and well-being of children and youth
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The word discipline means to impart knowledge and skill – to teach. However, it is often equated with punishment and control. There is a great deal of controversy about the appropriate ways to discipline children, and parents are often confused about effective ways to set limits and instill self-control in their child.
In medical and secular literature, there is great diversity of opinion about the short-term and long-term effects of various disciplinary methods, especially the use of disciplinary spanking. This statement reviews the issues concerning childhood discipline and offers practical guidelines for physicians to use in counselling parents about effective discipline.
The Canadian Paediatric Society recommends that physicians take an anticipatory approach to discipline, including asking questions about techniques used in the home. Physicians should actively counsel parents about discipline and should strongly discourage the use of spanking.
To be effective, discipline needs to be:
The physician can promote effective discipline through evaluation, anticipatory guidance and counselling.
The psychosocial interview, which is part of normal heath care, should include:
Anticipatory guidance should be appropriate to the child’s developmental level (for example, explain to parents that a toddler who resists being fed does it not to defy the parent, but rather as part of normal development). Areas of particular importance are those known to be problematic: feeding, toilet training and bedtime struggles.
Discipline is the structure that helps the child fit into the real world happily and effectively. It is the foundation for the development of the child’s own self-discipline. Effective and positive discipline is about teaching and guiding children, not just forcing them to obey. As with all other interventions aimed at pointing out unacceptable behaviour, the child should always know that the parent loves and supports him or her. Trust between parent and child should be maintained and constantly built upon.
Parenting is the task of raising children and providing them with the necessary material and emotional care to further their physical, emotional, cognitive and social development.
Disciplining children is one of the most important yet difficult responsibilities of parenting, and there are no shortcuts. The physician must stress that teaching about limits and acceptable behaviour takes time and a great deal of energy. The hurried pace of today’s society can be an obstacle to effective discipline.
The goal of effective discipline is to foster acceptable and appropriate behaviour in the child and to raise emotionally mature adults. A disciplined person is able to postpone pleasure, is considerate of the needs of others, is assertive without being aggressive or hostile, and can tolerate discomfort when necessary.
The foundation of effective discipline is respect. The child should be able to respect the parent’s authority and also the rights of others. Inconsistency in applying discipline will not help a child respect his or her parents. Harsh discipline such as humiliation (verbal abuse, shouting, name-calling) will also make it hard for the child to respect and trust the parent.
Thus, effective discipline means discipline applied with mutual respect in a firm, fair, reasonable and consistent way. The goal is to protect the child from danger, help the child learn self-discipline, and develop a healthy conscience and an internal sense of responsibility and control. It should also instill values.
One of the major obstacles to achieving these goals is inconsistency, which will confuse any child, regardless of developmental age. It can be particularly hard for parents to be consistent role models. Telling children to “Do as I say, but not as I do” does not achieve effective discipline. Parental disagreements about child-rearing techniques, as well as cultural differences between parents, often result in inconsistent disciplining methods. The physician needs to be mindful of these challenges and suggest steps that parents can take to resolve these differences .
It is important that in teaching effective discipline, physicians do not impose their own agendas on the families they counsel. A balanced, objective view should be used to provide resources, and the goal should be to remain objective. This means using principles supported by academic, peer-reviewed literature. This is particularly important when dealing with controversial issues such as disciplinary spanking.
Regardless of the developmental stage and age of the child, some basic principles can help guide the physician:
Infants need a schedule around feeding, sleeping and play or interaction with others. The schedule helps regulate autonomic functions and provides a sense of predictability and safety. Infants should not be overstimulated. They should be allowed to develop some tolerance to frustration and the ability to self-soothe. Discipline should not involve techniques such as time-out (see Forms of discipline), spanking or consequences.
At the early toddler stage, it is normal and necessary for toddlers to experiment with control of the physical world and with the capacity to exercise their own will versus that of others. Consequently, parental tolerance is recommended. Disciplinary interventions are necessary to ensure the toddler’s safety, limit aggression, and prevent destructive behaviour. Removing the child or the object with a firm “No,” or another very brief verbal explanation (“No – hot”), and redirecting the child to an alternative activity usually works. The parent should remain with the child at such times to supervise and ensure that the behaviour does not recur, and also to assure the child that the parent is not withdrawing love.
