Giving guidance on child discipline
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7230.261 (Published 29 January 2000) Cite this as: BMJ 2000;320:261All rapid responses
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A ban of a medical intervention would never be supported on the basis
of such meager evidence as was used recently to support a ban of the
parental intervention of smacking.1 "Significant adverse effects" and a
failure to "learn the desired behaviour" were based on a literature review
that is
unpublished2 and includes studies that incorporated severe types of
corporal punishment such as "beating with a stick," "still hurt the next
day," "burning," and "using a knife or gun." Most reviewed studies were
cross-sectional, which cannot disentangle the causal direction between
smacking and child misbehavior.2
In the only published review of child outcomes of nonabusive or customary
physical punishment, only 8 studies could disentangle the causal effects
of smacking.3 All eight of those studies, including four randomized
clinical trials, found nonabusive smacking to have beneficial child
effects when used to back up milder disciplinary tactics with 2- to 6-year
-olds.
Smacking then makes milder tactics more effective, not "harder to use" as
concluded by Waterston.1
Another unpublished study4 was cited to conclude that Swedish "public
opinion on the need for physical punishment changed dramatically after a
public education campaign" following their 1979 smacking ban. The so-
called
dramatic change was artificially created by comparing entirely different
survey questions before 1982 and in 1994. The 1994 survey question most
similar to the previous question showed an increased endorsement of mild
or
moderate physical punishment as sometimes necessary - from 26% in both
1978 and 1981 to 34% in 1994.5 The 1994 Swedish survey also found that
corporal punishment of teenagers was as prevalent after the 1979 ban as in
prior generations and that, overall, corporal punishment had decreased
very
little.5
Consequently, it is reassuring to see the British proposal aim for a
middle ground between the status quo and a 100% smacking ban. As
Waterston1 noted, parents are already motivated to find alternatives to
smacking, and positive parent-child involvement and enhancing appropriate
child behaviors are good places to start. The most difficult puzzle for
parents and professionals concerns effective methods for decreasing
misbehavior.
Eighteen studies in the 1996 review investigated alternative disciplinary
tactics as well as smacking.3 Only grounding was more effective than
smacking, in two studies of older children. In contrast, nine alternatives
were associated with more detrimental child outcomes than was smacking.
Parents need to be empowered with more effective alternatives, not dis-
empowered by premature bans on traditional disciplinary tactics.
Robert E. Larzelere, Ph.D.
Psychologist
Psychology Department,
Munroe-Meyer Institute,
University of Nebraska Medical Center,
Omaha, NE 68198-5450,
USA
1. Waterston T. Giving guidance on child discipline. British Medical
Journal (BMJ) 2000;320:261-262.
2. Gershoff ET. The effects of parental corporal punishment on
children: A process model and meta-analytic review. Tempe, AZ: Arizona
State University, 1999.
3. Larzelere RE. A review of the outcomes of parental use of
nonabusive or customary physical punishment. Pediatrics 1996;98:824-828.
4. Durrant JE. The status of Swedish children and youth since the
passage of the 1979 corporal punishment ban. London: Save the Children,
1997.
5. Sanden A. Spanking and other forms of physical punishment: A study
of adults' and middle school students' opinions, experience, and
knowledge.
Stockholm: Statistics Sweden, 1996.
Competing interests: No competing interests
The art of child rearing is a complex process where the outcome of a
parent's efforts is influenced by many factors unique to the child, the
parent, the environment, and the context. Dr. Waterston's editorial
promoting a ban on all disciplinary physical punishment does not respect
this complexity and oversimplifies the debate of a parent's use of
spanking (smacking).
Dr. Waterston cites the American Academy of Pediatrics consensus
conference on corporal punishment as a source of defense for his position.
As a participant at the conference, I would like to clarify some of the
committee's findings:
The group's goal was to develop consensus statements regarding "the
scientific evidence on the long and short-term effects of corporal
punishment on children." The proceedings of the conference were published
as a supplement to the October 1996 issue of Pediatrics.
Definitions were the first order of business for the group:
Corporal Punishment: "bodily punishment of any kind."
Spanking: "physically non-injurious, intended to modify behavior, and
administered with the open hand to the buttocks or the extremities."
