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A brief intervention affects parents’ attitudes toward using less physical punishment
Child Abuse & Neglect 37 (2013) 1192–1201
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Child Abuse & Neglect
A brief intervention affects parents’ attitudes toward using less physical punishment夽,夽夽, Antwon Chavis a , Julia Hudnut-Beumler b , Margaret W. Webb c , Jill A. Neely c , Len Bickman d , Mary S. Dietrich e , Seth J. Scholer f,∗ a
Meharry College of Medicine, USA Vanderbilt University, USA Vanderbilt University, School of Medicine, USA d Center for Evaluation and Program Improvement, Peabody Administration Building, 3rd Floor, 1212 21st Avenue South, Nashville, TN 37203-2402, USA e School of Nursing, School of Medicine (Biostatistics), Vanderbilt University, 461 21st Avenue, Nashville, TN 37240, USA f 8232 DOT, Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville TN 37232, USA b c
a r t i c l e
i n f o
Article history: Received 25 April 2013 Accepted 9 June 2013 Available online 13 July 2013
Keywords: Violence Child abuse Parenting Counseling Education Aggression
a b s t r a c t Consecutive English and Spanish speaking caregivers of 6–24 month old children were randomly assigned to either a control or intervention group. Parents in the intervention group were instructed to view at least 4 options to discipline a child in an interactive multimedia program. The control group participants received routine primary care with their resident physician. After the clinic visit, all parents were invited to participate in a research study; the participation rate was 98% (258/263). The key measure was the Attitudes Toward Spanking (ATS) scale. The ATS is correlated with parents’ actual use of physical punishment. Parents with higher scores are more likely to use physical punishment to discipline their children. Parents in the intervention group had an ATS score that was significantly lower than the ATS score of parents in the control group (median = 24.0, vs. median = 30; p = 0.043). Parents in the control group were 2 times more likely to report that they would spank a child who was misbehaving compared with parents in the intervention group (16.9% vs. 7.0%, p = 0.015). In the short-term, a brief intervention, integrated into the primary care visit, can affect parents’ attitudes toward using less physical punishment. It may be feasible to teach parents to not use physical punishment using a population-based approach. The findings have implications for how to improve primary care services and the prevention of violence. © 2013 Elsevier Ltd. All rights reserved.
夽 Support for the research was provided by the Scholarly Activities Fund, Division of General Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt. Vanderbilt University is a non-profit institution. The Morgan Family Foundation, a non-profit organization, helped to sponsor the development of the Spanish version of Play Nicely. There was no commercial funder for the development of the program or the research. All authors, independent of any commercial funder or sponsor, had full access to all the data in the study, and take responsibility for the integrity of the data and the accuracy of the data analysis. 夽夽 The Play Nicely program is owned by Vanderbilt University and Dr. Scholer is one of the authors of the program. The Play Nicely program can be viewed at no cost at www.playnicely.org. The study’s ClinicalTrials.gov identifier is NCT01459510. ∗ Corresponding author. 0145-2134/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.chiabu.2013.06.003
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Introduction Inappropriate discipline, including the use of physical punishment, is a risk factor for antisocial behavior, depression, anxieties, and many other adverse consequences (Durrant & Ensom, 2012; Durrant, 2008; Gershoff, 2002; Lansford, Chang, Dodge, Malone, Oburu, & Palmerus, 2005; MacMillan, Boyle, Wong, Duku, Fleming, & Walsh, 1999; Slade & Wissow, 2004; Straus, Sugarman, & Giles-Sims, 1997). Inappropriate discipline may lead to child maltreatment and be a form of toxic stress that has lifelong implications for adverse mental and physical problems (Shonkoff, Garner, Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics, 2012). Evidence is mounting that children who are physically punished are at increased risk of child abuse (Gershoff, 2002). As stated in an a report by the American Academy of Pediatrics (AAP), “The only way to maintain the initial effect of spanking is to systematically increase the intensity with which it is delivered, which can quickly escalate into abuse” (Stein & Perrin, 1998). To prevent violence, the World Health Organization (WHO) recommends that all parents learn appropriate methods to discipline their children (Krug, Mercy, Dahlberg, & Zwi, 2002). The pediatric primary care visit provides an excellent opportunity to teach parents appropriate methods to discipline and to discourage the use of physical punishment. The AAP and the Canadian Pediatric Society recommend that primary care physicians routinely encourage parents to use non-physical forms of discipline (“Effective discipline for children”, 2004; Stein & Perrin, 1998). Parents report they are ready and willing to learn discipline strategies that are alternatives to physical punishment (Olson, Inkelas, Halfon, Schuster, O’Connor, & Mistry, 2004; Taylor, Moeller, Hamvas, & Rice, 2013; Young, Davis, Schoen, & Parker, 1998), but there are missed opportunities within primary care to teach parents more effective strategies to discipline (Finch, Weiley, Ip, & Barkin, 2008; Olson et al., 2004; Young et al., 1998). Parents’ attitudes about physical punishment predict their actual use of physical punishment at home with their young children (Bower-Russa, 2005; Graziano, Hamblen, & Plante, 