PCIT International Position Statement on Time-Out

The PCIT International Policy and Advocacy Task Force is a group of stakeholders invested in 1) advocating for the needs of children and families and 2) addressing concerns, facilitating discussion, and providing assistance around PCIT dissemination, implementation, and sustainability within the community, especially in regards to policy. As such, this position statement was developed to respond to concerns that can arise regarding the use of a time-out protocol in PCIT, in order to help ensure that vulnerable children and families have access to this best practice for child conduct problems and physical maltreatment.

Background on PCIT:

• PCIT has over 40 years of research demonstrating that it is a safe and effective intervention that improves the parent-child relationship, increases parenting skills, decreases child conduct problems, and reduces the risk of maltreatment.
• PCIT has been recognized by the National Child Traumatic Stress Network1 as a trauma-informed intervention.
• PCIT has also been recognized by the California Evidence-Based Clearinghouse for Child Welfare,2 SAMHSA’s National Registry of Evidence-Based Programs and Practices,3 and the Federal Administration on Children, Youth and Families in the Child Welfare Information Gateway4 as being a best practice for the prevention and treatment of child conduct problems and child maltreatment.
• The time-out procedure in PCIT is only one component of the treatment, used in the context of a much larger set of strategies that include building a warm, supportive relationship between the caregiver and the child, using positive reinforcement of behavior, and managing misbehavior with proactive, positive strategies. Parents are not taught time-out until they master parenting skills focused on building a nurturing relationship with their child.

Background on the Use of Timeout

• Severe behavior problems in young children are likely to evolve into serious conduct and emotional problems unless parents are taught healthy, effective behavior management strategies. Early interventions, like PCIT, reduce the personal and societal costs of persistent behavioral and emotional problems.
• The time-out procedure is not unique to PCIT. Similar time-out procedures are used in other evidence-based parenting programs, including Parent Management Training – Oregon Model, Triple P, and the Incredible Years. A meta-analysis of research has shown the parent training programs that focus on positive caregiver-child relationship and teaching parents the effective, consistent use of time-out are more effective than programs without those components (Kaminski et al., 2008).
• The American Academy of Pediatrics5 and Centers for Disease Control6 supports the use of time-out as a best practice for the management of behavior problems and ADHD in young children within the context of building a positive parent-child relationship and reinforcing positive behaviors.

Questions and Clarifications:

1. What is the definition of time-out in PCIT?

Time-out is a term that is used to mean a variety of things in behavioral and mental health settings. For example, inpatient hospital settings may use the term “time-out” to refer to voluntary breaks that a consumer can take and terminate when they choose. It is important to understand how the definition of time-out in PCIT differs from other uses of the term.

Clarification:

• PCIT uses a specialized time-out procedure as part of a larger mental health intervention that has been shown to be effective with young children with significant behavioral issues.
• Time-out in PCIT refers to a specific parenting technique that is developmentally appropriate for young children and is consistent with recommendations by the American Academy of Pediatrics as a behavior management technique.
• Parents are taught to use time-out in a predictable and consistent manner, so that the child is familiar with the time-out procedure.
• In PCIT, children get clear directions and warnings so they are aware why they are being placed in time-out. Children are given another opportunity to follow the parent’s direction after the time-out. These steps are developmentally sensitive and highly predictable to help promote young children’s learning.
• Time-out in PCIT is the removal of a child from all types of reinforcement (e.g., caregiver attention, toys, screen time) for a specified, short period of time as a consequence for misbehavior. Time-out is effective because it is intended to be boring, or free from reinforcement, but also safe.
• In the PCIT protocol, the caregiver remains in a place where they can observe their child and determines when time-out is over. This is to make sure that time-out is safe and effective. If a child is allowed to come out of time-out on their own, the time-out will not be effective7 and this likely will lead to an increased number of time-outs8.
• The time-out procedure in PCIT is always followed with the caregiver returning to relationship building skills, so the child receives emotional support and positive reinforcement for pro-social behaviors.
  

Who delivers the time-out protocol?
Policies exist that limit the use of staff of mental health centers putting consumer in time-out.

Clarification: In PCIT, time-out is delivered by the parents.