Using these strict definitions prevented the common mistake of mixing
abusive physical punishment with non-injurious disciplinary spanking.
With these definitions, the committee could not reach any strong
conclusions favoring or opposing a parent's use of disciplinary spanking
between the ages of 2 and 11 years.
Central to the conference, however, was an exhaustive review of the
literature on corporal punishment presented by clinical psychologist, Dr.
Robert Larzelere. In his review he found stronger evidence of beneficial
than detrimental effects of nonabusive spanking by parents with preschool
children, ages 2 to 6 years.
Dr. Diana Baumrind of University of California, Berkley, noted in her
response to his review, "As Dr. Larzelere's review of quality studies
documents, a blanket injunction against disciplinary spanking by parents
is not scientifically supportable."
The conference Co-chairpersons, Drs. Stanford Friedman and Kenneth
Schonberg, concluded "Given a relatively 'healthy' family life in a
supportive environment, spanking in and of itself is not detrimental to a
child or predictive of later problems...[T]here is a lack of research
related to the use of corporal punishment."1
Developmental research indicates that optimal child outcomes result
from authoritative parenting which combines positive encouragement with
consistent behavioral control of the young child.2 Dr. Waterston
describes the process of encouragement well, but leaves parents short-
handed on techniques for behavioral control. Young children need
correction and punishment at times, but this fact is often ignored by
physical punishment opponents. Timeout and disapproval are effective
behavioral management tools, but they are not sufficient to control all
problem behavior with all young children. Physical punishment, when
properly applied, can augment nonphysical measures and optimize the
behavioral control process. To remove nonabusive physical punishment from
the repertoire of parents of young children could promote child abuse and
lead to increases in violence among older, unruly children. This seems,
from statistics, to have been an effect that the Swedish ban has had on
that society.
I would urge the makers of public policy in the United Kingdom to move
slowly, objectively and scientifically in analyzing this issue. A more in
-depth analysis of this subject can be found in an article on the Internet
at:
www.frc.org/fampol/fp96jpa.html
Den A. Trumbull, MD
Pediatric Healthcare
Montgomery, Alabama
1. Friedman, Stanford B., MD, Schonberg, S. Kenneth, MD, &
Sharkey, Mary (eds). "The Short and Long Term Consequences of Corporal
Punishment." supplement to Pediatrics, 1996; 98 (4):857-858.
2. Baumrind, D. The development of instrumental competence through
socialization. Minnesota Symp Child Psych. 1973;7:3-46.
Competing interests: No competing interests
A ban of a medical intervention would never be supported by a BMJ
editorial on the basis of such meager evidence as was used to support the
parental intervention of smacking.1 "Significant adverse effects" and a
failure to "learn the desired behaviour" were based on a literature review
that is unpublished2 and includes studies of severe corporal punishment
such as "beating with a stick,"3 "still hurt the next day,"4 5 "burning,"6
"authorities involved" due to being "severely harmed,"7 and "using a knife
or gun."8 9 This is like supporting a ban on surgery for cancer due to one
unpublished review of studies of knifing in cities with hospitals. Most of
the studies in the cited review were cross-sectional, which cannot
disentangle the causal direction between spanking and child misbehavior.2.
The editorial did cite the only prospective study of nonabusive
physical punishment that has found it to be associated with subsequent
aggression. That study found that the 4% of kindergarten children who had
not been spanked by a parent in the previous year were less aggressive on
the playground than the other 96% who had been spanked.10 Since they did
not control for how aggressive they were in the first place, it may have
been that the most mild-mannered children cooperated easily at home and,
the next year, on the playground.
In the only published review of child outcomes of nonabusive or
customary physical punishment, only 8 studies had taken the misbehavior
levels of the children into account.11 All eight of those studies,
including four clinical trials, found nonabusive spanking to have
beneficial child effects when used to back up milder disciplinary tactics
with 2- to 6-year-old children. Used in this manner, smacking makes milder
tactics more effective, not "harder to use" as concluded by Waterston.1
One of those clinical trials was cited in the BMJ editorial to support the
statement that "physical punishment is no more effective than other
methods."12 That clinical trial found only one of three alternative
disciplinary tactics to be as effective as a two-swat spank in enforcing
time-out: a brief room isolation enforced by holding the door shut. This
is like saying that a long-used drug should be banned once any other drug
has proven to be equally effective, even when that alternative drug is not
being recommended.
