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American Academy of Pediatrics

This policy is a revision of the policy in

  • 101(4):723
From the American Academy of PediatricsPolicy Statement

Effective Discipline to Raise Healthy Children

Robert D. Sege, Benjamin S. Siegel, COUNCIL ON CHILD ABUSE AND NEGLECT and COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH
Pediatrics December 2018, 142 (6) e20183112; DOI: https://doi.org/10.1542/peds.2018-3112
Robert D. Sege
Center for Community Engaged Medicine, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts; and
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Benjamin S. Siegel
Departments of Pediatrics andPsychiatry, Boston Medical Center and School of Medicine, Boston University, Boston, Massachusetts
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  • RE: AAP Authors of "Effective Discipline to Raise Healthy Children" response to "Should Pediatricians Base Their Parenting Advice on Advocacy or Science?"
    Robert D. Sege and Benjamin S Siegel
    Published on: 30 January 2019
  • RE: Effective Discipline to Raise Healthy Children
    Charles Ross Smith
    Published on: 15 January 2019
  • RE: Should Pediatricians Base Their Parenting Advice on Advocacy or Science?
    Robert E. Larzelere, Den A. Trumbull and Peter Nieman
    Published on: 20 December 2018
  • Published on: (30 January 2019)
    RE: AAP Authors of "Effective Discipline to Raise Healthy Children" response to "Should Pediatricians Base Their Parenting Advice on Advocacy or Science?"
    • Robert D. Sege, Pediatrician, Tufts University School of Medicine
    • Other Contributors:
      • Benjamin S Siegel, Pediatrician

    In response to the comment by Larzelere, et al., we note that all American Academy of Pediatrics policy statements represent the collective work of the primary authors, the two sponsoring AAP committees and over a dozen highly qualified experienced reviewers and staff members within the AAP, and are subject to Board review and approval. Policy statements represents a synthesis of available evidence, and include recommendations based on that evidence.

    The comment begins with claims that overlook or mischaracterize the content of the policy statement. Contrary to the authors’ assertions, (1) this policy 4 is based on a thorough review of the literature and the expert opinions of the authoring committees—advocacy groups played no role; and (2), many alternative approaches to spanking and supporting positive disciplinary strategies are discussed and endorsed—readers are referred to more comprehensive resources.
    A careful reading of the statement can easily clear up these and other issues raised in their note. The suggestion that this statement is a “rant against spanking” is inaccurate.

    In regards to corporal punishment as a method of child discipline, the policy notes that it is (1) ineffective, (2) contributes to a cycle of corporal punishment and aggressive behavior, (3) is a risk factor for nonoptimal child development, and (4) that physiological changes have been observed in children who experience it. Of these four factors that support the policy...

    Show More

    In response to the comment by Larzelere, et al., we note that all American Academy of Pediatrics policy statements represent the collective work of the primary authors, the two sponsoring AAP committees and over a dozen highly qualified experienced reviewers and staff members within the AAP, and are subject to Board review and approval. Policy statements represents a synthesis of available evidence, and include recommendations based on that evidence.

    The comment begins with claims that overlook or mischaracterize the content of the policy statement. Contrary to the authors’ assertions, (1) this policy 4 is based on a thorough review of the literature and the expert opinions of the authoring committees—advocacy groups played no role; and (2), many alternative approaches to spanking and supporting positive disciplinary strategies are discussed and endorsed—readers are referred to more comprehensive resources.
    A careful reading of the statement can easily clear up these and other issues raised in their note. The suggestion that this statement is a “rant against spanking” is inaccurate.

