Effective Discipline to Raise Healthy Children

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.