The whole pattern of findings is what you would expect for surgery
for cancer. Those who had such surgery last year would now be more likely
to suffer from cancer-related problems than people who had no such surgery
last year. But causally conclusive studies that took the original level of
cancer into account would find that such surgery reduced subsequent cancer
-related problems relative to no intervention, although perhaps equally as
much as an alternative intervention, such as radiation treatment.
The editorial also cited another unpublished study13 to conclude that
Swedish "public opinion on the need for physical punishment changed
dramatically after a public education campaign." The so-called dramatic
change was artificially created by comparing entirely different survey
questions asked in 1981 and in 1994. The 1994 survey question most similar
to the previous question showed an increased support for mild or moderate
physical punishment as sometimes necessary - from 26% in both 1978 and
1981 to 34% in 1994.14 The same Swedish survey found that "only" 32% of
the generation born after 1979 had received corporal punishment from their
father, compared to 34% in the next oldest generation.
Other Swedish studies have found a 498% increase in child abuse cases
under the age of 7 in criminal statistics and a 672% increase in assaults
by minors against minors from 1981 through 1994. 15 16 It is difficult to
attribute this increase to the spanking ban when spanking has changed very
little. But we need an unbiased explanation of these increases in child
abuse and youth violence before emulating the Swedish experiment.17
Given all this, it is reassuring to see the proposed British
legislation strive for a balance between "anything goes" and a 100%
smacking ban. As Waterston noted, parents are already motivated to find
alternatives to smacking, and positive parent-child involvement and
enhancing positive behaviors are good places to start. The most difficult
puzzle for parents and scientists concerns effective methods for
decreasing misbehavior. Eighteen studies in the 1996 review investigated
alternative disciplinary tactics as well as spanking.11 Only grounding was
more effective than spanking, in two studies of older children. In
contrast, nine alternatives were associated with more detrimental child
outcomes than was spanking. Parents need to be empowered with more
effective alternatives, not dis-empowered by premature bans on traditional
disciplinary tactics.
1. Waterston T. Giving guidance on child discipline. British Medical
Journal (BMJ) 2000;320:261-262.
2. Gershoff ET. The effects of parental corporal punishment on
children: A
process model and meta-analytic review. Tempe, AZ: Arizona State
University, 1999.
3. Engfer A, Schneewind KA. Causes and consequences of harsh parental
punishment: An empirical investigation in a representative sample of 570
German families. Child Abuse and Neglect 1982;6:129-139.
4. Holmes SJ, Robins LM. The influence of childhood disciplinary
experience on the development of alcoholism and depression. Journal of
Child Psychology and Psychiatry and Allied Disciplines 1987;28:399-415.
5. Holmes SJ, Robins LN. The role of parental disciplinary practices
in
the development of depression and alcoholism. Psychiatry 1988;51:24-36.
6. Rohner RP, Kean KJ, Cournoyer DE. Effects of corporal punishment,
perceived caretaker warmth, and cultural beliefs on the psychological
adjustment of children in St. Kitts, West, Indies. Journal of Marriage and
the Family 1991;53:681-693.
7. Dodge K, Pettit GS, Bates JE, Valente E. Social-information-
processing
patterns partially mediate the effect of early physical abuse on later
conduct problems. Journal of Abnormal Psychology 1995;104:632-642.
8. Muller RT. Family aggressiveness factors in the prediction of
corporal
punishment: Reciprocal effects and the impact of observer perspective.
Journal of Family Psychology 1996;10:474-489.
9. Muller RT, Hunter JE, Stollak G. The intergenerational
transmission of
corporal punishment: A comparison of social learning and temperament
models. Child Abuse & Neglect 1995;19:1323-1335.
10. Strassberg Z, Dodge KA, Pettit GW, Bates JE. Spanking in the home
and
children's subsequent aggression toward kindergarten peers. Development
and Psychopathology 1994;6:445-461.