    In regards to corporal punishment as a method of child discipline, the policy notes that it is (1) ineffective, (2) contributes to a cycle of corporal punishment and aggressive behavior, (3) is a risk factor for nonoptimal child development, and (4) that physiological changes have been observed in children who experience it. Of these four factors that support the policy recommendation against corporal punishment, the commenters only address concerns about the evidence supporting the conclusion that corporal punishment is a risk for non-optimal child development. In addition, while the comment asserts, that many of the citations were not primary data sources, we did include primary data in the current statement. The 1998 statement also has primary data sources. As with other policies, we also relied on systematic reviews that, while they do not contain original data, summarize the existing primary data. Among the many references cited were two that we now highlight to show the types of evidence cited: (1) a 2016 meta-analysis1 of studies that included over 160,000 children and documented “a link between spanking and increased risk for detrimental outcome,” and (2) a study by Afifi and others2,who reanalyzed the data from the Adverse Childhood Events study, which included an analysis of over 8,000 largely employed research participants. They concluded that spanking is an independent risk factor for poor adult health, and should be considered along with the other commonly assessed Adverse Childhood Experiences. These and other studies provide strong evidence to support the conclusions in the statement. We disagree with the commenters’ rejection of evidence supporting our conclusions.

    The commenters cite their own, methodologically-oriented, systematic reviews that showed little effect, positive or negative, of spanking. In contrast, a comprehensive review 3, published in 2018, after the policy statement went to press examined the question of causality using standard public health criteria that are used when randomized trials are not possible. Application of these criteria, originally developed to link studies of tobacco smoke to adverse health outcomes, led the authors to conclude that “physical punishment is linked with the same harms to children as physical abuse.”

    In their final paragraph, the writers of the comment note: “The AAP can best support children and families by requiring its policy statements to be based upon more objective summaries of the full range of relevant scientific evidence”. We could not agree more, and believe that the 2018 AAP policy 4 on Effective Discipline to Raise Healthy Children meets this description.

    Robert Sege, MD, FAAP and Benjamin Siegel, MD, FAAP

    1. Gershoff ET, Grogan-Kaylor A. Spanking and child outcomes: Old controversies and new meta-analyses. J Fam Psychol 2016;30:453-69.
    2. Afifi TO, Ford D, Gershoff ET, et al. Spanking and adult mental health impairment: The case for the designation of spanking as an adverse childhood experience. Child Abuse Negl 2017;71:24-31.
    3. Gershoff ET, Goodman GS, Miller-Perrin CL, Holden GW, Jackson Y, Kazdin AE. The strength of the causal evidence against physical punishment of children and its implications for parents, psychologists, and policymakers. The American psychologist 2018;73:626-38.
    4. Sege RD, Siegel BS. Effective Discipline to Raise Healthy Children. Pediatrics 2018;142:e20183112.

    Show Less
    Competing Interests: None declared.
  • Published on: (15 January 2019)
    RE: Effective Discipline to Raise Healthy Children
    • Charles Ross Smith, Pediatrician - retired, N/A

    Another Aspect of The Disciplining of Our Children

    I have wanted to write a response to the position paper on spanking of
    children that has been presented by The American Academy Of Pediatrics
    ( policy statement, to be published in the December 2018 “AAP Says
    Spanking Harms Children” )and, The New York Times.(“Spanking Is
    Ineffective and Harmful to Children, Pediatricians’ Group Says”
    By Christina Caron,Nov. 5, 2018)

    Over the years, I have had many opportunities to speak to parent groups about
    childcare, child rearing and of the many stresses of parenting. It has been
    quite evident to me that the practice of spanking, warning of physical
    consequences and administering pain is deeply engrained in the tradition of
    discipline of children.
    Despite the fact that I have counseled strongly against spanking or, indeed,
    any corporal punishment for children, there is a very strong resistance to
    change.
    My advice comes from the very basic premise that parenting should be the
    modeling of good human behavior.
    In times of stress, disagreement and negativity it is NOT an acceptable
    reaction to address the situation with physical aggression. When, after all,
    is it a good idea for (we adults) to hit the mechanic that has done something
    we see as wrong? When may we threaten bank tellers with a slap when they have
    been rude? When should we strike a person in our lin...

