Internet guidance on time out: inaccuracies, omissions, and what to tell parents instead

Practitioners' Use and Acceptability of Time-Out

Time-out is an empirically supported component of parenting interventions for child conduct problems; however, it is receiving increasing criticism among parents and some practitioners. This study aimed to investigate practitioners' use and acceptability of time-out for child conduct problems; examine whether perceived effectiveness and knowledge of evidence-based parameters of time-out implementation influence use and acceptability of time-out; and explore practitioners' perceptions about alternatives to time-out. One hundred and ten Australian and New Zealand practitioners who have worked with children and families completed an online survey investigating their use and acceptability of time-out for children with conduct problems. Results showed that 55.5% of the sample have used timeout, with 38.0% considered current TO users. Acceptability of the strategy varied, with some practitioners critical of time-out. Increased knowledge of evidence-based parameters of time-out implementation was associated with increased frequency of time-out use and acceptability, while perceived effectiveness was associated with increased acceptability only. Practitioners perceived a number of other parenting strategies as effective alternatives to time-out. These findings have important implications for improving practitioners' implementation of time-out with parents of children with conduct problems.

Evaluating a Mobile App Supporting Evidence-Based Parenting Skills: Thematic Analysis of Parent Experience

Background

Disruptive behavior disorders are among the most common disorders of childhood, and evidence-based parenting programs are the first-line treatment. Digital microinterventions have been proposed as one possible means of supporting parenting style change by giving parents in-the-moment advice about how to respond to challenging behavior. Until now, no digital microintervention supporting evidence-based parenting skills programs has been evaluated.

Objective

The aim of this study is to evaluate the subjective experience of parents using a digital microintervention to support evidence-based parenting skills, with particular attention to acceptability, usability, family relationships, and parents' values.

Methods

We conducted serial interviews with 11 parents of 33 children before and after spending 3 weeks using an app including 3 digital microinterventions. Parents were recruited via local authorities in the Midlands region of the United Kingdom. Previous participation in a parenting program was an inclusion criterion. Interviews explored family composition; child behavior problems; and experience of using the mobile app, including barriers to use. Thematic analysis was conducted from a user-centered design perspective, and illustrative case vignettes were produced.

Results

Many parents used the app in ways that helped them rather than strictly following the instructions they were given. Parents described a range of barriers to using the app including practical problems and failure to change child behavior. Parents and children responded in a variety of ways to the use of the phone, with many wholeheartedly embracing the convenience of technology. Case vignettes illustrate the uniqueness of each family's experience.

Conclusions

Parents' use of a mobile app supporting evidence-based parenting skills is difficult to predict due to the unique challenges each family encounters. Many parents found it an acceptable and helpful addition to family life, but increased personalization is likely to be key to supporting parents. Future digital microintervention developers should keep in mind that parents are likely to use the app pragmatically rather than following instructions, may struggle to use a complex app under pressure, and are likely to hold complex feelings about parenting with an app.

Developing the Technology-based Parenting Young Children Check-Up Intervention for Disruptive Behavior Problems Identified in Pediatric Primary Care

Objective

Behavioral parent training programs show clear efficacy and effectiveness in response to young children's disruptive behavior problems, but limitations in engagement and accessibility prevent many families from benefiting from these programs. The Parenting Young Children Check-up (PYCC) is a technology-based program designed to overcome these barriers and increase the reach of behavioral parent training. Developed for use in pediatric health care, the PYCC includes three components: 1) an initial check-up designed to motivate program involvement; 2) text messages to connect parents with program content and reinforce content; and 3) a parent training website involving video-based content to teach parenting skills. This report details initial steps to refine PYCC intervention components.

Methods

Seventeen mothers and 17 primary care physicians participated in this mixed methods data collection across three iterations by providing feedback on early drafts of the three components of the PYCC and completing a feedback questionnaire.

Results

Feedback from one iteration informed modifications that were then evaluated in subsequent iterations. Saturation of qualitative input, positive qualitative feedback, and positive quantitative ratings on the feedback questionnaire was achieved in iteration three.

Conclusions

Outcomes of this investigation informed the full version of the PYCC that will subsequently be tested in a proof-of-concept trial.

Implications for Impact Statement

Several barriers limit the reach of parenting skills programs that reduce child problem behavior. We gathered feedback from parents and physicians to refine a parenting program that uses technology and delivery in pediatrics to overcome barriers. Future testing of the program will further inform implementation in pediatric settings.

