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Parents’ Discipline of Young Children: Results From the National Survey of Early Childhood Health

Michael Regalado, MD^*,,,||, Harvinder Sareen, MPH^,||, Moira Inkelas, PhD^,||, Lawrence S. Wissow, MD, MPH^¶ and Neal Halfon, MD, MPH^,,||,#

^* Cedars-Sinai Medical Center, Los Angeles, California
UCLA Center for Healthier Children, Families, and Communities, Los Angeles, California
UCLA School of Medicine, Los Angeles, California
^|| UCLA School of Public Health, Los Angeles, California
^¶ Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
^# UCLA School of Public Policy, Los Angeles, California

	ABSTRACT

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Objective. To examine the use and predictors of different discipline practices by parents of very young children using data from the 2000 National Survey of Early Childhood Health (NSECH).

Methods. NSECH is a nationally representative telephone survey of 2068 parents of young children between the ages of 4 and 35 months conducted by the National Center for Health Statistics. The survey includes questions about parents’ use of 5 discipline practices: yelling, spanking, time out, toy removal, and explanations. ² analyses and logistic multivariate regression were used to examine associations between discipline practices and child, parent, and demographic factors.

Results. Among young children aged 19 to 35 months, frequent parental use of discipline strategies ranged from 26% (spanking) to 65% (taking away toy or treat), 67% (yelling), 70% (using time out), and 90% (providing explanations). In multivariate analyses, child age predicts reports of more frequent spanking and yelling, and child developmental risk is associated with increased reports of yelling. Parent frustration predicts frequent use of every discipline practice, including a greater inclination to use aversive practices. Lower parental emotional well-being is associated with reports of frequent yelling and spanking. Black ethnicity and maternal age predict more frequent spanking, and Spanish-speaking parents reported less frequent use of time out and taking away a toy.

Conclusion. Child age and developmental risk and parents’ ethnicity, emotions, and mental health are closely associated with discipline practices in the first 3 years of life. These factors are important for pediatricians to recognize in providing anticipatory guidance about discipline.

Key Words: infant • child • parenting • discipline • corporal punishment • anticipatory guidance

Abbreviations: AAP, American Academy of Pediatrics • NSECH, National Survey of Early Childhood Health • PEDS, Parents’ Evaluation of Developmental Status • MHI-5, Mental Health Index-5 • CI, confidence interval • OR, odds ratio

Health supervision guidelines recommend that pediatricians provide advice and information about child rearing and discipline to parents at routine health supervision visits. Indeed, parents regard advice about child development highly,¹ and most pediatricians report providing it at well-child visits.² Guidance about discipline is a key area of pediatric advice. In 1998, the American Academy of Pediatrics (AAP) Committee on Psychosocial Aspects of Child and Family³ published a statement describing the characteristics of effective discipline that included a conceptual framework composed of 3 elements: 1) a learning environment characterized by positive, supportive parent–child relationships; 2) proactive teaching and strengthening desired behaviors, eg, the use of positive reinforcement; and 3) reactive practices, eg, extinction (time out, removal of privileges) and punishment (eg, verbal reprimands) for decreasing or eliminating undesired behaviors.

This conceptual framework emphasizes the importance of parenting style (the social and emotional context for effective teaching) and specific parenting practices or behaviors in guiding children toward socialization goals.⁴ A major focus of discipline counseling has been advising parents about their choices for discipline practices. For example, recognizing the risks inherent in the use of corporal punishment, the 1998 AAP statement recommends that pediatricians advise parents to adopt discipline practices other than spanking.³ Because corporal punishment is so widely accepted and practiced, pediatric counseling efforts would necessarily be directed toward guiding parents to change their beliefs and behavior. If this type of counseling is to be effective, then it is important to understand factors related to parents’ use of different discipline practices.

Although there are many approaches that parents may use to discipline their children, much of the research in this area has focused on the use of corporal punishment. These studies have identified several child, parent, and demographic influences associated with parents’ use of corporal punishment. Child factors include age, gender, and temperament. Data from national and clinical surveys suggest that corporal punishment is used most with preschool-age children and least with children older than 5 years.^5,6 Analyzing data from the Commonwealth Survey of Parents With Young Children, Wissow⁷ found that 40% of parents of children <3 years reported that they yell at their child and 40% reported that they have spanked their child, including 16% who yell and 11% who have spanked their infants under 1 year of age. Similarly, with data from the National Survey of Families and Households, Day et al⁵ found that spanking peaks between 2 and 3 years of age and that parents’ personal resources (age, education, and mental health) and child characteristics (age and temperament) were the strongest predictors of spanking. Some studies have identified an association between child gender and corporal punishment, with boys spanked more often than girls,^5,8–10 whereas others have found no differences between boys and girls.⁶ The same inconsistency of findings holds for the relationship between child temperament or behavior and discipline with some studies suggesting that difficult temperament is associated with greater use of spanking,⁵ whereas others found no independent relationship.¹¹

