PEDIATRICS Vol. 117 No. 2 February 2006, pp. 441-447 (doi:10.1542/10.1542/peds.2005-0421)
Parental Expectations, Physical Punishment, and Violence Among Adolescents Who Score Positive on a Psychosocial Screening Test in Primary Care
a Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
b Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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OBJECTIVE. We sought to examine the relationship between perceived and stated parental expectations regarding adolescents' use of violence, parental use of physical punishment as discipline, and young adolescents' violence-related attitudes and involvement.
METHODS. Surveys were completed by 134 youth and their parents attending 8 pediatric practices. All youth were 10 to 15 years of age and had scored positive on a psychosocial screening test.
RESULTS. Multivariate analyses revealed that perceived parental disapproval of the use of violence was associated with a more prosocial attitude toward interpersonal peer violence and a decreased likelihood of physical fighting by the youth. Parental report of whether they would advise their child to use violence in a conflict situation (stated parental expectations) was not associated with the adolescents' attitudes toward interpersonal peer violence, intentions to fight, physical fighting, bullying, or violence victimization. Parental use of corporal punishment as a disciplining method was inversely associated with a prosocial attitude toward interpersonal peer violence among the youth and positively correlated with youths' intentions to fight and fighting, bullying, and violence victimization.
CONCLUSIONS. Perceived parental disapproval of the use of violence may be an important protective factor against youth involvement in violence, and parental use of physical punishment is associated with both violence perpetration and victimization among youth. Parents should be encouraged to clearly communicate to their children how to resolve conflicts without resorting to violence and to model these skills themselves by avoiding the use of physical punishment.
Key Words: adolescents • parental expectations • physical punishment • violence
Abbreviations: PSC-17—17-item Pediatric Symptom Checklist
VIOLENCE IS ONE of the major causes of mortality and morbidity among youth.1–5 Data from the 2003 Youth Risk Behavior Surveillance indicated that 1 of 3 high school students reported being in a physical fight.1 At least 4% of the students had been treated by a doctor or nurse for injuries sustained in a physical fight 
1 times during the 12 months preceding the survey.1 More than 877000 young people 10 to 24 years were injured in violent acts in 2002.2 In a nationally representative sample of >15000 US students in grades 6 through 10, 30% reported involvement in bullying as a bully, victim, or both.6
Studies have shown multiple factors to be associated with an adolescent's involvement in violence and other risky behaviors.7–14 Among the noted predictors of violence are individual factors such as exposure to violence, television-viewing hours, bullying and being bullied, victimization aggression, and other behavioral and emotional disorders.9–15 Despite these individual risk factors, some young people have overriding protective factors that preempt involvement in violence. Research points to family factors, particularly parental monitoring, parent-child communication, and family connectedness, as important forces that are associated with a lower likelihood of engaging in violence.8,13,14,16 Another family variable that may influence violence-related behaviors and attitudes among young adolescents is perceived parental expectations regarding the use of violence when provoked.
Social cognitive theory posits that the environment and social situations provide cues about acceptable types of behavior.17 From personal and behavioral interactions with the environment, individuals assume a mental representation of the environment, whether real or imagined, that may affect their behavior.18 Thus, parental behaviors, attitudes, and expectations regarding different behaviors such as involvement in violence may influence an adolescent's attitudes and behaviors. As reiterated by DuRant et al,19 many of the skills that adolescents use to resolve interpersonal conflict are learned from interactions with family members.
Of interest in the literature are several reports that indicate that perceived parental expectations and attitudes correlate more with adolescents' behaviors and attitudes than the stated parental expectations.20–23 Sieving et al20 found that although stated maternal disapproval did not significantly affect the timing of sexual debut for female adolescents, perceived maternal disapproval was associated with a delay in initiating intercourse. In the study by Acock and Bengston,21 who investigated what better predicted youth's attitudes, perceived parental opinions had a more direct effect than did stated opinions of parents.
Little is known about what parents would tell their child to do when faced with a potentially violent situation. Furthermore, the association between perceived or stated parental expectations regarding the use of violence and adolescents' involvement in violence has not been evaluated. However, there are reports on the relationship between perceived parental expectations about other issues and violence involvement. In their study of factors that are protective against health-compromising behaviors, Resnick et al8 found higher perceived parental expectations for school achievement to be weakly associated with lower levels of violence among older adolescents. Nansel et al6 reported that a perceived permissive parental attitude toward teen drinking was associated with bullying or being bullied for several groups of adolescents.
