Advising parents on discipline: what works

Discipline for children is one of the most common behavioral issues encountered when providing health care for children, and 90% of pediatricians report that they include advice about discipline most of the time when providing anticipatory guidance to families.[1] Although we should provide advice for discipline strategies that have evidence of being effective, this goal is quite complex because of the broad scope of what constitutes discipline and the multifactorial etiology of behavior problems.

THE BROAD SCOPE OF DISCIPLINE

Discipline refers to systems of teaching, learning, and nurturing that are used in child rearing. These systems include procedures that encourage appropriate behavior and deter misbehavior according to the child's developmental abilities. The systems' ultimate goals are for the child to achieve competence, self-control, and self-direction.[2] Some children make these teaching tasks more difficult than others, often due to differences in temperament.[3] Children who have aspects of their personality defined as "difficult" are both more likely to have behavior problems and to present a challenge for caregivers trying to be consistent and positive in their discipline teaching. Children with diagnosable mental health problems or developmental disabilities, including attention deficit hyperactivity disorder, often have their own additional special difficulties with socialization and learning. Conversely, children with higher intelligence and better language skills are more resilient to stress, have fewer behavior problems, and respond better to parent-mediated behavior training[4] and therefore are easier to discipline.

Many other factors affect a caregiver's ability to conceive of, establish, and maintain a system of discipline. Many of the same parental factors that interfere with establishing optimal discipline and responding to parent intervention programs are the ones that make it more likely that the child will have problematic behaviors. These include: lack of social support (insularity); marital discord; multiple. life stressors, especially social disadvantage and low educational or intelligence level; adult mental health problems, especially depression and antisocial personality disorder; substance abuse; teenage parenting; and family histories of antisocial behavior; substance abuse; or child maltreatment.[5] When caregivers were raised with poor methods of discipline these models may also be difficult to overcome.

The risk factor of psychosocial stress seems to have its effect on some groups through changes in discipline resulting in worse behavior of the children. When Snyder[6] studied 10 distressed, single, low-income mothers of 40- to 50-month-old boys with conduct problems, much of the relationship between the mother's distress and the child's behavior was mediated through the mother's reacting more irritably to the child's aversive behavior as well as not completing punishment of misbehavior. The correlation between this pattern of maternal discipline breakdown and the child's poor conduct was high (0.53) even when distress was partialled out implying that the altered discipline may account for the child's poor behavior. This correlation was not significant for middle class mothers, however.

Thus, the child's entire social context, including family psychosocial stressors, must be taken into account. A child with difficult temperament living in a home with severe marital discord, poverty, inadequate recreational outlets, and substance abuse may require a multidimensional, multiagency effort that includes marital counseling, job training, an after-school program, and substance abuse treatment in order for behavior management counseling to have any effects. In such severe cases, intervention for each of the risk factors seems to be necessary to for effective in altering child behavior at all.[7]

RESEARCHED ASPECTS OF DISCIPLINE

Keeping in mind the need for an ecological view of the child's context, there is research data to support the effectiveness of a number of components of a system of discipline. These fall into the general categories of parenting behaviors that promote the parent-child relationship, reinforce positive behaviors, and decrease undesired behaviors. It is clear that all three components are needed for discipline to result in improved child behavior; thus, "what works" is an entire system of discipline. Recommending one component without attention to the quality of the others can be useless or even detrimental to families.

PROMOTING THE PARENT-CHILD RELATIONSHIP

The best teachers of children are those people who are good models, whom the children care about and want to copy and please - usually the parents. Certain characteristics of the parent-child relationship have been found to be especially important in promoting good child behavior, such as compliance, including maintenance of a positive emotional tone in the home through play, parental warmth, and affection for the child.[8] Positive parent-child interactions and child behavior have also been associated with satisfaction with the parenting role and marital adjustment.[9] Even in a laboratory setting, warmth, described by Parke as prior "nurturance" delivered by the experimenter, resulted in more desirable behavior, which in this study manifest as increased resistance to misbehavior.[10] In one study of adolescents and their tendencies for aggression, delinquency, and poor psychological outcome, high quality of maternal involvement, including monitoring, was the most powerful correlate of good outcome (aggression -.37 for girls, -.50 for boys; delinquency -.39 for girls, -.25 for boys; psychological well being .73 for girls, .85 for boys; all P = 01).[11]