11. Larzelere RE. A review of the outcomes of parental use of
nonabusive
or customary physical punishment. Pediatrics 1996;98:824-828.
12. Roberts MW, Powers SW. Adjusting chair timeout enforcement
procedures
for oppositional children. Behavior Therapy 1990;21:257-271.
13. Durrant JE. The status of Swedish children and youth since the
passage
of the 1979 corporal punishment ban. London: Save the Children, 1997.
14. Sanden A. Spanking and other forms of physical punishment: A
study of
adults' and middle school students' opinions, experience, and knowledge.
Stockholm: Statistics Sweden, 1996.
15. Wittrock U. Barmisshandel i kriminalstatistiken, 1981-1991
[Violent
crimes against children in criminal statistics, 1981-1991]. KR Info
1992;7.
16. Wittrock U. Barmisshandel, 1984-1994 [Violent crimes against
children,
1984-1994]. KR Info 1995;5:1-6.
17. Larzelere RE, Johnson B. Evaluation of the effects of Sweden's
spanking ban on physical child abuse rates: A literature review.
Psychological Reports 1999;85:381-392.
Robert E. Larzelere
Psychologist
Psychology Department,
Munroe-Meyer Institute,
University of Nebraska Medical Center,
Omaha, NE 68198-5450,
USA
rlarzelere@unmc.edu
Competing interests: No competing interests
Editor - Tony Waterston's editorial, BMJ 29th January, page 261, is
most welcome in view of government reluctance to legislate against parent-
inflicted corporal punishment. We constantly hear expressions of concern
over violence and indiscipline in school.
Does it not occur to our legislators that we cannot deny to teachers the
only disciplinary measure that many children understand.
Physical methods of control should be outlawed alike for parents and those
in loco parentis.
M.C.Spencer.
Competing interests: No competing interests
EDITOR. Like Waterston I believe that physical punishment of
children should be strongly discouraged. Although I agree that the main
reason for the frequent use of physical punishment is parents' lack of
awareness of alternative strategies, I think this has more to do with the
ability to
change behaviours than the availability of advise.
Many parents experience either psychological difficulties such as
depressive illness, or a variety of other psychosocial stresses. Often
their own experiences of childhood and relationships with parents have
been deficient and sometimes even abusive leading to problems with
attachments and trust in adulthood. Webster-Stratton has reported that
this group of parents will often find it especially difficult to
effectively use help with parenting. I would suggest that the majority of
parents who smack their children feel guilty and make enormous efforts to
use other methods. For many of these parents being simply "educated" about
parenting is insuffiecient.
Instead they need to be aware that they will be helped and supported by
non-critical professionals that they can trust. Such help is currently
only patchily available through agencies such as Newpin, local-authority
run family centres, primary care groups via health visitors and child and
adolescent mental health services. In addition before they can benefit
many struggling parents require social and therapeutic assistance for
themselves.
As Dr.Waterston states in his editorial the majority of parents in
this country smack their children. This phenomenon has not occurred by
accident.
Many current parents have been "trained" by their childhood experiences to
do so and these learnt behaviours require considerable efforts to change.
Although we need to give a clear message that physical chastisement if
ineffective and if used regularly, harmful, making it illegal would deter
many parents from seeking help with their parenting for fear of
punishment.
It could also deter children who are physically abused from speaking up,
as there is now plenty of evidence that abused children protect their
parents.
One other possible consequence of banning physical punishment could be an
increase in emotional abuse, with the long-term sequellae of this.
Therefore there needs to be a major drive to make help, support and
training available
to all parents who need it in whatever form it is required. Taylor et al
emphasise the importance of socioeconomic factors in parenting. Making
physical methods of discipline illegal at this point in time runs the risk
of targetting mainly the most emotionally and materially deprived parents
in our society.
1, Waterston, T. Giving guidance on child discipline. BMJ
2000;7230:261-262.
2, Webster-Stratton C, & Herbert, M. Troubled families-problem
children. Working with parents: A collaborative process. Chichester :
Wiley, 1994.
3, Taylor J, Spencer N, Baldwin, N. Social, economic, and political
context of parenting. Arch Dis Child 2000;82: 113-120.
