Negative emotional behaviors
Oppositionality
Aggression
Infancy
• cries
in response to hunger, fatigue, frustration, no specific reason (particularly in the late afternoon, evening, and nighttime)
(frequently)
• flails
• pushes away
• shakes head
• gestures to indicate refusal
• dawdles
in response to frustration, need for control, stress separation from parents, intrusive interactions, etc.
• cries
• refuses comfort
• kicks
• bites
(intermittently)
Early childhood
• cries
• whines
in response to hunger, fatigue, frustration (frequently)
• hits
• bites
in response to anger
• tantrums
in response to not getting a desired outcome
(same as Negative Emotional Behaviors, but in a more mature fashion, including:)
• uses words
in response to dissatisfaction
• briefly argues
• uses bad language
• intentionally defies
• dawdles
in response to anger
• grabs toys
• shows hostility toward siblings/peers
• kicks
• shows verbal hostility toward others
(intermittently)
typically responds to parental reprimand
Middle childhood
• tantrums
• pounds fists
• screams
[same Negative Emotion Behaviors, but in a more mature fashion, including:]
• shows defiance to commands for chores or daily living tasks to be completed
• gives excuses
• uses bad language
• displays negative attitude
• gestures to indicate refusal
[same Negative Emotion Behaviors but with more intention, such as:]
• gets even in response to a perceived injustice
• causes pain to others
• uses profanity
• bullies
• hits peers
in response to provocation
(intermittently)
Adolescence
• hits objects
• slams doors
• curses
• screams
(occasionally)
• verbally argues
• demands reasons from parents
• gives excuses
• uses profanity
• argues
• speaks disrespectfully
(infrequently)
• physical aggression
in response to provocation
(infrequently)
Discipline in toddlerhood is almost universally challenging, as children seek autonomy while learning to understand limit setting from authority figures [15]. The primary reason parents seek help from mental health professionals is for child noncompliance [16, 17]. Noncompliance is defined as one of two interactions. The first is when children fail to do as their parents ask, even when the request is age-appropriate [10]. The other is when children intentionally do the opposite or something other than their parent requested [10]. In some cases, noncompliance reflects a lack of understanding of the parents’ limits [15]. When children do understand the limit but choose not to comply, this stems from either emerging self-assertion or from defiance [15]. Children who can state their preferences and dislike when authority figures’ limits stand in the way of their preferences are said to engage in self-assertion [18]. Self-assertion is apparent when the child’s choice of noncompliance is understandable. For example, a child who was told to clean up his toys but instead continues playing is not complying due to a specific preference for playing [18]. Defiance is more likely when the child’s resistance to authority figures’ directives result in a suboptimal outcome for the child [18]. After being told to clean up the toys, the defiant child does not continue playing but instead begins strewing the toys around the room [18]. This distinction marks the difference between normative child development that requires basic discipline techniques, and non-normative child development that increases the likelihood that the parent will need professional help for more challenging parent–child interactions [15].
Parents, particularly new parents, have always had questions about when their children’s behavior is “normal” or when it requires help. In addition to their doctors, parents typically turn to their social circles to gauge how much of their children’s behavior is in line with what other children exhibit. Now that many parents utilize social media for sharing about their children, this process has become complicated. Parents share to a much wider audience than they did before this mode of communication was available [19]. Consequently, parents see posts about children they barely know. Without a broader understanding of that child, the parent may not understand whether the sharing parent is highlighting an exceptionally positive or negative aspect of that child. Even when parents are presenting something positive about their child, they may use “humblebragging,” a method for bragging about one’s child that seems at first blush to be self-deprecating [19]. This behavior can be confusing to parents who are already worried about their children’s misbehavior, as they see parents purportedly complaining about their children’s positive behaviors.