In addition to the benefits of general parental warmth and affection in modeling positive behavior and promoting compliance, attention to the child by the parent is a key ingredient of a system of discipline because it increases the behavior attended to ("catch them being good") and provides frequent and immediate feedback to enhance learning. Parental attention also teaches skills basic to being capable including solitary play, and play and sharing skills to substitute for undesirable behaviors. Parents who encourage solitary play have been shown to be more effective in disciplining their child.[12] In addition, caregivers need to provide the child with frequent attention to "contrast" with ignoring or giving time out for undesirable behaviors.[13] When caregivers are responsive to the child, the child is more likely to be responsive to the caregivers' requests.

Conversely, both parental irritability and low parental involvement have been associated with children who have behavior problems, in particular those with conduct disorders.[14] Parental discipline predicting to child behavior problems has been described as harsh, inconsistent, and ineffective, and including low parental involvement.[7,15] Further evidence suggesting that negative parental tone or irritability predisposes or leads to behavior problems is that a system of parent training reduced child antisocial behavior by getting parents to give less aversive consequences for prosocial behaviors as well as for deviant behaviors.[16] This improvement in tone may be a major mediator of the resulting improvements in aggressive child behaviors.

Parents or couples treated for etiologies of lack of warmth such as depression, marital dissatisfaction, or personality characteristics related to their pasts can also be taught parental warmth behaviors. One such teaching program[17] includes having the therapist model positive behaviors. The parents are requested to track the therapist's use of social reinforcement, and they are provided with a list of socially reinforcing expressions, given immediate feedback on their use of social reinforcers with their spouse and child, and taught to track their use of social reinforcers at home.

Models are powerful influences on child behavior. Providing appropriate models of behavior and monitoring outside influences are important aspects of a system of discipline. Children copy models of aggression seen on television from at least 15 months old.11 Peer group influences are extremely strong from middle childhood on.3 Models of aggression among parents or siblings increase aggressive behavior of children in the home. Having at least one good adult role model was one of the protective factors predicting to good outcome in the 30-year longitudinal study on the island of Kauai.[19]

Another feature of the parent-child relationship is its rhythmicity, including consistency. The presence of regular times and patterns for daily activities reduces resistance in the child, especially those children who are temperamentally irregular. Parents who have been found to maintain more rhythmical caregiving are also those of higher educational levels; those with significant mental health problems provide less.[20] Predictability makes even inherently negative experiences less stressful.[21] Firm parental control represents consistent responses to similar behavioral situations, among other things. Such consistency reflects well-functioning adults but is also associated with harmonious parent-child relationships and more positive child outcomes, such as high self-esteem, competence, independence, and achievement orientation.[22] Conversely, inconsistency has been noted repeatedly in dysfunctional families of conduct-disordered children.[7] Inconsistency, part of intermittent reinforcement, prolongs learning a new contingency, such as a new rule that can be frustrating for both parent and child.

Some inconsistency has a positive role in parenting, however. It helps generalize responses to new situations.[23] Even infants learn tolerance through dealing with inconsistent parental responsiveness.[24] Parents who exhibit the firm control associated with positive child outcomes do this partially through listening to and negotiating with the child. This is especially important with older children because of their need for autonomy. This inconsistency, which might also be called flexibility, results in fewer episodes of child noncompliance and has been described as a kind of parent-child harmony.[22]

