Dr. K. K., a behavioral psychologist emailed me with the following concerns about the "big hug" item in the April PedSPAM, which I think should be promptly shared with the list and annotated to the archival copy. I add her comments with her gracious permission, and especially commend her additional comments on effective Time Out technique.

"Dear Dr. Hull,

As a behavioral psychologist I would like to offer some words of caution to your recommendation about the "big hug" intervention for time-out refusers. I will cite a 1990 study below in support of this, but a big concern with "hold" type techniques is that either they are too rough and hurt the child (witness several highly publicized cases of parents killing their "attachment disordered" children by using holding therapy) or are too gentle and actually serve to reinforce the negative behavior (hitting, tantrums) that initated the discipline encounter to begin with.

In general, behavior problems are functional and kids display problem behaviors for some purpose: to get attention, to get something they want, to get out of something they don't want, because they like it, etc. Only by disrupting the behavior-goal connection will any intervention reduce the problem. Teaching an appropriate means to achieve the same goal also helps.

So I have a couple words of caution about "big hugs": they are hard to do correctly when untrained (and when done wrong can hurt more than help); and they are not sensitive to the particular function of a given child misbehavior.

Here is one well-done study that examined different techiniques for dealing with time-out refusing tots:

Authors: Roberts, Mark W; Powers, Scott W.

Institution: Idaho State U, Pocatello, US.

Title: Adjusting chair timeout enforcement procedures for oppositional children.

Source: Behavior Therapy. Vol 21(3) 257-271, Sum 1990.

Abstract: 36 mothers of noncompliant, clinic-referred children (aged 2-6 yrs) were randomly assigned to 1 of 4 chair timeout (TO) enforcement procedures: Spank, Hold, Barrier, or Child Release. Hold procedures were associated with less compliance criterion performance and excessive TO escape efforts. Child Release procedures were associated with excessive TOs. Neither Hold nor Child Release procedures were recommended. Barrier and Spank procedures appeared equally effective, replicating prior studies by M. W. Roberts (see PA, Vol 76:19909; 1982). The importance of monitoring and adjusting initial clinic TO enforcement procedures was documented. Noncompliant Ss who resisted TO displayed significantly less improvement in compliance than noncompliant Ss who accepted TO. Group data were obtained in the home setting across 4 wks. Most Ss displayed near-zero levels of TO resistance within 3 wks in the home. (PsycINFO Database Copyright 1991 American Psychological Assn, all rights reserved)."

Dr. Hull: This is always a question we practioners get - "What do we do if he refuses time out? Whack him?" and we are usually at a loss for a glib solution. From the abstract, "whack him" seems to be one solution ;-)

"I should add here that in the study, the spank was very controlled (two swats, open hand, to the bottom) and was never used for *any* other purpose than to enforce chair time out (TO). The barrier technique was the most effective, but is hard to implement in most homes. It involves putting the child in a small, empty, gated area for 60 seconds, ignoring all child behaivor during that time, and then returning the child to TO.

Finally the hold technique as tested was poor (with the child seated in the chair, crossing the child's arms and holding the child's wrists from behind the chair for 10 seconds) but could be improved by releasing the hold contingently upon the absence of child struggling and faded gradually. Still, barrier and spank techniques are the most effective for enforcing chair TO.

Anecdotally, I have seldom seen an untrained parent implement TO correctly. They all talk too much/lecture their children during the procedure. Bad. Better to have the rules be clear ahead of time and not dilute a very effective discipline technique by giving lots of verbal attention."

This is an area where pediatricians (myself included) have been less than effective in dealing with the issue of toddler discipline and alternatives to spanking. It is easy for us to say "Put him in Time Out," but we often have little or no formal training in using or teaching this technique effectively. It is no wonder parents have trouble with using Time Out effectively.