attitudes of primary care physicians toward corporal

8/14/2019 Attitudes of Primary Care Physicians Toward Corporal

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Attitudes of Primary Care PhysiciansToward Corporal PunishmentKenelm F. McCormick, MD

Objective.\p=m-\Thepurpose of this study was to determine whether or not familyphysicians and pediatricians support the use of corporal punishment. Thefrequency with which these physicians offer anticipatory guidance on disciplinewas also studied.

Design.\p=m-\Self-reportsurvey, mailed to study participants.Participants.\p=m-\Thesample for this study was 800 family physicians and 400

pediatricians, randomly selected from the Ohio State Medical Board's roster offamily physicians and pediatricians. Physicians with a subspecialty were ex-cluded. Participants who did not return their surveys received a second, and ifnecessary, a third mailing of the survey. After three mailings, a total of 619 phy-sicians (61%) completed a survey.

Main Outcome Measure.\p=m-\Participants were considered to support corporalpunishment if they would tell a parent in their medical practice that spanking wouldbe an appropriate response to any one of a series of childhood misbehaviors pre-sented in the survey.

Results.\p=m-\Offamily physicians, 70% (95% confidence interval [Cl], 66% to75%) support use of corporal punishment. Of pediatricians, 59% (95% Cl, 52% to66%) support corporal punishment. Of pediatricians, 90% (95% Cl, 86% to 94%)indicated that they include discipline issues either always or most of the time whenproviding anticipatory guidance to parents. Significantly fewer family physicians(52%; 95% Cl, 47% to 57%) indicated that they discuss discipline either alwaysor most of the time when providing anticipatory guidance (P


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this analysis did not control for the severity of the violence experienced as achild, lumping all experience of any corporal punishment with abuse. Lefkowitzet al28 investigated the effects ofparentalpunishment practice on the behavior andattitudes of adults in a longitudinal design. The punishment practices of parents of a group of8-year-old children weredetermined, and the children were inter

viewed 10 years later, as young adults.The analysis showed that parental punishment practice influenced the attitudesof the young adults toward punishing children, and in some subgroups, aggressivebehavior in the adults. However, the authors note that several other sociocul-tural and individual variables accountedfor most of aggressive behavior.It is important to dig deeper than sta

tistics on documented physical abuse toidentify the danger in corporal punishment. Berger et al15 interviewed collegestudents about their childhood experience

with physical punishment. Usingwhat they believed to be a very stringent definition ofabuse, the authors foundthat 9% of the subjects had been physically abused in the name of punishment.A surprising number of the abused sub

jects did not identify themselves asabused. Using physical marks such aswelts and bruises to define abuse, Graziano and amaste11 found a similar(10.6%) prevalence of abuse in the nameof punishment in interviewed college students. Berkowitz et al29 have shown in anexperimental design that aversive conditions

maystimulate the

productionof

aggressive behavior, even when the target of the aggression is not the cause ofthe aversive conditions. In fact, much ofwhat passes for ordinary corporal punishment is not punishment at all, but aver-sively stimulated aggression against thechild.30 The goal of aversively stimulatedaggression is to inflict pain.31 Given thatthe real goal of much corporal punishment is to inflict pain, not to punish, it isnot surprising that much corporal punishment is abusive. Societal permissionto use corporal punishment is the child'sticket to victimization.

The purpose of discipline is to teachchildren how to behave; the purpose ofpunishment is to reduce children's misbehavior. When corporal punishment isused, the motivation for behaving well isavoidance of pain rather than good behavior for its own sake. Hoffman andSaltzstein32 used indexes of guilt, internalized moraljudgment, acceptance of responsibility for actions, and considerationfor others to measure the moral development of seventh-graders as affectedby parental disciplinary practice. The authors

compared powerassertion

parenting techniques (including corporal pun-

ishment) with love withdrawal and induction (focusing children's attention onthe harmfulness of their behavior). Theyfound that frequent use of power assertion techniques resulted "considerablyconsistently" in less advanced moral development compared with induction. Inthis study, mild corporal punishment wasnot considered separately from otherpower assertions, but was clearly the main

thrust in classifying parental practices.It

must be noted that the association of parental practices with moral developmentwas strong in middle-class children, butnot clear in the lower class. The authorssuggest that more socializing influencescome from outside the home in the lowerclass. In a longitudinal, prospective studyspanning 19 years, McCord33 found thataggressive parents raised more expressive and antisocial children. Punitive parents raised more egocentric and antisocial children. McCord postulated that expressive action, including doing physical

violence,was normalized for the children

of aggressive parents.Many proponents of corporal punish

ment argue that it is necessary and thatits abandonment will result in less disciplined children. Some cite their experience with children who are not physicallypunished and are not well-behaved. Farley et al34 interviewed officials of 36 schooldistricts in which corporal punishmenthad been eliminated. Only one school district reported increased problems becausecorporal punishment was eliminated. Although a large majority of American

youngstersare

subjectedto

corporal punishment, a considerable number arenot.1115 Studies of the consequences ofcorporal punishment such as those citedabove2728,32"34 provide no support for thenotion that children who are not physically punished behave inferiorly to thosewho are physically punished.

