Role of The Physician in Promoting Effective Discipline: Evaluation

The word discipline means to impart knowledge and skill – to teach.
However, it is often equated

with punishment and control. There is a great deal of controversy about the appropriate ways to
discipline children, and parents are often confused about effective ways to set limits and instill
self-control in their child.
In medical and secular literature, there is great diversity of opinion about the short-term and
long-term effects of various disciplinary methods, especially the use of disciplinary spanking.
This statement reviews the issues concerning childhood discipline and offers practical guidelines
for physicians to use in counselling parents about effective discipline.
The Canadian Paediatric Society recommends that physicians take an anticipatory approach to
discipline, including asking questions about techniques used in the home. Physicians should
actively counsel parents about discipline and should strongly discourage the use of spanking.
Go to:
ROLE OF THE PHYSICIAN IN PROMOTING EFFECTIVE DISCIPLINE

To be effective, discipline needs to be:
 given by an adult with an affective bond to the child;
 consistent, close to the behaviour needing change;
 perceived as ‘fair’ by the child;
 developmentally and temperamentally appropriate; and
 self-enhancing, ie, ultimately leading to self-discipline.
The physician can promote effective discipline through evaluation, anticipatory guidance and
counselling.
Evaluation
The psychosocial interview, which is part of normal heath care, should include:
 non-judgmental inquiry about parents’ attitudes toward discipline;
 questions about who disciplines and the type of discipline used;
 discussion of difficulties or problems with discipline; and
 inquiries about parental stressors.
Anticipatory guidance
Anticipatory guidance should be appropriate to the child’s developmental level (for example,
explain to parents that a toddler who resists being fed does it not to defy the parent, but rather as
part of normal development). Areas of particular importance are those known to be problematic:
feeding, toilet training and bedtime struggles.
Counselling
Counselling should:
 reinforce parental competence and help parents find strategies that suit the family’s
unique needs;
 suggest effective discipline techniques according to the child’s developmental level,
parent/child dyad, and cultural and social norms; and
 provide resources for parents in need, such as printed handouts or referral to other
appropriate professionals.
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GOALS OF EFFECTIVE DISCIPLINE

Discipline is the structure that helps the child fit into the real world happily and effectively. It is
the foundation for the development of the child’s own self-discipline. Effective and positive
discipline is about teaching and guiding children, not just forcing them to obey. As with all other
interventions aimed at pointing out unacceptable behaviour, the child should always know that
the parent loves and supports him or her. Trust between parent and child should be maintained
and constantly built upon.
Parenting is the task of raising children and providing them with the necessary material and
emotional care to further their physical, emotional, cognitive and social development.
Disciplining children is one of the most important yet difficult responsibilities of parenting, and
there are no shortcuts. The physician must stress that teaching about limits and acceptable
behaviour takes time and a great deal of energy. The hurried pace of today’s society can be an
obstacle to effective discipline.
The goal of effective discipline is to foster acceptable and appropriate behaviour in the child and
to raise emotionally mature adults. A disciplined person is able to postpone pleasure, is
considerate of the needs of others, is assertive without being aggressive or hostile, and can
tolerate discomfort when necessary.
The foundation of effective discipline is respect. The child should be able to respect the parent’s
authority and also the rights of others. Inconsistency in applying discipline will not help a child
respect his or her parents. Harsh discipline such as humiliation (verbal abuse, shouting, name-
calling) will also make it hard for the child to respect and trust the parent.
Thus, effective discipline means discipline applied with mutual respect in a firm, fair, reasonable
and consistent way. The goal is to protect the child from danger, help the child learn self-
discipline, and develop a healthy conscience and an internal sense of responsibility and control.
It should also instill values.
One of the major obstacles to achieving these goals is inconsistency, which will confuse any
child, regardless of developmental age. It can be particularly hard for parents to be consistent
role models. Telling children to “Do as I say, but not as I do” does not achieve effective
discipline. Parental disagreements about child-rearing techniques, as well as cultural differences
between parents, often result in inconsistent disciplining methods. The physician needs to be
mindful of these challenges and suggest steps that parents can take to resolve these differences
(1).
It is important that in teaching effective discipline, physicians do not impose their own agendas
on the families they counsel. A balanced, objective view should be used to provide resources,
and the goal should be to remain objective. This means using principles supported by academic,
peer-reviewed literature. This is particularly important when dealing with controversial issues
such as disciplinary spanking.
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DEVELOPMENTAL CONSIDERATIONS
Regardless of the developmental stage and age of the child, some basic principles can help guide
the physician:
 The purpose of effective discipline is to help children organize themselves, internalize
rules and acquire appropriate behaviour patterns.
 The temperaments of the child and the parents, particularly in the context of their
sociocultural milieu, require flexibility. Children with special needs and developmental
delay require additional adjustments and problem-solving (2).
 Effective discipline does not instill shame, negative guilt, a sense of abandonment or a
loss of trust. Instead, it instills a sense of greater trust between the child and the parent.
 Anticipatory guidance offers physicians an opportunity for prevention, to discuss the type
of discipline according to the child’s developmental age. Undesirable behaviours are best
avoided through prevention and by building supportive structures that include clear,
consistent rules (3).
 Physicians should take care to provide anticipatory guidance and appropriate support to
parents who are under stress, isolated, disadvantaged or impaired. Physicians should be
familiar with the resources in the family’s community.
 Physicians should consider the role of the parent in influencing the child’s misbehaviour.
For example, a depressed caregiver who is influencing the behaviour and development of
a child may require referral to another appropriate professional.
Infants (birth to 12 months)

