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PEDIATRICS Vol. 101 No. 4 April 1998, pp. 723-728
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ABSTRACT |
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Top
Abstract
Introduction
Recommendation
References
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When advising families about discipline strategies, pediatricians should use a comprehensive approach that includes consideration of the parent-child relationship, reinforcement of desired behaviors, and consequences for negative behaviors. Corporal punishment is of limited effectiveness and has potentially deleterious side effects. The American Academy of Pediatrics recommends that parents be encouraged and assisted in the development of methods other than spanking for managing undesired behavior.
Parents often ask pediatricians for advice about the
provision of appropriate and effective discipline. In fact, 90% of
pediatricians report that they include advice about discipline when
providing anticipatory guidance to families.1 The
American Academy of Pediatrics held a consensus conference on corporal
punishment, the report of which was published in Pediatrics
and serves as one major source of information for this
statement.2
The word discipline, which comes from the root word disciplinare The earliest discipline strategy is passive and occurs as infants
and their caregivers gradually develop a mutually satisfactory schedule
of feeding, sleeping, and awakening. Biologic rhythms tend to become
more regular and adapt to family routines. Signals of discomfort, such
as crying and thrashing, are modified as infants acquire memories of
how their distress has been relieved and learn new strategies to focus
attention on their emerging needs.4
The main parental discipline for infants is to provide generally
structured daily routines but also to learn to recognize and respond
flexibly to the infant's needs. As infants become more mobile and
initiate more contact with the environment, parents must impose
limitations and structure to create safe spaces for them to explore and
play. Equally important, parents must protect them from potential
hazards (eg, by installing safety covers on electric outlets and by
removing dangerous objects from their reach) and introduce activities
that distract their children from potential hazards. Such proactive
behaviors are central to discipline for toddlers. Communicating
verbally (a firm no) helps prepare the infant for later use of
reasoning, but parents should not expect reasoning, verbal commands, or
reprimands to manage the behavior of infants or toddlers.
As children grow older and interact with wider, more complex physical
and social environments, the adults who care for them must develop
increasingly creative strategies to protect them and teach them orderly
and desirable patterns of behavior. As a result of consistent structure
and teaching (discipline), children integrate the attitudes and
expectations of their caregivers into their behavior. Preschoolers
begin to develop an understanding of rules, and their behavior is
guided by these rules and by the consequences associated with them. As
children become school age, these rules become internalized and are
accompanied by an increasing sense of responsibility and self-control.
Responsibility for behavior is transferred gradually from the
caregiving adult to the child, and is especially noticeable during the
transition to adolescence. Thus, parents must be prepared to modify
their discipline approach over time, using different strategies as the
child develops greater independence and capacity for self-regulation
and responsibility. The process can be more challenging with children
who have developmental disabilities and may require additional or more
intense strategies to manage their behavior.
Effective discipline requires three essential components: 1) a
positive, supportive, loving relationship between the parent(s) and
child, 2) use of positive reinforcement strategies to increase desired
behaviors, and 3) removing reinforcement or applying punishment to
reduce or eliminate undesired behaviors. All components must be
functioning well for discipline to be successful.
Promoting Optimal Parent-Child Relationships and Reinforcing
Positive Behaviors
For discipline techniques to be most effective, they must occur in
the context of a relationship in which children feel loved and secure.
In this context, parents' responses to children's behavior, whether
approving or disapproving, are likely to have the greatest effect
because the parents' approval is important to the children. Parental
responses within the context of loving and secure relationships also
provide children with a sense that their environment is stable and that
a competent adult is taking care of them, which leads to the
development of a sense of personal worth. As children respond to the
positive nature of the relationship and consistent discipline, the need
for frequent negative interactions decreases, and the quality of the
relationship improves further for both parents and children. To this
end, the best educators of children are people who are good role models
and about whom children care enough to want to imitate and please.
Certain conditions in the parent-child relationship have been found to
be especially important in promoting positive child behavior,
including:
INTRODUCTION
Top
Abstract
Introduction
Recommendation
References
to
teach or instructrefers to the system of teaching and nurturing that
prepares children to achieve competence, self-control, self-direction,
and caring for others.3 An effective discipline system must
contain three vital elements: 1) a learning environment characterized
by positive, supportive parent-child relationships; 2) a strategy for
systematic teaching and strengthening of desired behaviors (proactive);
and 3) a strategy for decreasing or eliminating undesired or
ineffective behaviors (reactive). Each of these components needs to be
functioning adequately for discipline to result in improved child
behavior.