In spite of evidence that corporal punishment is not a useful discipline technique, parents and physicians will beunwilling to give it up if there are noalternatives. Many studies have shownthat effective alternatives to corporal

punishmentexist and can be learned

byparents.3539 Published studies vary fromcase reports of one subject using extinction40 to a controlled experimentaldesign with 32 subjects using time-outto modify behavior.41

In summary, evidence for the futilityand harm of corporal punishment spansthe research of a variety of disciplinesfrom laboratory psychology to educationto medicine. Also, the literature of thesedisciplines is poor in work that supportsthe use of corporal punishment. Althoughthe use of mild corporal punishment (suchas

spanking) by parentshas not been stud

ied often, application ofprinciples derived

from the work of investigators in a variety of fields shows that the practice canbe damaging and unnecessary.

Since corporal punishment can beharmful, and effective alternatives exist, its use should be discouraged byphysicians. Several national organizations, including the American AcademyofPediatrics, have taken at least limitedstands against the use of corporal pun

ishment.81642"45 These organizationsare

not always supported in their objectionsto corporal punishment by the peoplethey represent. In a study of pediatricians' attitudes toward use of corporalpunishment in schools, only 13% indicated strong disagreement with the useof corporal punishment.46 In anotherstudy, only 10% of pediatricians and family physicians agreed that light spanking was inappropriate as a disciplinarymeasure.47 A survey of psychologistsfound that the majority used corporalpunishment in their own homes.48

Small,mobile

contemporaryfamilies

allow little opportunity for young peopleto learn parenting skills by observationand practice with younger siblings. Thus,young parents often turn to the familyphysician or pediatrician for advice onchild-raising issues. Common behavioralconcerns and questions, including discipline questions and problems, were themost frequent behavioral issues encountered in a study of pediatrics in familypractice.49Many behavioral problems maybe avoided or more effectively managedif parents have skills to deal with the

problemsbefore

theyoccur.1750'61

Thus,anticipatory guidance on discipline shouldbe considered an essential part of thefamily physician's or pediatrician's preventive medicine program for youngfamilies.

The purpose of this study was to determine what family physicians' and pediatricians' attitudes are toward corporal punishment. The frequency withwhich these physicians offer anticipatoryguidance on discipline was also studied.

METHODS

SubjectsThe sample for this study was 800 fam

ily physicians and 400 primary care pediatricians randomly selected from theOhio State Medical Board's roster of licensed physicians.52 The study population (948 pediatricians and 1902 familyphysicians) was meant to include physicians who spend a significant amount oftime taking care of children, and who mayfrequently receive questions from parents about discipline problems. Physiciansidentified as pediatricians or family physicians with a

subspecialty (eg, pediatriegastroenterologist) were excluded.

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Study DesignA self-report survey was used for the

study. Subjects were asked to completethe survey and return it in apreaddressed,stamped envelope. A cover letter accompanied the survey and assured respondents of response confidentiality. To maximize the response rate, the survey wasremailed to nonresponders about 4 weeksafter the first mailing. A third mailingwas

done 4 weeks after the second. Thefirst round of surveys was mailed in February 1991; data collection was completedin the first week of June 1991.

The date of return of each survey wasnoted to identify any differences betweenearly and late responders. To identify potential bias due to nonresponders, the sex,age, and practice location of the respondent familyphysicianswas compared withdata on all Ohio family physicians provided by the American Academy of Family Physicians.53,54 Similar data were notavailable for pediatricians.

Study InstrumentIn the survey, the term spanking was

used. Spanking was explicitly definedas only "mild spanking" (striking of thechild's buttocks or hand with an openhand, lightly, leaving no mark excepttransient redness). The term was specifically meant to exclude practices thatmight be considered abusive. The survey included questions about the physicians' demographic characteristics andpractice location and questions about thephysicians' approach to the practice ofcorporal punishment.

The survey presented respondentswith nine scenarios of childhood misbehavior, three different behaviors for threeages. The scenarios were meant to sample respondents' opinion about corporalpunishment in various age groups as wellas in response to dangerous, trivial, andaggressive misbehaviors. Subjects wereasked to state whether they would advise a parent in their practice that spanking is an appropriate response for eachcombination ofmisbehavior and age. Thesurvey also asked respondents to indicate how often they include discipline-related issues when providing anticipatory guidance.

