OBJECTIVE: The objective was to determine if a primary care intervention can help caregivers develop appropriate methods of discipline.
PATIENTS AND METHODS: A randomized, controlled trial was conducted in a pediatric primary care clinic. Consecutive English- or Spanish-speaking caregivers of 1- to 5-year-old children were randomly assigned (1:1 ratio) at triage. Members of the intervention group (n = 130) were instructed (ie, required) to view at least 4 strategies of their choosing for responding to childhood aggression in the Play Nicely educational program; Spanish-speaking caregivers viewed the Spanish edition. The intervention duration was 5 to 10 minutes. Those in the control group (n = 129) received standard care. At the end of the clinic visit, 258 of 259 caregivers (99.6%) consented to participate in a brief personal interview. The key measure was whether caregivers were helped in their plans to discipline, defined as a caregiver who could verbalize an appropriate change in how they would discipline their child in the future.
RESULTS: Overall, caregivers in the intervention group were 12 times more likely to have been helped in developing methods of discipline compared with caregivers in the control group (83% vs 7%; P < .001). Within this group, Spanish-speaking caregivers (n = 59) in the intervention group were 8 times more likely to have been helped compared with those in the control group (91% vs 12%; P < .001). Caregivers in the intervention group were more likely than caregivers in the control group to report that they planned to do less spanking (9% vs 0%; P < .001).
CONCLUSIONS: A brief, required, primary care intervention helps English- and Spanish-speaking caregivers develop appropriate methods of discipline. The findings have implications for violence prevention, child abuse prevention, and how to incorporate counseling about childhood aggression and discipline into the well-child care visit.
- child abuse
- prevention and control
- child behavior
- primary care
WHAT'S KNOWN ON THIS SUBJECT:
Use of inappropriate discipline and persistent childhood aggression are risk factors for violence. No practical solution has been identified for the problem of low rates of anticipatory guidance being provided to parents regarding childhood behavior and discipline.
WHAT THIS STUDY ADDS:
Brief interventions, incorporated into the primary care visit, can markedly increase the proportion of English- and Spanish-speaking parents of young children who are helped with developing plans to discipline their child. The study has implications for violence prevention.
Inappropriate parental discipline and childhood aggression are strong risk factors for violent behavior later in life.1,–,7 As defined by the World Health Organization,1 some types of discipline constitute child abuse. In theory, violence, including child abuse, could be reduced if parents used appropriate methods to discipline their children in the early years.8,–,10 Leading organizations, such as the American Academy of Pediatrics, that focus on children's health have recommended that primary care providers routinely address childhood behavior and discipline during well-child visits.11,–,14 Studies have documented that parents want their providers to teach them about how to discipline and primary care providers are interested in providing the information.15,–,21 However, messages about discipline are not being routinely delivered in primary care.22,23
Research has documented that parents can be taught parenting skills, but few studies have been conducted in primary care settings.24,–,32 Specifically, a concerning gap in the literature is that no practical solution has been identified for the problem of low rates of anticipatory guidance being provided to parents regarding childhood behavior and discipline. We are not aware of any randomized, controlled study that has been able to demonstrate a practical way to help parents develop appropriate discipline strategies during the course of a routine primary care visit.
To address this gap in the literature, we conducted a randomized, controlled trial of a multimedia intervention in a primary care clinic. Our primary objective was to determine if a required primary care intervention can help English- and Spanish-speaking parents of 1- to 5-year-old children develop methods of discipline. Our secondary objective was to determine if the intervention was helpful to all caregivers or only those with certain sociodemographic characteristics. If a brief intervention could help caregivers of various backgrounds, this study would have implications for improving primary care offerings related to child maltreatment prevention and violence prevention.
Design and Setting
The study was a randomized, controlled trial conducted in the Vanderbilt Pediatric Primary Care Clinic in June and July of 2008. Pediatric residents staff the clinic. The study was approved by the Vanderbilt Institutional Review Board.
Potential participants were consecutive parents presenting with their child for a well child visit. Eligibility criteria were being the caregiver of a child between the ages of 12 months and 5 years and being able to speak either English or Spanish. A research assistant (Ms Hudnut-Beumler) assessed eligibility during triage (see Fig 1 to review the flow of participants in the study). Most (80%) of the families who are seen in the clinic are on TennCare (Tennessee's Medicaid-managed insurance program); 15% have commercial insurance, and 5% are private pay.
Intervention and control designations were sealed in an equal number of opaque envelopes that were mixed together. For all eligible caregivers, the research assistant drew and opened an envelope at random to randomly assign the parent into either an intervention or control group (1:1 ratio). Randomization was performed without the caregivers' knowledge.