Other child factors have received less attention. For example, it has been suggested that a child’s health has important effects on their socialization,¹² and 1 mechanism for this may be through an influence on parent’s choice of discipline practices. Likewise, discipline practices by parents who have concerns about their child’s development or behavior have not received attention. The nature and timing of parents’ concerns about development and behavior are associated with different probabilities of having a developmental disability.¹³ Examining the relationship between parents’ concerns about development and their discipline practices may shed light on how atypical development influences parent behaviors and socialization practices.

Parent characteristics as well have been cited as important influences on discipline behaviors. Young parents are more inclined to use corporal punishment.^5,7,8,10,14 In 2 national studies, parents’ depressive symptoms have been associated with the use of harsh punishment.^7,9 Other family and demographic factors that have been related to parents’ use of harsh discipline include larger family size,¹⁵ marital status,^16,17 and low socioeconomic status.^8,14,18 However, studies of ethnic influences have been inconclusive. Compared with white parents, some studies have found that black or Hispanic American parents use corporal punishment more often.^5,8,10,18 Other studies have found less spanking by Hispanic Americans and Asian Americans^7,15 or no ethnic differences.¹⁹

The current study builds on this literature with an analysis of data from the National Survey of Early Childhood Health (NSECH). This national data set improves on most previous studies given its national scope, comprehensive content, and large sample of black and Hispanic children. The NSECH includes questions about parents’ use of discipline practices with children from 4 to 35 months of age. The survey allows an analysis of how discipline practices vary during the first 3 years of life and of factors associated with their use. Our specific research questions were 1) how often do parents of very young children use different discipline practices; and 2) how are individual child, parent, and demographic factors associated with the use of different discipline practices? To answer these questions, we examined the frequency and correlates of different discipline practices using multivariate analyses to identify significant predictors of each. Special attention was directed toward examining the association of child health and developmental risk with parents’ discipline practices.

	METHODS

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Sample
The 2000 NSECH, conducted by the National Center for Health Statistics, used a stratified random-digit-dial sampling design to achieve a nationally representative sample of children between the ages of 4 and 35 months. Black and Hispanic subjects were oversampled to permit precise estimates for these subgroups. Child-level sampling weights were developed to adjust for nonresponse, oversampling, and the survey sampling design. Thirty-minute structured telephone interviews were conducted in English or Spanish between February 16, 2000, and July 16, 2000, with parents of a child in the target age group. Eighty-seven percent of the respondents were mothers of the sampled child. The remaining were fathers (11%), grandparents (2%), or other guardians (<1%). The Council of American Survey Research Organizations response rate for the survey was 65.6%. Data were weighted to represent US children between the ages of 4 and 35 months. Stata (Stata Corp, College Station, TX) was used for data analysis and to account for the complex survey design. A more complete description of the NSECH is presented elsewhere in this volume.²⁰

Measures
For examining the frequency of different discipline practices, parents were asked how often they currently use aversive (spanking and yelling) and nonaversive (time out, taking away a toy, and explanations) practices in the following manner: "Parents vary a lot in how they discipline, and children also vary in their response to being disciplined. I am going to read a list of methods of discipline that parents might use with children [child]’s age. For each, please tell me if you use that method often, sometimes, rarely, or never with [child]." Parents with children 19 months or older were asked to report on use of all discipline practices, whereas parents with children from 4 to 18 months of age were asked about yelling and spanking only.

