Editorials for Clinical Practice

 
CHADIS Co-Director and President, Dr. Barbara Howard is a regular contributor to the Behavioral Consult column of Pediatric News and an Assistant Professor of Pediatrics at The Johns Hopkins University School of Medicine.

 

Dr. Howard is a developmental-behavioral pediatrician trained by Dr. T. Berry Brazelton at Harvard University. She is a national speaker on child behavior problems and is a past president of the Society for Developmental and Behavioral Pediatrics. She was a contributing author for Bright Futures™, Diagnostic and Statistical Manual for Primary Care (DSM-PC) and Bright Futures in Practice: Mental Health and has served on national committees of the American Academy of Pediatrics.

Dissuading Parents From Using Corporal Punishment 

The American Academy of Pediatrics recently issued an updated policy statement on discipline,1 calling for us to teach parents not to use corporal punishment or verbally abuse their children. While a 2016 survey of 787 pediatricians found only 6% endorsed spanking as a positive, and, in a 2013 Harris Poll, fewer parents (72%) endorsed spanking, compared with 87% in 1995, we still have a lot of work to do given the even clearer adverse effects of painful discipline.

One of the difficult things about teaching parents to stop corporal punishment is that it works. A smack instantly stops many misbehaviors, but, when asked closely, parents admit that the pause is only about 10 minutes. Instant results are highly reinforcing, and smacking gives welcome emotional release for adults. Most parents who hit their children also were hit growing up. Hitting seems a natural and appropriate method of parenting because this is what their own beloved parents did. Hitting is not a logical decision but a reflex reinforced by early and current experiences.

Another barrier to stopping hitting is that, while some adverse effects appear immediately, most occur later. Immediate effects of the child screaming, telling the parent “I hate you,” throwing things, or stomping to their room may upset the parent, but also may be seen as signs that their action was effective, if retribution is their unconscious goal. Parenting comes at you like a fire hose, and our visits with families can be a special opportunity for reflection on their goals and how well their methods are working.

We can help parents see the later effects appearing hours or days after the hitting. Children feel degraded by spanking, and they may talk back; act sassy; refuse to follow directions or cooperate; and be mean to siblings, pets, or peers. Wait, you say, those were the behaviors the parent cited for hitting the child in the first place! This “hit, act up, hit” cycle perpetuating corporal punishment2 may be invisible to the parent.

Corporal punishment effects

“But he knows I love him,” parents will say, “and he respects me because of the way I have raised him.” Those things may be true, but the residual of loving combined with fearing has been shown to result in adulthood with increased aggression towards loved ones, including child abuse, partner violence, and sadistic sexual behaviors.

We can explain the much-later effects of corporal punishment: A child who experiences pain from the person they love and count on the most in life may develop very mixed feelings in future relationships. Especially if the pain was not countered by affection and admiration from the parent most of the time, the child may become aggressive; numb to others and to him/herself; and develop low self-esteem, learning difficulties, and depression or other mental health disorders. In some cases, the emotionally wounded child is driven to cause similar pain in others through mean acts, stealing things, hurting animals, and violence. “People hurt me so I am going to hurt them” is their unconscious path. As an adult, coping with old hurts may include numbing it with alcohol, drugs, overeating, smoking, or excessive sexual activities.

Do these sound like the familiar aftereffects of having adverse childhood experiences (ACE)? In fact, data from the original ACEs group who were recalling their childhoods showed that corporal punishment had a similar but independent impact as abuse, increasing suicide, and alcohol and substance use disorder.3 And the brain changes on MRIs of children with repeated corporal punishment had similar reductions of the prefrontal cortex and similar abnormalities of stress-related cortisol release.4

Parents commonly counter our advice not to hit their child by saying they were spanked and “came out okay.” But as for other medical problems, the effects of corporal punishment vary from child to child. Feelings are more easily and permanently damaged for some than for others, and we cannot predict who will have the worst outcomes. We do know that hitting is more harmful if not counteracted with affection, that more arbitrary hitting is worse than planned hitting for breaking prespecified rules, that more frequent hitting over time and to a later age has worse outcome, and that effects are smaller in studies of African Americans. Abuse, most often an acceleration of a disciplinary encounter, of course must be stopped and reported. Considered independently of parent factors, the children most likely to get hit are those with frequent impulsive misbehavior, such as ADHD, where our counseling to distinguish intentional from ADHD-related behaviors is most crucial. Anxious children likely take hitting to heart.

We can help parents see the later effects appearing hours or days after the hitting. Children feel degraded by spanking, and they may talk back; act sassy; refuse to follow directions or cooperate; and be mean to siblings, pets, or peers. Wait, you say, those were the behaviors the parent cited for hitting the child in the first place! This “hit, act up, hit” cycle perpetuating corporal punishment2 may be invisible to the parent.

Specific strategies

We can’t just count on words and a handout to counter reflexes to hit, although these have some proven benefit. We have to convince parents to take action on other invisible health conditions such as high cholesterol or blood pressure, prescribing difficult changes in family diet and exercise. While these are also challenging they are not fraught with similar emotion. Parents resorting to hitting are more likely to be depressed, stressed, or have their own histories of ACEs. While we need to advise parents in practical strategies, we need to do this while attending to their strong feelings, family loyalty, frustration with the child’s misbehavior, and personal context, not just the facts about adverse outcomes.

Knowing that this is complex, I always leave advice about corporal punishment to the latter part of a visit. It is wise to ask permission to address this topic which some families think is none of our concern. One might say, ”I would like to help you manage this behavior. May I suggest some things that have evidence for helping?” To be effective, we need to lower defensiveness by praising parts of parenting they are doing well, then focusing on one challenging behavior.

Before it must come eliciting a specific example (What would s/he have to do to get hit? How did it work?), empathy with their pain (That sounds really [upsetting, frustrating, embarrassing]), problem-solving (What have you tried so far? What has worked best?), and connecting to family opinions (What do your parents/partner say about this? How would your/his or her parents have handled this when you/he or she were growing up?).

Often advice for daily irrevocable special time and quick attention to desirable bits of behavior are first steps to breaking negative parent-child cycles. When a behavior requires intervention, eye contact at child level, acknowledgment of the child’s point of view, brief explanation of why a behavior is not okay, and an age- and offense-relevant consequence (removal of toy, time out, chore card, loss of privileges) have best evidence for reducing misbehavior over time. Letting them know that smaller consequences work better than larger ones is a relief for both child and parent!

The new AAP policy article has references for parenting programs, videos, and handouts – all good ideas. But parents are more likely to make the effort to use these resources when you develop understanding of their situation without judging them, explain reasons for choosing noncorporal discipline, provide evidence-based alternatives, and offer return visits to support them in changing their ways.

Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She reported no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com