Using Non-Violent Discipline Tools: Evidence Suggesting the Importance of Attunement

Training in non-violent discipline is important to prevent violence against children and ensure that their caregivers remain a safe base for them. This paper aims to deepen understanding of non-violent discipline by exploring attunement as a mechanism in the effectiveness of non-violent discipline tools. Attunement describes the sensitive responsiveness of caregivers towards their children and has been found to be central to the formation of secure attachment bonds and development of self-regulation. It includes understanding or being "in tune with" the child's needs and signals, matching these with appropriate responses. The objective of this paper is to explore attunement in relation to non-violent discipline. Peer-reviewed systematic reviews previously included in a systematic overview of evidence on non-violent discipline options were screened for information relevant to attunement. All reviews were published in English between 1999 and 2018 and offered evidence on at least one non-violent discipline tool. Although no reviews explicitly addressed attunement, evidence was found suggesting its importance in the use and effectiveness of discipline methods. Research directly investigating attunement in discipline is needed.

Toward evidence-informed child rearing: Measurement of time-out implementation in a community sample

BACKGROUND

Time-out (TO) is a widely used parental discipline strategy with strong research support in programmes that promote positive child development. Concerns have been raised, however, regarding adverse impact on child mental health (CMH) in part driven by evidence of widespread variability in appropriate implementation. There are no existing measures of TO. We present the first measure of procedural implementation of TO in a community sample of parents of children aged 6-8 years.

METHODS

A nationally representative sample (N = 474) of parents completed a survey on the implementation of TO, parent-child relationships, and emotional and behavioural difficulties. The scale of TO use was used to test the convergent validity between TO implementation and parenting practices/family adjustment and CMH.

RESULTS

Consistent with international research, >70% of parents have used TO with their children. There was high variability in the levels of appropriate implementation of TO. Scale reliability (Cronbach's alpha) was acceptable and tests of convergent validity indicated that as expected, less appropriate implementation of TO was associated with worse CMH and poorer parenting and family adjustment.

CONCLUSIONS

The current findings suggest that the scale is a psychometrically sound instrument for measuring the appropriate procedural implementation of TO with young children.

Technology Matters: Digital micro interventions to support parenting: Evaluating time out apps

Digital interventions to support parenting skills are popular but engagement can be low. Digital micro interventions such as apps targeting specific aspects of parenting are a novel development with the potential to overcome this challenge. Time out is an evidence-based component of many parenting skills training programmes and is an appropriate target for digital micro intervention. We describe the eight requirements of high-quality time out according to the literature and how these can be supported by an app. Searches of the App Store, Google Play, and Alexa Skills in the UK identified six apps designed to support time out. Current time out apps all promoted consistency, but they all risked low-quality time out through inappropriate initiation, duration, and termination. Professionals in child and adolescent mental health should explore the details of any digital micro interventions being used by parents for time out and provide appropriate counselling. We recommend that all future digital micro interventions in this area should incorporate evidence-based guidance.

Parent Discipline and Pre-schoolers' Social Skills

Educators recognize children's social competence as an indicator of school readiness. Children's social competence may be promoted prior to kindergarten through parents' discipline; however, prior research largely focused on parenting and social competence in older children or only focused on children's problem behaviours. We assessed parent discipline as a predictor of 37 low-income pre-schoolers' social skills over four months. Parents answered open-ended questions about how they would respond to child behaviours; children's pre-school teachers rated their social skills. In a hierarchical regression controlling for children's age and initial social skills, parents' inductions significantly predicted children's later social skills. Although children's social skills were correlated with parents' pairing of consequences and inductions, this relation was no longer significant when controlling for age and initial social skills. Power assertive discipline and time-outs were not significantly correlated with children's social skills. The results suggest that parents' inductions may be beneficial for children's social skills by focusing the child's attention on the reasons the behaviour was inappropriate.

Nonviolent Discipline Options for Caregivers and Teachers: A Systematic Overview of the Evidence

Violence against children is a widespread problem with devastating consequences, and corporal punishment is a risk factor for more serious forms of physical abuse. One reason for the persistence of corporal punishment may be the lack of awareness of positive disciplinary alternatives. Nonviolent options offered to caregivers and teachers must be effective in addressing challenging behavior, or they may be rejected in favor of a return to physical punishment. There is an urgent need to determine which discipline options are evidence-supported and what that evidence says so that robust alternatives to corporal punishment can be made available. The primary objective of this research was to find, and explore the state of the science on, individual nonviolent interventions for challenging behavior, in so doing forming a "tool kit" for use by caregivers and teachers. A systematic overview of systematic reviews was conducted. Included systematic reviews were peer-reviewed and published in English between 1999 and 2018. Screening, quality assessment using AMSTAR, and data extraction were performed independently by two reviewers. A total of 223 reviews were included, covering data from 3,921 primary studies. A wide range of evidence-supported interventions exist, many of which have been found effective with severely challenging behavior. Important positive outcomes shown suggest that the use of these tools should be promoted not only for the prevention of violence but also for optimum child development. More research is needed on the use of these methods in home situations and on de-escalation skills.