PROVIDING POSITIVE REINFORCEMENT FOR

DESIRED BEHAVIORS

In addition to its benefits to the essential ingredient of positive tone for the parent-child relationship, positive reinforcement is an important part of a system of discipline for increasing desired behaviors. Positive reinforcement of approximations of desired behaviors is a strategy that can shape new behaviors that are out of the child's usual repertoire. The simplest positive reinforcer is the social reinforcer of parental attention to the child. There are some advantages to this attention being nonverbal, ie, a touch, hug, smile, wink, etc, because it interferes less with ongoing behavior and is less susceptible to commonly associated "qualifiers" such as "Thanks for cleaning up your room. I wish you had done that 2 hours ago when I first asked you." Such embedded criticism counteracts the value of the positive reinforcement or at least conveys ambivalence. Embedded criticism and lack of clarity are more commonly observed in parents of conduct-disordered children than of average children.[17] Teaching parents to select desirable behaviors, count a baseline rate for them in their child, begin to provide selective positive reinforcement, and record changes in the rates of those behaviors is basic to most effective behavior modification programs for parents.[17,25-30] Positive reinforcement of compliant behavior alone or in combination with ignoring only the noncompliant episode has not been found to be sufficient in altering that behavior without the addition of punishment such as time out except when all behavior is ignored for a minimum period in normal preschoolers.[31] With the addition of time out to a parent training program, compliance to commands increased from 25.8% to 81.6%. Contingent attention acquired its reinforcement effect only after time out was introduced in Roberts' paradigm.[32] In other words, a system of discipline was needed that included both positive reinforcement and punishment. Parents find learning to provide rewards to their children for positive behaviors both a highly acceptable and useful addition to their repertoire.[33]

Sometimes parents inadvertently provide positive reinforcement for the very behavior they wish to change, either by attending to it with scolding, yelling, or punishing where the attention and affective arousal is worth more to the child than being ignored) or by backing off a demand in response to a child's angry reaction to the request. Both of these patterns are part of what Patterson[17] calls the coercive family cycle.

Positive reinforcement and punishment both are most effective when they are delivered consistently every time the targeted behavior occurs. When caregivers provide consequences of different strengths for the same behavior at different times they may undermine the effectiveness of their efforts. If consequences for the same behavior are gradually increased, the child adjusts to the higher consequence without an improvement in behavior. Providing a strong consequence initially is more effective. However, caregivers want to be humane, flexible, and rational with children, too. Parents who react equally strongly to every misdeed lose their power to teach subtle differences in importance. Calm delivery of both instruction and correction has been found to be more effective with children because more extreme delivery can result in children, especially preschoolers, having a reflex/angry reaction or excitation of a response before they can consider it fully. When different strengths of consequences are given in different settings the lesser one loses some of its effectiveness. This is particularly a problem if physical punishment is used in one setting such as the home, making time out less effective in another setting such as the school.[23]

Reinforcement of desired behaviors can be social, by using smiles, touches, hugs, comments, or praise, or tangible, by using points, tokens, stickers, toys, food, or other rewards. Both social and tangible reinforcement have been taught effectively and used in parent training programs.[17,25-30] The desired goal of positive reinforcement is for the child to feel pride and satisfaction in acting correctly. Although this is more difficult to assess, in one study of different levels of consequences children were found to discount their own internal reasons for behaving in the presence of stronger consequences and inferred internal reasons in their absence. They were also more likely to continue to avoid deviation when the admonition was smaller.[34]

The clarity and amount of explanation caregivers provide to children when making behavioral requests have several important results. Single requests are more effective. Complex, emotionally charged directives are more common in families with conduct-disordered children.[15] Instead, effective parent training programs teach the use of simple, clear instructions.[17,25-30] Teaching parents to provide at least a 5-second pause after an instruction increased child compliance.[35] For older children, providing a reason for the parent's request improved the child's performance. When first and second graders were given more complete versus less complete explanations for why they would be punished for touching certain toys, learning proceeded more efficiently as reflected in greater response inhibition (which was being trained) and elimination of the superiority of immediate over delayed (by 5 seconds) punishment.[10] In another study, 80 normal 3- to 5-year-olds were more compliant with a method in which the planned consequence for misbehavior was explained or explained and modeled. These children also had fewer inappropriate behaviors, and their parents were more satisfied with the behavior-change strategy.[36] Older children whose parents used more verbal rationale or inductive reasoning in disciplinary exchanges showed greater maturity of moral development, more altruistic behavior, less aggression, greater resistance to deviation, and greater psychological adjustment.37 Teaching aggressive 7- to 12-year-olds behavioral rehearsal and self-instruction resulted in improved interpersonal problem solving.[37] Involving the child in decision making as much as possible not only ensures that the child hears the rationale for rules but also provides greater role-taking opportunities, which has been associated with long-term superiority of moral judgment.[38]