Intervention and Control Groups
After the family was in the examination room, caregivers in the intervention group viewed the educational intervention on a mobile desktop computer before the physician visit. Caregivers were instructed that viewing the program was a part of the clinic visit. After viewing, the pediatrician conducted the well-child visit. Caregivers in the control group had a routine well-child visit with the pediatrician. The pediatricians were not given any instructions in the study.
The intervention was the Play Nicely program, a multimedia educational program.33 Permission to demonstrate the program to multiple viewers was obtained from the copyright holder.33 English-speaking caregivers viewed the 2nd English-language edition and Spanish-speaking caregivers viewed the Spanish edition. In the program, viewers are presented with a hypothetical situation of a young child having hurtful behavior toward another child; then, viewers are presented with 16 options (20 options in the Spanish version) (Table 1). Caregivers in the intervention group were instructed to view 4 of the interactive options of their choosing by using a standard introduction: “As part of your visit today, your doctor would like you to watch this video … please pick as many options as you want, but pick at least four.” On average, it takes 1 minute to view 1 option. The research assistant stayed in the room whenever possible to monitor the viewing process and help with child care as needed. It was estimated that more than 95% of the parents viewed the program without additional instruction, and 90% of children sat on their parent's lap and watched the program with their parent. Except for 1 parent who declined to view the program, all caregivers (129 of 130) in the intervention group viewed at least 4 options; 34% (44 of 130) viewed >4 options.
Recruitment into the study occurred immediately after the physician visit. Using a standardized dialogue, the research assistant invited caregivers to participate in a 2-minute research interview. Caregivers were enrolled in the study and data were collected only if they provided verbal informed consent. When >1 caregiver viewed the intervention, the caregivers decided who would be the research participant. Almost all (258 of 259 [99.6%]) parents solicited agreed to participate.
Measures included demographic information and measures of caregivers' plans to change how they discipline. Demographic characteristics were caregivers' age, gender, education, race, marital status, and years of experience working in day care or preschool. Race was classified by the participant from options defined by the investigators. All caregivers were asked, “As a result of your clinic visit today, do you plan to change how you discipline your child or respond to your child's behavior in the future?” If the answer was yes, caregivers were asked an open-ended follow-up question about what they planned to do more or less. Responses were recorded and categorized into 1 of the following predefined strategies:
time-out: parent mentions time-out or removing child from area;
saying “no”: parent uses only the word “no”;
setting the rule or verbal reprimand: parent explains the rule for proper behavior (ie, more than saying “no”);
promoting empathy: parent speaks to child about how behavior affects others;
explaining why: parent discusses with child about why hurtful behavior is wrong;
talking to children: parent discusses child's behavior but does not discuss why what the child did was wrong;
physical punishment: parent hits child with his or her hand or an object;
redirecting: parent has child engage in a nonhurtful behavior;
taking away a privilege: parent takes away something the child likes; or
praising for good behavior: parent gives positive comment for behaving properly.
We defined a parent who had been helped in developing appropriate methods for discipline as one who (1) answered “yes” to the question about whether they planned to change how they discipline their child in the future and (2) was able to verbalize a specific change about how they would discipline in the future that was an appropriate way to discipline children as described in material published by the American Academy of Pediatrics,11,34,35 the National Association for the Education of Young Children,36,37 or the American Psychological Association.35 The research assistant who assigned group allocation also assessed outcomes.
For the intervention and control groups, we compared the proportion of caregivers who had been helped with methods for discipline. We performed this comparison for caregivers with different sociodemographic backgrounds. For each of these comparisons, we used the Pearson χ2 test.
We compared the proportion of caregivers in the intervention group who verbalized a specific change (eg, less spanking) with those caregivers in the control group. These comparisons were calculated by using the Pearson χ2 test or, if 1 or more of the cells had an expected frequency of 5 or less, the Fisher's exact test. Because of the large number of tests used in these analyses, an α level of .001 (ie, P < .001) was required for suggesting statistical significance.
There were 259 caregivers who were randomly assigned to be in the study; 130 were allocated to the intervention group and 129 to the control group. One caretaker in the intervention group did not complete the study; therefore, the analysis includes 129 caretakers in the intervention. Spanish was the primary language for 59 (23%) of the caregivers. Demographic characteristics are listed in Table 2. None of the differences between the groups were statistically significant (P > .05).