Internet Addiction Among Male Adolescents in Indonesia: A Qualitative Study

Internet has become an important part of the daily life of adolescents. Easy access to internet and its social appeal among adolescent males render them at an increased risk of internet addiction and the associated adverse physical and psychosocial effects. We conducted a qualitative study using a phenomenological approach. A purposive sample of nine male adolescents was recruited in West Java, Indonesia. Semistructured interviews were conducted until data saturation was achieved. Data were subjected to thematic analysis. We identified four main themes from the experiences of adolescents with internet addition: reasons for internet addiction, unmet social need without the internet, effects of internet addiction, and self-control over internet usage. Internet addiction among male adolescents is a major public health problem that should be addressed. The findings of this study may be useful for health professionals and families to help male adolescents manage their internet addiction.

Longitudinal Relationship Between Time-Out and Child Emotional and Behavioral Functioning

OBJECTIVE

Time-out is a widely used child discipline strategy and one of the only strategies currently recommended by the American Academy of Pediatrics. Despite its widespread use and significant evidence to support its effectiveness in decreasing problem behavior, time-out is often suggested to be harmful or ineffective by the popular media and select professional organizations. Empirical evidence regarding possible side effects of time-out is limited. The present study examined the relationship between reported use of time-out and child emotional and behavioral functioning and parent-child relationships using longitudinal, archival data.

METHODS

The study used archival, longitudinal data from the Early Head Start Research and Evaluation study. This study tracked families with children in Early Head Start at 3 different time points as follows: baseline (aged 0-3 years), pre-kindergarten, and fifth grade. Parent interviews, including questions on the use of time-out, were conducted when the children were 36 months old. Indicators of child emotional and behavioral health were measured at 36 months, pre-K, and fifth grade. Statistical analyses were completed to assess for potential side effects of time-out on child behavioral and emotional functioning and parent-child relationships.

RESULTS

Analyses for all outcome variables suggest no significant difference for children whose parents reported using time-out versus those who did not.

CONCLUSION

Parental reported use of time-out was not associated with long-term negative outcomes. Further research in this area is necessary to continue to address the multitude of concerns related to time-out that are presented by the media.

Relationships matter: How clinicians can support positive parenting in the early years

A secure attachment relationship with at least one healthy adult is essential for a child to develop optimal coping abilities. Primary care providers like paediatricians and family physicians can help by supporting parents in practice settings. Every clinician encounter is an opportunity to ask parents about children's relationships and their behaviour, daily routines, and overall family function. This statement, which focuses on children aged 0 to 6 years, describes basic principles in support of positive parenting and recommends in-office practices to promote secure parent-child relationships, engage families and build trust with parents. Crying, sleep, and difficult behaviours are described as opportunities for clinicians to provide anticipatory, responsive guidance to parents.

L’importance des relations : comment les cliniciens peuvent soutenir des pratiques parentales positives pendant la petite enfance

Il est essentiel que l’enfant forme des liens d’attachement stables avec au moins un adulte en bonne santé pour développer des capacités d’adaptation optimales. Les professionnels de la santé de première ligne, tels que les pédiatres et les médecins de famille, peuvent y contribuer en soutenant les parents dans leur milieu de pratique. Le clinicien peut profiter de chaque rencontre pour s’informer auprès des parents des relations et des comportements des enfants, des habitudes quotidiennes et du fonctionnement global de la famille. Le présent document de principes, qui porte sur les enfants de 0 à six ans, décrit les principes de base pour soutenir des pratiques parentales positives et recommande des pratiques en cabinet pour promouvoir des relations parents-enfant stables, mobiliser les familles et établir un climat de confiance avec les parents. Les pleurs, le sommeil et les comportements difficiles sont décrits comme des occasions pour le clinicien de donner des conseils préventifs et réceptifs aux besoins des parents.

Impacting Pediatric Primary Care: Opportunities and Challenges for Behavioral Research in a Shifting Healthcare Landscape

Behavior analysts have long recognized the potential of a partnership with pediatric medicine as an opportunity to expand the influence of behavior analysis and positively impact population health. Despite significant achievements in this domain, the impact of behavioral science on the daily practice of pediatrics has been limited. In this commentary, the authors argue that the current health care and research environments are ripe for a renewed focus on behavioral modification in pediatric primary care, with a particular emphasis on the study of high-frequency, low-intensity problems. They provide some analysis of why behavioral pediatrics has failed to gain traction in primary care, describe aspects of the current primary care practice and research landscapes that provide opportunities for an expanded portfolio of research, identify several exemplars from the behavior analytic literature that have influenced pediatric primary care or have the potential to do so, and make recommendations for producing influential data.