Several covariates are assessed. The Parents’ Evaluation of Developmental Status (PEDS), a clinical screening tool recently adapted for telephone interview administration, is used to assess risk of developmental delay. It consists of 10 questions that elicit concerns about speech and language, motor development, behavior, social skills, self-help skills, school skills, sensory problems (vision or hearing), and global cognitive function.²¹ Using parents’ responses to the specific probes, children were categorized as being at high, moderate, low, or no developmental risk on the basis of the profile of their developmental and behavioral concerns and according to validated scoring.^22–23 The Mental Health Index-5 (MHI-5) is used as a measure of the parent’s emotional well-being. The MHI-5 is a 5-item version derived from the 38-item MHI used in the Medical Outcome Study, and consists of the following questions: How much of the time during the last month have you 1) been a very nervous person, 2) felt calm and peaceful, 3) felt down-hearted and blue, 4) felt so down in the dumps that nothing can cheer you up, and 5) been a happy person?²⁴ Items 1, 4, and 5 use a 6-point Likert scale ranging from 0 for "all of the time" to 100 for "none of the time." Items 2 and 5 have reversed scoring so that the mean score (range: 0–100) represents overall emotional well-being. Parent frustration was measured by the following questions: In a typical day, how often would you say you feel frustrated or aggravated with your child’s behavior? Would you say always, sometimes, rarely, or never? Parents were also asked to rate their child’s health: In general, how would you describe [child]’s health? Would you say [his/her] health is excellent, very good, good, fair, or poor?

Data Analysis
Frequencies were determined for each discipline practice. ² analyses were conducted with discipline practices dichotomized as frequent (often/sometimes) versus infrequent (rarely/never) to examine variations in parents’ use of discipline according to selected child, parent, and demographic characteristics. These included child age (4–9 months; 10–18 months, 19–35 months), child developmental risk (any vs none), child health status (excellent/very good vs good/fair/poor), frustration with parenting (frequent [always or sometimes] vs infrequent [rarely or never]), parent’s race/ethnicity (white non-Hispanic, black non-Hispanic, Hispanic English speaking [Hispanic parent who completed the interview in English], Hispanic Spanish speaking [Hispanic parent who completed the interview in Spanish]), annual household income ($17 500, $17 501–$35 000, $35 001–$60 000, >$60 000), maternal education (<high school vs high school), and maternal marital status (married vs not married). Logistic multivariate regression was used to examine the association between the use of each discipline practice (frequent vs infrequent) and child, parent, and demographic factors. Findings from bivariate analyses guided the development of the multivariate models. Confidence intervals (CIs) for variables with >1 degree of freedom (having >2 categories) were adjusted for multiple comparisons using the Bonferroni correction method.

	RESULTS

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Univariate and Bivariate Analyses
Discipline Practices and Child Age
Table 1 shows reported frequencies for aversive discipline practices for children aged 4 to 35 months and for nonaversive practices for children aged 19 to 35 months. The use of yelling and spanking increases with child age. Thirty-two percent of parents reported ever yelling at infants 4 to 9 months of age, while 13% yell frequently. Approximately 47% of parents with children between 10 and 18 months and 67% of parents with children between 19 and 35 months reported yelling frequently. Six percent of parents reported that they ever spank their infants between the ages of 4 and 9 months, with the rate increasing to 29% of parents with children between 10 and 18 months and 64% of parents of 19- to 35-month-old children. Eleven percent of parents with 10- to 18-month-old children and 26% of parents with 19- to 35-month-old children reported frequent spanking. For parents of children between 19 and 35 months of age, frequent use of discipline practices ranges from 70% for time out to 65% for taking away a toy and 90% for providing explanations.

Because parents’ reports of feeling frustrated are associated with all discipline practices and an inclination to use aversive discipline behaviors, we examined how frustration varies by demographic, parent, and child factors (Table 4). Overall, 39% of parents reported frequently feeling frustrated with their child’s behavior. The only demographic factor associated with parent frustration is maternal employment, ie, fewer mothers who are employed reported frequent frustration with parenting. Greater child age, developmental risk, and poorer child health status are also associated with frustration. Lower parent emotional well-being is associated with greater frustration.

	DISCUSSION

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Demographic Factors and Discipline Practices
Our findings of relationships between demographic factors and discipline practices are consistent with previous national studies, particularly the findings of Wissow,⁷ who used a similar method. The data reflect the importance of parent age and ethnic/racial factors in the variation of reported discipline practices. More adolescent parents relative to older parents and more black parents reported spanking, findings similar to previous national surveys.^7,8 The basis for the association with parent age is uncertain but may be attributable to teenage parents’ inexperience. The latter finding has been explained in terms of spanking’s adaptive significance to black socialization challenges.²⁵ Ethnic and racial differences, including acculturation, are possible factors in the relationship between Hispanic ethnicity and discipline practices. It is not surprising that Spanish-speaking Hispanic parents reported that they are less likely to use time out and taking away a toy given that these are largely American parenting practices. Maternal education, marital status, and income do not predict discipline practices in the multivariate model in contrast to other studies.^{8,10,14,16,17} Nevertheless, the data reflect important demographic influences, particularly of race and ethnicity, that must be considered in helping parents with child-rearing challenges.