1996; Jackson, Thompson, Christiansen, Colman, Wyatt, & Buckendahl, 1996; Socolar & Stein, 1995; Vittrup, Holden, & Buck, 2006). There is evidence that parents develop their attitudes about discipline early in the lives of their children before children have time to display chronic behavior problems (Vittrup et al., 2006). A logical question is whether primary care interventions can help teach parents of young children to not use physical forms of discipline. Many parenting interventions have been studied in community and primary care settings (Barkin, Finch, Ip, Scheindlin, Craig, & Steffes, 2008; Dubowitz, Feigelman, Lane, & Kim, 2009; Fennell & Fishel, 1998; Minkovitz, Hughart, Strobino, Scharfstein, Grason, & Hou, 2003; Minkovitz, Strobino, Mistry, Scharfstein, Grason, & Hou, 2007; Olds, Eckenrode, Henderson, Kitzman, Powers, & Cole, 1997; Reich, Penner, Duncan, & Auger, 2012; Reid, Webster-Stratton, & Baydar, 2004; Scholer, Hamilton, Johnson, & Scott, 2010; Scholer, Hudnut-Beumler, & Dietrich, 2010; Sege, Perry, Stigol, Cohen, Griffith, & Cohn, 1997; Zubrick, Ward, Silburn, Lawrence, Williams, & Blair, 2005) and several studies of parenting interventions indicate that parental attitudes and behavior regarding physical punishment can be changed (Dubowitz et al., 2009; Fennell & Fishel, 1998; Minkovitz et al., 2003, 2007; Reich et al., 2012; Scholer, Hamilton, Johnson, & Scott, 2010; Scholer, Hudnut-Beumler, & Dietrich, 2010). Because it would be best for all parents to learn about appropriate methods to discipline, more work is needed to determine if parents’ attitudes can be affected using a population-based approach. The intervention in this study was the Play Nicely program, an educational program that was developed to help educate parents about discipline in primary care and early education settings. Developed at Vanderbilt University, the content of the program is based on material from the American Academy of Pediatrics, the National Association for the Education of Young Children, and the American Psychological Association (Scholer, 2010). Multiple evaluations of the program have laid the foundation for the population-based approach used in this study. In the setting of a general pediatric clinic, parents of 1–7 year old children were asked if they desired to learn more about discipline (Scholer, Mukherjee, Gibbs, Memon, & Jongeward, 2007). Of parents who agreed to participate, 30% spontaneously reported that they planned to use less spanking as a result of viewing the program (Scholer et al., 2007). In another study of parents in clinic and a preschool setting, we found that viewing the Play Nicely program was associated with a change in parents’ attitudes toward using less physical punishment in an intervention group; however the study did not find a difference comparing the intervention and control groups (Scholer, Hamilton, Johnson, & Scott, 2010). These earlier studies were limited in that parents agreed to participate, resulting a selection bias. Additional studies of the Play Nicely program were needed to demonstrate that it is possible to use a population base based approach to teach parents about discipline. In a general pediatric clinic, one group of parents was invited (i.e. parents had to opt in) to view information about discipline and another group was instructed (i.e. parents had to opt out) to view the material as part of the well visit (Scholer, Walkowski, & Bickman, 2008). Regardless of the group assignment, 100% of parents were pleased that the program was provided in the office (Scholer et al., 2008). In a randomized controlled trial of consecutive parents of 1–5 year old children presenting for a well visit, parents in an intervention group were 12 times more likely to revise their plans to discipline compared with a control group (83% vs. 7%; p < 0.001) (Scholer, Hudnut-Beumler, & Dietrich, 2010). Parents in the intervention group were more likely to verbalize that they planned to use less spanking (9% vs. 0%; p < 0.001) (Scholer, Hudnut-Beumler, & Dietrich, 2010). Although these evaluations are promising, studies are now needed to confirm that brief programs can actually affect parents’ attitudes toward using less physical punishment. The objective of this randomized controlled study was to determine if a brief intervention, integrated into the primary care visit, can affect parents’ attitudes toward using less physical punishment. The results of this study have implications for how to improve primary care offerings, the prevention of child abuse, and the prevention of violence.
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Methods Overview The study design was a randomized controlled trial conducted in a pediatric primary care clinic at Vanderbilt University from June to August in 2010. Participants were parents of infants and children between the ages of 6 months and 24 months presenting for a well visit. Parents were excluded if they could not speak English or Spanish. We used an atypical methodological approach by randomizing participants without their knowledge to an intervention before the clinic visit. After the visit, parents were invited to participate in a research study in the form of a personal interview; all participants provided verbal informed consent. The participant flow is illustrated in Fig. 1. The pediatric clinic is staffed by pediatric residents with supervision by attending pediatricians. Most children seen in the clinic have TennCare, Tennessee’s government sponsored health care insurance program that is similar to Medicaid. The average age of the participants was 28 years and almost half of the participants had at least some college education. The majority of participants were White, Black, or Hispanic. The ages of the children tended to be between 8 and 17 months. There were no statistically significant differences between the groups for any of these characteristics (Table 1).
