The Time-Out Wars: A Case for Curiosity

Dan Siegel's new book No-Drama Discipline is calling attention to our innate need for connection. In his Time magazine piece provocatively titled Time-Outs Are Hurting Your Child he writes:

The problem is, children have a profound need for connection. Decades of research in attachment demonstrate that particularly in times of distress, we need to be near and be soothed by the people who care for us. But when children lose emotional control, parents often put them in their room or by themselves in the “naughty chair,” meaning that in this moment of emotional distress they have to suffer alone. 

Not surprisingly, his views are causing significant backlash from the pediatric community. This is from the Journal of Developmental and Behavioral Pediatrics

TIME magazine recently highlighted an editorial by Drs. Daniel J. Siegel and Tina Payne Bryson in their parenting section. In it, the authors claim that the time-honored tradition of time-out for discipline may actually be harming our children as a form of traumatizing experience. This has caused a wave of black lash from the behavioral health community, who retort that Drs. Siegel and Payne Bryson's claims are not only unsupported by research, but show a lack of understanding of proper use of time-out.

Extreme views generate publicity and lots of “hits” A more nuanced view is less popular in social media, as evidenced by this wise blog post on Psychology Today that got a meager 25 tweets:

To me, “time-ins” don’t solve it. But the concept does expose a nuance of giving time-outs that we don’t talk about enough. Namely, there’s a massive difference between giving your child a time out in anger and giving your child a time out in a loving, calm way. Too often we apply the technique, but not the spirit of technique. Time-outs are meant to deescalate a volatile situation and to help our children regain control, as much as they are to provide a consequence for unruly behavior.

The essence of Dan Siegel’s point is not to leave a child alone with out-of-control feelings. It is not the time out per se but rather the sense of abandonment that is potentially harmful. I articulate this point in a previous post entitled Never Leave a Child Alone During a Meltdown.

When a child is repeatedly abandoned both physically and emotionally in the middle of a meltdown, that experience in itself may be traumatic. In such a situation frequency and intensity of meltdowns often worsens.

A recent American Academy of Pediatrics document Bringing Out the Best in Your Child makes the important distinction between discipline, which means to teach, and punishment, which is rarely effective in changing behavior in a positive way. For young children, a matter-of-fact time out in the face of biting or hitting can help to teach them that this behavior is unacceptable. The shortcoming of this document is that it is very focused on the behavior, rather than the meaning of the behavior.

Taking time to listen to our child, and to take care of ourselves, is key. Rather than an either-or approach, a stance of wondering, of curiosity, will lead to the answer of “what to do.” We might ask the question, why is my child feeling out-of-control? Is he stressed from fatigue or hunger? Is he responding to tension in the home from marital conflict, a new sibling, or a parent’s new job with long hours? And what about my child’s behavior is provoking such anger, anxiety or some other intense response in me? Is it my fear that he will suffer as I did as a child with similar challenges? Is it my embarrassment, or even worse, shame, that I am not a good parent? Am I feeling alone and abandoned myself, by a spouse or parent, and so unable to tolerate my child’s need for me? When parents feel recognized and understood, they are better able to listen to their child. They are better able to connect with their natural intuition. They know "what to do."

Our ability to find meaning in behavior is essential to our humanity. Listening, being present in a way that supports connection, leads to healthy development. It is not so much about “what to do” as “how to be.” We are a culture of advice and quick fixes. Dr. Siegel's book is rich with important information and ideas. However, perhaps rather than spending precious free time reading another "how-to" parenting guide, taking a walk with a friend or going to a yoga class might be a better use of parents' all-too-limited time for themselves.

The poop wars: why Miralax is just a band-aid

A recent article in the New York Times identifies the possible overuse of Miralax for treating chronic constipation in children. Many take it on a daily basis for years, despite the fact that it is only approved for use in adults. As a pediatrician I have prescribed Miralax many times, and find it to be a very useful medication. The problem comes when only the symptom, and not the underlying cause, is treated.

In my experience the cause of chronic constipation is usually not insufficient fiber in the diet, but rather a combination of a habit of stool holding with sometimes complex emotional issues around autonomy and control (the exception being an underlying neurologic or other medical condition.) I'm all for a healthy diet, but if you make this an issue about eating more fruits and vegetables, you may be simply shifting the battleground from one end to the other. It is best to avoid battles over either what goes in or what comes out, because in these battles the child, by using his body, will always win.

 I hope readers don't mind some details-as a pediatrician I have to be comfortable talking about poop.  On excellent use for Miralax is for a toddler who has a hard painful stool and then holds in his stool for fear of repeating this experience.  This may be more likely to happen in a child who is sensitive not only to bodily sensations but also other forms of sensory input, such as sound and touch.  This problem can occur whether or not a child is in diapers. It is best nipped in the bud. Miralax acts by drawing water into the stool. If you give the right amount, the stool is too soft for the child to hold it in. With time the child will forget the painful experience and then go back to normal stooling.

Stool holding and conflicts around toilet training may also occur if a child feels things are out of control in some other aspect of his life. For example, most parents intuitively recognize that toilet training a toddler around the time of the birth of a sibling is not a good idea. One child I took care of dug in his heels around potty training when his parents were going through a difficult divorce.

Parents who have dealt with this problem know that kids can be very adept at holding in stool. They may stand in a corner turning red in the face with effort.  This may be interpreted as trying to push the poop out, but most of the time what is actually happening is that they are working to hold the stool in. Just as biceps get strong when you lift weights, the anal muscles can get very strong with repeated use in this way.  If this cycle is not broken, kids can go on to have problems for many years. However, with time and careful attention, kids can learn to use their muscles the right way and to have a healthy relationship with their body and bowel habits.

There are often tremendous social pressures on parents to toilet train their children. When parents come to see me in my behavioral pediatrics practice, they often have had ongoing conflicts with their child about sitting on the potty, but have recognized that this approach is not working. They may even wish to have their child take charge of the issue, only to be thwarted by pressures in the school setting. I am all for using motivation for encouragement when a child is ready. Pediatrician Barton Schmitt coined the term "poop candy" for rewards for pooping in the potty. But if a child is not ready, either physically or emotionally, even the promise of a trip to Disney World will not get him to poop in the potty.

Toilet training occurs at a time when children are taking ownership of their bodies. Eric Erikson referred to it as the stage of autonomy vs. shame and doubt. As much as is possible, its best to simply let a child take charge. If problems arise, short term use of Miralax to avoid stool holding while the underlying issues are addressed is certainly reasonable. But it should not be used for long-term treatment. I am not speaking to the safety of the drug, because its long-term risk is not known. Rather, using any drug for years without in- depth exploration of the cause of the problem, a trend far too common in our medication-happy culture, is not a good idea.