DEVELOPMENTAL APPROACH TO DISCIPLINE
STRATEGIES FOR EFFECTIVE DISCIPLINE
These factors are important in developing a positive, growth-enhancing relationship between parent and child. Even in the best relationships, however, parents will need to provide behavioral limits that their children will not like, and children will behave in ways that are unacceptable to parents. Disagreement and emotional discord occur in all families, but in families with reinforcing positive parent-child relationships and clear expectations and goals for behavior, these episodes are less frequent and less disruptive.
Rewarding Desirable or Effective Behaviors
The word discipline usually connotes strategies to reduce or eliminate undesirable behaviors. However, more successful child-rearing systems use procedures to both increase desirable behaviors and decrease undesirable behaviors. Eliminating undesirable behavior without having a strategy to stimulate more desirable behavior generally is not effective. The most critical part of discipline involves helping children learn behaviors that meet parental expectations, are effective in promoting positive social relationships, and help them develop a sense of self-discipline that leads to positive self-esteem. Behaviors that the parents value and want to encourage need to be identified by the parents and understood by their children.
Many desirable behavioral patterns emerge as part of the child's normal development, and the role of adults is to notice these behaviors and provide positive attention to strengthen and refine them. Other desirable behaviors are not part of a child's natural repertoire and need to be taught, such as sharing, good manners, empathy, study habits, and behaving according to principles despite the fact that immediate rewards for other behaviors (eg, lying or stealing) may be present. These behaviors must be taught to children through modeling by parents and shaping skills through parental attention and encouragement. It is much easier to stop undesired behaviors than to develop new, effective behaviors. Therefore, parents must identify the positive behaviors and skills that they want for their children and make a concerted effort to teach and strengthen these behaviors.
Strategies for parents and other caregivers that help children learn positive behaviors include:
Such strategies have several potential benefits: the desired behavior is more likely to become internalized, the newly learned behavior will be a foundation for other desirable behaviors, and the emotional environment in the family will be more positive, pleasant, and supportive.
Reducing and Eliminating Undesirable Behavior
When undesirable behavior occurs, discipline strategies to reduce or eliminate such behavior are needed.11 Undesirable behavior includes behavior that places the child or others in danger, is noncompliant with the reasonable expectations and demands of the parents or other appropriate adults (eg, teachers), and interferes with positive social interactions and self-discipline. Some of these behaviors require an immediate response because of danger or risk to the child. Other undesirable behaviors require a consistent consequence to prevent generalization of the behavior to other situations. Some problems, particularly those that involve intense emotional exchanges, may be handled best by taking a break from the situation and discussing it later when emotions have subsided, developing alternative ways to handle the situation (removing attention), or, in many cases, avoiding these situations altogether.
Extinction including time-out and removal of privileges, and punishment are two common discipline approaches that have been associated with reducing undesired behavior. These different strategies, sometimes both confusingly called punishment, are effective if applied appropriately to specific behaviors. Although they both reduce undesired behavior, they work in very different ways and have very different short- and long-term effects. For both strategies, the following factors may increase the effectiveness:
Occasionally, the consequence for an undesired behavior is immediate, without parental involvement (eg, breaking one's own toy), and may be effective in teaching children to change their behavior. When this consequence is combined with parental reprimand, there is an increase in the likelihood that the child's behavior will be affected for future similar situations.
Time-Out or Removal of Privileges
Time-out and removal of privileges are approaches that involve removing positive reinforcement for unacceptable behavior. For young children, time-out usually involves removing parental attention and praise (ignoring) or being placed in a chair for a specified time with no adult interaction. For older children and adolescents, this strategy usually involves removing privileges or denying participation in activities (eg, grounding for an evening with no TV or loss of driving privileges). To be effective, this strategy requires that a valued privilege or reinforcer is removed. In preschool children, time-out (removal of positive parental attention) has been shown to increase compliance with parental expectations from ~25% to 80%,12 and similar effectiveness is seen when used appropriately with older children.14 To be effective, however, time-out must be used consistently, for an appropriate duration, not excessively, and with strategies for managing escape behavior in place before the time-out is imposed. To be successful, time-out requires effort and practice on the part of the parents and, in some cases, requires specific education with a professional.