Randomization A research assistant (RA) randomized eligible parents to an intervention or control group by opening an opaque envelope. As recommended by the CONSORT guidelines designed to improve reporting of data in randomized controlled trials, “Informed consent by study participants is typically required in intervention studies.” Although typically required, it is not mandatory if there is justification. In the IRB proposal, we provided our rationale for randomizing parents without their knowledge. First, the experiences in the study are very similar to what parents experience as part of a routine primary care clinic visit. Second, advance knowledge of the purpose of the study would likely bias the results by creating a demand characteristic for a socially desirable response. Finally, without using this approach, we would not be able to answer the research question about the effect of an intervention that has been integrated into the visit because we have learned that many parents, if asked, will decline to view educational material about discipline (Scholer et al., 2007, 2008). In a study in which parents were invited to view the intervention immediately after the clinic visit, approximately 50% declined (Scholer et al., 2007). In a separate study, we asked parents in the waiting room if they would like to spend a few minutes learning about how to discipline their child while they were waiting to be checked into the triage area; 60% of parents declined (Scholer et al., 2008). This is in contrast to another group of parents who were instructed that the next part of the clinic visit was to view strategies to discipline their child; 100% of parents in the “required” group agreed (Scholer et al., 2008). We submitted the rationale for our approach and the study was approved by the Vanderbilt Institutional Review Board (IRB).
Research assistant approached consecuve parents of 6-12 month old children presenng for a well visit (n=263)
Exclusion criteria: Parent who could not speak English or Spanish
RANDOMIZATION Control group received standard offerings in primary care (n=132)
Mulmedia Intervenon Viewed intervenon (n=131) Declined (n=0)
Accepted (n=128) Declined (n=3)
RECRUITMENT Parent invited to parcipate in a brief survey immediately aer clinic visit. Informed consent Open ended queson 10 item scale Fig. 1. Participant flow.
Accepted (n=130) Declined (n=2)
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Table 1 Demographic characteristics of participants. Characteristic
Study group Control (n = 130)
Intervention (n = 128)
p-value
Age of caregiver, years median (IQR) Gender of caregiver, female
28.0 (23.0, 32.0) 112 (86.2)
28.0 (23.0, 32.0) 109 (85.2)
0.494 0.819
Caregiver relationship to child Mother Father Other
106 (81.5) 17 (13.1) 7 (5.4)
103 (80.5) 18 (14.1) 7 (5.5)
Education
21 (16.3) 47 (36.4) 38 (29.5) 23 (17.9)
20 (15.7) 55 (43.3) 33 (26.0) 19 (15.0)
Race White Black Hispanic Asian Other
35 (27.1) 60 (46.5) 23 (17.8) 5 (3.9) 6 (4.7)
28 (21.9) 61 (47.7) 32 (25.0) 5 (3.9) 2 (1.6)
Marital status Now married Never married Divorced Separated Widowed
51 (39.5) 70 (54.3) 7 (5.4) 1 (0.8) 0 (0.0)
48 (38.1) 72 (57.1) 4 (3.2) 1 (0.8) 1 (0.8)
Gender of child, female Age of child (months) median (IQR) Total no. of children median (min, max)
69 (52.3) 12.0 (8.0, 15.3) 2.0 (1, 3)
56 (43.4) 12.0 (9.0, 16.8) 2.0 (1, 3)
0.972
0.628
0.360
0.681
0.152 0.587 0.320
All data presented as n (%) unless indicated otherwise. IQR indicates inter-quartile range.
Intervention The intervention, viewed in the examination room, was the Play Nicely program, a multimedia program that teaches how to manage childhood aggression and appropriate strategies to discipline children (Scholer, 2010). The program can viewed on a CD ROM or on the internet and is available in English and Spanish. In one part of the program, viewers are presented with the hypothetical situation of one young child hitting another and provided with a list of 20 options to respond. When the viewer clicks on a specific option, he/she views approximately 1 min of multimedia material that explains whether the option is (1) a great option, (2) a good option after others have been tried and failed, or (3) an option that is not recommended (see Table 2). The focus of the study was to determine if an intervention could affect attitudes about physical punishment. When parents clicked on the option, “Spank your child”, English-speaking parents heard the following script accompanied by bulleted points: “Spanking may seem to help in the short run, but it can actually make matters worse in the long run. Spanking may get a child’s attention, but it does nothing to explain why the behavior is wrong. You are your child’s role model. If you spank them, they will learn from you that physically hurting someone else is an acceptable way to deal with a challenging situation. It does not make sense to teach a child not to hit by hitting them. It is much better to use other ways such as redirecting to teach your child how not to hurt people. Because there are much better options to consider, spanking is not recommended as a form of discipline. Some justify spanking by quoting the Biblical phrase that says, “Spare the rod, you spoil the child”. However, shepherds usually used a rod to guide sheep, not to hit them. Children should not be guided with being hit or spanked; rather they should be guided by setting the rule, redirecting behavior, teaching why hurtful behavior is wrong, and getting them to think about the feelings of others. It is likely that if you spare the guidance, your child will develop behavior problems.” Readers who are interested can view the actual multimedia program, including the Spanish version, at www.playnicely.org. Intervention group The RA approached all parents allocated to the intervention group (n = 134) after their child was triaged and instructed them that the next part of the clinic visit was to view at least 4 of the interactive options in the Play Nicely program. Viewing
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Table 2 List of discipline options in the intervention.a Great options Set the rule by firmly saying “No hitting” Redirect by giving your child an example of how to be helpful with his hands Redirect by asking your child what should be done with his hands Ask your child how the other child feels Later in the day, praise your child for playing nicely Discuss why hurtful behavior is wrong Tell your child that you expect the right choice next time Role play at another time Good options after others have been tried Place your child in Time-Out Take away a privilege Say “No” to your child Tell your child what to expect if he is hurtful again (i.e. give warning) Hold and give hugs to your child At another time, encourage rough and tumble play Ask your child about his feelings Leave the area There are better options Spank your child Ignore the behavior Yell or speak angrily at your child Tell your child that he is hurtful child a Parents in the intervention group were asked to view at least 4 of options in this list. After the parent chooses an option, he/she learns if the option is a great option, a good option, or if there are better options. Each option is described in more detail with multimedia content (approximately 1 min/option). Spanish-speaking parents viewed the Spanish version.