Mothers' Facebook posts about infant health: findings from the Grow2Gether study

BACKGROUND

Social media is a common way for mothers to seek advice about their infants. However, little is known about how low-income urban mothers use social media to obtain infant health information and whether this information is consistent with expert pediatric recommendations.

OBJECTIVES

(1) identify the types of health questions asked by low-income mothers of infants in a social media parenting group; (2) describe whether peer answers are consistent with or contradict AAP guidelines; (3) identify the practices that mothers post about that are inconsistent with AAP guidelines.

METHODS

Forty-three low-income mothers were enrolled in Grow2Gether, a private Facebook group intervention focused on infant care and moderated by a psychologist. All health questions posted by mothers were coded thematically; answers to questions from the group were assessed for consistency with American Academy of Pediatrics (AAP) guidelines related to infant feeding, sleep, screen time, and safety. Additionally, all unique posts that contained practices inconsistent with these AAP guidelines were thematically coded.

RESULTS

In total, 215 posts were coded. Participants posted 61 questions related to infant health, most commonly solid food introduction (8/61), teething (8/61), and breastfeeding (7/61). Of the 77 answers given by peers, 6 contradicted guidelines. Separately, mothers had 73 posts demonstrating practices inconsistent with AAP guidelines [safe sleep (43/73) and screen time (21/73)].

CONCLUSIONS

Mothers' Facebook group interactions in the context of an infant care intervention revealed that when mothers posed direct questions regarding infant health, their peers generally gave answers that did not contradict AAP guidelines. In contrast, mothers' posts simply describing sleep and screen time practices commonly contradicted guidelines.

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

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.

A Survey of Parents' Perceptions and Use of Time-out Compared to Empirical Evidence

OBJECTIVE

To assess parents' perceptions and use of time-out (TO) in contrast to empirical indications and examine the relationship between reported implementation procedures and perceived effectiveness.

METHODS

We surveyed parents of preschool and school-age children (n = 401, aged 15 months to 10 years) at well-child visits with regard to their awareness, perception, and usage of TO. Parents were specifically surveyed regarding TO components that have been empirically evaluated or pertain directly to its underlying behavioral principles. Descriptive analyses, group comparisons, and correlational analyses were used to characterize responses and evaluate the relationship between TO administration variation and perceived effectiveness.

RESULTS

Most parents (76.8%) reported using TO in response to misbehavior, but a large majority of these parents (84.9%) reported implementing TO in a manner counter to empirical evidence. Parents who endorsed TO as effective varied significantly from those who did not on key implementation components (eg, use of a single warning). Further, several reported implementation practices were correlated with perceived effectiveness and challenging child behavior. For example, requiring a child to be calm before ending TO was positively correlated with perceived effectiveness.

CONCLUSIONS

These results cement TO as a widely disseminated practice but cast doubt on the fidelity with which it is typically implemented. Better methods of educating parents on evidence-based discipline are needed.

Quality of consumer-targeted internet guidance on home firearm and ammunition storage

BACKGROUND AND OBJECTIVES

Four storage practices protect against unintentional and/or self-inflicted firearm injury among children and adolescents: keeping guns locked (1) and unloaded (2) and keeping ammunition locked up (3) and in a separate location from the guns (4). Our aim was to mimic common Google search strategies on firearm/ammunition storage and assess whether the resulting web pages provided recommendations consistent with those supported by the literature.

METHODS

We identified 87 web pages by Google search of the 10 most commonly used search terms in the USA related to firearm/ammunition storage. Two non-blinded independent reviewers analysed web page technical quality according to a 17-item checklist derived from previous studies. A single reviewer analysed readability by US grade level assigned by Flesch-Kincaid Grade Level Index. Two separate, blinded, independent reviewers analysed deidentified web page content for accuracy and completeness describing the four accepted storage practices. Reviewers resolved disagreements by consensus.

RESULTS

The web pages described, on average, less than one of four accepted storage practices (mean 0.2 (95% CL 0.1 to 0.4)). Only two web pages (2%) identified all four practices. Two web pages (2%) made assertions inconsistent with recommendations; both implied that loaded firearms could be stored safely. Flesch-Kincaid Grade Level Index averaged 8.0 (95% CL 7.3 to 8.7). The average technical quality score was 7.1 (95% CL 6.8 to 7.4) out of an available score of 17. There was a high degree of agreement between reviewers regarding completeness (weighted κ 0.78 (95% CL 0.61 to 0.97)).

CONCLUSIONS

The internet currently provides incomplete information about safe firearm storage. Understanding existing deficiencies may inform future strategies for improvement.