Overall, caregivers in the intervention group were 12 times more likely to have been helped in developing appropriate methods of discipline compared with caregivers in the control group (83% vs 7%; P < .001). Categorizing by sociodemographic characteristics (Table 3), the proportion of caregivers who were helped varied, but overall, caregivers were many times more likely to have been helped if they were in the intervention group compared with the control group. For the 59 Spanish-speaking caregivers in the study, those who were in the intervention group were 8 times more likely to have been helped compared with the control group (91% vs 12%; P < .001).
Caregivers who reported that they planned to change how they discipline as a result of the clinic visit were asked to list what they planned to do more and less frequently (Table 4). Caregivers in the intervention group verbalized more planned changes on average compared with caregivers in the control group (1.2 [range: 0–4] vs 0.1 [range: 0–2]; P < .001). Caregivers in the intervention group were more likely than controls to report that they planned to do more explaining of the reasons for not using hurtful behavior to their child (21% vs 2%; P < .001), talking to their child (16% vs 2%; P < .001), time-out (13% vs 0%; P < .001), and redirecting (9% vs 0%; P = .001). Caregivers in the intervention group were more likely than controls to report that they planned to do less spanking (9% vs 0%; P < .001). Twelve caregivers, all in the intervention group, stated that they planned to do less spanking and were asked what they saw or heard during the visit to cause them to consider using less spanking; their demographic characteristics are listed in Table 2 and their responses are paraphrased in Table 5.
We found that a brief primary care intervention can help caregivers develop methods of discipline. Compared with a control group, caregivers of 1- to 5-year-old children who were required to view an adjunctive multimedia intervention as part of the well-child visit were 12 times more likely to be helped in developing alternative discipline strategies. The results have implications for child abuse prevention, violence prevention, and how to improve anticipatory guidance counseling related to parental discipline.
Compared with the cost of other parenting programs,24,–,27 implementation of the intervention was inexpensive and practical in our primary care setting. Necessary equipment included a CD-ROM program and a computer on a mobile table. The program must be introduced to the caregiver by a person; however, this person requires no training in pediatrics or childhood development.
These findings are important because they pave the way for an important public health topic to be routinely addressed within the well-child visit for caregivers with markedly different sociodemographic backgrounds. First, the intervention addresses known precursors for violence, a leading public health problem.1,38,39 In the United States, interpersonal violence, which includes child abuse, is 1 of the top 10 leading causes of death39 from age 1 through age 44 and it consumes ∼3.3% of the US gross domestic product.40 Poor parenting practices and a history of violent behavior are 2 key risk factors in an ecological model for interpersonal violence published by the World Health Organization.1
Second, the study demonstrates that primary care providers may have a practical way to follow recommendations by leading organizations to counsel parents about appropriate discipline strategies on a routine basis. The American Academy of Pediatrics recommends that physicians “discuss discipline during well-child visits” and that “parents be encouraged and assisted in the development of methods other than spanking for managing undesired behavior.”11 The Canadian Paediatric Society recommends that physicians “take an anticipatory approach to discipline” and “include a discussion on effective means of discipline.”13 Despite these recommendations, ours is the first study, to our knowledge, to describe a practical solution for caregivers to be helped in learning discipline options in primary care settings on a routine basis (ie, primary prevention).
Third, this study's results suggest that addressing discipline can be accomplished successfully with caregivers of different backgrounds. It is known that discipline strategies vary between cultures,41 and that minorities may be reluctant to receive parenting advice from an ethnically different health care provider.19,42 In general, we found that the intervention affected the discipline plans of caregivers, regardless of whether they were mothers or fathers, young or old, highly educated or not, or black or white. In addition, the program was effective for caregivers who spoke a language other than English.
Finally, this is the first study, to our knowledge, to provide an estimate of how often physicians affect parents' plans to discipline. Physicians counsel parents about discipline ∼40% of the time.22,23 Thirty–five percent of caregivers in the current study reported that their resident physician discussed discipline or child behavior (to be addressed in a separate study). However, only 7% of caregivers seen by the resident physician were able to verbalize a specific planned change. The authors of future studies should measure not only rates of counseling, but also rates of counseling that helps parents. That only 7% of parents were helped also calls for more efforts to teach counseling skills to professionals.43
It is interesting that some parents in the intervention group planned to use time-out more frequently and other parents planned to use time-out less frequently. We believe that the most likely explanation is that, consistent with recommendations the National Association for the Education of Young Children recommendations,37 time-out is described in the program as a good option for children older than 2 years after other options have failed. Thus, at baseline, some parents may have been overusing or underusing this strategy. Nevertheless, this study was limited by not collecting data regarding baseline discipline strategies.
