 2024
BEHAV THER

Georgette E Fleming

A Naturalistic Evaluation of Parent-Child Interaction Therapy (PCIT) and PCIT with Trauma-Directed Interaction (PCIT with TDI) in Australian Children Exposed to Abuse and Neglect

Article

Apr 2024

Evidence Base Update for Psychosocial Treatments for Disruptive Behaviors in Children

Article

Full-text available

May 2017

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.

Parenting Programs for the Prevention of Child Physical Abuse Recurrence: A Systematic Review and Meta-Analysis

Article

Full-text available

Sep 2017
CLIN CHILD FAM PSYCH

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.

Meta-Emotion: How Families Communicate Emotionally

Book

Feb 2013

Parameters of Time-out: Research Update and Comparison to Parenting Programs, Books and Online Recommendations

Article

Sep 2017
BEHAV THER

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.

Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories.

Article

May 2005

Bessel A van der Kolk

Mind in society: The development of higher psychological processes

Book

Jan 1978

Lev S Vygotsky

A Systematic Review and Meta-Analysis of the Evidence for Group-Based Foster Parent Training Programs in Reducing Externalizing Child Behaviors

Article

Jun 2017

The current study undertook a narrative and meta-analytic review of the literature to examine the effectiveness of group-based in-service foster parent training programs in reducing externalizing child behaviors. All studies reported a significant decrease in at least one measure of child behavior problems for treatment-group participants. The programs appear to be effective across ethnically and nationally diverse samples and produce similar results for older and younger children, as well as boys and girls. Overall the evidence suggests that group-based foster parent programs are an effective method for reducing problem behaviors among children in out of home care.

Perspectives on parent discipline and child outcomes

Article

Jun 2017

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.

Weighing in on the time-out controversy: An empirical perspective

Article

Jan 2015

Appropriate implementation of time-out has been shown for decades to produce positive outcomes ranging from the reduction in child problem behaviors to reduced levels of child maltreatment. Although the literature indicating positive outcomes on time-out is abundant, time-out continues to elicit controversy. While this controversy has been long-standing, more recent, outspoken skeptics have contested time-out using widely-viewed mediums. Unfortunately, critics present arguments against time-out without consulting the abundant, empirical literature on its positive effects. Moreover, these misinformed views can have devastating consequences by swaying families away from appropriate time-out implementation who may otherwise benefit. This paper utilizes the breadth of research on time-out to addresses myths surrounding its implementation.

Parent-Child Interaction Therapy

Chapter

Feb 2017

Parent-child interaction therapy (PCIT), a program for young children and their families, is a strong evidence-based treatment that repeatedly receives the highest rankings possible in reviews of such treatments (e.g., California Evidence-Based Clearinghouse for Child Welfare, 2015; nrepp.samhsa. gov). PCIT was originally developed for use with young children (2–7 years of age) with disruptive behavior problems (McNeil and Hembree-Kigin 2010; Zisser and Eyberg 2010). As PCIT continued to show significant positive outcomes including improved child behaviors, reduced parenting stress, and improved parent-child relationships (Brinkmeyer and Eyberg 2003; Eyberg and Robinson 1982), the application of PCIT to children at risk or exposed to trauma seemed a logical step.

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

Abstract

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