Parent Emotions and Discipline Practices
Strong and consistent relationships were identified between parents’ emotions, (frustration with parenting and emotional well-being) and discipline practices. These findings clearly show that frustration with child rearing increases during the first 3 years of life and that this increase is associated with a greater output of reactive discipline similar to findings reported by Wissow.⁷ The data also suggest that frustration (an emotion reflecting anger) and emotional well-being reflect a propensity to react in a harsh manner by either yelling or spanking. The finding that maternal employment was associated with less frustration in multivariate analysis suggests that it may be providing respite from the demands of child rearing.

Child Factors
Child age and developmental risk are directly related to discipline practices in the multivariate model. They are also associated with frustration, along with child health, suggesting that their influence on parents’ discipline choices may occur in part through this emotional channel. These health-related factors add to the complexity in which child characteristics may influence socialization. They also underscore the important role that physicians can play in helping parents with discipline choices by addressing these health issues in the context of development and behavior.

Clinical Implications
The findings from this study have important implications for primary care practice. With increasing evidence of the harmful effects of aversive discipline,^26,27 discipline counseling takes on greater significance. Therefore, the findings by Olson et al (this volume) that more than half of parents with children between 10 and 35 months of age reported that they did not discuss discipline with their physician at a health visit in the past year suggests an important missed opportunity.²⁸ It is also of concern that parents reported spanking and yelling at their infants before 9 months, with one third of parents spanking their children before 18 months, a time when the risk of escalation to child abuse is considered to be particularly high.³ Current health supervision guidelines do not address discipline until the 9-month visit, and the current AAP statement on discipline does not address modification of recommended timetables for counseling.^3,29,30 Our findings suggest that such modifications should be considered.

The findings from this study also underscore the importance of evaluating parents’ emotions in the context of discipline counseling. Parents’ emotions are a sensitive indicator of the health of the parent–child relationship,³¹ and harsh, negative, and controlling parenting is associated with a wide range of negative developmental outcomes.³² Because there is empirical support for the efficacy of early intervention in modifying discipline practices,⁹ the appraisal of parents’ emotions relevant to child rearing becomes an important consideration for routine clinical practice. Parents who indicate that they are struggling emotionally with the demands of child rearing may be helped by a variety of community supports and services. The pediatrician can play an important role by identifying this need and facilitating access to these services. Other clinically important implications include the need for careful attention to communication and counseling techniques given the emotionally sensitive nature of this topic.³³ Finally, the consistency in which race influences discipline practices underscores the need for clinical models that elaborate these ethnic and cultural factors in counseling parents.

Limitations
There are several limitations to this study. The survey sampled only reactive practices so that the broad picture of how parents use discipline, including proactive strategies, is not represented. The context within which discipline practices are used is an important factor and was not measured; neither could different parenting styles be determined from these data. Another limitation is that the method for eliciting parents’ recall may underestimate rates reported. For example, there was no referent period established for parents, and studies that have used long referent periods (eg, the past year) have reported very high prevalence rates.²⁶ A clear definition of spanking was not provided to parents so that parents may have excluded extremes of corporal punishment. Also, severity of spanking cannot be determined beyond frequency. Therefore, inferences about the significance of the discipline practices surveyed are limited.

	CONCLUSIONS

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In summary, the data from this study highlight the complex ways in which child, parent, and demographic factors influence parents’ use of discipline in the first 3 years of life. Important findings include a significant percentage of parents’ reporting the use of aversive discipline behaviors in young infants; relationships between parents’ negative emotions and the use of aversive discipline practices; ethnic variation in the use of both aversive and nonaversive practices; and apparent influences of child age, health, and developmental risk factors. These findings have important implications for primary care counseling. They underscore the importance of addressing the needs of both parents and children at the health visit³⁴ as well as understanding the social and emotional dynamics of the parent–child relationship in effectively helping parents with child-rearing challenges.³⁵

	ACKNOWLEDGMENTS

 
This research was made possible by funding from The Gerber Foundation, the American Academy of Pediatrics Friends of Children Fund, the Maternal and Child Health Bureau in the Health Resources and Services Administration (5-U05MC-00010200), and The Commonwealth Fund.

	FOOTNOTES

 
Received for publication Oct 20, 2003; Accepted Jan 13, 2004.

Reprint requests to (M.R.) Cedars-Sinai Medical Center, 8700 Beverly Blvd, MOT 1165W, Los Angeles, CA 90048. E-mail: michael.regalado{at}cshs.org

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