The survey instrument was the product of multiple revisions tested on smallgroups of family practice residents andfaculty and pediatrie residents. The original survey attempted to identify attitudes toward corporal punishment moredirectly. Subjects were asked to statewhether they felt spanking was "definitely," "probably," "probably not," or"definitely not" a useful strategy in child-raising. The results of this survey weredifficult to interpret because many sub-

Percent of Physicians Who Would Support Spanking in a Given Situation

Age, y

I-1

2 5 8

_

-1 -1 I I

Family Family FamilySituation Pediatric ians Physicians Pediatricians Physicians Pediatricians Physicians

Child refuses to go to 4 9 6 20 5 16bed at the usual,established time

Child runs into the 46 44 33 46 16 29street without looking

Child hits one of his or 9 18 10 31 8 25her playmates

jects stated that they objected to spanking, but noted certain circumstances inwhich they would approve of it. Thecircumstances cited most often were "dif-ficult-to-control" children and grave misbehavior. Also, the age of the child wasa factor.

Since the stated question in this investigation was to find out whether the studygroup supports the use of corporal punishment, the survey was constructed toaccount for individuals who find any reason to use corporal punishment. To tapattitudes, the survey asked respondentsto state what they would advise parentsunder a variety of circumstances.

AnalysisRespondents who indicated that they

would advise parents that spanking wasappropriate in any one or more of thesurvey scenarios were classified as supporting corporal punishment. Severalphysicians indicated in written commentsthat they were not opposed to corporalpunishment, although they would not advise it in any of the scenarios presented.These individuals were classified as notopposed to corporal punishment. Practice location was considered urban if the

practice was located in an Ohio countythat is part of a metropolitan statisticalarea.55

To detect any effect related to physicians' age, respondents were assigned totwo age groups, less than 40 years and 40years or older. Logistic regression analysis was used to detect age-related differences that might be confounded by parenthood status. Survey data were tabulated and statistics calculated using standard statistical software packages.5657RESULTS

A total of 183 surveys were undeliv-erable or excluded from analysis becausethe respondent was not a family physician orprimary care pediatrician. Six hundred nineteen surveys were returned fora response rate of 61%. One hundredninety-seven (59%) pediatricians and 422(61%) family physicians returned surveys.Surveys returned from the first mailingnumbered 431; 128 surveyswere returned

in the second mailing and 60 surveys werereturned in the third mailing. No differences were detected in attitudes and characteristics of physicians who respondedin the second and third mailing.

The number of physicians who supportthe use of corporal punishment was 413(67%; 95% confidence interval [CI], 63%to 70%). Of pediatricians, 116 (59%; 95%CI, 52% to 66%) support the use of corporal punishment. Of family physicians,297 (70%; 95% CI, 66% to 75%) indicatedthat they support the use of corporal punishment. The difference in attitude between pediatricians and family physicianswas significant (P


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ishment, 90% have one or more childrenof their own, 23% are female, and 25%practice in a rural setting. Of physicianswho do not support corporal punishment,93% have children, 25% are female, and22% practice in a rural setting. Therewas no significant difference betweenphysicians supporting or not supportingcorporal punishment for these characteristics. Physicians less than 40 years of

age are less likely to have children oftheir own (85%) than older physicians(96%). For family physicians, there wasno difference between the average age,sex, and practice location ofthe Ohio family physician population compared withrespondents.

Significantly more support for corporal punishment was found among physicians younger than 40 years (72%) compared with physicians 40 years or older(63%, P


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patory guidance practices of these physicians may differ from those of physicians in other regions ofthe United States.

CONCLUSIONS

According to Wessel,10 "A physician,educator, or other professional child careworker who inflicts or sanctions corporalpunishment, even with parental permission, misjudges his or her professional role

and responsibility." In this study, mostprimary care pediatricians and familyphysicians were found to support the use ofcorporal punishment in childhood discipline. This opinion is held in spite of considerable evidence that corporal punishment is neither necessary nor beneficialin child-raising. The opinion is also heldcontrary to the official position of scientific and professional groups. Also, onlyabout half of family physicians include discussion of discipline issues when providing anticipatory guidance to parents.

Interpersonal violence is a source of

great suffering in terms of emotional andphysical health in this country. The cycleof violence begins in early childhood withthe use of corporal punishment. Corporalpunishment teaches the use of violenceas a problem-solving method. A contribution to ending the cycle of violencewould be made if parents abandoned corporal punishment in favor of effective,nonviolent disciplinary techniques. Family physicians and pediatricians can contribute by teaching and encouraging parents to use such techniques. Unfortunately, most physicians still believe that

corporal punishment is appropriate. Family medicine and pediatrics educators canhelp end the cycle of violence by teachingresidents about appropriate disciplinetechniques and by encouraging the inclusion of such issues when providing anticipatory guidance to parents.

This study was supported by a grant from theOhio Academy of Family Physicians Foundation,Columbus.

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