Jeannette Phillips, Consultant Child and Adolescent Psychiatrist,
Invicta Community Care NHS Trust, Unit 1 Twisleton Court, Priory Hill,
Dartford, DA1 2EN.
Competing interests: No competing interests
Dear Sir, In his article "Giving guidance on child discipline" (BMJ
29th. January 2000) Dr.Waterston rightly states that "there can be no more
important activity within society than bringing up our children, and
discipline is crucial to this." Few, I think, would disagree with this
view. Unhappily it does not necessarily follow that the total absence of
physical punishment will achieve this goal in the societies in which we
actually live, for reasons that he has in fact set out in his paper.
In this respect it is worth noting that whilst most research on child
discipline has been done in the USA, the behaviour of American children
would not lead on to suppose that the research had had much impact on
them.
Of far greater significance are Dr.Waterston's observations with
regard to parental behaviour. Whilst in an ideal world all parents should
understand that children respond well to routine, to consistency of
parental reaction, to involvement in decision making and to explanation of
the reasons for discipline, the truth is that we do not live in such a
world.
As Dr.Waterston rightly perceives "Children learn best from what they
see and model their behaviour on that of their parents." The question is
whether all parents are an ideal model for their children, and there is of
course the wider question as to whether all that children see provides
them with an ideal role model? In a society in which to an increasing
extent both parents will be away from home all day, will the example of
child carers (whoever they may be) provide children with an adequate role
model, particularly in the formative pre-school years of life?
This talk of the ills of physical punishment has been going on for
half a century or more, yet if the growth in our prison population has any
relationship to self-discipline, it would seem that we are a long way off
identifying those factors that lead to adequate self-discipline in adults,
and I would suggest that adult indiscipline is to a major extent the
product of childhood indiscipline.
Whilst as a society we pay lip-service to the role of the mother and
of parents, in practice we grossly undervalue their worth and do nothing
in economic terms to assist the parental role which Dr.Waterston so
rightly identifies as crucial in terms of children's behaviour patterns.
Until society makes it possible for parents to observe the positive
factors for behavioural control that he has identified, some more
practical guidelines need to be set out, and it may be that a little
physical chastisement may not be out of place.
Dr.C.O.Lister
Competing interests: No competing interests
Waterston articulates the current arguments for restraint and
possible legislation on physical punishment well1. Why then, as a child
psychiatrist and family therapist who espouses and promotes these ideas
daily in my professional practice, and as a father with two children under
five against whom my wife and I have never raised a hand (though sorely
tempted), do I still demur? I think it is because I do not wish the State
to be placed where it does not belong. Similar arguments apply and
applied to child sexual abuse and seatbelt legislation. Both are now
"state-intervenable" matters. Why is smacking different?
The best I can
come up with (and it may not be intellectually rigorous) is that I also
believe, professionally and personally, that it is important that parents
be in charge of their children. In this sense the use of physical
punishment is qualitatively different from sexual abuse. There is a
benign aim in the use of punishment that cannot be said to exist in CSA,
albeit that all the evidence suggests there are better ways to get to the
aim. We must allow for individuality in parenting styles, and the
spectacle of children suing their parents for physical chastisement does
not encourage me to believe that this would produce more benign
environment for that child or, more importantly for public policy,
children as a whole. Indeed it may only lead to inversion of the, perhaps
unpolitically correct but bald fact that parents need to be more powerful
than children in the hierarchical structure that we call family, and at
the very least represents the best we have yet come up with for successful
child-rearing, in early years at least. Public education, as cited by
Waterston in Sweden, may be a more effective route to change, and the
prominence given to this subject by the BMJ is most welcome.
Let us hope
that the debate, and consequent changing of minds, continues but let us
not try to impose values that may not lead where we want to go. Perhaps
the government has got it right?
Richard Fry
consultant child and family psychiatrist
CFACS, Uxbridge, Middx, UB8 1BN
1 Waterston T. Giving guidance on child discipline. BMJ 2000;320:261
-2. (29 January.)