Infants need a schedule around feeding, sleeping and play or interaction with others. The
schedule helps regulate autonomic functions and provides a sense of predictability and safety.
Infants should not be overstimulated. They should be allowed to develop some tolerance to
frustration and the ability to self-soothe. Discipline should not involve techniques such as time-
out (see Forms of discipline), spanking or consequences.
Early toddlers (one year to two years)

At the early toddler stage, it is normal and necessary for toddlers to experiment with control of
the physical world and with the capacity to exercise their own will versus that of others.
Consequently, parental tolerance is recommended. Disciplinary interventions are necessary to
ensure the toddler’s safety, limit aggression, and prevent destructive behaviour. Removing the
child or the object with a firm “No,” or another very brief verbal explanation (“No –hot”), and
redirecting the child to an alternative activity usually works. The parent should remain with the
child at such times to supervise and ensure that the behaviour does not recur, and also to assure
the child that the parent is not withdrawing love.
Early toddlers are very susceptible to fears of abandonment and should not be kept in time-out
away from the parent. However, occasionally, a parent may become so frustrated with the child
that he or she needs a period of separation from the child.
Early toddlers are not verbal enough to understand or mature enough to respond to verbal
prohibitions. Therefore, verbal directions and explanations are unreliable forms of discipline for
early toddlers (4).
Example: The toddler wants to play with a breakable glass object on a hard kitchen floor.
Remove the child and the object and redirect the toddler’s attention to a more appropriate
activity such as playing with a ball in another room. The parent should remain with the child.
Late toddlers (two years to three years)

The struggle for mastery, independence and self-assertion continues. The child’s frustration at
realizing limitations in such struggles leads to temper outbursts. This does not necessarily
express anger or willful defiance. The caregiver should have empathy, realizing the meaning of
these manifestations. At the same time, the caregiver should continue to supervise, set limits and
routines, and have realistic expectations of the child’s achievement capabilities. Knowing the
child’s pattern of reactions helps prevent situations in which frustrations flare up. When the child
regains control, the parent should give some simple verbal explanation and reassurance. The
child should be redirected to some other activity, preferably away from the scene of the tantrum.
The toddler cannot regulate behaviour based on verbal prohibitions or directions alone.
Example: The toddler has a temper tantrum in a public place. Remove the child from the place of
misbehaviour. Hold the child gently until the toddler gains control. Give a short verbal
instruction or reassurance followed by supervision and an example.

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The word discipline means to impart knowledge and skill – to teach.

However, it is often equated

ROLE OF THE PHYSICIAN IN PROMOTING EFFECTIVE DISCIPLINE

GOALS OF EFFECTIVE DISCIPLINE

Infants (birth to 12 months)

Early toddlers (one year to two years)

Late toddlers (two years to three years)

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