Contents

• Role of the physician in promoting effective discipline
• Goals of effective discipline 
• Developmental considerations
• Setting rules and applying consequences
• Forms of discipline
• Summary
• References

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.

Role of the physician in promoting effective discipline

To be effective, discipline needs to be:

• given by an adult with an affective bond to the child;

• consistent, close to the behaviour needing change;

• perceived as ‘fair’ by the child;

• developmentally and temperamentally appropriate; and

• self-enhancing, ie, ultimately leading to self-discipline.

The physician can promote effective discipline through evaluation, anticipatory guidance and counselling.

Evaluation
The psychosocial interview, which is part of normal heath care, should include:

• non-judgmental inquiry about parents’ attitudes toward discipline;

• questions about who disciplines and the type of discipline used;

• discussion of difficulties or problems with discipline; and

• inquiries about parental stressors.

Anticipatory guidance
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.

Counselling
Counselling should:

• reinforce parental competence and help parents find strategies that suit the family’s unique needs;

• suggest effective discipline techniques according to the child’s developmental level, parent/child dyad, and cultural and social norms; and

• provide resources for parents in need, such as printed handouts or referral to other appropriate professionals.

Goals of effective discipline 

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 (1).

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.

Developmental considerations

Regardless of the developmental stage and age of the child, some basic principles can help guide the physician:

• The purpose of effective discipline is to help children organize themselves, internalize rules and acquire appropriate behaviour patterns.

• The temperaments of the child and the parents, particularly in the context of their sociocultural milieu, require flexibility. Children with special needs and developmental delay require additional adjustments and problem-solving (2).

• Effective discipline does not instill shame, negative guilt, a sense of abandonment or a loss of trust. Instead, it instills a sense of greater trust between the child and the parent.

• Anticipatory guidance offers physicians an opportunity for prevention, to discuss the type of discipline according to the child’s developmental age. Undesirable behaviours are best avoided through prevention and by building supportive structures that include clear, consistent rules (3).

• Physicians should take care to provide anticipatory guidance and appropriate support to parents who are under stress, isolated, disadvantaged or impaired. Physicians should be familiar with the resources in the family’s community.

• Physicians should consider the role of the parent in influencing the child’s misbehaviour. For example, a depressed caregiver who is influencing the behaviour and development of a child may require referral to another appropriate professional.

Infants (birth to 12 months)
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.

Early toddlers (one year to two years)
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 (4).

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.

Late toddlers (two years to three years)
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.

Preschoolers and kindergarten-age children (three years to five years)
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.

School-age children (six years to 12 years)
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.

Adolescents (13 years to 18 years)
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.

Setting rules and applying consequences

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:

• Reinforce desirable behaviour. Praise positive behaviour and “catch children being good”.

• Avoid nagging and making threats without consequences. The latter may even encourage the undesired behaviour.

• Apply rules consistently.

• Ignore unimportant and irrelevant behaviour, eg, swinging legs while sitting.

• Set reasonable and consistent limits. Consequences need to be realistic. For example, grounding for a month may not be feasible.

• State acceptable and appropriate behaviour that is attainable.

• Prioritize rules. Give top priority to safety, then to correcting behaviour that harms people and property, and then to behaviour such as whining, temper tantrums and interrupting. Concentrate on two or three rules at first.

• Know and accept age-appropriate behaviour. Accidentally spilling a glass of water is normal behaviour for a toddler. It is not willful defiance. On the other hand, a child who refuses to wear a bicycle helmet after repeated warnings is being willfully defiant.

• Allow for the child’s temperament and individuality (goodness of fit). A strong-willed child needs to be raised differently from the so-called ‘compliant child’.

In applying consequences, these suggestions may be helpful:

• Apply consequences as soon as possible.

• Do not enter into arguments with the child during the correction process.

• Make the consequences brief. For example, time-out (see Forms of discipline) should last one minute per year of the child’s age, to a maximum of five minutes.

• Parents should mean what they say and say it without shouting at the child. Verbal abuse is no less damaging than physical punishment.

• Follow consequences with love and trust, and ensure that the child knows the correction is directed against the behaviour and not the person. Guard against humiliating the child. Model forgiveness and avoid bringing up past mistakes.

Forms of discipline

Three forms of discipline, in particular, are discussed in the current scientific literature:

• time-out;

• reasoning, or away-from-the-moment discussions; and

• disciplinary spanking.

