American Academy of Pediatrics Says No More Spanking or Harsh Verbal Discipline

January 20, 2019 Facebook Twitter LinkedIn Google+ Articles of Interest

JAMA. Published online January 16, 2019. doi:10.1001/jama.2018.18429

The largest professional organization for US pediatricians is taking a strict stance against parents, caregivers, and other adults using spanking, hitting, or slapping to discipline children. The American Academy of Pediatrics (AAP) recently released an updated policy statement on corporal punishment—the first major revise since 1998—based on accumulating evidence that physical punishments don’t work in the long-term and could even cause unintended harms. The policy also recommends against verbal discipline that causes shame or humiliation.

Robert Sege, MD, PhD, the policy’s coauthor and a pediatrician at the Floating Hospital for Children at Tufts Medical Center in Boston, recently spoke with JAMA about the AAP’s position on corporal punishment and how physicians can help parents discipline more safely and effectively. The following is an edited version of that conversation.

JAMA:What’s the AAP’s new policy on corporal punishment?

Dr Sege:First, parents should not use corporal punishment, including hitting and spanking, either in anger or as punishment. And, also, they shouldn’t use verbal punishment that causes shame or humiliation.

JAMA:What’s different about this policy statement?

Dr Sege:The 1998 statement discouraged parents from spanking their children and suggested that pediatricians help parents not to spank their children, but it was a little wishy-washy. What’s happened in the 20 years since then is that the data has really been overwhelming about how corporal punishment is ineffective and how it’s potentially risky. Parenting is a very personal thing and, of course, parents make their own decisions about how they want to raise their children. Our feeling at the American Academy of Pediatrics is that the role of doctors is to give parents the best evidence-informed guidance that we possibly can with which to make their decisions. And all of what we know says parents should never hit their children.

JAMA:What do recent studies tell us about the effectiveness of spanking and other physical discipline?

Dr Sege:A meta-analysis of a large number of studies showed that corporal punishment doesn’t work. It doesn’t cause children to change their own behavior, certainly not in the medium- or long-term. There were small studies that had mediocre study quality that showed that there’s a temporary change in a child’s behavior. But, of course, what parents want is to change the children’s behavior over the longer-term.

JAMA:What do we know about the consequences of corporal punishment on children?

Dr Sege:There are 3 main kinds of consequences. The first is that it increases their aggressive behavior and causes them more problems in school and with their parents. In the largest study of its kind—a longitudinal study that followed children over several years—children who were spanked had more problematic and aggressive behavior [later]. Corporal punishment often led to a vicious cycle, where the children became more oppositional as they experienced corporal punishment, causing their behavior to get worse. [The association between spanking and higher levels of aggression and rule-breaking remained after child and family characteristics were controlled for, including earlier behavior problems and mother’s parenting stress.]

The second consequence, which is a little harder to be as certain about, is there is evidence that the use of corporal punishment affects children’s brain development. There was a study that looked at a group of [young adults], some of whom had consistently been exposed to harsh corporal punishment and some who had not. Those who had been disciplined through corporal punishment had lower prefrontal cortical gray matter [volume] and performance IQ. This is the area of the brain that’s responsible for self-regulation and executive function. By itself, the study was small. But it goes to a large group of studies that look at the effects of experience on children’s brain growth. We know, for example, that toxic stress can cause similar changes in children’s brains. What we are concerned about is that [corporal punishment] may actually affect the physical development of the child’s brain. The authors of these studies suggest that elevated cortisol levels are responsible for the changes in the brain.

The third set of outcomes are mental health problems. In a fair number of studies, children who have had corporal punishment have mental health problems including anxiety and depression.

So, [the evidence] we have is that corporal punishment is ineffective and puts children at risk for poor developmental and behavioral outcomes. And with that, the Academy felt very strongly that parents should not be spanking their kids or verbally humiliating them.

JAMA:What does verbal humiliation include?

Dr Sege:It’s if discipline is intended to shame or humiliate a child. So, instead of staying, “Don’t do that,” [a parent says,] “You’re an awful person,” or “I wish you’d never been born,” or all kinds of nasty things that parents can say to children in anger. It turns out that this has very similar consequences to corporal punishment in the few studies that have looked at it. As a doctor, this makes complete sense because, with rare exceptions, there’s no physical injury from being hit by your parents. What happens is the psychological injury of shame and humiliation. If you remove the physical part and you have the shame and humiliation, it has the same negative effects on children.

JAMA:Does this mean that parents should never yell at their kids or that they should feel bad about it?

Dr Sege:I’m sure there have been parents in the history of mankind who never yelled at their kids, and my hat is off to them. But there’s a difference between saying, “Stop,” and yelling at them in a way that’s meant to be degrading.

JAMA:What approaches to discipline work better than spanking or verbal abuse? And are there better approaches for different ages?