Other limitations in this study include lack of geographic variability. We included a diverse group of parents including a subgroup whose primary language was Spanish; however, more studies are needed to determine if these findings can be replicated in other locations. Pilot studies suggest that preschools and child care sites should also be studied.44,45 Another limitation was that the research assistant who conducted the postvisit interview was not blinded to the intervention allocation. To reduce the likelihood for bias during the interview, we made no subjective measurements (eg, parenting behavior) and the research assistant asked questions by using a standardized approach. The proportion of parents who were helped in developing discipline strategies in the intervention group (83%) was consistent with findings from a study in which 90% of parents reported a planned change in how they would discipline.31 We believe that we defined our key outcome rather conservatively; a parent who was helped in developing methods of discipline had to verbalize an appropriate planned change.
We did not measure longitudinal behavior outcomes so that we could enroll consecutive caregivers who were representative of a population. Longitudinal studies of primary prevention interventions that measure behavior change are certainly needed; however, they have an inherent limitation of a selection bias (ie, participants willing to enroll may be more likely to respond to the intervention and/or be at lower risk of violent behavior). In addition, it is difficult to demonstrate behavior change by using a population-based approach because of sample size issues. For example, conduct disorder is a surrogate marker for violence later in life. Assuming a rate of conduct disorder of 5% and assuming that one would like to be able to detect a reduction of 10% in the rate of conduct disorder in an intervention group compared with a control group, investigators would need to enroll 28 000 participants and follow them through early childhood (α = .05 and β = .8).46 This would be a tremendous undertaking. Furthermore, in the end, one would only be measuring a marker for violent acts later in life and, because of selection bias, not be sure that the results apply to the entire population. Waiting for longitudinal evidence proving that brief primary prevention interventions affect rates of violent behavior will likely delay progress in the area of violence prevention.
If, as the American Academy of Pediatrics and the Canadian Paediatric Society recommend, all parents are to receive anticipatory guidance about discipline strategies, we believe that 2 obstacles will need to be overcome. First, primary care providers will need to change how they introduce parents to information about discipline. In a waiting room study in which parents were invited to learn about behavior management, less than half participated if given the choice, but all agreed if viewing the information was required.32 Physicians will also miss opportunities if they counsel on the basis of parents' comfort level.31 Physicians should consider taking the approach that “learning how to discipline or respond to behavior problems is the next part of the clinic visit.” Ethical concerns may be sparked by requiring parents to learn about discipline strategies, but discussions should be balanced with the ethical concerns of children being reared by parents who may not know appropriate discipline methods.
The second change is a reassessment of health care reimbursement policies. A busy private practitioner will lose financially with any intervention that lengthens time in the examination room. In 1 study, 71% of pediatricians reported that they have insufficient time during the well-child visit to address violence prevention issues.23 In another study, only 17% of pediatricians reported that they were adequately reimbursed for counseling efforts.47 Physicians who expressed the most concern about time constraints were less likely to report that they counseled parents.47 Health care providers currently have no incentive to routinely counsel and some may actually feel financial pressure not to counsel.
“Poor monitoring and supervision of children by parents and the use of harsh physical punishment to discipline children are strong predictors of violence during adolescence.”1 Brief primary care interventions can help parents develop appropriate strategies to discipline their children, and, in theory, hold promise for reducing rates of violence in our society.
Support for the research was provided by the Scholarly Activities Fund, Division of General Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt. Vanderbilt University is a nonprofit institution. The Morgan Family Foundation, a nonprofit organization, was a sponsor for the development of the Spanish-language version of Play Nicely. There was no commercial funder for the development of the program or the research. All 3 authors, independent of any commercial funder or sponsor, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
We thank Drs Aida Yared and Barron Patterson for review of the article, and we acknowledge Dr Richard E. Tremblay, whose epidemiologic research in the area of childhood aggression provided inspiration for the development of the Play Nicely program. We acknowledge Brian Connatser for his work as the software engineer for the Play Nicely program. We thank Laurie Albritton for her efforts in translating the program into Spanish.
- Accepted September 2, 2009.
- Address correspondence to Seth J. Scholer, MD, MPH, Vanderbilt University, Department of Pediatrics, 8232 Doctor's Office Tower, Nashville, TN 37232. E-mail:
FINANCIAL DISCLOSURE: The Play Nicely program is owned by Vanderbilt University, and Dr Scholer is one of the authors of the program; Ms Hudnut-Beumler and Dr Dietrich have indicated they have no financial relationships relevant to this article to disclose.
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- Copyright © 2010 by the American Academy of Pediatrics