CHAPTER 50

Discipline

Carol D. Berkowitz, MD, FAAP

Discipline can be defined as an educational process in which children learn how to behave in a socially acceptable manner. The word is derived from disciplinare, meaning to teach or instruct. It involves a complex set of interactions of attitudes, models, instructions, rewards, and punishments. Discipline is not synonymous with punishment, which denotes a negative consequence to one’s actions. The goal of effective discipline is to help children gain self-control and respect for others and to learn behavior that is appropriate for given situations. It also serves to ensure a child’s safety in the environment. Proactive discipline is action taken by parents to encourage good behavior, and reactive discipline is parental action following misbehavior. To be effective, child discipline must have 3 components: a learning environment with a positive, supportive parent-child relationship; a refined strategy for teaching and reinforcing desired behaviors; and a defined strategy for decreasing or extinguishing undesired behaviors. Children thrive in a supportive environment in which they are praised for socially appropriate behavior and are able to participate in the responsibilities and activities of the household. Appropriate discipline teaches a child empathy and to consider how other children feel when they are hit or teased. Parents, however, may be more focused on eliminating unwanted behaviors and may bring these specific concerns to their child’s pediatrician.

Parental monitoring relates to the oversight of children’s activities at home, in school, and in the community. The extent and form of parental monitoring varies with the age of the child. Parental monitoring occurs when parents ask their children, “With whom are you going to be? Where are you going? What will you be doing?” Parental oversight involves children’s access to and use of the internet and social media (see Chapter 7). Inadequate parental monitoring has long-term sequelae, including an increased incidence of risk-related behaviors. Parental monitoring must be coupled with parental discipline to promote desirable behaviors and eliminate undesirable ones.

Anticipatory Guidance: Talking With Parents About Discipline

Practitioners can assist parents by giving them guidance about

appropriate childhood discipline related to routine and problem

development and to counsel about the scope of monitoring. The age and temperament of the child are important factors to consider. In addition, pediatricians can educate parents about corporal punishment, especially as the major method of discipline. Pediatricians also have a role in advising against corporal punishment in schools. While most states have banned corporal punishment in the school setting, 19 states, mostly in the south, still permit it.

Parenting Styles

Diana Baumrind is credited with delineating a classification of parenting styles, which are known as Baumrind’s parenting typology and consist of 4 distinct categories. Authoritarian parenting focuses on specific rules and the belief that the rules should be followed without exception. Children are not encouraged to participate in decision-making or problem-solving. Children are punished for their mistakes and, as a consequence, self-esteem may be negatively affected.

Authoritative parenting, however, encourages participation of children in decision-making and focuses on positive discipline strategies and reinforcing desired behaviors. Rules and consequences do exist, but children play a participatory role. Children’s feelings are considered, children learn empathy, and high self-esteem is fostered.

Permissive parenting is also referred to as indulgent or lenient parenting. Rules are rarely enforced, although children may be threatened, such as, “If you do that again, you will be grounded. I really mean it this time!” Children may feel anxious because they are uncertain about the boundaries that might separate them from harmful decisions they make on their own.

Uninvolved parenting occurs when parents may be more involved in their own lives and have less interest in or time with their children. They are unaware of their children’s progress in school, their children’s interests, or their children’s friends.

These categories suggest mutually exclusive parenting styles, but many parents use all styles for truly effective parenting. There are times when parents may have to say, “Because I said so” (authoritarian), and other times when they say, “Go ahead; it’s fine with me if you want to try that” (permissive).

Regardless of parenting style, it is important to encourage parents to establish a positive interactive environment with verbal communication, monitoring children’s behavior and commending desirable behavior, ignoring trivial problems, and consistently applying predetermined consequences for misbehavior. Psychologist Marshall B. Rosenberg promotes the concept of compassionate communication, using the analogy of the language of the giraffe, which is a language of requests, versus the language of the jackal, one of demands. Identifying feelings is integral to the language of giraffes. Rules should be simple, clear, and established ahead of time.

Frequently, physicians fail to inquire about children’s behavior. Unless parents bring up the topic, discipline is not routinely discussed during the physician visit. On average, physicians spend only 90 seconds per visit on anticipatory guidance and counseling. However, a survey of mothers in a physician waiting room showed that up to 90% were concerned about 1 aspect of behavior. Sixty percent of mothers surveyed found physician advice quite helpful. The American Academy of Pediatrics recommends anticipatory guidance about discipline at each health supervision visit between 9 months and 5 years, and studies report that physicians counsel parents about discipline about 40% of the time. Such counseling is especially important to help parents understand the value of appropriate discipline in shaping their children’s self-esteem. Information about discipline in the media may be confusing and contradictory and often supports the unfounded approaches of nonprofessionals. Starting when a child is 5 years old, physician-parent discussions should include the notion of monitoring.

