Structure vs. Punishment
The other day, I was working with a patient and we began to venture down a very interesting path. As a result of that discussion, I decided that I would break from my talks about TDD and Bipolar Disorder, and talk a little about the difference between structure and punishment.
As you can tell from some of my previous posts, I am a firm believer in structure. I often work with parents to build firm boundaries and strategies for managing their children. What structure does is provide consistency and predictability. Let’s begin with a concrete example… actual concrete. If you build a concrete wall (a structure), that wall becomes relatively permanent. It will look the same, feel the same, and “react” the same way every time. If you run into the wall today, it will feel the same way as when you ran into the wall yesterday. It is always the same… a constant.
Structured parenting is very similar. I encourage parents to be a constant. The rules today, are the rules tomorrow. The expectations today, are the expectations tomorrow. And, when needed, the consequences today, are the consequences tomorrow. The importance of consistency is that it leads to predictability. Predictability implies learning. Let’s go back to our concrete wall example, if you are running, and without warning, run into the wall, you will quickly learn (hopefully) that the wall is impassable. You cannot go through it. It cannot be manipulated. You learn that, every time you run into the wall, you will be stopped. Predictability in parenting should create the same scenario (aside from the bruises caused by the concrete wall). The more consistent you are, the faster your child will “learn” the boundaries of your structure. Sure they may test the stability of your structure from time to time, just to make sure that the wall has not weakened. But in general, they learn what is expected of them and understand that those expectations do not waiver. This structure makes for a healthy developmental environment for your child.
Overall, structure (in the form of consistency and predictability) helps your child learn what to do, instead of just what not to do. So often parents tell their children to “Stop this” and “Don’t do that.” Consistency and predictability encourages a scenario where parents do not just tell their child what NOT to do, but what they should be doing. It may be time for a simple example. Let’s say that your child is coloring a wonderful masterpiece… on the wall. Most parents will respond (maybe in a loud voice), “What are you doing? Don’t color on the walls!” I am not sure why, but situations like these tend to evoke loud and somewhat urgent responses from parents even though the damage is done and the child is likely to stop as soon as you say the first word. Why do we act as though it is an emergency? It is not getting any worse once the child stops drawing. Emergencies lead to impulsivity (which we will talk about in a few minutes). In any event, responding in this way, of course, tells the child what they are not to do, but does not tell the child what is expected of them… that is, what they should be doing.
Good structure would lead the parent to respond differently. With our example, the parent may respond by saying, “Remember Konor (my son’s name because, of course, this is an example from my life), coloring is for paper, not walls. Let’s go sit at the table and I will get you some more paper.” You may even have the child help you clean the walls. This will teach what is expected and applies an APPROPRIATE consequence (helping to clean the walls) for the action. Most importantly, the child knows what is expected (coloring on paper, not walls), as well as the consequences of the action (cleaning the walls). Notice how the consequence makes sense (for example, it would not make sense to take away his video games because he colored on the walls). This response to your child’s behavior is not, as I hope you can tell, punitive. No yelling. No imposed fear. No demeaning words. Just loving responses that educate.
Punishment, well that is a different story. Research has demonstrated, time and time again, that punishment is an ineffective way to teach expectations and redirect behaviors. Just the word evokes negative feelings and fear. Punishment.
The primary problem with punishment is that it is, by its very nature, punitive. There is little to no education involved. In my practice I see many families who use punishment. Invariably, they say, “He (the child) does it over and over again, no matter what. I can spank him five times a day, but it seems like he just doesn’t care.” When parents feel this way, they begin to incorporate emotion into the punishment (“I will make him care.”). This observation is exactly what the research predicts. Punishment based upon the perspective that children should do what I say, “because I am the adult,” has not worked for decades. Children today are VERY different than we were as kids. They know more, are exposed to more, and are much more savvy than we were. As a part of our culture, we look for “loop holes” and exceptions to the rule. Children are no different. Think about it, how many times have you said, “If I would have done/said that, I would have been in SO much trouble.”
For all of these reasons, and this is important (so I will use all caps), PUNISHMENT DOES NOT LEAD TO RESPECT. At best, use of punishment leads to fear, anger, and resentment; none of which is part of good parenting. The times are different, and different times call for different approaches to parenting.
Another problem with punishment is that it is usually impulsive. Your child does something and you respond impulsively. As such, there is no forethought and your punishments (consequences) are often different (inconsistent). For example, when your child makes a poor choice one day, you may spank him. The next time he does the same thing, you may send him to his room (“timeout”). The third time he does it, you may take away his video game privileges. This inconsistency does not help the child learn your expectations. He cannot learn cause and effect, “If I do ‘X,’ ‘Y’ will happen.” Structure, as we discussed above, remedies the typical problems seen with the use of punishment.
As parents, we have to shift away from punitive, impulsive responses. We have to have a plan, which is implemented consistently and predictably, and with the goal of educating. Education reduces the likelihood of errors (in the form of misbehavior). While there will always be mistakes (on your and your child’s part), we must work hard to maintain our expectations and ensure that we educate our children instead of simply applying haphazard consequences.