Despite these challenges, social media and blogging are immensely popular among new parents [20]. While some studies show that parents with higher Internet use disconnect from in-person relationships [21], others show no negative impact on in-person connection and feelings of loneliness [22]. One study of 157 mothers of children 1.5 years or younger reported daily use of social media and feelings of social connection, social support, and wellbeing [20]. While this study was purely correlational (study authors cannot conclude that social media use caused these feelings), it is unlikely that parents will leave social media en masse any time soon. It is therefore all the more important that primary care physicians take the time to assess parents’ primary behavioral concerns, as we outline below in the Conclusion.
Common Misconceptions
Spanking is universally cruel versus spanking is a necessary component of discipline
This misconception requires stating both extremes of opinion, as research has evidence refuting both statements. Over 30 countries have now established laws that prohibit the use of any corporal punishment for children, including spanking [24]. The United States is not among that group (nor is Canada) [24]. Accordingly, spanking in the United States is still fairly common according to repeated surveys. One survey found that 7 out of 10 American parents reported using some corporal punishment with their children [25]. The benefits and risks of spanking have been hotly contested in the child development literature for decades [1, 4, 13]. Parents will typically have their own impressions about spanking, often formed by their childhood experiences. The value of spanking is often in the eye of the beholder: parents with more positive attitudes toward spanking are more likely to spank their children [26].
It is not unusual to encounter parents who speak well of spanking. They may have been spanked as a child and did not experience any ill effects. They may also cite the fact that it works. While this statement would be based on parental observation, the data back up this assertion. In one of the most cited meta-analyses of spanking—which is notoriously anti-spanking—the author did concede that spanking is effective in gaining children’s compliance in the short-term [27]. An original experimental design found that while other discipline methods could be just as effective as spanking, spanking was still more effective than doing nothing in response to children’s behavior [28].
Other parents may be staunchly against spanking. They could have upsetting memories of their parents using this technique. Others could have observed children responding with tears when their parents spanked them in a public setting, such as a park. Or they may recognize that spanking does nothing to teach the child what behavior they should have exhibited instead of whichever one preceded the spanking. They would also be correct. Research shows that while spanking effectively changes children’s behavior in the immediate term, it does not result in children internalizing a particular moral code in the longer term [27].
Despite this array of opinions, there is evidence that parental attitudes regarding spanking can be altered [29]. One study compared parents who interacted with a computer-based psychoeducational program about various discipline techniques [30]. Specifically with regard to spanking, parents who viewed the program responded differently about how they would manage their children’s aggression compared to a control group of parents who did not receive the information [30].
Mirroring parents’ strong opinions, the research in the area of spanking as a discipline technique remains hotly contested. A widely-cited meta-analysis of spanking and other forms of punishment concluded that spanking caused detrimental long-term outcomes in children who were spanked [27]. Measures of long-term outcomes tend to measure concepts such as aggression in children and academic performance. Critics of this work have noted that the statistical methods used to arrive at these conclusions were not appropriate for the data [4, 31]. Illustrating this point, researchers applied the same statistical methods to measure nonphysical forms of punishment, such as sending children to their rooms and removing privileges [32]. The statistical method told the same story—that these punishments had similar effects on long-term outcomes [32]. Similarly unadjusted correlational analyses show similar effects for time-out, another nonphysical punishment [33].
Instead, when researchers account for pre-existing differences between children who were spanked compared to children who were not, any long-term negative outcomes associated with disruptive behaviors disappear [4]. This is presumably because parents are more likely to spank children who are already misbehaving, rather than children who are not. Looking at children who were spanked according to how much they misbehave later in life may not represent an effect of spanking, as much as it shows that these children are continuing to have trouble controlling their behavior despite having been spanked [4, 31].
Analyses that use these unadjusted correlations to draw their conclusions do not consider other pre-existing characteristics of families where the spanking occurred, such as parent education, age, income, marital status, and depression [34–38]. Once these kinds of factors are incorporated into the analysis, the effect sizes become minuscule [4]. This means that while there may be a statistically significant difference between children who are spanked and not spanked on these long-term outcomes, the size of the difference between them is not only not causational, but the difference is very small. These small differences can disappear completely if other factors are considered, such as how frequently the children were spanked [39].