PUNISHING UNDESIRABLE BEHAVIORS

The third essential adjunct to establishing good behavior through an effective system of discipline that promotes the parent-child relationship and provides positive reinforcement for desired actions is to deter misbehaviors by following them with unpleasant consequences. This is defined as punishment. Such unpleasant consequences can take the form of emotional or verbal disapproval, time out, loss of tokens or points, or job consequences. These are more effective when they are part of a system that includes positive reinforcement and rationales for consequences. Verbal disapproval alone actually has been found to increase undesired behavior and increase noncompliance to adult requests.[39] Shouted commands to stop a behavior actually may start a response because of their excitatory effect rather than inhibit one, at least in preschoolers. Shouted commands were less effective than calmly stated ones in stopping an ongoing behavior.[40]

Ignoring is a form of punishment useful especially for minor misbehavior. Ignoring noncompliance, however, only worked for 80 mothers of normal 36-to 90-month-olds if the ignoring consequence was explained or explained and modeled for the child as being contingent on specific behavior such as "not listening".[36]

Although clear, short instructions are important to teaching children and obtaining their cooperation, repeating commands with or without glaring at the child for 1 minute actually increased noncompliance to commands of 32 middle-class 4- to 6 1/2-year-olds, whereas glaring silently immediately after an episode of noncompliance decreased noncompliance to 33% versus 60% baseline with repeated requests (P < .05).[41]

Time out is one of the most effective and acceptable punishments to change any degree of child misbehavior. The details of administration of time out[2] have been researched and are important for maximal effectiveness.

Explanation to the Child

Explaining to toddlers and preschoolers that they would receive time out for noncompliance did not decrease the need for or length of time out.[42] However, punishments including time out have been found to be most effective in delaying recurrences of misbehavior in 2- to 3-year-olds when combined with reasoning.[43] Asking preschoolers to state what they are being asked to do does not increase the rate at which they do it.[44] Explaining a reason for a rule has benefits of increased prosocial behavior but not clearly before age 6,[41] with girls more sensitive to reasoning than boys.[34] Actual use of time out was needed to teach the technique. Modeling, explanation, or rehearsal alone, although still recommended, especially for older children, did not suffice to teach time out.[45]

Warnings

Warning 2- to 6-year-olds once before they receive time out for noncompliance decreased the needed time outs by a factor of four compared with the group receiving no warning, although there was no difference in noncompliance.[46] For aggression, however, providing warnings for sibling aggression instead of immediate time out actually increased aggression.[47]

The Form of Time Out

Time out has been shown to be effective when the child has been placed in a chair, a room, the bathroom, or when the opportunity for reinforcement is removed, such as by removing the object of dispute or having the mother leave the room, or stay but ignore the child completely. Scarboro and Forehand[31] compared having the mother leave the room versus stay in the room but ignore the child completely as two alternative forms of time out and found them to be equally effective in reducing noncompliance, although mothers staying in the room had to administer more time outs. The fact that time out is also effective when it consists of removing attention or objects from the child rather than placing the child in exclusion[23] is especially important to understand when beginning to use time out with older, larger, or more combative children who would be difficult to get to a time out chair or to restrain there in the case of an escape attempt.