    Show More

    Another Aspect of The Disciplining of Our Children

    I have wanted to write a response to the position paper on spanking of
    children that has been presented by The American Academy Of Pediatrics
    ( policy statement, to be published in the December 2018 “AAP Says
    Spanking Harms Children” )and, The New York Times.(“Spanking Is
    Ineffective and Harmful to Children, Pediatricians’ Group Says”
    By Christina Caron,Nov. 5, 2018)

    Over the years, I have had many opportunities to speak to parent groups about
    childcare, child rearing and of the many stresses of parenting. It has been
    quite evident to me that the practice of spanking, warning of physical
    consequences and administering pain is deeply engrained in the tradition of
    discipline of children.
    Despite the fact that I have counseled strongly against spanking or, indeed,
    any corporal punishment for children, there is a very strong resistance to
    change.
    My advice comes from the very basic premise that parenting should be the
    modeling of good human behavior.
    In times of stress, disagreement and negativity it is NOT an acceptable
    reaction to address the situation with physical aggression. When, after all,
    is it a good idea for (we adults) to hit the mechanic that has done something
    we see as wrong? When may we threaten bank tellers with a slap when they have
    been rude? When should we strike a person in our line when they have “butt
    in”?
    Our behavior to each other in civil society does not permit problem solving
    and frustration to include responding to a conflict with violence, however
    mild.
    Do we, as parents, want to show our children a problem solving strategy that
    is unacceptable in all other corners of mature and civil behavior?
    We are the adults in the room.
    The standard of other strategies such as “time out”, imposing
    consequences, etc. are reasonable and sane for the young mind. We should,
    when appropriate reason, re-explain, show disappointment, and, perhaps,
    remove privileges. Not threaten with and administer pain.
    The image of Daddy with a strap or belt, Mother with her switch should be
    relegated to a historical sadness.

    ID #138288
    12/31/2018
    C. Ross Smith, MD
    Pediatrics
    Wayne, PA 19087
    crosssmith@gmail.com

    Show Less
    Competing Interests: None declared.
  • Published on: (20 December 2018)
    RE: Should Pediatricians Base Their Parenting Advice on Advocacy or Science?
    • Robert E. Larzelere, Professor, Oklahoma State University
    • Other Contributors:
      • Den A. Trumbull, Pediatrician
      • Peter Nieman, Pediatrician, Clinical Assistant Professor

    The new AAP Policy Statement, Effective Discipline to Raise Healthy Children, appears to rely primarily on an advocacy group, the Global Initiative to End all Corporal Punishment of Children, whereas the previous AAP Policy Statement on discipline1 was informed by an AAP-sponsored scientific consensus conference on corporal punishment. Accordingly, the latest Policy Statement reads more like a rant against spanking than scientifically informed recommendations for “effective discipline.” With its prohibition of all physical punishment, only time-out is recommended for childhood misbehavior, citing only one study which concluded “There was no significant effect for timeout use.”2, p. e15 Privilege removal has been dropped in the current Statement.

    Should pediatricians therefore conclude that the only key to effective parental discipline is simply to avoid spanking? The Statement’s cited evidence against physical punishment is drawn from one meta-analysis of unadjusted correlations, 55% of them concurrent correlations,3 ignoring another meta-analysis that reported “trivial” effect sizes in risk-adjusted outcomes.4 Would any medical therapy be evaluated using correlations that are not risk-adjusted (for differences in illness severity or in persistent defiance)? A new meta-analysis just showed that this correlational evidence against spanking disappears after accounting for the predisposition of some children to be more difficult to discipline than others.5

    Th...

    Show More

    The new AAP Policy Statement, Effective Discipline to Raise Healthy Children, appears to rely primarily on an advocacy group, the Global Initiative to End all Corporal Punishment of Children, whereas the previous AAP Policy Statement on discipline1 was informed by an AAP-sponsored scientific consensus conference on corporal punishment. Accordingly, the latest Policy Statement reads more like a rant against spanking than scientifically informed recommendations for “effective discipline.” With its prohibition of all physical punishment, only time-out is recommended for childhood misbehavior, citing only one study which concluded “There was no significant effect for timeout use.”2, p. e15 Privilege removal has been dropped in the current Statement.