Anticipatory guidance about violence should include advice to parents on teaching their children about handling a potentially violent conflict, because parents will likely convey their values regarding conflict resolution to their children.24 Health care professionals should not assume that, because parents want their children to be safe, they expect their children to handle conflicts without violence. They should also not assume that parents who want their children to have nonviolent conflict resolution skills model those skills. They may model a contrasting behavior. Ascertaining how parents expect their children to resolve conflicts and understanding the relationship between parental expectations and the youth's intentions, attitudes, and behaviors when handling conflicts may generate information to improve anticipatory guidance on violence prevention.
To examine these violence related issues and variables, our study population was derived from a sample of clinic-attending adolescents who scored positive on a psychosocial screening test, the 17-item Pediatric Symptom Checklist (PSC-17),25,26 and their parents, who were part of a violence intervention study. Because the PSC-17 identifies youth with risk factors for violence participation, the rationale for using this study population was to facilitate the investigation of the variables in which we were interested. The objectives of the study were to (1) assess in this sample of young adolescents and their parents what parents would tell their child to do in a potentially violent situation and their adolescent's intentions under those same circumstances and (2) explore the association between perceived and stated parental expectations regarding their child's use of violence when provoked and parent modeling of violent behavior through use of corporal punishment and the following outcomes: adolescents' attitude about the appropriateness of using violence to resolve conflicts; adolescents' intentions to use violence when provoked; and perpetration of violence and victimization. We hypothesized that perceived parental disapproval of the use of violence would correlate more with a prosocial attitude toward interpersonal peer violence and less involvement in physical fighting and bullying among the youth than would parental report of how they would advise their child to handle conflicts. In addition, we expected that parental use of corporal punishment would be significantly associated with youth violence.
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METHODS |
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Participants
This study is an analysis of data from a sample of 134 parents and their 10- to 15-year-old adolescents, who were part of a primary care–based intervention study.27 The study was conducted in 8 outpatient pediatric practices: 2 urban community clinics, 2 urban private practices, and 4 suburban private practices located in the Minneapolis-St Paul metropolitan area from June 2001 through November 2001. During the study period, all English-speaking parents of adolescents 10 to 15 years of age who were attending the clinics were approached to complete the PSC-17. The PSC-17 is a validated screening test (with 3 subscales) that enables primary care providers to identify and refer children with psychosocial problems.25,26,28 The 3 subscales consist of an internalizing subscale ("feels sad, unhappy," "feels hopeless," "is down on self," "worries a lot," "seems to be having less fun"), attention subscale ("fidgety, unable to sit still," "daydreams too much," "distracted easily," "has trouble concentrating," "acts as if driven by a motor"), and externalizing subscale ("fights with other children," "does not listen to rules," "does not understand other peoples' feelings," "teases others," "blames others for his/her troubles," "refuses to share," "takes things that do not belong to him/her"). For each of these items, parents are asked to mark "often," "sometimes," or "never," which are scored as 2, 1, or 0 points, respectively. The sum of these points provides the PSC-17 total as well as the subscale scores. A positive score on the PSC-17 is defined as scoring a minimum of 15 points on the complete screen or scoring the respective points on at least 1 of the 3 subscales:
5 for the internalizing subscale, 7 for the attention subscale, and 7 for the externalizing subscale.25 To be eligible for the study, participants should have had a positive score on the PSC-17 and had not yet been seen by the clinician by the time the screening test was scored. Trained interviewers conducted baseline interviews with the eligible youth and their parents by telephone soon after the visit to the clinic, speaking separately with each parent and youth. Parents were asked about parenting style, parental health, and their relationship and communication with their child. The youth responded confidentially to questions about their relationship with their parents, mental health issues, and victimization and attitude toward interpersonal violence. Both parents and youth separately answered questions on the youth’s involvement in fights and bullying. The University of Minnesota Institutional Review Board approved the procedures and consent and assent forms for the study.
Measures
Parents' Stated Instructions and Children's Intentions
What parents would tell their child to do in a potentially violent situation and the adolescent's intentions under those same circumstances were assessed by a single question from the parent questionnaire and a close equivalent from the child questionnaire, respectively. The statement for the parents was: "Please answer ‘yes’ if you can see yourself telling your child that it's okay to hit if a person pushes or hits him or her, and answer ‘no’ if you do not think it would be okay to hit." The adolescent's intentions were assessed by asking them to answer "yes" or "no" to the question: "If a person pushes or hits me, it would make me mad enough to fight."
The main research question explored the association between perceived and stated parental expectations and the youths' attitude about violence and involvement in violence.