Dealing With Escape Behavior

To keep the child in time out there was no difference in reaching the criterion of following 10 commands each within 5 seconds between placing the child for 60 seconds in a 4 x 5-foot room behind a plywood plank from which he could see the mother versus spanking the child twice to enforce time out. If spanking didn't work, the barrier did, and vice versa. Of the three techniques- using a barrier, spanking, or holding - only holding with arms crossed from behind the time out chair for 10 seconds increased escape efforts. The mean frequency of escape attempts from time out was 7 of 10 in the first week, dropping dramatically week 2, and nearly 0 in 2 of 3 children after 4 weeks of use at home.[45] The mean number of spankings required per time out in initial training was 8.6.[48] Because surveyed parents (even those at risk for abuse) rate spanking as an unacceptable strategy they may be more likely to be unsuccessful in initial training for time out if this is the method suggested for escape behavior.

Duration

Time out is more effective if it lasts at least several minutes. Four minutes worked better than either 1 minute or 10 seconds in 4- to 6-year-olds and also resulted in better maintenance of compliance after the training period.[45] Longer durations of time out make shorter durations given at other times less effective, however. Older children respond better to a longer time Out.[23] One study added 5 minutes of time out for each minute of resistance for up to 30 minutes, and after that additional consequences were added.[49]

Consistency of Use

Parents should use time out each time the child breaks the preannounced rules in order to decrease the behavior most quickly. Once the behavior has decreased, however, intermittent use of time out (which probably happens anyway) may be preferable, in that it helps generalize and maintain the learning.[23]

Criteria for Release From Time Out

When release from time out is contingent on the child being quiet for at least 15 seconds, and the parent determines when the child is let out, the children are less disruptive in time out and the undesirable behavior is more effectively reduced.[23] For noncompliant preschoolers, release from time out contingent on a minimum duration (eg, 2 minutes) and at least 15 seconds of quiet is most effective. This is not necessary in initial teaching with the child, however, because Day and Roberts[48] found no difference in disruptions of time out between noncompliant preschoolers required to be quiet for 15 seconds before release and those required only to serve the minimum time.

Age of Use

Time out can be used for children 9 months of age and older. Mathews found that after 1 hour infants less than 1 year old with teenaged mothers who were taught to provide brief physical contact when the children were not misbehaving and to place the child in a playpen for dangerous behaviors decreased those behaviors from an average of 40% of the time to 6%.[12] After age 12, grounding or job grounding, which are variations of time out, are more acceptable and more instructive.[12]

Effects of Time Out on Parenting

After being taught time out, mothers in Christophersen and Sykes' study showed an increase in the number of positive verbal statements they made to the child, spent more time attending to the child and used fewer verbal commands with much higher compliance rates. The children's behavior was also substantially improved.[12] Parents should be monitored in their use of time out to avoid coercive or ineffective use, however.[45] Once parents have learned to use time out, they rate it as acceptable as praise as a parenting strategy.[4]

TEACHING PARENTS DISCIPLINE STRATEGIES

The aspects of a system of discipline presented above are effective in homes and schools as well as in laboratory settings. Parents can be taught their use effectively through reading,[50] individual family review at home of videotapes of behavioral situations,[33] individual instruction by a nurse in a health care setting,[53] individual family counseling with a therapist, group didactic teaching, group instruction with modeling either through role playing or videotapes, or direct feedback about interaction with their child. Webster-Stratton[33] compared results of parent intervention for 79 mothers and 52 fathers of 3- to 8-year-olds referred for behavior problems. The three 10- to 12-week interventions were: parent groups studying video examples, discussion groups, and home viewing of instruction videotapes. All three types of intervention had high levels of parent satisfaction regardless of parental income or social class and produced gains in satisfaction with improvement of child behavior. However, the biggest changes were with the therapist-lead group using videotapes (P < .02 immediately, P < .002 1 year later). Mothers felt that the two group formats were the easiest from which to learn.[33]

