Child and Adolescent Psychiatry

(singke) #1

332 Chapter 39


the behaviour re-emerges later and has not been truly extinguished.
It may have a role in immediate suppression of damaging behaviour,
such as putting fingers into power sockets, or running across the road,
but needs to be followed by explanation and plentiful reinforcement of
actions incompatible with those being punished. This is very different
from the destructive cycles that can occur when desperate parents use
harsh physical punishment in extreme, inconsistent, retaliatory ways,
without accompanying choices or encouragement for more acceptable
alternative behaviours. For all these reasons and because of instances
of abuse, application of aversive stimuli is seldom a part of therapeutic
programmes, which tend to use other methods, seeing reduced parental
use of physical punishments as an index of successful substitution of
more appropriate methods. Even mild physical punishment is against
the law in some countries, providing all parents with a clear message
that they need to rely entirely on non-physical approaches to discipline.
Time out. This is shorthand for ‘time out from positive reinforcement’.
Usually it involves taking a child aged around 3–8 away from the
context where the behaviour occurred, to a dull quiet place for a few
minutes. This differs from extinction since the child is removed from all
the usual general social stimulation and reinforcement, not just from
a specific identified reinforcer. It has the advantage of being a high-
impact procedure that is not noxious (although it may well be perceived
by the child as a punishment). There are a number of practicalities
to setting up a time out programme. These include the following: the
rules must be clear, and it should be given for fairly major infractions;
a warning and an alternative behaviour should be given to the child
before applying it (‘please stop hitting and sit down or you’ll go to time
out’); the child should be taken there in a calm way, using physical
force if necessary but not hurting the child; the space or room must
be cleared of entertaining items; the parent or teacher must keep an
eye on the child but not engage in conversation or recrimination (this
would unwittingly be giving attention); and the child must be calm for
aminutebeforecomingout.
Response cost. Here specified amounts of reinforcers are withdrawn from
the child when he or she displays the unwanted behaviour. This requires
that a previous reward system is in place, involving money, points,
privileges, etc.; there has to be something positive to withdraw.
Over-correction. The child is required not only to put right what he or
she did wrong, but do more by way of restitution. A variant gets the
child to over-learn a response physically incompatible with the original
misbehaviour, for example, repeatedly taking shoes off on entering a
house having trailed mud in previously.
Desensitisation. The repeated exposure to an aversive stimulus in a sit-
uation where the child is relaxed and reassured. For example, going
up through a hierarchy of phobic stimuli while the child is practising
relaxation techniques with the mother present. This method is notably
successful in treating PTSD and specific phobias.
Free download pdf