pediatrics
November 2018, VOLUME /ISSUE

Effective Discipline to Raise Healthy Children

  1. Robert D. Sege, MD, PhD, FAAPa,
  2. Benjamin S. Siegel, MD, FAAPb,c,
  3. COUNCIL ON CHILD ABUSE AND NEGLECT,
  4. COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH
    1. aCenter for Community Engaged Medicine, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts; and
    2. bDepartments of Pediatrics and
    3. cPsychiatry, Boston Medical Center and School of Medicine, Boston University, Boston, Massachusetts
    1. Drs Sege and Siegel created the first draft of this statement, responded to committee and Board comments, and edited the Policy Statement; and all authors approved the final manuscript as submitted.

    Abstract

    Pediatricians are a source of advice for parents and guardians concerning the management of child behavior, including discipline strategies that are used to teach appropriate behavior and protect their children and others from the adverse effects of challenging behavior. Aversive disciplinary strategies, including all forms of corporal punishment and yelling at or shaming children, are minimally effective in the short-term and not effective in the long-term. With new evidence, researchers link corporal punishment to an increased risk of negative behavioral, cognitive, psychosocial, and emotional outcomes for children. In this Policy Statement, the American Academy of Pediatrics provides guidance for pediatricians and other child health care providers on educating parents about positive and effective parenting strategies of discipline for children at each stage of development as well as references to educational materials. This statement supports the need for adults to avoid physical punishment and verbal abuse of children.

  1. Abbreviations:
    AAP
    American Academy of Pediatrics
    UN
    United Nations
  2. Introduction

    Pediatricians are an important source of information for parents.1 They are often asked by parents and guardians about nutrition, development, safety, and overall health maintenance. Pediatricians form a relationship with parents, within which they partner with parents to achieve optimal health, growth, and development in their children, including childhood behavior management. Duncan et al2 reviewed periodic surveys of members of the American Academy of Pediatrics (AAP) and noted that between 2003 and 2012, pediatricians had increased their discussions of discipline with parents. By 2012, more than half (51%) of the pediatricians surveyed responded that they discussed discipline in 75% to 100% of health supervision visits with parents of children ages 0 through 10 years.

    A recent survey (2016) indicated that US pediatricians do not endorse corporal punishment. Only 6% of 787 US pediatricians (92% in primary care) who responded to this survey held positive attitudes toward spanking, and only 2.5% expected positive outcomes from spanking. Respondents did not believe that spanking was the “only way to get the child to behave” (78% disagreed) or that “spanking is a normal part of parenting” (75% disagreed).3

    This policy statement incorporates new research and updates the 1998 AAP clinical report titled “Guidance for Effective Discipline,”4 which suggested, “Parents should be encouraged and assisted in developing methods other than spanking in response to undesired behaviors.”

    Background

    In 1989, the United Nations (UN) Convention on the Rights of the Child, through its Committee on the Rights of the Child, called on all member states to ban corporal punishment of children and institute educational programs on positive discipline.5 In the UN report, article 19 reads, “Parties shall take all appropriate legislative, administrative, social, and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse, while in the care of [the] parent(s) [or] legal guardian(s) or any other person who has the care of the child.”

    The Global Initiative to End all Corporal Punishment of Children provided a comprehensive definition of spanking and corporal punishment: “The definition of corporal or physical punishment adopted by the Committee on the Rights of the Child in its General Comment No. 8 (2006) has the key reference point, ‘any punishment in which physical force issued and intended to cause some degree of pain or discomfort, however light.’ According to the committee, this mostly involves hitting (“smacking,” “slapping,” or “spanking”) children with the hand or with an implement (a whip, stick, belt, shoe, wooden spoon, or similar), but it can also involve, for example, kicking, shaking, or throwing children; scratching, pinching, biting, pulling hair, or boxing ears; forcing children to stay in uncomfortable positions; burning, scalding, or forced ingestion (for example, washing a child’s mouth out with soap or forcing them to swallow hot spices). Nonphysical forms of punishment that are cruel and degrading and thus incompatible with the convention include, for example, punishment which belittles, humiliates, denigrates, scapegoats, threatens, scares, or ridicules the child. In the view of the committee, corporal punishment is invariably degrading.”6

    For the purpose of this policy statement, corporal punishment is the “noninjurious, open-handed hitting with the intention of modifying child behavior.”7 Spanking can be considered a form of physical punishment. As Gershoff and Grogan-Kaylor7 noted, most people understand “corporal punishment, physical punishment, and spanking as synonymous.” The term “verbal abuse” is used to mean nonphysical forms of punishment as defined above.