Time-out
Time-out is one of the most effective disciplinary techniques available to parents of young children, aged two years through primary school years (5). 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 (2-5). 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:

• Introduce time-out by 24 months.

• Pick the right place. Be sure the time-out place does not have built-in rewards. The television should not be on during time-out.

• Time-out should last 1 min per year of the child’s age, to a maximum of 5 min.

• Prepare the child by briefly helping him or her connect the behaviour with the time-out. A simple phrase, such as “no hitting,” is enough.

• Parents should avoid using time-out for teaching or preaching. When the child is in time-out, he should be ignored.

• The parent should be the time keeper.

• After time-out is over, it is over. Create a fresh start by offering a new activity.  Don’t discuss the unwanted behaviour. Just move on.

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.

Reasoning or away-from-the-moment discussions
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 (6).

Disciplinary spanking
The Psychosocial Paediatrics Committee of the Canadian Paediatric Society has carefully reviewed the available research in the controversial area of disciplinary spanking (7-15). 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.

Summary

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.

References

1. Emery RE, Coiro MJ. Divorce: Consequences for children. Pediatr Review 1995;16:306-10.

2. Howard BJ. Discipline in early childhood. Pediatr Clin North Am 1991;38:1351-69.

3. Parrish JM. Behaviour management in the child with developmental disabilities. Pediatr Clin North Am 1993;40:617-28.

4. Blum NJ, Williams GE, Friman PC. Disciplining young children: The role of verbal instructions and reasoning. Pediatrics 1995;96:336-41.

5. Christophersen ER. Discipline. Pediatr Clin North Am 1992;39:395-411.

6. Dworkin PH, Schmitt BD, Turechi S. Office treatment of pediatric behavioural problems [transcript of audiocassette]. AAP Pediatric Update 1995;15:3-5.

7. MacMillan HL, Boyle MH, Wong MY, Duku EK, Flemming JE, Walsh A. Slapping and spanking in childhood and its association with a lifetime prevalence of psychiatric disorders. CMAJ 1999;161:805-9.

8. Strauss MA. Is it time to ban corporal punishment in children? CMAJ 1999;161:821.

9. Larzelere RE, Johnson B. Evaluation of the effects of Sweden’s spanking ban on physical child abuse rates: A literature review. Psychol Rep 1999;85:381-92.

10. Durrant JE. Trends in youth crime and well-being since the abolition of corporal punishment in Sweden. Youth Soc 2000;31:437-55.

11. Durrant JE. Evaluating the success of Sweden’s corporal punishment ban. Child Abuse Negl 1999;23:435-48.

12. Roberts JV. Changing public attitudes toward corporal punishment. Child Abuse Negl 2000;24:1027-35.

13. Larzelere RE. Child outcomes of non-abusive and customary physical punishment by parents: An updated literature review. Clin Child Fam Psychol Rev 2000;3:199.

14. Strauss MA, Sugarman DB, Giles-Sims J. Spanking by parents and subsequent antisocial behaviour of children. Arch Pediatr Adolesc Med 1997;151:761-7.

15. Larzelere RE, Schneider WN, Larson DB, Pike PL. The effects of discipline responses in delaying toddler misbehaviour recurrences. Child Family Ther 1996:18:35-7. 

Psychosocial Paediatrics Committee (2003-2004)

Members: Drs Kim Burrows, Kelowna, British Columbia; Anthony Ford-Jones, The Burlington Professional Centre, Burlington, Ontario; Gilles Fortin, Hôpital Sainte-Justine, Montreal, Quebec; Sally Longstaffe, Children’s Hospital, Winnipeg, Manitoba (chair); Theodore Prince, Calgary, Alberta; Sarah Shea, IWK Health Centre, Halifax, Nova Scotia (board representative)
Liaisons: Drs Jane Foy, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA (Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics); Rose Geist, The Hospital for Sick Children, Toronto, Ontario (Canadian Academy of Child Psychiatry); Anton Miller, Sunny Hill Health Centre for Children, Vancouver, British Columbia (Developmental Paediatrics Section, Canadian Paediatric Society)
Principal authors: Drs Peter Nieman, Calgary, Alberta; Sarah Shea, IWK Health Centre, Halifax, Nova Scotia

Last updated: April 2008