each option takes 1–2 min, resulting in a viewing duration ranging from 5 to 10 min. If the parent indicated that he/she did not want to view the program or he/she wanted to stop viewing for any reason, the research assistant had been instructed to discontinue the viewing experience; however, no parent declined to view the intervention. Parents whose primary language was Spanish viewed the Spanish version. All parents in the intervention group were asked to view at least 4 discipline options from the interactive section of the program. The RAs did not track which options were viewed. For a minority of intervention parents (approximately 20%), we experimented with a variation of this introduction by asking parents to find 2 great options to discipline and 2 options that are not recommended. The RAs did not record which parents experienced this variation in introducing the intervention. Control group The control group participants (n = 132) received routine primary care with their resident physician. Recruitment After the clinic visit with their pediatrician, all parents were invited to participate in a 2 min research study. Parents who provided verbal informed consent were enrolled in the study. The RA who recruited the parent was different from the RA who introduced the intervention and was blinded to the intervention allocation. See Fig. 1 for a description of the participant flow. Measures Demographic information included parents’ age, gender, marital status, education level, ethnicity/race, relationship to the child, and number of other children. The first measure was parents’ response to a hypothetical scenario of one young child hurting another. Parents were asked to consider the following scenario: “Assume you are the parent of a 2 year old boy and you see him hit another child.” Parents were then asked two open-ended questions: (1) “list at least 2 things that you might do to respond” and (2) “list at least 2 things that you would not do to respond.” The parents’ responses were reviewed by the authors. The authors developed definitions for each of the eight most common responses. Then, one of the researchers, (AC), blinded to the group allocation, coded the responses based upon the following definitions: 1. Spanking: parent reported that they would spank, pop, hit, slap or use other “physical” punishment. Does not include vague references such as using “discipline” or “punishment”. 2. Time-out: parent used the term “time out”. Does not include pulling child away or removing child from situation.
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Table 3 Parents’ report of how they would respond to a hypothetical scenario of a child with aggression. Response Spank Time-out Remove from situation Set limit Explain Redirect Stop child from hitting Apology
Control (n = 130)
Intervention (n = 128)
p-value
22 (16.9) 40 (30.8) 24 (18.5) 61 (46.9) 36 (39.1) 4 (3.1) 10 (7.7) 24 (18.5)
9 (7.0) 34 (26.6) 10 (7.8) 56 (43.8) 56 (60.9) 23 (18.0) 8 (6.3) 7 (5.5)
0.015 0.455 0.011 0.609 0.007 <0.001 0.649 0.001
All data presented as n (%). Note: Columns do not sum to 100% because more than one response was possible.