Dr. B
Autism and Parent Training
I was not sure what I wanted to discuss for my first, truly mental health related post. There are many “hot topics” out there right now and there is so much to say about them all. Nonetheless, as I was making my decision, I was reading in the Journal of the American Academy of Child and Adolescent Psychiatry, which is THE JOURNAL for child and adolescent psychiatry. In the Journal’s December 2010 issue (yes, you will have somewhat of a jump start by reading this post) there is an article written by researchers at the NIMH Research Units on Pediatric Psychopharmacology (RUPP) Autism Network. In this article, the authors describe the results of a study meant to compare the benefits of medication alone to medication plus parent training in reducing the behavioral issues associated with Autism, PDD-NOS, and Asperger’s Disorder (if you do not know the differences between these diagnoses, keep checking this site, as I will be posting other threads to describe them in more detail). In this post I will review the article as well as give you my own impressions and views.
In the article, the authors reported that there has been a significant increase in the use of medication in children with Autism and Autistic Spectrum Disorders (ASD) over the past few years. In fact, research suggests that 45 to 83% of individuals with ASD are prescribed medications. The most common medications prescribed are selective serotonin reuptake inhibitors (SSRI; e.g., Prozac), antipsychotics (e.g., Risperdal and Abilify), alpha 2 adrenergic agonists (e.g., Clonidine), psychostimulants (e.g., Ritalin), and anticonvulsants (i.e., Depakote). While most of these medications are used “off label” (meaning that they are not FDA approved for children with ASD), in October 2006, the FDA has approved the use of Risperdal (risperidone) for use in children with ASD who exhibit maladaptive and aggressive behaviors. Further, in November 2009 (just a few weeks ago) the FDA approved Abilify (aripiprazole) for use in ASD related irritability. Unfortunately, while these medications to be beneficial, research has shown that there are no lasting benefits once the medication is discontinued.
<<I want to add a brief note here. The last statement I made, regarding the lack of continued benefit once the medication is discontinued, should not be surprising to anyone. Medications do not teach skills. Medications do not teach right from wrong. All that medication does is make you “available.” I will spend more time on this issue in another post, but the primary purpose of medication is to stop a particular behavior or set of behaviors. Medication, in and of itself, does not teach appropriate behaviors!>>
Because medication has no long lasting gains once it is stopped, the researchers at RUPP Autism Network conducted a study to determine the benefits of adding a Parent Training (PT) program to the treatment of children with ASD. In this study, 124 children between the ages of 4 and 13 years participated. To be included in the study, the children had to have a diagnosis of Autism, PDD-NOS, or Asperger’s Disorder. In addition to other inclusion and exclusion criteria, the participants had to demonstrate clinically significant behavior problems.
As part of the 24-week study, all of the children were prescribed risperidone (though a few were changed to Abilify during the study as a result of poor response), but only a portion of the participants also received PT. This design allows for comparisons between two groups; the group where the children were just getting medication (MED) and the combination group where the children were getting medication and the parents were receiving PT (COMB). The researchers used multiple rating scales to assess behavioral issues, which were administered throughout the study to measure changes in the severity of the child’s behavior. Through this research study, the researchers hoped to demonstrate that risperidone treatment coupled with PT would be superior to risperidone treatment alone in reducing serious behavior problems in children with ASD.
The results of this study are very promising. Children in both groups demonstrated improved compliance, as reported by their parents. However, the COMB group reported greater improvements in compliance than those seen in the MED group. That is, although all of the children demonstrated improvement, children whose parents were in the PT program demonstrated greater improvement. Even more exciting was the fact that the children in the COMB group showed greater reduction in irritability. Again, although all of the children demonstrated less irritability, the children whose parents received the PT demonstrated the greatest improvement.
This study demonstrated, yet again, the benefits of behavioral and psychological treatments in the management of challenging behaviors. While medication is a useful tool for treating troublesome behaviors and emotions, the addition of psychological treatment (in the form of parent training, behavioral support, and therapy) results in greater, longer-lasting benefits. I frequently recommend my patients to prescribing physicians to determine if medication could be helpful for them. While I do not believe that medication is a “cure-all,” it has its place in helping the patient become “available” to the treatment I am providing. Once the patient has benefitted from my treatment, there is the potential that the medication can be reduced or even completely stopped. While all patients cannot be taken off of their medications, the additional benefits of psychological support are clear and well worth the additional treatment. Now, if only we could get the insurance companies to agree…
Here is the reference for those of you who would like to see the full article:
Aman, MG; McDougle, CJ; Scahill, L; Handen, B; Arnold, LE; Johnson, C; et.al. (2009). Medication and Parent Training in Children with Pervasive Developmental Disorders and Serious Behavior Problems: Results From a Randomized Clinical Trial. Journal of the American Academy of Child & Adolescent Psychiatry. 48 (12), p. 1143-1154.