One of the issues that can push your button as a pediatrician is hearing from your nurse that the parent you are about to see hit the child in the waiting room. Sometimes, the parent even hits the child right in front of you during the visit!

Your first reaction may be to want to tell the parents not to spank. But how well does that advice work?

Parents tend to use the same methods of child rearing that were used for them when they were growing up. This is deeply ingrained and tends to be accepted as "natural" even when they do not rationally believe in it. This requires that any intervention about corporal punishment be a conversation, not an edict from you. They may nod their heads if you tell them not to spank, but shut out any future advice from you on this topic.

There are some real facts that can help you address the parents’ reasons for spanking. The first "fact" that pediatricians often pull out is that "hitting the child does not work." Wrong. Hitting a child works fast to stop an unwanted behavior – but it has side effects. If you deny this, you lose credibility. If you acknowledge this, you will have the ears of the parents. Then you can point out some related truths – the child will soon go back to the same behavior whether hit or not because that is what young children do. Avoiding repeat behavior requires adjusting the environment, removing the child, and often changing the mood of the interaction. It is a fact that painful punishments must be progressively increased to maintain effectiveness and make nonpainful interventions less effective. I sometimes muse, "What are the teachers going to do at school if only hitting can control his behavior?"

The next fact is that other consequences, notably time out, work just as well as spanking to reduce unwanted behaviors, but without the side effects. What are these side effects? There are immediate side effects of corporal punishment, even if no bruising or harm occurs, and also long-term side effects. The immediate side effects are to increase the child’s aggressiveness to peers, siblings, and often the parent, and to increase fear of the parent. Fear of the parent undermines the child’s wanting to do as the parent asks, makes the child avoid the parent – making him/her less available to all parenting, and interferes with the problem solving that the child needs to do when facing a stressful situation such as conflict with a sibling. Longer term fear of the parent makes a child sneaky and less likely to admit mistakes. That is certainly not what anyone wants, especially when the child becomes a teen.

It may be hard to believe, but 25% of infants 1-6 months and 50% of infants 6-12 months are spanked for discipline. The implication is that it is never too early to have a conversation about discipline – certainly by 12 months of age. This early teaching helps parents establish control and helps prevent the early use of corporal punishment. Help parents understand that infants cannot learn to avoid a behavior from being struck; they can only become confused and frightened of their parent. In fact, 0- to 23-month-old white (not black or Latino) children had worse behavior at 6 years if they were frequently spanked, even controlling for maternal warmth (Pediatrics 2004;113:1321-1330).

Hitting a child is especially dangerous for children under age 2 years due to their size and head/body proportions. At this stage, a hit by an adult is more likely to cause serious injury even when the adult thought they were under control and managing the amount of force used. It is sobering to know that one-third of child abuse occurs to children under 6 months of age. If evidence of abuse is seen, it is your obligation to report it immediately. But you have a lot more value in educating about effective and safe discipline early on to prevent this. The American Academy of Pediatrics recommends that parents be "assisted in the development of methods other than spanking for managing undesired behavior" and that means you!

But doesn’t a toddler need discipline to learn how to behave? We know that verbal correction without action actually increases noncompliance in toddlers. But in one study, two-thirds of children under age 6 years were hit in the last week, on average 3 times per week. This is because toddlers and preschoolers typically misbehave every 6-8 minutes! Some consequence is needed as a back-up to reasoning to decrease recurrence of misbehavior, but noncorporal consequences are equally effective. The more children ages 3-6 years are spanked, the greater their antisocial behavior 2 years later, controlled for baseline behavior. Even IQ is lower at age 4 years when there is more spanking.

Asking older children "What happens if you do something bad" is a regular part of my visits. Why? Because 60% of 10- to 12-year-olds are struck and have increased aggression and decreased self-esteem as a result. Don’t forget that 40% of 14-year-olds and 25% of 17-year-olds are still hit even though the result is that 8- to 17-year olds who are struck have increased delinquency, controlling for family violence, alcohol, and parenting competence.

Most parents do not want to hit their child. Actually, 85% of parents who believe in spanking say that it was the wrong thing to have done the last time they used it. Yet about 90% of parents hit their 3-year-olds. Why? Parents who hit say that they don’t know what else to do when their children act out. They may try not to spank, but end up spanking out of anger and frustration. And hitting not only stops behavior, but also relieves the anger parents feel in dealing with their child. Even though they may regret it afterward, it feels good to them at the time.

How can you approach this touchy subject with your patients? The first principle is to resist your impulse to correct the parent and instead say nothing – at least right away. Carry on your visit and observe the child’s behavior. Some misbehavior is likely to appear. Then comment on what you see about child – "He sure is busy!" Then ask, "How is that for you?", or "How bad does it get?" Be nonjudgmental. Instead praise acceptable techniques they already use well, such as distracting the child or removing temptation.

Because parenting is learned from our own experiences, it is important to explore how the parents were raised. You might start by asking, "How would your parents have handled that behavior when you were growing up?" then "What have you decided about how you want to discipline your children?" Often, you will find that they do not want to repeat history, but don’t know other ways. Now you have an opening to offer other effective techniques. You might even ask permission, for example, "Would you like to hear about some other things that can work?" The main strategies you can teach quickly include first paying attention to acceptable behavior, and also proper use of Time Out. For toddlers and preschoolers, I also teach parents to use "only one request then move" the child silently to do as told.

Your advice will be more effective when you individualize the plan to make small adjustments to their current parenting with which the family can agree and be successful. For example, if one parent is willing to try these alternatives but the other is not or is unsure I suggest an agreement for use of Time Out instead of hitting for 2-3 weeks by the willing parent and noninterference plus limits on physical punishment (spank on clothed buttocks only) by the other parent. What usually happens is that the "Time Out parent" has success in this time period, and the other parent sees this and adopts the same method. It is really important to schedule one or more follow up visits soon, at least by phone, to reinforce their success and problem solve any difficulties. Changing such an ingrained habit is difficult but worthwhile and deserves your support.

Advising to avoid corporal punishment can be even more difficult for some doctors and in some settings. You may have been raised with spanking yourself and see it as not harmful or even helpful to your own development. Remember, spanking only increases the chances of a poor outcome by a factor of four, so most people grow up fine! The parents’ or your religion may even advise the use of spanking. I like to translate "spare the rod" as meaning "draw a line in the sand with the rod" to set limits. You may be of a different culture than your patient in which their belief is that corporal punishment is the key to neighborhood survival and gaining the child’s respect. But a child who is hit is actually more likely to bring him/herself trouble through aggression or delinquency.

To be effective in counseling about corporal punishment, you need to be clear about your own ideas on the acceptability of hitting. You need to be rational and avoid strong emotions during the visit. Instead, show empathy to the difficulties of parenting and work to understand and address the parents’ justifications for spanking with the facts. If you have shown knowledge of behavior and development in the regular care you provide, you will be a credible source and influence on this important area.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.

Talking with families about corporal punishment