3. Remove from situation: parent reported that they would remove the child from the situation. This could include pulling, taking, or moving the child. 4. Set limit: parent would say “No” or in another way, set rule that hitting is not allowed. 5. Explain: parent reported that they would “explain” to child why he child should not hit. For example, parent would tell the child that hitting is not right. 6. Redirect: parent reported that they would redirect the child toward a more positive behavior. 7. Stop child from hitting: parent reported that they would stop the child from hitting. 8. Apologize: parent reported that they would respond with an apology, either from themselves or from the child who hit. A second reviewer (SS), who again was blind to group allocation, independently reviewed parents’ responses; there was 95% agreement for all responses. For the category of spanking, there was 99% agreement. Coding by the first reviewer was used for the analysis. The second measure was the Attitudes Toward Spanking (ATS) scale, a 10 item scale that is correlated with parents’ use of physical punishment. Examples of items on the scale are “Spanking is a normal part of my parenting”, “Sometimes a spank is the best way to get my child to listen”, and “A spank is not an effective method to change my child’s behavior for the long term”. Participants respond to each item using a 7 point Likert scale ranging from 1 = ‘strongly disagree’ to 7 = ‘strongly agree’. A global ATS score is generated by summing the responses to the 10 items after reversing the scores for four of the items so that a higher score is associated with an increased likelihood of using spanking to discipline. Previous work has demonstrated the validity and psychometric properties of the ATS (Vittrup et al., 2006). Statistical analysis Sample size estimates were based on the desire to detect at least the difference in the ATS observed in a previous study (Scholer, Hamilton, Johnson, & Scott, 2010). In this previous study, parents viewed at least 8 interactive options, as compared with 4 options in this study, and we used a 5 point Likert scale for the ATS rather than a 7 point scale. Control participants in earlier work reported ATS mean values of ∼30 with SD = ∼14.5. A difference of ∼4 points between the control and intervention group was observed in a previous cross-sectional study (effect size ∼0.28). Given this expected high variability relative to the mean and a logistic distribution of scores, a sample size of 150 would provide 80% statistical power for detection of a change in ATS as small as 3.2 scale points (two-sided alpha = 0.05). This change translates into a standardized effect size of 0.22. After compensating for differences between the previous study and this study, we estimated that enrolling at least 200 families would be sufficient to detect differences as small as those noted above (less than a quarter standard deviation). We did not aim to enroll enough parents in this study to assess for differences in the ATS between sociodemographic subgroups. Frequency distributions were used to summarize the nominal demographic characteristics and parental responses to the hypothetical scenario. Differences in these distributions between these groups were tested using the likelihood chi-square statistic. The distributions of the continuous demographic characteristics and the ATS scores were skewed, therefore the median was used to represent the middle of these distributions and the 25th and 75th inter-quartile ranges (IQR) representing the middle 50% of the values are presented as the best summaries of variability in these measures. Mann–Whitney tests were used to compare the distributions of these variables between the two study groups. A p-value of less than 0.05 was used for determining statistical significance. Results Of the 263 parents who were randomized, 258 (98%) completed the survey. Parents’ responses to the hypothetical situation of one young child hurting another for each of the groups are summarized in Table 3. Parents in the control group were 2 times more likely to report that they would spank the child compared with parents in the intervention group (16.9% vs. 7.0%, p = 0.015). Parents in the control group were more likely to report that they would respond by removing the child from the situation and using an apology. Parents in the intervention group were more likely to report that they would redirect the child and explain why hitting is wrong.
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Table 4 Comparison of ATS scores for parents in the intervention and control groups. ATS median (IQR) Intervention
Control
All parents (n = 258)
24 (16,35)
30 (18,38)
Race White (n = 63) Black (n = 121) Hispanic (n = 55)
22 (16,35) 28 (20,36) 22 (16,29)
25 (16,34) 32 (20,39) 34 (16,46)
Education
19 (12,24) 24 (16,35) 25 (20,34) 34 (23,40)
31 (15,47) 28 (16,37) 34 (21,41) 24 (16,36)
Maternal age <25 (n = 88) 25–35 (n = 128) >35 (n = 42)
25 (16,36) 24 (17,34) 26 (17,32)
28 (17,37) 34 (19,39) 26 (15,44)
*
p = 0.043*
The p-value was not calculated for subgroups because the study was not powered to detect a difference in ATS scores between subgroups.
Overall, the scores on the ATS were in the lower portion of the range of possible scores (median = 27.0, IQR = 17, 36, possible range = 10, 70). Parents in the intervention group had a lower ATS score compared with parents in the control group (median = 24.0, IQR = 16, 35 vs. median = 30, IQR = 18, 38; p = 0.043). ATS scores are listed in Table 4 for parents with different race/ethnic backgrounds, ages, and education levels [Note: the ATS scores for parents in different sociodemographic categories should be interpreted with caution due to an inadequate sample size for the analyses of subgroups (see Methods)]. In general, parents with different sociodemographic backgrounds had ATS scores that were lower in the intervention group compared with the control group. The one exception was parents with a college education in the intervention group had a higher ATS score compared with parents in the control group. Discussion These results of this study advance what is known about how to teach more parents that spanking is not a recommended form of discipline. We found that a brief, one-time, multimedia intervention can affect parents’ attitudes toward using less physical punishment. Compared with parents in a control group, parents randomized to