Guidance for Effective Discipline

When advising families about discipline strategies, pediatricians should use a comprehensive approach that includes consideration of the parent–child relationship, reinforcement of desired behaviors, and consequences for negative behaviors. Corporal punishment is of limited effectiveness and has potentially deleterious side effects. The American Academy of Pediatrics recommends that parents be encouraged and assisted in the development of methods other than spanking for managing undesired behavior. Parents often ask pediatricians for advice about the provision of appropriate and effective discipline. In fact, 90% of pediatricians report that they include advice about discipline when providing anticipatory guidance to families.1 The American Academy of Pediatrics held a consensus conference on corporal punishment, the report of which was published in Pediatrics and serves as one major source of information for this statement.2 The word discipline, which comes from the root word disciplinare—to teach or instruct—refers to the system of teaching and nurturing that prepares children to achieve competence, self-control, self-direction, and caring for others.3 An effective discipline system must contain three vital elements: 1) a learning environment characterized by positive, supportive parent–child relationships; 2) a strategy for systematic teaching and strengthening of desired behaviors (proactive); and 3) a strategy for decreasing or eliminating undesired or ineffective behaviors (reactive). Each of these components needs to be functioning adequately for discipline to result in improved child behavior. DEVELOPMENTAL APPROACH TO DISCIPLINE The earliest discipline strategy is passive and occurs as infants and their caregivers gradually develop a mutually satisfactory schedule of feeding, sleeping, and awakening. Biologic rhythms tend to become more regular and adapt to family routines. Signals of discomfort, such as crying and thrashing, are modified as infants acquire memories of how their distress has been relieved and learn new strategies to focus attention on their emerging needs.4 The main parental discipline for infants is to provide generally structured daily routines but also to learn to recognize and respond flexibly to the infant’s needs. As infants become more mobile and initiate more contact with the environment, parents must impose limitations and structure to create safe spaces for them to explore and play. Equally important, parents must protect them from potential hazards (eg, by installing safety covers on electric outlets and by removing dangerous objects from their reach) and introduce activities that distract their children from potential hazards. Such proactive behaviors are central to discipline for toddlers. Communicating verbally (a firm no) helps prepare the infant for later use of reasoning, but parents should not expect reasoning, verbal commands, or reprimands to manage the behavior of infants or toddlers. As children grow older and interact with wider, more complex physical and social environments, the adults who care for them must develop increasingly creative strategies to protect them and teach them orderly and desirable patterns of behavior. As a result of consistent structure and teaching (discipline), children integrate the attitudes and expectations of their caregivers into their behavior. Preschoolers begin to develop an understanding of rules, and their behavior is guided by these rules and by the consequences associated with them. As children become school age, these rules become internalized and are accompanied by an increasing sense of responsibility and self-control. Responsibility for behavior is transferred gradually from the caregiving adult to the child, and is especially noticeable during the transition to adolescence. Thus, parents must be prepared to modify their discipline approach over time, using different strategies as the child develops greater independence and capacity for self-regulation and responsibility. The process can be more challenging with children who have developmental disabilities and may require additional or more intense strategies to manage their behavior. STRATEGIES FOR EFFECTIVE DISCIPLINE Effective discipline requires three essential components: 1) a positive, supportive, loving relationship between the parent(s) and child, 2) use of positive reinforcement strategies to increase desired behaviors, and 3) removing reinforcement or applying punishment to reduce or eliminate undesired behaviors. All components must be functioning well for discipline to be successful. Promoting Optimal Parent–Child Relationships and Reinforcing Positive Behaviors For discipline techniques to be most effective, they must occur in the context of a relationship in which children feel loved and secure. In this context, parents’ responses to children’s behavior, whether approving or disapproving, are likely to have the greatest effect because the parents’ approval is important to the children. Parental responses within the context of loving and secure relationships also provide chilPEDIATRICS Vol. 101 No. 4 April 1998 723 by guest on January 22, 2018 http://pediatrics.aappublications.org/ Downloaded from dren with a sense that their environment is stable and that a competent adult is taking care of them, which leads to the development of a sense of personal worth. As children respond to the positive nature of the relationship and consistent discipline, the need for frequent negative interactions decreases, and the quality of the relationship improves further for both parents and children. To this end, the best educators of children are people who are good role models and about whom children care enough to want to imitate and please. Certain conditions in the parent–child relationship have been found to be especially important in promoting positive child behavior, including: • maintaining a positive emotional tone in the home through play and parental warmth and affection for the child5; • providing attention to the child to increase positive behavior (conversely ignoring, removing, or withholding parent attention to decrease the frequency or intensity of undesirable behaviors).6 For older children, attention includes being aware of and interested in their school and other activities; • providing consistency in the form of regular times and patterns for daily activities and interactions to reduce resistance, convey respect for the child, and make negative experiences less stressful7; • responding consistently to similar behavioral situations to promote more harmonious parent– child relationships and more positive child outcomes8; and • being flexible, particularly with older children and adolescents, through listening and negotiation to reduce fewer episodes of child noncompliance with parental expectations.8 Involving the child in decision-making has been associated with longterm enhancement in moral judgment.9 These factors are important in developing a positive, growth-enhancing relationship between parent and child. Even in the best relationships, however, parents will need to provide behavioral limits that their children will not like, and children will behave in ways that are unacceptable to parents. Disagreement and emotional discord occur in all families, but in families with reinforcing positive parent–child relationships and clear expectations and goals for behavior, these episodes are less frequent and less disruptive. Rewarding Desirable or Effective Behaviors The word discipline usually connotes strategies to reduce