Several aspects of time-out must be considered to ensure effectiveness. When time-out is first implemented, it usually will result in increased negative behavior by the child, who will test the new limit with a display of emotional behavior, sometimes approaching a temper tantrum. The parent who accepts this normal reaction and does not respond to the child's behavior will find that outbursts become less frequent and that the targeted undesirable behavior also diminishes or disappears. When time-out is used appropriately, the child's feelings are neither persistent nor damaging to self-esteem, despite the intensity of the reaction. However, if the parent engages in verbal or physical interaction with the child during this disruptive behavior, the emotional outburst, as well as the behavior originally targeted, not only will persist, but may worsen. Second, time-out often is not effective immediately, although it is highly effective as a long-term strategy. Third, it is often difficult emotionally for a parent to ignore the child during periods of increased negative behaviors or when the child begins pleading and bargaining for time-out to end. The inability of parents to deal with their own distress during a time-out is one of the most common reasons for its failure.
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PUNISHMENT |
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Punishment is defined as the application of a negative stimulus to reduce or eliminate a behavior. There are two types typically used with children: punishment involving verbal reprimands and disapproval and punishment involving physical pain, as in corporal punishment.
Verbal Reprimands
Many parents use disapproving verbal statements as a form of punishment to alter undesired behavior. When used infrequently and targeted toward specific behaviors, such reprimands may be transiently effective in immediately halting or reducing undesirable behaviors. However, if used frequently and indiscriminately, verbal reprimands lose their effectiveness and become reinforcers of undesired behavior because they provide attention to the child. Verbal reprimands given by parents during time-out are a major cause of reduced effectiveness of this form of discipline. Verbal reprimands should refer to the undesirable behavior and not slander the child's character.
Corporal Punishment
Corporal punishment involves the application of some form of
physical pain in response to undesirable behavior. Corporal punishment ranges from slapping the hand of a child about to touch a hot stove to
identifiable child abuse, such as beatings, scaldings, and burnings.
Because of this range in the form and severity of punishment, its use
as a discipline strategy is controversial. Although significant
concerns have been raised about the negative effects of physical
punishment and its potential escalation into abuse, a form of physical
punishmentspankingremains one of the strategies used most commonly
to reduce undesired behaviors, with >90% of American families
reporting having used spanking as a means of discipline at some
time.15 Spanking, as discussed here, refers to
striking a child with an open hand on the buttocks or extremities with
the intention of modifying behavior without causing physical injury.
Other forms of physical punishment, such as striking a child with an
object, striking a child on parts of the body other than the buttocks
or extremities, striking a child with such intensity that marks lasting
more than a few minutes occur, pulling a child's hair, jerking a child
by the arm, shaking a child, and physical punishment delivered in anger
with intent to cause pain, are unacceptable and may be dangerous to the
health and well-being of the child. These types of physical punishment should never be used.
Despite its common acceptance, and even advocacy for its use,16 spanking is a less effective strategy than time-out or removal of privileges for reducing undesired behavior in children. Although spanking may immediately reduce or stop an undesired behavior, its effectiveness decreases with subsequent use. The only way to maintain the initial effect of spanking is to systematically increase the intensity with which it is delivered, which can quickly escalate into abuse. Thus, at best, spanking is only effective when used in selective infrequent situations.
The following consequences of spanking lessen its desirability as a strategy to eliminate undesired behavior.
Parents who spank their children are more likely to use other unacceptable forms of corporal punishment.21 The more children are spanked, the more anger they report as adults, the more likely they are to spank their own children, the more likely they are to approve of hitting a spouse, and the more marital conflict they experience as adults.20 Spanking has been associated with higher rates of physical aggression, more substance abuse, and increased risk of crime and violence22 when used with older children and adolescents.
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RECOMMENDATIONS |
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Top
Abstract
Introduction
Recommendation
References
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Because of the negative consequences of spanking and because it has been demonstrated to be no more effective than other approaches for managing undesired behavior in children, the American Academy of Pediatrics recommends that parents be encouraged and assisted in developing methods other than spanking in response to undesired behavior.