• PCIT therapists do not:

          1) Tell a child to go to time-out
          2) Move a child to time-out

• In PCIT, therapists teach and support parents in delivering the time-out protocol and make sure the child is aware of the procedure before it is implemented.
• The therapist provides live coaching of parents in how to correctly and safely implement a time-out procedure. Given research indicating that parents often incorrectly implement this technique on their own9, therapists support parents’ use of time-out to:

          1) Use a calm tone of voice
          2) Maintain physical safety with the child
          3) Keep the length of time-out developmentally appropriate
        4) Focus on enhancing the relationship and supporting emotion regulation with the      
              child after the time-out sequence has ended

How is the time-out space different from seclusion?
In PCIT, if children get out of the time-out chair they are briefly (1 minute with 5 seconds of quiet) placed in a backup time-out space to help the child learn to stay in the chair. Concerns exist that the time-out space cannot be used in states or agencies with policies against seclusion.

• Parents, not staff, place children in the time-out space, which is part of the safe and effective protocol.

• The intention of the time-out space is to help the child learn to sit on the time-out chair. This shaping procedure teaches the child to remain in the time-out chair and the need for the time-out space decreases significantly once the caregiver has successfully taught the child to sit in time-out.
• The caregiver is actively coached by the therapist while implementing the time-out space procedure, so that the caregiver remains calm, consistent and predictable.
• The time-out space provides brief physical separation between parents and children to support safety in situations where the child leaves the chair.
  

Is time-out appropriate for children with trauma histories?
Though PCIT is recommended for children with trauma histories10,11, concerns have been raised about using time-out with this population.

Clarification: A supportive, positive caregiver-child relationship and safe, consistent predictable limits and consequences (of which time-out is one component) are emphasized in PCIT. Both relationship building and limit setting are essential for children with trauma histories12.

• Trauma symptoms decrease for children who receive the caregiver-child relationship building and limit setting skills taught in PCIT13.
• Caregivers with histories of physical abuse, who learn how to use time-out in a safe and effective manner in PCIT, are less likely to use physical punishment14.
• Time-out helps children gain emotion regulation skills and self-control15.
• Time-out teaches children that even when they misbehave, parents will treat them respectfully and consistently.

 
References
PCIT: Parent-Child Interaction Therapy. Retrieved from http://www.nctsn.org/sites/default/files/assets/pdfs/pcit_general.pdf

Parent-Child Interaction Therapy (PCIT). Retrieved from http://www.cebc4cw.org/program/parent-child-interaction-therapy/

Parent-Child Interaction Therapy. Retrieved from https://nrepp.samhsa.gov/Legacy/ViewIntervention.aspx?id=23

Parent-Child Therapy With At-Risk Familes. Retrieved from https://www.childwelfare.gov/pubPDFs/f_interactbulletin.pdf

Guidance for Effective Discipline. Retrieved from http://pediatrics.aappublications.org/content/101/4/723

Attention-Deficit/ Hyperactivity Disorder (ADHD) Recommendations. Retrieved from https://www.cdc.gov/ncbddd/adhd/guidelines.html

Everett, G. E., Hupp, S. D., & Olmi, D. J. (2010). Time-out with parents: A descriptive analysis of 30 years of research. Education and Treatment of Children, 33(2), 235-259.

Roberts, M. W., & Powers, S. W. (1990). Adjusting chair timeout enforcement procedures for oppositional children. Behavior Therapy, 21(3), 257-271.

Riley, A. R., Wagner, D. V., Tudor, M. E., Zuckerman, K. E., & Freeman, K. A. (2017). A Survey of Parents' Perceptions and Use of Time-out Compared to Empirical Evidence. Academic pediatrics, 17(2), 168-175.

Chadwick Center for Children and Families. (2004). Closing the quality chasm in child abuse treatment: Identifying and disseminating BEST practices. San Diego, CA: Author.

Saunders, B. E., Berliner, L., and Hanson, R. F. (Eds.). (2004). Child Physical and Sexual Abuse: Guidelines for Treatment (Revised Report: April 26, 2004). Charleston, SC: National Crime Victims Research and Treatment Center.

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

Pearl, E., Thieken, L., Olafson, E., Boat, B., Connelly, L., Barnes, J., and Putnam, F. (2012). Effectiveness of community dissemination of parent–child interaction therapy. Psychological Trauma: Theory, Research, Practice, And Policy, 4(2), 204-213. 

Chaffin, M., Funderburk, B., Bard, D., Valle, L. A., & Gurwitch, R. (2011). A combined motivation and parent–child interaction therapy package reduces child welfare recidivism in a randomized dismantling field trial. Journal Of Consulting And Clinical Psychology, 79(1), 84-95. 

​Graziano, P. A., Bagner, D. M., Sheinkopf, S. J., Vohr, B. R., & Lester, B. M. (2012). Evidence-based intervention for young children born premature: Preliminary evidence for associated changes in physiological regulation. Infant Behavioral Development, 35(3), 417-428.