Guidance for Effective Discipline
AMERICAN ACADEMY OF PEDIATRICS
Parents often ask pediatricians for advice about the provision of appropriate and effective discipline. The word discipline, which comes from the root word disciplinare—to teach or instruct—refers 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);
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
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.
STRATEGIES FOR EFFECTIVE DISCIPLINE
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:
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.
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.
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 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 punishment—spanking—remains 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.
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
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.
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.