    This policy statement incorporates results accrued from research and new knowledge of brain development and recommend that pediatricians advise parents against the use of any form of corporal punishment. Verbal abuse (for a definition, see above: the Global Initiative to End All Corporal Punishment of Children) by parents intended to cause shame and humiliation of the child also has deleterious effects on children’s self-esteem. This policy statement complements a previous AAP policy statement that recommended the abolishment of corporal punishment in schools.8

    Effective Discipline Supports Normal Child Development

    Optimal child development requires the active engagement of adults who, among other functions, teach children about acceptable behavior. The word “discipline” is derived from the Latin word “disciplinare,” meaning to teach or train, as in disciple (a follower or student of a teacher, leader, or philosopher). Effective disciplinary strategies, appropriate to a child’s age and development, teach the child to regulate his or her own behavior; keep him or her from harm; enhance his or her cognitive, socioemotional, and executive functioning skills; and reinforce the behavioral patterns taught by the child’s parents and caregivers.

    There are a number of approaches to discipline that pediatricians may discuss with parents during well-child visits and those visits that are designed to address discipline issues. These approaches are reviewed in Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents,9 on the AAP Web site HealthyChildren.org,10 and in the AAP program Connected Kids: Safe, Strong, Secure.11 Bright Futures includes sections on discipline for each age group. Each of these recommended approaches to discipline is based on the broad concepts of child development and related common behavioral concerns.

    Corporal Punishment

    Use of Corporal Punishment

    There is evidence that support for corporal punishment among parents is declining in the United States. According to a 2004 survey,12 approximately two-thirds of parents of young children reported using some sort of physical punishment. These parents reported that by fifth grade, 80% of children had been physically punished, and 85% of teenagers reported exposure to physical punishment, with 51% having been hit with a belt or similar object.1215 These findings suggest that, in 2004, many parents considered spanking to be a socially acceptable form of discipline. In contrast, a more recent national survey of adults shows declining support for spanking (or hitting), particularly among young parents. A 2013 poll16 conducted by Harris Interactive found that support for the statement “good, hard spanking is sometimes necessary to discipline a child” had dropped from 84% in 1986 to 70% in 2012. Parents younger than 36 years more often believed that spanking was never appropriate, and only half reported ever spanking their own children. An analysis of a 2016 national survey conducted by yougov.com revealed that respondents with young children in the home, regardless of race and ethnicity, did not support corporal punishment, “suggesting the possibility that a generational shift in social norms [about corporal punishment] may be taking place.”17

    Direct Observations of Corporal Punishment

    Although some studies of discipline practices used observations during home visits,1 a small study published in 201418 used voice recordings to explore parent-child interactions during daily activities. The recordings of 15 of the 33 families in the study (45%) included the use of corporal punishment. Most parents used a verbal disciplinary strategy before corporal punishment. Corporal punishment then occurred at a mean of 30 seconds later, suggesting that parents may have been “responding either impulsively or emotionally rather than instrumentally and intentionally.” The effects of corporal punishment were transient: within 10 minutes, most children (73%) had resumed the same behavior for which they had been punished.

    Ineffectiveness of Corporal Punishment

    A 2016 meta-analysis showed that current literature does not support the finding of benefit from physical punishment in the long-term.7 Several small, older studies (including meta-analyses),1922 largely of parents who were referred for help with child behavior problems, demonstrated apparent short-term effectiveness of spanking. Only a single 1981 study of 24 children showed statistically significant short-term improvement in compliance compared with alternative strategies (time-out and a control group).23

    Cycle of Corporal Punishment and Aggressive Child Behavior

    Evidence obtained from a longitudinal cohort study suggested that corporal punishment of toddlers was associated with subsequent aggressive behavior. The Fragile Families and Child Wellbeing Study was based on a population-based birth cohort of approximately 5000 children from 20 large US cities between 1998 and 200024; data were collected at birth and 1, 3, 5, and 9 years of age. Young children who were spanked more than twice per month at age 3 years were more aggressive at age 5 even when the researchers controlled for the child’s aggressive behavior at age 3, maternal parenting and risk factors, and demographic factors.25 A follow-up study26 assessed these children at 9 years of age and noted correlations between spanking at age 5 years and higher levels of externalizing behavior and lower receptive vocabulary scores at age 9. A subsequent study analyzed data from all 4 waves and concluded that an increased frequency of spanking was associated with a subsequent increased frequency of externalizing behaviors, which were then associated with more spanking in response.27 This interaction between spanking and misbehavior occurs over time; each negative interaction reinforces previous negative interactions as a complex negative spiral.