Analyses that group together children who are spanked only occasionally with children who are routinely spanked do not give an accurate impression for children whose parents may use spanking only in select circumstances [31]. Other analyses that many use as evidence against spanking also include harsher forms of physical punishment such as beatings with whips, belts, and sticks [40]. A recent meta-analysis shows that while there may be some remaining influences of spanking on long-term child outcomes, they are small and may be accounted for by other factors not yet identified [4].
What is clear is that spanking does not occur in a vacuum. Spanking and other forms of physical punishment are more or less problematic within a wider context that includes the parent/child relationship, cultural norms, child factors, frequency, and harshness.
Parent/child relationship: There is some evidence that spanking that occurs within an overall loving and warm parent/child relationship is not viewed poorly by children. A Canadian study surveying 818 college students found that young adults had more favorable views regarding corporal punishment if they were spanked by parents they perceived as warm and supportive in general [41]. Alternatively, students who noted that their parents seemed to use corporal punishment impulsively had less favorable attitudes [41]. Otherwise supportive and loving parents seem to mitigate possible poor outcomes of these punishments [42]. Children are also more likely to accept the punishment if they feel it was objective, that is, formed by preplanned parental thought rather than in a heated parental emotional reaction [27].
Cultural norms: Research among several nations indicates that harsh punishments cause different child outcomes, based on whether those punishments are normative in those countries [43]. A study of eleven countries examined the relationship between corporal punishment and maternal warmth on children’s aggression and anxiety [43]. Results indicated that the level of authoritarian makeup of the country (or cultural subgroup within a country) influenced reported child outcomes [43]. Countries or cultures with more authoritarian values showed fewer negative effects of corporal punishment [43].
Child factors: While it appears that harsh punishments act differentially on children depending on their age, sex, and ethnic background, the research literature has not determined these effects in a way that are clinically useful [1]. Many studies contradict one another, creating a lack of clarity as to specific interactions between these child characteristics and outcomes [1]. For example, while one study shows that Hispanic preschoolers’ cognitive development may be enhanced by the use of harsh physical and verbal punishment [42], another finds that Hispanic preschoolers’ adjustment suffers more than other children’s when subjected to these kinds of punishments [3]. The research comparing boys’ and girls’ responses to harsh punishments are similarly varied and inconclusive [27, 44].
In addition to demographic characteristics, one study sought to determine if children’s knowledge of emotions moderated the effects of harsh punishment [1]. These researchers found that in their sample of 250 preschool children, those with better emotional knowledge were affected more detrimentally by their parents’ harsh punishments. In comparison to their emotionally attuned peers, those with poorer emotion knowledge either benefitted or were neutrally affected by their parents’ harsh punishments. Study authors interpreted their findings to mean that children who understand their parents are angry or upset when using harsh punishment are more likely to feel frightened or think that the punishment is unfair. However, this is only a hypothesis. Because the mechanism causing these results is unclear, it is possible other explanations may account for these observed differences.
Frequency: Frequency of physical punishment has a rather obvious influence on child outcomes. Infants who experienced physical punishment frequently were shown to exhibit a high hormonal stress response [45]. Parents who rely primarily on spanking for directing their children’s behavior must often increase the rate and intensity of spanking over time for it to maintain its desired effect [46]. This is suboptimal for children and parents. There is a concern that the escalation required to maintain spanking’s efficacy can, over time, turn into abuse [46].
Harshness: In one retrospective study of over 34,000 adults, those who reported harsh physical punishment prior to age 18 displayed higher odds of developing adult health conditions such as cardiovascular disease, arthritis, and obesity [13]. This effect held even among participants who did not report other forms of child abuse or maltreatment that commonly occur in situations where harsh physical punishments are used [13]. Regardless of stances on spanking, the evidence base categorically rejects discipline techniques that use harsh punishments [1]. Even those who criticize the research methods that provide arguments against spanking eschew harsh forms of corporal punishment [31].