Early in the physician-parent relationship, physicians may express their interest in behavioral problems by saying, “I am interested not only in your child’s physical well-being but also in his [or her or their] growth and development and how he [or she or they] gets along with friends and family.” They may then question parents about how children spend their days. During subsequent visits, pediatricians may say, “Parents of children of [child’s name]’s age frequently worry about discipline. I wonder if you have any concerns.” In making these inquiries, the physician may establish what factors, such as religious or ethnic beliefs, or family influences are shaping parents’ decisions about discipline. Certain tools exist that can assist the primary care physician with counseling parents. One such model, Play Nicely, involves a multimedia educational program in English and Spanish that presents videos of hypothetical scenarios and has parents select from a list of options how they would manage the behavior. The program helps augment parents’ repertoire of responses to their child’s behaviors.

Corporal Punishment

The relationship among harsh punishment, use of corporal punishment, and child abuse has been addressed in a number of studies. The American Academy of Pediatrics has published extensively on the issue of corporal punishment and highlighted how approval of corporal punishment as an acceptable means of disciplining children has significantly decreased in recent years. It is of interest that the UN Convention on the Rights of the Child (1989) endorses banning corporal punishment and promoting positive discipline. Slapping, smacking, spanking, kicking, shaking, and throwing are all enumerated, as are other punitive measures. Data support physical discipline as being associated with subsequent aggressive behavior on the part of toddlers. There are also data linking corporal punishment with adverse childhood experiences (see Chapter 142). Scolding (yelling) is sometimes equated with harsh verbal abuse, especially if it is pervasive and may escalate to physical punishment. Receiving harsh verbal abuse before 13 years of age has been linked to adolescent behavioral and mental health issues.

Common Problem Behaviors

Common behavioral problems can be placed in 5 major categories.

1. Problems of daily routine. Such problems include the refusal of children to go about their daily activities, such as eating, going to bed, awakening at a certain time, and toilet training.

2. Aggressive-resistant behavior. Such behavior is characterized by negativism and includes temper tantrums and aggressive responses to siblings and peers. Some undesirable behavior can place children or those around them in danger or at risk for injury.

3. Overdependent or withdrawal behavior. This behavior is typical of children who are very attached to their parents These children find separation difficult, especially when beginning preschool.

4. Overactivity or excessive restlessness.

5. Undesirable habits, which include thumb-sucking, nail-biting, throat clearing, and playing with genitals (see Chapter 54).

Some of the listed behaviors are age appropriate, and physicians can help parents by counseling them about stage-related behavior, such as oppositional behavior in a 2-year-old and independence-dependence conflicts in a 3- to 5-year-old. Parents may be more tolerant of a particular behavior if they understand what is typical at a given age. Just because something is typical, however, does not mean that it should be tolerated. Physicians can suggest to the parents means of dealing with age-appropriate behavior (eg, placing breakable objects out of reach of toddlers).

Some behavioral problems reflect differences in childhood temperaments. Temperament is the biological predisposition to a style of behavior. William B. Carey, MD, has compiled a series of temperament scales to assess children and adolescents of different ages. For example, some children are shy and have a hard time adjusting to new situations. If parents anticipate such problems, they are often less angry when difficulties arise. Parental expectations can vary with a child’s sex. Boys may be permitted to act a certain way (“He’s all boy!”) that would be disapproved of in girls. Physicians can discuss such expectations at health supervision visits.

Physicians can also be particularly helpful in detecting and advising parents about disparities in the achievement of different developmental skills. Some children acquire motor skills before verbal skills, yet parents expect their children to be equally versatile in speech and movement.

Psychophysiology

All behaviors are modified by the responses and reactions of other individuals. The basic premise of discipline is to discourage unwanted behavior and to encourage desired behavior. This is accomplished by using techniques that are based on conditioning modalities.

Several factors contribute to an increased incidence of behavioral problems in children. Ten percent to 15% of all preschool-age children are raised in challenging or disrupted family situations. Homes may be affected by divorce, death, separation, violence, parental substance use, mental illness, or extreme poverty (see Chapter 141). Parental inexperience may also be a factor. In addition, families may have fewer social contacts than they once did because of greater mobility within society. As a result, families face greater social isolation and less availability of extended family.

Differential Diagnosis

In addition to providing anticipatory guidance about discipline, consider whether a specific behavior represents typical childhood behavior or an abnormality in behavior that warrants more specific intervention. Between 8% and 18% of behavioral disturbances may deserve physician intervention. More intensive management may be necessary for problems related to aggressive- resistant behavior and hyperactivity. Overactive behavior, which may exist as part of attention-deficit/hyperactivity disorder (ADHD), may be a sign of a significant underlying problem that warrants 1-to-1 intervention or the use of neuropharmacological agents (see Chapter 133).

Occasionally, children will be seen and noted to have bruises that were sustained during physical punishment. Although physical punishment is not illegal, the presence of significant bruises or injuries may warrant a report to child protective services.

Evaluation

History

The key component in the evaluation process is the assessment of the means parents use to discipline children (Box 50.1). To obtain this information, physicians may simply ask parents, “How do you get your child to mind you?” This question is designed to lead to a discussion of how parents interact with their children. A follow-up question could be, “What do you do if your child doesn’t mind you?” This may help initiate a discussion related to parenting style and whether physical punishment is used to achieve adherence to parental rules. If parents have specific concerns, such as oppositional behavior, they should be questioned about the strategies they have used in their effort to discipline their children. It may also be useful to ask parents how they were disciplined as children to better understand their personal experience.

Stay updated, free articles. Join our Telegram channel

Join