    In a study that explored parental discipline approaches,28 researchers noted that both European American and African American parents used an escalation strategy in disciplining their 6- to 8-year-old children. Both groups of parents used reasoning more frequently than yelling. The next most frequent strategy was denying privileges, and spanking was the least frequent method reported by all parents. Similarly, in focus groups conducted around the country in 2002 during the development of the AAP Connected Kids materials, participating parents reported the use of corporal punishment as a last resort.11,29

    Special Populations

    Children in foster care who have experienced abuse or neglect may exhibit challenging behaviors. Programs exist that assist foster parents in addressing discipline. A recent AAP clinical report describes the behavioral effects of maltreatment and offers suggestions for helping these children heal.30 Pediatricians may advise foster parents to consider the behavioral consequences of past abuse in understanding how these children may respond differently to their foster parents’ attempts to correct their behavior.31

    Parents of children with special health care needs may need additional assistance regarding discipline strategies. These strategies begin with an understanding of a child’s physical, emotional, and cognitive capacities. In some cases, consultation with a developmental-behavioral pediatrician may be helpful.32

    Parental Factors Associated With Reliance on Corporal Punishment

    Parental Depression

    A longitudinal study examined the interactions between parental corporal punishment, parental depression, negative perceptions of a child’s behavior, and the child’s externalizing behavior.33 The sample included 245 children and parents in stable relationships from mostly middle-class, married, European American parents. Depressive symptoms for both mothers and fathers were related to more negative appraisals of the child’s behavior and more frequent corporal punishment and predicted higher levels of child externalizing problems at 5.5 years of age.

    Influence of Past Parental Trauma

    A recent article, Kistin et al34 reported interviews with 30 low-income mothers and provided an important perspective on the complexity of disciplinary strategies used by mothers who had themselves experienced trauma. They reported that mothers related their children’s negative behaviors to their own past experiences; harsh discipline was used in an attempt to prevent future behavioral problems.

    Corporal Punishment As a Risk Factor for Nonoptimal Child Development

    There appears to be a strong association between spanking children and subsequent adverse outcomes.3553 Reports published since the previous 1998 AAP report have provided further evidence that has deepened the understanding of the effects of corporal punishment. The consequences associated with parental corporal punishment are summarized as follows7,19,21,27,35,5462:

    • corporal punishment of children younger than 18 months of age increases the likelihood of physical injury;

    • repeated use of corporal punishment may lead to aggressive behavior and altercations between the parent and child and may negatively affect the parent-child relationship;

    • corporal punishment is associated with increased aggression in preschool and school-aged children;

    • experiencing corporal punishment makes it more, not less, likely that children will be defiant and aggressive in the future;

    • corporal punishment is associated with an increased risk of mental health disorders and cognition problems;

    • the risk of harsh punishment is increased when the family is experiencing stressors, such as family economic challenges, mental health problems, intimate partner violence, or substance abuse; and

    • spanking alone is associated with adverse outcomes, and these outcomes are similar to those in children who experience physical abuse.

    The association between corporal punishment and adverse adult health outcomes was examined in a 2017 report that analyzed original data from the 1998 Adverse Childhood Experiences Study, which recommended that spanking be considered as an additional independent risk factor, similar in nature and effect to other adverse childhood experiences.63 In their analysis of the original 1998 Adverse Childhood Experiences study data, the investigators found that spanking was associated with increased odds of suicide attempts, moderate-to-heavy drinking, and substance use disorder in adulthood independent of the risks associated with having experienced physical and emotional abuse.

    Physiologic Changes Associated With Corporal Punishment and Verbal Abuse

    A history of parental corporal punishment and parental verbal abuse has been associated with changes in brain anatomy that can be visualized by using MRI. Researchers studied a group of young adults (N = 23; ages 18–25) who had prolonged and repeated exposure to harsh corporal punishment and compared the results of brain MRIs to those from a matched control group (N = 22). They reported reduced prefrontal cortical gray matter volume and performance IQ.64 A similar study from this group noted MRI results that revealed differences in white matter tracts in young adults (N = 16) who were exposed to parental verbal abuse and had no history of trauma.65 A more recent review noted relationships between physical punishment and cortisol levels.66 Elevated cortisol levels reflect stress and have been associated with toxic stress and subsequent changes in brain architecture.

