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Dr. Vellody discusses behavioral issues commonly associated with Down syndrome and the use of time-out as a discipline technique.
Hello everyone and welcome to our latest Down Syndrome Center of Western PA podcast. I’m your host, Dr. Kishore Vellody. Today, we are going to be discussing behavioral issues in Down syndrome. Talking about behavioral management is at the top of the list of most difficult things I do during a clinic visit. As a father, I know how hard it can be to manage challenging behaviors, especially if your child is exhibiting those behaviors right in front of your family, friends, or doctor! However, with the right mindset, I think we can help our children learn their boundaries and bring their behaviors where they are expected to be. Today, we are specifically going to be focusing on how to use time-out effectively. Time-out is a technique that can be highly effective but only if used correctly and used correctly every time. We will talk about why time-out may even be more effective for many of the behaviors seen in children with Down syndrome than those behaviors seen in other children.
So how commonly are behavioral issues seen in children with Down syndrome? It’s estimated that significant behavioral problems are present in up to 15-30% of children with Down syndrome. I think that’s a very high number. It has been my observation that the majority of the behavioral issues that I see in my patients actually have nothing to do with an extra 21st chromosome. There is no gene on that chromosome that causes Johnny to push his sister or Sally to talk back to her mother. I think that with a good understanding of the reason for the behaviors and learning some parental discipline techniques like time-out, many of the behaviors can be managed effectively.
Behavioral specialists always say that “all behavior is communicative.” When Johnny pushes his sister, he is likely not trying to intentionally cause her injury or send her to the hospital. More likely, he is communicating that his sister is bothering him in some way. Maybe she is saying things that annoy him or singing that song from Frozen for the umpteenth time! In that case, Johnny pushing her is communicating that he does not like those things. Or, maybe his sister has been getting all of their parents’ attention for getting a good grade on her test. In that case, Johnny is communicating that he wants some of that attention for himself. Pushing his sister results in all the attention being diverted to Johnny. Even though the attention is probably negative, it is attention nonetheless. And children will take any form of attention . . .
The other thing that families tell me is that they have a difficult time disciplining their child with Down syndrome. Many times, they tell me that they don’t think their child can understand discipline. That’s just not the case. Children with Down syndrome have excellent receptive language skills. That means that even while we’re waiting on their verbal speech to really take off, they can understand everything that you are saying to them at an age appropriate level most of the time. They also can tell when their sibling without Down syndrome gets corrected for doing something, but they themselves don’t get corrected for doing the same thing. That is a recipe for getting them to have ingrained behaviors that are very hard to fix later on.
As parents, the way that we respond to undesired behaviors plays a major role in whether we will continue to see those behaviors in the future. In an ideal world, our children would do only good and nice things. They would never misbehave. Unfortunately, it’s not that easy. Children are always going to test their limits. The importance of setting clear and consistent limits cannot be emphasized enough. If a child does not feel that there are limits, their behavior can only worsen and not get better.
The broad concept of limit setting includes positive praise for desired behaviors and withdrawal of all attention for undesired behaviors. Another way of putting this is “time-in” and “time-out.” They must be used together and neither is effective on its own in terms of limit setting and behavioral modification. An example of “time-in” is drawing attention when you catch your child doing something good. If you happen to see Johnny using his words instead of pushing his sister, that’s a great time to let him know that he did a good job. Immediate praise and reward is a great way to do “time-in.”
But what about when they don’t do the desired behavior? That’s when you use time-out. Many times when I bring up time-out in clinic, I see parents roll their eyes and say that “it never works.” However, when I get more detail on how exactly time-out is being done, many times I find that they are actually reinforcing the behavior that they are trying to extinguish. Essentially, the exact opposite of their goal! With all the misconceptions of time-out, it’s sometimes even better to use a different phrase for what you’re going to be doing. Maybe calling it “taking a break” instead of time-out in your home. Just to avoid confusion, I’m going to continue to call it “time-out” for the remainder of this podcast but you can use whatever phrase you would prefer in your home when doing the exact same concepts.
So how is time-out done correctly? Time-out needs to be a complete removal of all attention for a period of time. Before first using time-out, it should be explained to the child at an appropriate developmental level. Tell them that when they do something wrong, they will be told to sit in time-out. You may even want to demonstrate this in a play role, perhaps with one of their dolls or action figures. And every person who cares for the child has to be consistent with the time-out procedure. Kids are very smart and can easily play one caregiver against another if only one is doing the discipline. This includes grandparents.