Dependent Variables
The dependent variables were youths' attitude about violence, intentions to use violence, and involvement in violence and victimization. The adolescents’ attitude about violence was measured by a 12-item scale that assesses their attitude toward interpersonal peer violence.29 Respondents had the choice of agreeing or disagreeing with statements such as "When actions of others make me angry, I can usually deal with it without getting into a physical fight," and "The best way to stop a fight before it starts is to stop the argument (problem) that caused it." The scale was standardized to range from 0 to 1 (1 reflects a prosocial attitude toward peer violence) and had a Cronbach's 
of .62.
Endorsing the statement, "If a person pushes or hits me, it would make me mad enough to fight," was used as the measure of the adolescent's intention to fight when provoked.
Two measures were used to assess for involvement in violence. The first measure was the adolescent's self-report of being in a physical fight at least once in the year preceding the survey. Parental report of their child bullying others more than twice in school or away from school during the past school term was the second measure. Parental report of their child being a bully, as opposed to the child's self-report of bullying behavior, was chosen because of concerns that youth may not accurately self-identify as a bully.30
Self-report of victimization in the last school term was assessed by a 7-item scale that was standardized to range from 0 to 1 and had a Cronbach's of .81. Items in this measure included statements such as "A student threatened to hurt me or hit me" and "A student said things about me to make other students laugh." The youth responded "never," "once or twice," "sometimes," or "once a week" to the items.
Independent Variables
There were 3 key independent variables: perceived parental disapproval of the use of violence in a potentially violent situation, parent report of what they would tell their adolescent to do when provoked, and parent’s use of corporal punishment as a discipline method.
Perceived parental disapproval regarding the use of violence was measured by taking the mean of 2 dichotomous items: "My family would be mad at me if I got into a fight with another student no matter what the reason" and "If a student hits me first, my family would want me to hit them back" (reverse coded). The response categories were "agree" and "disagree." The Pearson correlation coefficient for the 2 items was 0.29 (P < .001). A high value indicates higher perceived parental disapproval of the use of violence.
A 5-item scale measured parents' report of what they would advise their adolescent to do regarding the use of violence when provoked. For these items, parents answered "yes" or "no" to whether they would tell their adolescent that it was okay to hit in different situations, ranging from another person insulting them to a person hitting or pushing them.31 Cronbach's for the scale, standardized to range from 0 to 1, was .72. The higher end of the scale indicates a parent's endorsement of the use of violence.
Two questions answered by the youth assessed the use of corporal punishment as a discipline method: "Your parents spank you when you are disobedient" and "Your parents use physical punishment as a way of disciplining you." Response options were "never," "sometimes," and "always." The Pearson correlation coefficient for the 2 items was 0.31 (P < .001). A higher value indicates greater use of corporal punishment by the parents to discipline their child.
Demographic Variables
Demographic data collected from study participants included the youth's age, gender, race, receipt of welfare by a household member, and marital status of the adults with whom the youth lived.
Data Analysis
Multivariate analyses were used to assess the associations between the dependent and independent variables after controlling for age, gender, number of parents with whom the youth lived, and welfare status. To control for clustering of participants by pediatric practices, Proc Genmod Statement from SAS (SAS Institute, Inc, Cary, NC) was used for continuous and dichotomous measures. A P value of <.05 was used as the criterion for statistical significance.
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RESULTS |
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A total of 1281 parents with 10- to 15-year-olds completed the PSC-17 screen. There were 296 (23%) screens with a positive score. Of those with a positive score, 100 parent-youth pairs (34%) were excluded because they saw the clinician before being asked to take part in the study, and 42 (14%) declined participation. The 134 parent-youth dyads who formed the study population for the present analyses consisted of youth and their corresponding parents with completed questionnaires in the telephone interviews. There was no difference in demographic characteristics between the study population and those who were excluded or declined participation. The demographic characteristics of the 134 study participants are outlined in Table 1. The youth in the study had a mean age of 12.2 years (SD: 1.6). The study population was predominantly white. Males comprised almost 60% of the youth. More than half of the adolescents (56%) reported being in a physical fight in the year preceding the survey. The majority of the adult respondents (84%) were the mother of the youth, and 37% had a college degree or higher education.
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Presented in Fig 1 are the parent and child responses when presented with the prospect of the adolescent being in a hypothetically violent situation. Almost 40% of the parents said they would tell their child it was okay to hit if he or she was pushed or hit by another person. Two of 3 adolescents reported that if a person hit or pushed them, it would make them mad enough to fight.