a brief intervention had a lower ATS score. Compared with parents in the control group, parents in the intervention group were less likely to report that they would spank a child who was misbehaving. This study has implications for how to improve primary care offerings related to child abuse prevention and violence prevention. In this study, a brief intervention was integrated into the routine pediatric primary care visit because it is a logical step in determining how to educate more parents about not using physical punishment. It is known that parenting programs work (Barkin et al., 2008; Dubowitz et al., 2009; Fennell & Fishel, 1998; Minkovitz et al., 2003, 2007; Olds et al., 1997; Reich et al., 2012; Reid et al., 2004; Scholer, Hamilton, Johnson, & Scott, 2010; Scholer, Hudnut-Beumler, & Dietrich, 2010; Sege et al., 1997; Zubrick et al., 2005). Successes have been reported in the settings of homes, community classrooms, and primary care clinics. However, limitations of previous studies include selection bias (i.e. parents who enroll may be very different from the general population) and the challenges related to taking a comprehensive intervention to a larger scale. It would be best if all parents, not just parents who agree to be in a study, were aware that there are better options than using physical punishment. The intervention has some notable strengths that differentiate it from other parenting programs and, subsequently, lay the foundation for advancing the field. Using the interactive part of the program, the intervention is brief and can be easily integrated into the existing primary care schedule (Scholer, Hudnut-Beumler, & Dietrich, 2010; Scholer, Hudnut-Beumler, & Dietrich, 2012) The intervention takes advantage of the time between when parents are placed in an examination room and when the physician starts the well child visit. With the methodology we used, families are seen by their pediatrician immediately after viewing the intervention; thus the health care provider may answer parents’ questions and provide additional education as indicated. However the person who introduces the program to parents before the visit does not have to have any specific training in child development or parenting. Compared with the costs of providing parenting classes, digital program content is inexpensive; the internet version of the program is available at no cost through Vanderbilt University. Although the intervention was originally developed for parents of children between the ages of 1 and 7 years, we enrolled parents of children between the ages of 6 and 24 months. It is known that parents’ attitudes toward using physical punishment are relatively stable throughout the preschool years, indicating that parents’ attitudes about the use of physical punishment will not typically change on their own (Vittrup et al., 2006). It is also known that parents’ attitudes and behaviors related
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to the use of physical punishment become manifest during the first 6–12 months of their child’s life (Vittrup et al., 2006). Thus, to decrease parents’ use of physical punishment, interventions are needed early in the parenting process (e.g. prenatal period, parent of child < 2 years). We did not track which options were viewed by parents. Some parents may not have viewed the option that teaches why physical punishment is an inappropriate discipline strategy. Thus, it is not known what is driving the observed treatment effect. For example, was the driving force learning that physical punishment is inappropriate, that other options are better, or a combination of these factors? Graziano found that in a group of parents in which 93% justified spanking, 85% stated that they would rather not spank if they had an alternative in which they believed (Graziano et al., 1996). Thus, it is possible that many parents in our study wanted to learn alternatives. More studies are needed to determine what is driving parents’ change in attitudes. Parents’ response to the hypothetical scenario of one child hitting another corresponded with program content (see Table 2). Apologizing is not discussed in the program. Time-out is recommended as a second line option for older children after other options have been tried; this level of recommendation for time-out is consistent with material published by leading organizations (“Connected Kids”, 2005; “Time out for “Time-Out””, 1996). Because the scenario that parents viewed in the program consisted of one young child hitting another, it is possible that parents learned about managing aggression but did not learn about discipline in general. However, the ATS scale measures parents’ attitudes toward spanking related to discipline for misbehavior; there is no mention of aggression in the ATS. Also, in other studies, we have asked parents, after viewing the intervention, what they plan to do differently to discipline their children and results confirm that this intervention can be used as a platform to teach discipline strategies (Scholer, Hudnut-Beumler, & Dietrich, 2010; Scholer et al., 2007). The study has other potential limitations. This study was conducted at one medical center and, subsequently, is limited by a lack of geographic variability. However, the population that is served in the Vanderbilt pediatric primary care clinic is diverse, and we included a group of minority participants whose primary language was Spanish. Still, it is unclear how the results might differ in other settings such as private practice offices where the parent–physician relationship is more established or in communities in which baseline attitudes about physical punishment are different. No parent, whether in the intervention or control group, was made aware of their intervention allocation. Still, it is possible that some parents in the intervention group may have noted that viewing a video had not been a part of their primary care experience in the past; thus, the study was not a double-blind trial. We purposefully did not collect baseline data in this study so that participation could be maximized. Based upon previous studies, 50–60% of parents would have declined to participate in our study had we invited parents to be in our study before randomization and collected baseline data (see Methods) (Scholer et al., 2007, 2008). Our study is limited by not having longitudinal data. A change is attitudes about physical