Early toddlers are very susceptible to fears of abandonment and should not be kept in time-out away from the parent. However, occasionally, a parent may become so frustrated with the child that he or she needs a period of separation from the child.
Early toddlers are not verbal enough to understand or mature enough to respond to verbal prohibitions. Therefore, verbal directions and explanations are unreliable forms of discipline for early toddlers .
Example: The toddler wants to play with a breakable glass object on a hard kitchen floor. Remove the child and the object and redirect the toddler’s attention to a more appropriate activity such as playing with a ball in another room. The parent should remain with the child.
The struggle for mastery, independence and self-assertion continues. The child’s frustration at realizing limitations in such struggles leads to temper outbursts. This does not necessarily express anger or willful defiance. The caregiver should have empathy, realizing the meaning of these manifestations. At the same time, the caregiver should continue to supervise, set limits and routines, and have realistic expectations of the child’s achievement capabilities. Knowing the child’s pattern of reactions helps prevent situations in which frustrations flare up. When the child regains control, the parent should give some simple verbal explanation and reassurance. The child should be redirected to some other activity, preferably away from the scene of the tantrum. The toddler cannot regulate behaviour based on verbal prohibitions or directions alone.
Example: The toddler has a temper tantrum in a public place. Remove the child from the place of misbehaviour. Hold the child gently until the toddler gains control. Give a short verbal instruction or reassurance followed by supervision and an example.
At three years to five years of age, most children are able to accept reality and limitations, act in ways to obtain others’ approval, and be self-reliant for their immediate needs. However, they have not internalized many rules, are gullible, and their judgment is not always sound. They require good behavioural models after which to pattern their own behaviour. The consistency should apply not only in the rules and actions of the primary caregiver, but in other adults who care for the child.
Reliance on verbal rules increases, but still the child requires supervision to carry through directions and for safety. Time-out can be used if the child loses control. Redirection or small consequences related to and immediately following the misbehaviour are other alternatives. Approval and praise are the most powerful motivators for good behaviour. Lectures do not work well and some consider them to be counterproductive.
Example: The preschooler draws on the wall with crayons. Use time-out to allow him to think about the misbehaviour. Consider using also logical consequences, eg, take the crayons away and let the child clean up the mess to teach accountability.
The child’s increasing independence may lead to conflicts. School-age children tend to act autonomously, choose their own activities and friends, and, to some extent, recognize other than parental authority. Parents should continue to supervise, provide good behavioural models, set rules consistently, but also allow the child to become increasingly autonomous. Parents should continue to make the important decisions because school-age children cannot always put reasoning and judgment into practice.
Praise and approval should be used liberally, although not excessively, to encourage good behaviour and growth into a more mature human being. The use of appropriate motivators should be encouraged; for example, buy a keen reader his or her favourite book.
Acceptable means of discipline include withdrawal or delay of privileges, consequences and time-out.
Example: The child destroys toys. Instead of replacing these toys, let the child learn the logical consequences. Destroying toys will result in no toys to play with.
Conflicts frequently ensue because the adolescent adheres increasingly to the peer group, challenges family values and rules, and distances himself from the parents. Parents can meet these challenges by remaining available, setting rules in a noncritical way, not belittling the adolescent, and avoiding lectures or predicting catastrophes. Contracting with the adolescent is also a useful tool. Disciplinary spanking of adolescents is most inappropriate.
Despite their challenging attitudes and professions of independence, many adolescents do want parental guidance and approval. Parents should ensure that the basic rules are followed and that logical consequences are set and kept in a nonconfrontational way.
Example: The adolescent defiantly takes the car and has an accident. The logical consequence would be that there is no car to drive and that the teenager has to help pay for the repairs. This teaches accountability.