    Should pediatricians therefore conclude that the only key to effective parental discipline is simply to avoid spanking? The Statement’s cited evidence against physical punishment is drawn from one meta-analysis of unadjusted correlations, 55% of them concurrent correlations,3 ignoring another meta-analysis that reported “trivial” effect sizes in risk-adjusted outcomes.4 Would any medical therapy be evaluated using correlations that are not risk-adjusted (for differences in illness severity or in persistent defiance)? A new meta-analysis just showed that this correlational evidence against spanking disappears after accounting for the predisposition of some children to be more difficult to discipline than others.5

    The Policy Statement cites 33 studies in its section on “Corporal Punishment as a Risk Factor for Nonoptimal Child Development,” including three other literature reviews that found the effects of spanking to be “trivial,” or “small” at worst. The 33 cited studies also included six publications lacking any original data (five by anti-spanking advocates); five studies of what predicts physical punishment rather than child outcomes predicted by physical punishment; four studies that only investigated other parenting variables (e.g., reprimands, verbal hostility, psychologically intrusive control); and studies of inappropriate physical punishment which was overly severe (six studies) or used during adolescence (one study). This left seven studies, six of which had trivial adverse effect sizes (mean  = .07; equivalent to d = .15 or AOR = 1.31) after controlling for pre-existing child differences, consistent with the few quality meta-analyses that were limited to risk-adjusted prospective studies of spanking.4,5 Remarkably, the latest published meta-analysis shows that these tiny effect sizes become tiny beneficial effects when evaluated with an alternative method of adjusting for pre-existing differences.5 The seventh and final cited study showed better adolescent outcomes for spanked children than never-spanked children as long as the spanking was phased out by age 11. Overall, this cited evidence fails to support the Policy Statement’s conclusion of “a strong association between spanking and subsequent adverse outcomes” (p. 4).

    This policy statement seems informed more by the cited advocacy organization than a fair assessment of scientific evidence. Would pediatricians oppose any other widespread practice (e.g., aspirin for childhood fevers) based mostly on correlational evidence and without recommending a scientifically based alternative? Of course not. The AAP can best support children and families by requiring its policy statements to be based upon more objective summaries of the full range of relevant scientific evidence.

    References

    1. American Academy of Pediatrics. Guidance for effective discipline. Pediatrics. 1998;101:723-728.
    2. Barkin SL, Finch SA, Ip EH, et al. Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics. 2008;122(1):e15-e25.
    3. Gershoff ET, Grogan-Kaylor A. Spanking and child outcomes: Old controversies and new meta-analyses. Journal of Family Psychology. 2016;30:453-469.
    4. Ferguson CJ. Spanking, corporal punishment and negative long-term outcomes: A meta-analytic review of longitudinal studies. Clinical Psychology Review. 2013;33:196-208.
    5. Larzelere RE, Gunnoe ML, Ferguson CJ. Improving causal inferences in meta-analyses of longitudinal studies: Spanking as an illustration. Child Development. 2018;89(6):2038-2050.

    Show Less
    Competing Interests: None declared.
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Effective Discipline to Raise Healthy Children
Robert D. Sege, Benjamin S. Siegel, COUNCIL ON CHILD ABUSE AND NEGLECT, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH
Pediatrics Dec 2018, 142 (6) e20183112; DOI: 10.1542/peds.2018-3112

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Effective Discipline to Raise Healthy Children
Robert D. Sege, Benjamin S. Siegel, COUNCIL ON CHILD ABUSE AND NEGLECT, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH
Pediatrics Dec 2018, 142 (6) e20183112; DOI: 10.1542/peds.2018-3112
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    • Abstract
    • Introduction
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    • Effective Discipline Supports Normal Child Development
    • Corporal Punishment
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  • Sege RD, Siegel BS; Council on Child Abuse and Neglect; Committee on Psychosocial Aspects of Child and Family Health. Effective Discipline to Raise Healthy Children. Pediatrics. 2018;142(6):e20183112
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