The time-out location must be very boring to the child. There can be no TV, iPads, books, etc. in the time-out area. A bedroom is often not a great place for time-out because their favorite toys or stuffed animals are typically there to play with. The best place for time-out is in an easily accessible location where the child can still be seen. A hallway or corner of the kitchen are good ideas. Time-out should never be in a scary location like a closet or dark basement. The purpose is to remove attention from the child, not to scare them. In the time-out area should be a chair or mat for the child to sit on.
Let’s say Johnny hits his sister. Start with a very calm and brief statement saying something like “Johnny, you hit your sister so go sit in time-out.” Do not repeat expand on the statement. If Johnny does not go to time-out within a few seconds, give him one reminder but no more. If you keep threatening him with time-out but don’t actually do it until the 5th warning, he will quickly learn that your initial request means nothing. If he does not go to time-out after the first warning, pick him up with him facing away from you and put him in the time-out area. Ignore any protests. After getting him to the time-out area, if he keeps trying to get up, then non-verbally keep him in the area by gently placing your hand on his shoulder. Do not keep conversing with him or verbally telling him to keep quiet and such. Many parents fall into the trap of the hearing the child saying “Mommy, please, I won’t do it again” and then the parent responds, “You said that last time.” Then the child continues the conversation and next thing you know, there has been no time-out. In fact, the child has received a great time-in reinforcement of the behavior that you didn’t want in the first place! There should be absolutely no verbal exchange from the initial statement telling them to go to time-out until the time-out is completely over.
The length of time that a child should stay in time-out is about 1 minute for every year of age. I think a 5 minute maximum is a good idea. Since it can be hard to keep track of the time, set an audible timer that the child can hear. The child should be told that time-out does not start until they are quiet and staying in the time-out area. If the child is screaming/yelling or trying to escape at the end of the time limit, restart the timer again. Do not verbally explain why you are resetting the timer. Pretty soon, they’ll learn to calm themselves down so the timer doesn’t keep getting reset. It takes patience and consistency on the parents’ part, but it will work.
While the child is in time-out, it is important for life to go on for the rest of the family members. Do not just stand around the time-out area watching the timer yourself. The child needs to know that they are being completely ignored. You should expect loud protests, especially in the beginning of the ignoring phase. This is actually a good sign that your child is understanding the concept of time-out. You want them to dislike the separation period so they don’t want to go back there again. Again, remember that it should not be scary for the child, just unwanted.
After the timer sounds, the child should not jump out of the chair for themselves. Rather, they need to wait until they are formally excused from time-out from their parent. The parent should then ask the child to do or correct whatever it was that got them into time-out in the first place. If they Sally talked back to her mother when she was asked to pick up the pencil that fell, she should be asked to pick it up again after the time-out is over. If she does it, they should be praised. If she does not do it, the time-out procedure should be done again. After the second time-out, Sally should again be asked to do the desired behavior. This actually brings up a key point. In those first few minutes after at time-out, it is really important to keep an eye out for any desired behaviors that your child does. Praise them for anything you catch them doing that is good, no matter how minor. Say things like, “Sally, you really are doing great helping your brother clean up today.” In order for time-out to work effectively, there has to be many more “time-ins” than “time-outs.”
Once the concept is learned effectively at home for both parent and child, time-out can be used in any location. All you need is a quiet corner of a room and the procedure can be done just as it is done at home. If Sally is not listening at the grocery store, a quiet area where there is not much shopping traffic can be an excellent place for a time-out. Once the children learn that appropriate behavior is expected everywhere, they will be learning about self-control at all times.
I hope you found this brief overview of time-out helpful. We have several handouts on this technique that we’d be happy to share if you’d like more information. Please know that you are definitely not alone in any behavioral struggles with your children. Please also know that you can get through this! Remember, very rarely, if ever, is undesired behavior due to the genetics of Down syndrome. More likely, it is just behavior that is seen in any child of that age or developmental stage. Keep thinking about what your child is communicating through the behaviors. Never let them think that they are the ones in charge or calling all the shots. They need to learn to respect not only your authority, but authority figures in general. All children need to learn appropriate behaviors in order to be fully functioning adults able to eventually participate in society and in the workforce. If the children learn appropriate behaviors from an early age, their interaction with their co-workers and supervisors will be much easier for them as adults. Being a parent is a tough job, and we’re happy to help with any suggestions or resources that we can find. If you’ve tried everything, just let us know and we can try to get you connected with a behavioral therapist in your area. But first, try these techniques we talked about today and I hope you can find them helpful. Until next time, enjoy your children . . . they get big too quick and that’s probably the hardest part of being a parent! Bye, bye.
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