Dr Sege:For infants, most of what you do is simply distraction or redirection. If you have a baby who’s crawling toward danger, you can just pick them up, turn them 180 degrees around, and they’ll continue crawling in a new direction. As children develop cognitively, they begin to crave their parents’ attention. For toddlers and preschoolers, their parent is the most important person in the world and parental attention is the most important thing. Part of it is preparing the child in advance about what behavior is expected and then noticing when they’re good. You can use this craving for attention to teach them good behavior. Of course, children will still misbehave. The Academy suggests a time-out where a child is put in a corner for approximately a minute per year of age. During that time, they don’t receive the parental attention that they crave.

As kids get older they can begin to experience the natural consequences of what they’re doing. If a child is cooking something in the kitchen and it’s a mess, they can be made to clean up the kitchen even though they’d rather do something else. If a younger child isn’t careful when they’re crossing the street, the parents can say, “From now on you have to have me or an adult hold your hand when you cross the street until you demonstrate you’re always looking both ways.”

Teenagers are more complicated because the task of being a teenager is becoming an adult. Parents can incrementally increase the independence of a child as she or he begins to be more responsible. Again, this requires setting expectations clearly and being around to monitor that the child is following those expectations. As the child demonstrates responsibility, provide more independence and understand that the 12-year-old child will become a 20-year-old adult not overnight, but with time.

JAMA:Do pediatricians and family physicians have a role in improving how discipline is meted out in families?

Dr Sege:Absolutely. Pediatricians in the periodic surveys that the Academy has done said that they discuss discipline in 75% to 100% of health supervision visits. We spend a lot of time talking with parents about child behavior. We’re unlikely to say, “Hello Mrs. Smith, please don’t spank your child.” We’re much more likely to hear from a parent about a problematic child behavior and then begin to help them address that without using spanking.

JAMA:What resources exist for physicians?

Dr Sege:There’s a great deal of material available through our policy statements and other resources, including parent handouts on and training at our regional and national meetings around child behavior. Most pediatricians also have a developmental and behavioral pediatrician available to them for a consultation.

JAMA:How can physicians talk about discipline with parents in a sensitive and productive way?

Dr Sege:Parents come to us looking for help with their child’s problematic behavior, and sometimes this problematic behavior is simply normal child development. For example, all babies cry. Just having that insight and wisdom to tell a parent that this is what the child does at this age can be enormously helpful. When there are other problematic behaviors like not sleeping or opposition, we can engage with parents in mutual problem-solving. Often an in-depth discussion about the behavior can lead to a much better understanding on the part of the parent of why the child is doing that and, therefore, a strategy that might succeed in changing it.

JAMA:What if a parent and a child are in a doctor’s office and the physician witnesses some form of corporal punishment or verbal abuse?

Dr Sege:We usually suggest starting with being empathetic: “Oh, my gosh, this is so hard. I know how much you love Joey, and this looks like it’s been very upsetting for both of you.” And then recommend other ways of helping [children] behave besides hitting them: “Here are some strategies you might use, because we know that hitting can cause problems in the long-term.”

JAMA:Recent research suggests that fewer parents spank their kids today. What’s turning the tide?

Dr Sege:I think that it has to do with the general change in this generation about the acceptability of violence within the home. We are fortunately much less tolerant of screaming, yelling, and hitting within marital relationships, and I think that that same idea is extending to how we treat our children. It is a really good thing.

JAMA:What do you say to parents who defend spanking because they believe it worked on them?

Dr Sege:I always start off by saying, “I’m so glad that you’re okay.” [And then,] “We now know that there are ways to teach a child right from wrong that don’t put fear and violence into the loving relationship with the parents. So I want you to try some of those things.” Other times I ask parents, “What else did your parents do besides spank you? What else do you remember from your childhood?” And often you get a much broader, richer idea of what happened to them when they were kids.

JAMA:You can relate to the frustration of wanting your child to behave. What are some of the mental techniques that you can use to redirect that energy in a positive way?

Dr Sege:That’s a really good question. I am the proud father of three kids, and they have at times been frustrating. Kids are like that, right? One of the things about a time-out is that it also gave me a chance to have a time-out and cool down. I think that’s really important. Being able to reach out to another adult to help you when you’re feeling frustrated and angry is important as well. There’s not a parent in the world who hasn’t experienced that kind of frustration with their kids. But the important thing to remember is that, overall, children want to be good.

JAMA:For a parent who has reacted in anger and yelled and said something inappropriate or maybe slapped their kid across the face, is it appropriate to apologize?

Dr Sege:Yes. All of us are human. Sometimes no matter what we do, we’re in the moment. And it’s okay to model for a child that we feel badly and that we didn’t mean whatever it was we said or did in anger. That works okay if this is an occasional thing. If it’s a more common problem, there are parent resource centers. There are parenting classes. There are all sorts of resources for parents who really are struggling with this issue. For parents who were themselves shamed, humiliated, or spanked when they were a child and those are their prominent memories of childhood, it can be really helpful to go to a longer, more intense parenting class to help understand a whole range of different ways they can deal with the frustrations of being a parent.

Parents are a child’s first and most important teachers. And we can help parents learn to teach their children right from wrong without injecting fear and violence into the most important relationship that any of us have.