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Results from the multivariate analyses are shown in Table 2. Adolescents who perceived parental disapproval of the use of violence had a more prosocial attitude toward interpersonal peer violence and were less likely to report fighting. The inverse relationship between perceived parental disapproval of the use of violence and the adolescents' intentions to fight when provoked was on the verge of significance (P = .053). On the other hand, parent report of what they would advise their child to do in a situation of potential conflict was not associated with any of the 4 violence-related variables: attitude toward interpersonal peer violence, intentions to fight, fighting, and bullying and victimization.
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Youth report of the use of corporal punishment as discipline by the parent was significantly found to be inversely associated with a prosocial attitude toward interpersonal peer violence and positively correlated with intentions to fight when provoked, fighting, bullying, and youth report of victimization.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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In this sample of youth and their parents who visited these outpatient pediatric practices, we found that young adolescents who perceive parental disapproval of the use of violence in a provocative situation were more likely to have a prosocial attitude toward interpersonal peer violence. Perceived parental disapproval was also found to be significantly protective against fighting. In contrast, parents' stated expectations regarding their children's use of violence did not predict adolescents' violence-related attitudes, intentions, and behaviors. Parental use of corporal punishment for disciplining was strongly associated with the youth having a less prosocial attitude about violence, more violent intentions and behavior, and greater report of victimization.
To our knowledge, this is the first study to specifically examine perceived parental disapproval regarding the use of violence and violence-related attitudes and behaviors of young adolescents. Our findings are consistent with the body of research that points to a greater role played by perceived protective parental and family expectations in influencing adolescent attitudes and behaviors compared with stated parental expectations.8,20–22 Stated parental expectations in this study measured parents’ reports of what they would advise their children to do when provoked. It may be that many parents do not discuss these expectations with their children. As a result, children may be guided by what they perceive to be their parents' expectations on the use of violence rather than what the parents actually condone. Smith23 pointed out that agreement by parent and child on a particular issue may be affected mainly by the clarity and persuasiveness of parental communication on that issue. Parents therefore need to recognize the importance of clearly stating to their child what the child should do when faced with potential conflict. Communication that occurs within the context of a close parent-child relationship increases the likelihood of adolescents accurately perceiving their parents’ expectations.20
Results of our study underscored that we cannot assume that all parents advocate that their child use a nonviolent means of resolving conflicts. Almost 40% of the parents indicated that they would tell their child it is okay to hit if another person pushes him or her. The pervasiveness of community violence may impose dilemmas on parents that may influence parenting practices.32 For some parents, advising their child to fight back when provoked is the best way they think their child will be safe. The current study also showed that the use of corporal punishment as a disciplining method by parents was a risk factor for youth violence, a finding reported by others.10 DuRant et al33 pointed out that substantial social learning occurs when children observe violence among family members. The observation of parents using corporal punishment may inadvertently suggest to young people that the use of physical force in dealing with a problem is normative.
This study has a number of limitations. With no means of external validation, the self-report nature of this study leaves room for reporter bias on the part of both the youth and their parents. The majority of the adult respondents were mothers, which may have influenced the data. The study is cross sectional, and therefore it is not possible to determine either causality or directionality of the variables analyzed. Finally, because the study population was limited to a select group of young people, clinic-attending adolescents who scored positive on the PSC-17 and their parents, the findings cannot be generalized to all adolescents. Additional research to further explore the findings should be longitudinal in nature and should include a larger and more diverse group of adolescents.
Despite the limitations, this study has important implications for clinical practice. The findings reiterate the importance of health care providers actively engaging parents in violence-anticipatory guidance for young adolescents. Perhaps in recognition of the emerging independence and self-reliance of adolescents, recommendations on violence-prevention counseling and interventions strategies in the literature usually emphasize interaction with the adolescent patient.34,35 Although this is good practice, periodic parental counseling is important also.36 Good prevention messages will tell parents that violence is preventable.24 Parents should be reminded of the importance of modeled behavior in influencing violence-related attitudes and behaviors in adolescents. Health care providers should elicit from parents their views on conflict resolution and help them identify nonviolent means of handling confrontations, which includes discussing nonviolent alternatives to physical punishment as a means of discipline. In addition, parents need to be encouraged to communicate with their children regarding how to resolve conflicts without violence.
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ACKNOWLEDGMENTS |
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This study was supported in part by the Robert Wood Johnson Foundation Generalist Physician Faculty Scholar Award and Leadership Education in Adolescent Health, University of Minnesota, Project 1 T71 MC00025-01 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services.
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FOOTNOTES |
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Accepted May 25, 2005.
Address correspondence to Iris Wagman Borowsky, MD, PhD, Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota Gateway, 200 Oak St, SE; Suite 260, Minneapolis, MN 55455. E-mail: borow004{at}umn.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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