Competing interests: No competing interests
The opinion presented by Tony Waterston, BMJ 2000; 320: 261-262,
regarding physical punishment of children makes too much of the available
data. The subheading "Physical punishment works no better than other
methods and has adverse effects" could equally well have read, "Physical
punishment works as well as other methods and has no worse adverse
effects."
Working with children, I see a stream of impossibly behaved children
whose parents have a policy of not smacking. The parents have listened to
the 'experts' and are struggling to cope with a variety of alternative
strategies while their youngsters makes their life hell. The parents have
often adopted a variety of manipulative behaviours designed to keep little
Johnny from screaming in the supermarket if he isn't given his icecream.
Timeout is used inappropriately, rewards become bribes and "incentives"
become used as weapons.
I believe that given time, energy and commitment, optimal parenting
does not require smacking. Unfortunately, those requirements are often
lacking. Smacking itself can of course be inappropriate and harmful but
many parents use it at times because they find it to be quick and
effective. Waterston argues that smacking "teaches that violence is a
solution to interpersonal conflict". As a parent, I suspect that this is
taught more effectively by television, bombs and ethnic cleansing than by
receiving a smack when you are two.
Competing interests: No competing interests
Following the same logic, could I suggest it should be legal and
socially acceptable that one should have the right and duty to spank one's
colleagues and other adults who are irritating? As a structured "safety
valve"..!!! :^)
Competing interests: No competing interests
Smacking and verbal abuse of children by parents
EDITOR - Waterston (1) rightly calls attention to the possibility
that corporal punishment may be harmful to children. But this debate
should consider other ways in which parents make their children fearful
and lower their self-esteem. In the adult psychiatric clinic it is not
rare to find patients who have been made to feel unwanted, bad or
worthless by the purely verbal behaviour of a parent. These parental
inputs may well be more harmful than smacking, and we should consider
whether a parent inhibited from smacking a child by custom or by law might
revert to verbal abuse in order to discharge their feelings of irritation
with a naughty child.
The topic of parental chastisement of children is of interest to
evolutionary biology (2,3). There is a very wide variation in the way
parents treat children, ranging from the abuse mentioned above to the most
fulsome outpourings of love and praise. This adds to the wide variation
in sensitivity to punishment which we see in children. As a result, there
is a large variation in adult self-esteem, first pointed out by Abraham
Maslow (4). There may be co-evolved psychological mechanisms by which the
interaction of parents and children induces this variation. We have
suggested (5) that the life-long traits of high and low self-esteem may be
looked on as alternative strategies for dealing with the social
environment, and that the variation between high and low self-esteem may
be
induced by parent/child interaction, and maintained by negative frequency-
dependent selection (for instance, there is an advantage in having low
self-esteem if everyone else has high self-esteem).
In the debate on smacking children, it is important to bear in mind
the different sensitivities of children to punishment, the possibility
that inhibiting physical punishment may increase more harmful forms of
verbal punishment, and the possibility that we are dealing with an evolved
psychological mechanism for inducing in the child a level of self-esteem
which will give it the best chance of reproductive success in the
environment into which it is born. This is not to support the
"naturalistic fallacy" that smacking is good because it has evolved
through
natural selection. Rather, in forming our opinions we should be aware of
as much information as possible at both ultimate (evolutionary) and
proximate (social) levels of causation.
John Price
locum consultant psychiatrist
Brighton General Hospital,
Elm Grove, Brighton BN2 3EW
1. Waterston T. Giving guidance on child discipline: physical
punishment works no better than other methods and has adverse effects.
British Medical Journal 2000;320:261-262.
2. Stevens A, Price J. Evolutionary Psychiatry: A New
Beginning. Second edition. London: Routledge, 2000.
3. Price JS. Subordination, self-esteem and depression. In Sloman
L, Gilbert, P, eds. Subordination and Defeat: An
Evolutionary Approach to Mood Disorders and their Therapy. Mahwah NJ,
Lawrence Erlbaum, 2000, 165-177.
4. Maslow AH. Dominance-feeling, behavior, and status.
Psychological Review 1937;44:404-429.
5. Price JS, Sloman L, Gardner R, Gilbert P, Rohde P. The
social competition hypothesis of depression. British Journal of
Psychiatry 1994;164:309-135.
Competing interests: No competing interests