Rules are established for children so they can learn to live cooperatively with others, to teach them to distinguish right from wrong, and to protect them from harm. Children raised without reasonable limits will have difficulty adjusting socially. The following are some ways that parents can use rules and limits to promote effective discipline:
In applying consequences, these suggestions may be helpful:
Three forms of discipline, in particular, are discussed in the current scientific literature:
Time-out is one of the most effective disciplinary techniques available to parents of young children, aged two years through primary school years . The time-out strategy is effective because it keeps the child from receiving attention that may inadvertently reinforce inappropriate behaviour. Like any other procedure, time-out must be used correctly to be effective. It must be used unemotionally and consistently every time the child misbehaves. Research on why time-out works effectively has been published in detail . How time-out is initiated is important, as is what the child does during this time, how time-out is terminated, and what the parent does when it is over.
Some suggestions for parents on effective time-out include the following:
As with other disciplinary techniques, parents should refrain from hurting the child’s self-esteem by instilling shame, guilt, loss of trust or a sense of abandonment.
If used properly, time-out will work over time. It may not necessarily eliminate the unwanted behaviour, but it will decrease the frequency. If time-out does not work after repeated tries, a consult is recommended.
Parents should be advised that these general guidelines may need to be adjusted to suit the particular temperament of the child. Parents may have to experiment with the length of time-out, because 1 min per year of age may be too long for some children.
Physicians may want to have a handout available that teaches parents how to use time-out procedures correctly according to the child’s age, personality, level of development, and so on.
Discipline involves teaching positive behaviour as well as changing unwanted behaviour. That is, children need to know what to do as well as what not to do. In general, it is more effective to anticipate and prevent undesirable behaviour than to punish it. ‘Away from the moment’ refers to dealing with the difficult behaviour not in the heat of the moment, but rather in advance or away from the actual misbehaviour. An away-from-the-moment discussion can help prevent undesirable behaviour by giving parents the opportunity to teach the child the desirable behaviour in advance. This technique is not appropriate for use in children younger than three years to four years of age .
The Psychosocial Paediatrics Committee of the Canadian Paediatric Society has carefully reviewed the available research in the controversial area of disciplinary spanking -. The existing research is not in the form of double-blind, randomized controlled trials, as such studies would be impossible to conduct. Moreover, no modern ethics committee is likely to approve research that involves violence against children. The research that is available supports the position that spanking and other forms of physical punishment are associated with negative child outcomes.
The Canadian Paediatric Society, therefore, recommends that physicians strongly discourage disciplinary spanking and all other forms of physical punishment. Physical redirection or restraint to support time-out or to prevent a child from harming himself or others may be necessary, but should be done carefully and without violence.
Physical harm to a child inflicted by a parent out of control and in a rage is completely inappropriate and dangerous. During periods of anticipatory guidance on appropriate discipline, physicians should also remind parents to take a time-out for themselves before they lose control.
Discipline is about changing behaviour, not about punishing children. Discipline allows children to develop self-discipline, and helps them become emotionally and socially mature adults. There are many effective techniques that can help parents teach and guide their children, and some forms of discipline will always remain controversial.
The physician’s role is to take an anticipatory approach to discipline, which involves asking questions about techniques used in the home. Physicians should actively counsel parents about discipline and specifically discourage all forms of physical punishment, including the use of spanking.
The physician, while taking a complete psychosocial history, should include a discussion on effective means of discipline. A balanced view should be offered to families. The physician should be an advocate for the child as well as a resource for the parent in offering counselling and anticipatory guidance. Inappropriate forms of discipline should be identified and corrected. Special attention should be given to the child’s age, level of development and temperament when giving advice on effective means of discipline.
Consideration should be given to cultural differences, and adjustments should be made for a developmentally challenged child. It is essential to emphasize to parents the importance of being consistent, being a good role model and avoiding empty threats, ie, not following through with consequences.
Effective discipline should be based on academic facts rather than subjective opinion. The conclusions and recommendations in this statement should, therefore, be viewed as subject to revision and clarification as data continue to accumulate.
Members: Kim Burrows MD; Anthony Ford-Jones MD; Gilles Fortin MD; Sally Longstaffe MD (chair); Theodore Prince MD; Sarah Shea MD (board representative)
Liaisons: Jane Foy MD, Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics; Rose Geist MD, Canadian Academy of Child Psychiatry; Anton Miller MD, Developmental Paediatrics Section, Canadian Paediatric Society
Principal authors: Peter Nieman MD; Sarah Shea MD
Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.