The intensity and duration of intervention needed to produce a change in family interaction depends on the severity of the behavior problems and the other stresses present in the family rather than on income level or social class. Interveners for the more difficult problems need experience, clinical skill to deal with family resistance, and ongoing support for themselves in dealing with the families. Studies have shown generalization from laboratory training to the home, to school,[50] to untreated sibling behavior, and across time. Parent training has been found to be more effective when: a competency-based model is used in which performance criteria have to be reached in role playing clinical situations before moving to the next subject of the curriculum;[52] booster sessions are given at later times;[4] and attendance is enhanced by home visits, financial incentives, flexibility in scheduling and location of sessions, frequent reminders, tracking, provision of child care during the sessions,[3] and even a lottery based on child achievement.[4]

Teaching older children skills for their own behavior can be effective in conjunction with parent training. In a study of 40 children hospitalized on a psychiatric ward for acute disorders, a 13-week, 2-hours / session parent-management training course as developed by Patterson and colleagues was provided for individual parents, and a 20-session problem-solving steps course was provided for the children ages 7 to 12 years. The problem-solving treatment taught the children: steps they could use to manage interpersonal situations, to generate alternative solutions, to develop end-means and consequential thinking, and to take the perspective and recognize the feelings of others. Child behavior ratings, including internalizing, externalizing, prosocial, and school behaviors, and teacher ratings were all significantly improved compared with a contact control group 1 month and 1 year posttreatment (P < .05 and p < .001).[53]

Even when parents do not present with behavioral complaints, intervention can be effective. For parents presenting for health supervision visits, written instruction about discipline and use of time out along with a brief explanation by a research assistant was given to 70 low-income mothers. The experimental group also received endorsement and review of the material by the clinic nurse. Three weeks later both groups reported increased use of explanations and ignoring, less difficulty with child management (P < .05), and increased use of praise (P < .01), whereas the nurse-coached group reported greater use of ignoring and time out (P < .05). The control group had a decline in spanking, and the experimental group had a slight increase resulting in a significantly higher rate of spanking. These results encourage even brief intervention regarding discipline but also suggest that such limited instruction can result in misinterpretation, which should be monitored.[54] The family's entire system of discipline must be considered as a whole when making an intervention, especially the quality of the parent-child relationship.

Parent focus groups conducted by Wissow et al[55] discussing physician interviewing strategies regarding behavior had some repeated themes for physicians to keep in mind when counseling families on discipline: (1) Be clear in your own mind about what is acceptable discipline and avoid strong emotions during the visit; (2) Work to understand the parents' justification of their current practices and address their reasoning when presenting alternatives. Offer privacy from the children for this discussion; (3) Demonstrate interest and expertise in child development and behavior during general care; (4) Use good interviewing skills to show empathy; (5) Let the family take the lead in individualizing a plan and choosing among techniques presented that are acceptable to them. Address the views of other influential family members; (6) Look for examples of when the parents were effective in their discipline, and help them gain strength and generalize from that for other situations; (7) Follow up on the discussion; (8) Start discussing discipline to establish reasonable behavioral control early, emphasizing prevention; and (9) Be part of public education on discipline to have allies.

Adults tend to parent in ways similar to how they were parented and to justify the practices their parents used by thinking they are more acceptable than do adults who were parented differently. In a survey of 801 random adults, those who reported being spanked at least weekly as children were far more likely to report spanking their children as often (RR 5.37) and those yelled at daily more likely to yell as often (RR 3.78).[56] Discussing the care givers' own history of being parented and reflecting on its impact on their current relationships is very useful in engaging parents to change their disciplinary strategies.

Because established negative behaviors are often extremely resistant to change, it is preferable to work toward preventing these problems. Some of the factors that are associated with resiliency to stress and good social outcome include: female gender, higher intelligence, high self-esteem, adaptable temperament, consistent family roles and structure, presence of at least one positive adult role model, and active participation in religious activities.[19] Cultures with children with relatively few behavior problems have been characterized by clear role definitions, clear expectations for the children's active work role in the family, very stable family constellations, and involvement of other community members in child care and supervision. A broader view of what works in a system of discipline should include the entire societal structure.

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