punishment immediately after an intervention may not result in sustained attitude changes. We did attempt a follow-up phone call with parents, but we were unsuccessful because of a high attrition rate (40%) and because many of the parents who were reached expressed an unequivocal lack of interest in completing the ATS questionnaire a second time in such a short period (2 weeks). There is some evidence that brief interventions can have an effect on parents’ attitudes for months post-intervention (Reich et al., 2012; Scholer, Hamilton, Johnson, & Scott, 2010). The current study advances the field by using a population-based approach. In the future, greater efforts (e.g. incentives for participation) will be required to capture longitudinal data with a high proportion of parents. We found a difference between the ATS score for parents in the intervention group compared with the control group but we did not measure behavior change. Although the 6 point difference was statistically significant and it is known that the ATS score is associated with parents’ use of physical punishment (Vittrup et al., 2006) it is unclear what a 6 point difference means in regard to an actual change in behavior of using less physical punishment at home after the intervention. Demand characteristics should be considered as a possible explanation for the findings. In other words, parents being interviewed in a pediatric clinic under the purview of their physician may respond more favorably than parents in another setting. That said, we feel that the potential for demand characteristics to have significantly affected our results is relatively small. First, both the control group and intervention group were recruited using a standard dialog and neither group was informed about the focus on physical punishment. Second, the RA asked the open ended question about how the parent might discipline their child before completing the ATS. Finally, parents were interviewed by a RA whom they had not met and who was unaware of the parents’ intervention allocation status. Other methods could be employed in future studies to reduce the effect of demand characteristics and other limitations of this study but these methodological changes may well result in biases that we sought to avoid. For example, a long-term study of parents’ behavior outside of clinic would likely decrease participation rates and result in a selection bias. This study may lay the foundation for larger and more complex studies. Larger studies are needed to determine whether there are certain subgroups of parents who are more or less likely to respond to the intervention. Because our study was not powered to detect differences for subgroups of parents, it is unknown whether parents of different backgrounds will respond similarly. Parents with a college education had an unexpected direction with their ATS score and it is currently unclear whether this is a true finding or merely a result of performing multiple comparisons. A stronger study design could include a second control group that was exposed to a parenting intervention void of explicit mention of physical punishment. It would be best if more parents were aware of non-physical forms of discipline. The results of this study indicate that an educational program, integrated into the primary care visit, can affect parents’ attitudes toward using less physical
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punishment in the short-term. Given the association between physical punishment, child abuse, and many other adverse consequences, these results have implications for how to improve primary care services, child abuse prevention, and violence prevention. Acknowledgments We acknowledge Dr. George Holden who developed and validated the ATS scale and provided permission for its use. We acknowledge Brian Connatser for his work as the software engineer for the Play Nicely program. We thank Laurie Albritton for her efforts in translating the program into Spanish. References Barkin, S. L., Finch, S. A., Ip, E. H., Scheindlin, B., Craig, J. A., Steffes, J., Weiley, V., Slora, E., Altman, D., & Wasserman, R. C. (2008). Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics, 122(1), e15–e25. Bower-Russa, M. (2005). 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A., Weiley, V., Ip, E. H., & Barkin, S. (2008). Impact of pediatricians’ perceived self-efficacy and confidence on violence prevention counseling: A national study. Maternal and Child Health Journal, 12(1), 75–82. Gershoff, E. T. (2002). Corporal punishment by parents and associated child behaviors and experiences: A meta-analytic and theoretical review. Psychological Bulletin, 128(4), 539–579. Graziano, A. M., Hamblen, J. L., & Plante, W. A. (1996). Subabusive violence in child rearing in middle-class American families. Pediatrics, 98(4 (Pt 2)), 845L 848. Jackson, S., Thompson, R. A., Christiansen, E. H., Colman, R. A., Wyatt, J., Buckendahl, C. W., Wilcox, B. L., & Peterson, R. (1999). Predicting abuse-prone parental attitudes and discipline practices in a nationally representative sample. Child Abuse & Neglect, 23(1), 15–29. Krug, E. G., Mercy, J. A., Dahlberg, L. L., & Zwi, A. B. (2002). The world report on violence and health. The Lancet, 360(9339), 1083–1088. Lansford, J. E., Chang, L., Dodge, K. A., Malone, P. S., Oburu, P., Palmerus, K., Bacchini, D., Pastorelli, C., Bombi, A. S., Zelli, A., Tapanya, S., Chaudhary, N., DeaterDeckard, K., Manke, B., & Quinn, N. (2005). Physical discipline and children’s adjustment: Cultural normativeness as a moderator. Child Development, 76(6), 1234–1246. MacMillan, H. L., Boyle, M. H., Wong, M. Y., Duku, E. K., Fleming, J. E., & Walsh, C. A. (1999). Slapping and spanking in childhood and its association with lifetime prevalence of psychiatric disorders in a general population sample. Canadian Medical Association Journal, 161(7), 805–809. Minkovitz, C. S., Hughart, N., Strobino, D., Scharfstein, D., Grason, H., Hou, W., Miller, T., Bishai, D., Augustyn, M., McLearn, K. T., & Guyer, B. (2003). A practice-based intervention to enhance quality of care in the first 3 years of life: The Healthy Steps for Young Children Program. JAMA: The Journal of the American Medical Association, 290(23), 3081–3091. Minkovitz, C. S., Strobino, D., Mistry, K. B., Scharfstein, D. O., Grason, H., Hou, W., Ialongo, N., & Guyer, B. (2007). Healthy steps for young children: Sustained results at 5.5 