or eliminate undesirable behaviors. However, more successful child-rearing systems use procedures to both increase desirable behaviors and decrease undesirable behaviors. Eliminating undesirable behavior without having a strategy to stimulate more desirable behavior generally is not effective. The most critical part of discipline involves helping children learn behaviors that meet parental expectations, are effective in promoting positive social relationships, and help them develop a sense of self-discipline that leads to positive self-esteem. Behaviors that the parents value and want to encourage need to be identified by the parents and understood by their children. Many desirable behavioral patterns emerge as part of the child’s normal development, and the role of adults is to notice these behaviors and provide positive attention to strengthen and refine them. Other desirable behaviors are not part of a child’s natural repertoire and need to be taught, such as sharing, good manners, empathy, study habits, and behaving according to principles despite the fact that immediate rewards for other behaviors (eg, lying or stealing) may be present. These behaviors must be taught to children through modeling by parents and shaping skills through parental attention and encouragement. It is much easier to stop undesired behaviors than to develop new, effective behaviors. Therefore, parents must identify the positive behaviors and skills that they want for their children and make a concerted effort to teach and strengthen these behaviors. Strategies for parents and other caregivers that help children learn positive behaviors include: • providing regular positive attention, sometimes called special time (opportunities to communicate positively are important for children of all ages); • listening carefully to children and helping them learn to use words to express their feelings; • providing children with opportunities to make choices whenever appropriate options exist and then helping them learn to evaluate the potential consequences of their choice; • reinforcing emerging desirable behaviors with frequent praise and ignoring trivial misdeeds; and • modeling orderly, predictable behavior, respectful communication, and collaborative conflict resolution strategies.10 Such strategies have several potential benefits: the desired behavior is more likely to become internalized, the newly learned behavior will be a foundation for other desirable behaviors, and the emotional environment in the family will be more positive, pleasant, and supportive. Reducing and Eliminating Undesirable Behavior When undesirable behavior occurs, discipline strategies to reduce or eliminate such behavior are needed.11 Undesirable behavior includes behavior that places the child or others in danger, is noncompliant with the reasonable expectations and demands of the parents or other appropriate adults (eg, teachers), and interferes with positive social interactions and self-discipline. Some of these behaviors require an immediate response because of danger or risk to the child. Other undesirable behaviors require a consistent consequence to prevent generalization of the behavior to other situations. Some problems, particularly those that involve intense emotional exchanges, may be handled best by taking a break from the situation and discussing it later when emotions have subsided, developing alternative ways to handle the situation (removing attention), or, in many cases, avoiding these situations altogether. 724 GUIDANCE FOR EFFECTIVE DISCIPLINE by guest on January 22, 2018 http://pediatrics.aappublications.org/ Downloaded from Extinction including time-out and removal of privileges, and punishment are two common discipline approaches that have been associated with reducing undesired behavior. These different strategies, sometimes both confusingly called punishment, are effective if applied appropriately to specific behaviors. Although they both reduce undesired behavior, they work in very different ways and have very different shortand long-term effects. For both strategies, the following factors may increase the effectiveness: • clarity on the part of the parent and child about what the problem behavior is and what consequence the child can expect when this behavior occurs; • providing a strong and immediate initial consequence when the targeted behavior first occurs; • consistently providing an appropriate consequence each time a targeted problematic behavior occurs; • delivering instruction and correction calmly and with empathy; and • providing a reason for a consequence for a specific behavior, which helps children beyond toddler age to learn the appropriate behavior12 and improves their overall compliance with requests from adults.13 Occasionally, the consequence for an undesired behavior is immediate, without parental involvement (eg, breaking one’s own toy), and may be effective in teaching children to change their behavior. When this consequence is combined with parental reprimand, there is an increase in the likelihood that the child’s behavior will be affected for future similar situations. Time-Out or Removal of Privileges Time-out and removal of privileges are approaches that involve removing positive reinforcement for unacceptable behavior. For young children, time-out usually involves removing parental attention and praise (ignoring) or being placed in a chair for a specified time with no adult interaction. For older children and adolescents, this strategy usually involves removing privileges or denying participation in activities (eg, grounding for an evening with no TV or loss of driving privileges). To be effective, this strategy requires that a valued privilege or reinforcer is removed. In preschool children, time-out (removal of positive parental attention) has been shown to increase compliance with parental expectations from ;25% to 80%,12 and similar effectiveness is seen when used appropriately with older children.14 To be effective, however, time-out must be used consistently, for an appropriate duration, not excessively, and with strategies for managing escape behavior in place before the time-out is imposed. To be successful, time-out requires effort and practice on the part of the parents and, in some cases, requires specific education with a professional. Several aspects of time-out must be considered to ensure effectiveness. When time-out is first implemented, it usually will result in increased negative behavior by the child, who will test the new limit with a display of emotional behavior, sometimes approaching a temper tantrum. The parent who accepts this normal reaction and does not respond to the child’s behavior will find that outbursts become less frequent and that the targeted undesirable behavior also diminishes or disappears. When time-out is used appropriately, the child’s feelings are neither persistent nor damaging to self-esteem, despite the intensity of the reaction. However, if the parent engages in verbal or physical interaction with the child during this disruptive behavior, the emotional outburst, as well as the behavior originally targeted, not only will persist, but may worsen. Second, time-out often is not effective immediately, although it is highly effective as a long-term strategy. Third, it is often difficult emotionally for a parent to ignore the child during periods of increased negative behaviors or when the child begins pleading and bargaining for time-out to end. The inability of parents to deal with their own distress during a time-out is one of the most common reasons for its failure.