    Harsh Verbal Abuse Associated With Child and Adolescent Mental Health Problems

    In 2009, the UN Children’s Fund defined “yelling and other harsh verbal discipline as psychologically aggressive towards children.”28 In a longitudinal study investigating the relationship between harsh verbal abuse by parents and child outcomes, researchers noted that harsh verbal abuse before age 13 years was associated with an increase in adolescent conduct problems and depressive symptoms between ages 13 and 14. Adolescent behavior affected parental behavior as well; misconduct predicted increases in parents’ use of harsh discipline between ages 13 and 14 years. Furthermore, parental warmth did not moderate the longitudinal associations between harsh discipline by parents and adolescent conduct and depressive symptoms.67

    Strategies for Promoting Effective Discipline

    Effective disciplinary techniques grow from an understanding of normal child development. Parents value advice from their pediatricians, as illustrated by a 2012 study1 involving 500 parents in New Orleans, Louisiana. The investigators found that parents were more likely to follow the advice of pediatricians compared with other professionals, and nearly half (48%) indicated that they were most likely to consult their pediatricians for advice on corporal punishment. In a second article,68 these investigators further noted that perceived social norms were the strongest predictor of having a positive attitude toward corporal punishment, with the second-strongest predictor being perceived approval of corporal punishment by professionals.

    Clinical Setting

    Pediatricians may assist parents by providing information about child development and effective parenting strategies. Although parents often seek information and hold their pediatricians in a position of trust, discussions of discipline may prove challenging. This section presents approaches to counseling.

    Anticipatory Guidance

    A direct discussion advising against any form of corporal punishment may be useful. When appropriate, the pediatrician may counsel family members that spanking is not an appropriate or effective disciplinary strategy. Parents may be counseled that although spanking seems to interrupt a child’s misbehavior, it is ineffective in the longer-term. For many children, spanking increases aggression and anger instead of teaching responsibility and self-control. This advice will be most helpful if it is combined with teaching parents new strategies to replace their previous use of corporal punishment. Appropriate methods for addressing children’s behavior will change as the children grow and develop increased cognitive and executive function abilities.9

    Teaching parents effective strategies may allow them to avoid escalating to the point of using corporal punishment. In a randomized trial, Barkin et al69 demonstrated that it was possible to teach parents to use time-outs within the constraints of an office visit. Clinicians used motivational interviewing techniques to help parents learn to discipline using other techniques.

    When discussing corporal punishment, pediatricians may explore and acknowledge parents’ current experiences, past social-emotional development, attitudes, and beliefs. Because parents may use spanking as a last resort, they may spank less (or not at all) if they have learned effective discipline techniques.11 Specific discussions of behavior problems and behavior management strategies allow pediatricians to provide useful advice that is based on an understanding of child behavior.

    Educational Resources

    Pediatric providers may reinforce behavioral counseling through recommending or distributing parent education materials. For example, studies have shown that in-office videos may be able to deliver messages to multicultural parents.70,71 Having parents read brief research summaries of problems associated with corporal punishment decreased positive attitudes about it.72 Each of these approaches reinforced verbal advice with other means of supporting caregivers in learning new parenting techniques.

    The Centers for Disease Control and Prevention has posted positive parenting tips on its Web site.73 The AAP provides content for parents through its HealthyChildren.org Web site and its Connected Kids: Safe, Strong, Secure11 and Bright Futures9 programs. Each of these resources encourages parents to use positive reinforcement as a primary means of teaching acceptable behavior. For example, parents can learn that young children crave attention, and telling a child, “I love it when you . . .” is an easy means of reinforcing desired behavior.

    Community Resources

    Although pediatricians offer anticipatory guidance, many parents will want or need more assistance in developing strong parenting skills. The medical home can link parents to community resources. Health care sites may implement the Safe Environment for Every Kid74,75 program. The program includes a brief questionnaire that examines family risk factors. Parents who identify needs, including parenting challenges, meet with a colocated social worker who can link them to parent supports in the community. This program also has online educational modules.76,77

    A variety of national and community-based organizations offer parents support through Triple P,78 which is one example of an evidence-based parent education program. In another program, HealthySteps,79 a developmental specialist is placed in the office setting to help support families of children ages 0 to 3 years. In most states, Children’s Trust Funds and child welfare agencies sponsor parent resource centers. Help Me Grow,80 a state-based information and referral network, has been implemented in the majority of the United States. The Center for the Improvement of Child Caring offers resources specifically tailored to African American families.8183

    Many clinic- and community-based programs are specifically oriented toward helping parents effectively address their children’s behavior.84 Examples include The Incredible Years,85 a brief office-based video intervention in the office that is used to discuss discipline issues86; Safety Check, which is used to teach time-outs69; the Family Nurturing Program, which is used to improve parenting attitudes and knowledge87; and the Chicago Parent Program, a comprehensive 12-week parenting skills training program.88 The Video Intervention Project is an evidence-based parenting program that involves feedback on parent-child interactions by trained child development staff in a primary care office setting.89

    The 2012 AAP clinical report was focused on the psychological maltreatment of children and adolescents and contained a comprehensive review of preventive measures that provide alternatives to the use of corporal punishment.90 The literature describe other resources and programs, such as Internet-based training and group-based parent training programs.9193 This list of resources is not intended to be comprehensive; many national organizations and local communities also offer effective parenting resources.