Rather than deciding between advocating spanking or prohibiting it, a moderation approach is recommended. The very small (or in some cases trivial) effects of spanking should be communicated carefully to the public [4]. Some small amount of spanking is likely not harmful to children [31]. Without necessarily endorsing spanking, parents can be aware that spanking may not be as detrimental as they thought, but that there are still other, preferred methods for disciplining young children that are effective and “least negative” [4].
To Explain to a Patient
Research in spanking is a contentious issue because of the moral undertones. Parents who believe spanking is effective and safe consider parents who do not use this method to be too lax and likely to raise their children to be reckless. Those who believe spanking is primitive and harmful judge parents who use this method because they believe they are intentionally inflicting harm on defenseless children. Both options sound terrible, and both sides are already convinced they are correct. Researchers have biases and opinions just like everyone else. Research will likely never arrive at one straight answer that can either exonerate or fully support spanking. What the current research seems to show is that if you are not spanking your child now, you should not start. If you do spank your child, make sure that you do so very sparingly and not in anger.
As long as parents do not physically punish their children, their discipline is not harsh
Harsh verbal punishment falls short of emotional abuse. Emotional abuse is characterized by direct attacks on the child’s sense of self, occurs without regard to children’s behavior, and is not culturally normative (i.e., a reasonable parent would not engage in these attacks in a public location for fear of negative feedback from observers) [1]. In contrast, harsh verbal punishments may include yelling or cursing but do not directly attack the child’s sense of self [1]. Because these verbal onslaughts occur in response to children’s misbehavior, they are classified as punishments [1]. Yet they often occur in the context of parental frustration, thus typically serving an emotional function for the parent rather than a disciplinary function in the true sense of teaching the child [1].
Some level of harsh verbal punishment may be culturally normative. Anecdotally, many parents concede that they at times “lose it and blow up,” or describe some other form of yelling in response to their children’s misbehavior. Although it is not emotional abuse, harsh verbal punishment is still not a recommended strategy for discipline. Research has found an association between harsh verbal punishment and negative outcomes in child aggression, cognitive development, self-concept, and academic achievement [42, 47].
Parents should avoid punishment entirely
Positive parenting strategies can and should be used as part of a parent’s disciplinary repertoire. Discipline should both teach the child what not to do and also provide guidance as to what the child should do instead [30]. Teaching children what is acceptable need not mean lectures for every infraction. Instead, positive parenting practices are excellent for accomplishing this goal. Positive parenting includes [30]:
stating rules firmly without explanation (e.g., “We don’t hit in this house.”)
providing children with alternative appropriate behavior options (e.g., “Please put your hands in your lap.”)
asking children to provide alternative options (e.g., “What can you do with your hands right now?”)
praising children when they behave appropriately at another time, using specific, labeled praise as to what the child is doing well (e.g., “I like how you’re keeping safe hands when playing with your little sister.”)
These strategies are not punishment and they guide children to display the desired behavior. But children will inevitably test what happens if they do not follow these injunctions. Children are not born with the knowledge of socially appropriate behavior or the motivation to engage in prosocial behaviors [48, 49]. It is consequently the parents’ role to teach them [10]. Children test parents’ limits to varying degrees, from the quite frequently (for example, as is seen in children diagnosed with Oppositional Defiant Disorder) to regularly (as occurs in the context of normative learning about consequences for actions) to rarely (as occurs in children who are more temperamentally compliant, easygoing, eager-to-please, or anxious). If parents respond to limit testing with no punishment (even a small one, such as saying “No” in a firm tone), the child cannot be expected to learn that their behavior was inappropriate. Without punishment, parents send their children the message that the behavior was acceptable.
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