The Pediatrician's Role
Encouraging alternative methods may evoke strong responses from
some parents and pediatricians because 90% of parents in the United
States spank their children, and most adults were spanked when they
were children. A survey indicated that 
59% of pediatricians support
the use of corporal punishment, at least in certain
situations.1 Support for spanking is higher in
response to a child who runs into the street than it is as a punishment
for hitting another child, even though the adult reaction of fear is
the most effective deterrent in the former. As with other adults,
pediatricians have learned much of their parenting skills from their
own parents, who likely used spanking, and find their parents'
practices more acceptable than other methods.23 Changing
discipline methods in the United States is likely to take time and to
occur gradually, but it should be a goal of pediatricians and parents.
Discussing discipline with parents can be difficult and emotionally charged because opinions about these practices are formed in childhood. This learning occurred under emotional circumstances and is affected by parents' needs to justify their own parents' practices. Also, some religious groups take strong positions on this issue, often in favor of corporal punishment. In addition, discipline practices are under public scrutiny because of the increasing recognition of child abuse, which pediatricians are required to report. As a result, parents may be cautious about discussing their discipline practices. One effective way to start a discussion is by making an observation about the child's behavior during a health care visit and asking about the child's behavior at home. If parents comment negatively about their child's behavior, the severity of the problem should be determined. Eliciting specific examples of disciplinary encounters and responding nonjudgmentally to them are key to understanding the degree of behavioral disturbance24 and the appropriateness of parental response. Asking about the parents' childhood experiences with discipline, their decision about how they would discipline as parents, and what other key people in their lives say about how they should discipline their children can be beneficial to understanding the parents' philosophy about discipline. It is important to obtain information about all three aspects of the system of discipline (parent-child relationship, shaping and teaching desired behavior, and reducing undesired behavior) to determine which aspects may require intervention.3 Generally, a visit with all the key caregiving adults is most effective when there is a problem, although this may not be necessary in cases involving minor discipline problems.25 Parenting is difficult; parents deserve information, encouragement, and support over time.
Specific Physician Activities
When counseling families about discipline, physicians need to26:
The aspects of the system of discipline presented herein are effective when used at home, in out-of-home child care, at school, and in laboratory settings. Parents can be taught the use of appropriate discipline effectively through reading27; at-home family review of videotapes presenting behavioral situations28; individual instruction by a nurse in a health care setting29; individual or family counseling with a competent professional; group didactic teaching; or group instruction with modeling, role-playing, videotapes, or direct feedback about their parent-child interactions.30 The intensity and duration of intervention needed to produce a change in family interaction depend on the severity of the child's behavior problems and on other stresses in the family, rather than on income level or social class. Studies have shown generalization from laboratory settings to the home, school,28 and untreated sibling behavior, and across time. Pediatricians must be creative, persistent, and hopeful to generate change in the gradual manner in which it is likely to occur. A broader view of discipline needs to include the entire social structure. For example, cultures with children with relatively few behavior problems have been characterized by clear role definitions, clear expectations for the child's active work role in the family, very stable family constellations, and involvement of other community members in child care and supervision.31 Advocacy by pediatricians for other supports within communities also is desirable.
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SUPPLEMENTARY INFORMATION |
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50% of the time because the parent had lost it. Approximately 85%
expressed moderate to high anger, remorse, and agitation while punishing their children.21 These findings challenge
most the notion that parents can spank in a calm, planned manner. It is best not to administer any punishments while in a state of anger.
COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH,
1997 TO 1998
Mark L. Wolraich, MD, Chairperson
Javier Aceves, MD
Heidi M. Feldman, PhD, MD
Joseph F. Hagan, Jr, MD
Barbara J. Howard, MD
Anthony J. Richtsmeier, MD
Deborah Tolchin, MD
Hyman C. Tolmas, MD
LIAISON REPRESENTATIVES
F. Daniel Armstrong, PhD
Society of Pediatric Psychology
David R. DeMaso, MD
American Academy of Child and Adolescent
Psychiatry
William J. Mahoney, MD
Canadian Paediatric Society
Peggy Gilbertson, RN, MPH, CPMP
National Association of Pediatric
Nurses Association and Practitioners
CONSULTANT
George J. Cohen, MD
National Consortium for Child Mental
Health Services
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REFERENCES |
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Top
Abstract
Introduction
Recommendation
References
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Statement of reaffirmation:
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