    Conclusions

    Parents look to pediatric providers for guidance concerning a variety of parenting issues, including discipline. Keeping in mind that the evidence that corporal punishment is both ineffective in the long-term and associated with cognitive and mental health problems can guide these discussions. When parents want guidance about the use of spanking, pediatricians can explore parental feelings, help them better define the goals of discipline, and offer specific behavior management strategies. In addition to providing appropriate education to families, providers can refer them to community resources, including parenting groups, classes, and mental health services.94

    The AAP recommends that adults caring for children use healthy forms of discipline, such as positive reinforcement of appropriate behaviors, setting limits, redirecting, and setting future expectations. The AAP recommends that parents do not use spanking, hitting, slapping, threatening, insulting, humiliating, or shaming.

    Policy Recommendations

    Parents value pediatricians’ discussion of and guidance about child behavior and parenting practices.

    1. Parents, other caregivers, and adults interacting with children and adolescents should not use corporal punishment (including hitting and spanking), either in anger or as a punishment for or consequence of misbehavior, nor should they use any disciplinary strategy, including verbal abuse, that causes shame or humiliation.

    2. When pediatricians offer guidance about child behavior and parenting practices, they may choose to offer the following:

      • a. guidance on effective discipline strategies to help parents teach their children acceptable behaviors and protect them from harm;

      • b. information concerning the risks of harmful effects and the ineffectiveness of using corporal punishment; and

      • c. the insight that although many children who were spanked become happy, healthy adults, current evidence suggests that spanking is not necessary and may result in long-term harm.

    3. Agencies that offer family support, such as state- or community-supported family resource centers, schools, or other public health agencies, are strongly encouraged to provide information about effective alternatives to corporal punishment to parents and families, including links to materials offered by the AAP.

    4. In their roles as child advocates, pediatricians are encouraged to assume roles at local and state levels to advance this policy as being in the best interest of children.

    Lead Authors

    Robert D. Sege, MD, PhD, FAAP

    Benjamin S. Siegel, MD, FAAP

    Council on Child Abuse and Neglect Executive Committee, 2015–2017

    Emalee G. Flaherty, MD, FAAP

    CAPT Amy R. Gavril, MD, FAAP

    Sheila M. Idzerda, MD, FAAP

    Antoinette Laskey, MD, MPH, MBA, FAAP

    Lori Anne Legano, MD, FAAP

    John M. Leventhal, MD, FAAP

    James Louis Lukefahr, MD, FAAP

    Robert D. Sege, MD, PhD, FAAP

    Liaisons

    Beverly Fortson, PhD – Centers for Disease Control and Prevention

    Harriet MacMillan, MD, FRCPC – American Academy of Child and Adolescent Psychiatry

    Elaine Stedt, MSW – Office on Child Abuse and Neglect, Administration for Children, Youth and Families

    Staff

    Tammy Piazza Hurley

    Committee on Psychosocial Aspects of Child and Family Health, 2016–2017

    Michael W. Yogman, MD, FAAP, Chairperson

    Rebecca Baum, MD, FAAP

    Thresia B. Gambon, MD, FAAP

    Arthur Lavin, MD, FAAP

    Gerri Mattson, MD, FAAP

    Raul Montiel-Esparza, MD

    Lawrence Sagin Wissow, MD, MPH, FAAP

    Liaisons

    Terry Carmichael, MSW – National Association of Social Workers

    Edward Christophersen, PhD, FAAP (hon) – Society of Pediatric Psychology

    Norah Johnson, PhD, RN, NP-BC – National Association of Pediatric Nurse Practitioners

    Leonard Read Sulik, MD – American Academy of Child and Adolescent Psychiatry

    Staff

    Stephanie Domain, MS

    Footnotes

    • Address correspondence to Robert D. Sege, MD, PhD, FAAP. E-mail: rsege{at}tuftsmedicalcenter.org
    • Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

    • The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

    • All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

    References