years. Pediatrics, 120(3), e658–e668. Olds, D. L., Eckenrode, J., Henderson, C. R., Jr., Kitzman, H., Powers, J., Cole, R., Sidora, K., Morris, P., Pettitt, L. M., & Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA: The Journal of the American Medical Association, 278(8), 637–643. Olson, L. M., Inkelas, M., Halfon, N., Schuster, M. A., O’Connor, K. G., & Mistry, R. (2004). Overview of the content of health supervision for young children: Reports from parents and pediatricians. Pediatrics, 113(6 Suppl.), 1907L 1916. Reich, S. M., Penner, E. K., Duncan, G. J., & Auger, A. (2012). Using baby books to change new mothers’ attitudes about corporal punishment. Child Abuse & Neglect, 36(2), 108–117. Reid, M. J., Webster-Stratton, C., & Baydar, N. (2004). Halting the development of conduct problems in head start children: The effects of parent training. Journal of Clinical Child & Adolescent Psychology, 33(2), 279–291. Scholer, S. J. (2010). Play Nicely Program: Recommendations for managing aggression in young children. , from http://www.playnicely.org Scholer, S. J., Hamilton, E. C., Johnson, M. C., & Scott, T. A. (2010). A brief intervention may affect parents’ attitudes toward using less physical punishment. Family & Community Health, 33(2), 106–116. Scholer, S. J., Hudnut-Beumler, J., & Dietrich, M. S. (2010). A brief primary care intervention helps parents develop plans to discipline. Pediatrics, 125(2), e242–e249. Scholer, S. J., Hudnut-Beumler, J., & Dietrich, M. S. (2012). Why parents value a brief required primary care intervention that teaches discipline strategies. Clinical Pediatrics (Philadelphia), 51(6), 538–545. Scholer, S. J., Mukherjee, A. B., Gibbs, K. I., Memon, S., & Jongeward, K. L. (2007). Parents view a brief violence prevention program in clinic. Clinical Pediatrics (Philadelphia), 46(8), 724–734. Scholer, S. J., Walkowski, C. A., & Bickman, L. (2008). Voluntary or required viewing of a violence prevention program in pediatric primary care. Clinical Pediatrics (Philadelphia), 47(5), 461–468. Sege, R. D., Perry, C., Stigol, L., Cohen, L., Griffith, J., Cohn, M., & Spivak, H. (1997). Short-term effectiveness of anticipatory guidance to reduce early childhood risks for subsequent violence. Archives of Pediatrics and Adolescent Medicine, 151(4), 392–397. Shonkoff, J. P., Garner, A. S., Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–e246. Slade, E. P., & Wissow, L. S. (2004). Spanking in early childhood and later behavior problems: A prospective study of infants and young toddlers. Pediatrics, 113(5), 1321–1330. Socolar, R. R., & Stein, R. E. (1995). Spanking infants and toddlers: Maternal belief and practice. Pediatrics, 95(1), 105–111. Stein, M. T., & Perrin, E. L. (1998). Guidance for effective discipline. American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health. Pediatrics, 101(4 (Pt 1)), 723–728. Straus, M. A., Sugarman, D. B., & Giles-Sims, J. (1997). Spanking by parents and subsequent antisocial behavior of children. Archives of Pediatrics and Adolescent Medicine, 151(8), 761–767. Taylor, C. A., Moeller, W., Hamvas, L., & Rice, J. C. (2013). Parents’ professional sources of advice regarding child discipline and their use of corporal punishment. Clinical Pediatrics (Phila), 52(2), 147–155.
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Contents lists available at ScienceDirect
Child Abuse & Neglect
A brief intervention affects parents’ attitudes toward using less physical punishment夽,夽夽, Antwon Chavis a , Julia Hudnut-Beumler b , Margaret W. Webb c , Jill A. Neely c , Len Bickman d , Mary S. Dietrich e , Seth J. Scholer f,∗ a
Meharry College of Medicine, USA Vanderbilt University, USA Vanderbilt University, School of Medicine, USA d Center for Evaluation and Program Improvement, Peabody Administration Building, 3rd Floor, 1212 21st Avenue South, Nashville, TN 37203-2402, USA e School of Nursing, School of Medicine (Biostatistics), Vanderbilt University, 461 21st Avenue, Nashville, TN 37240, USA f 8232 DOT, Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville TN 37232, USA b c
a r t i c l e
i n f o
Article history: Received 25 April 2013 Accepted 9 June 2013 Available online 13 July 2013
Keywords: Violence Child abuse Parenting Counseling Education Aggression
a b s t r a c t Consecutive English and Spanish speaking caregivers of 6–24 month old children were randomly assigned to either a control or intervention group. Parents in the intervention group were instructed to view at least 4 options to discipline a child in an interactive multimedia program. The control group participants received routine primary care with their resident physician. After the clinic visit, all parents were invited to participate in a research study; the participation rate was 98% (258/263). The key measure was the Attitudes Toward Spanking (ATS) scale. The ATS is correlated with parents’ actual use of physical punishment. Parents with higher scores are more likely to use physical punishment to discipline their children. Parents in the intervention group had an ATS score that was significantly lower than the ATS score of parents in the control group (median = 24.0, vs. median = 30; p = 0.043). Parents in the control group were 2 times more likely to report that they would spank a child who was misbehaving compared with parents in the intervention group (16.9% vs. 7.0%, p = 0.015). In the short-term, a brief intervention, integrated into the primary care visit, can affect parents’ attitudes toward using less physical punishment. It may be feasible to teach parents to not use physical punishment using a population-based approach. The findings have implications for how to improve primary care services and the prevention of violence. © 2013 Elsevier Ltd. All rights reserved.
夽 Support for the research was provided by the Scholarly Activities Fund, Division of General Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt. Vanderbilt University is a non-profit institution. The Morgan Family Foundation, a non-profit organization, helped to sponsor the development of the Spanish version of Play Nicely. There was no commercial funder for the development of the program or the research. All authors, independent of any commercial funder or sponsor, had full access to all the data in the study, and take responsibility for the integrity of the data and the accuracy of the data analysis. 夽夽 The Play Nicely program is owned by Vanderbilt University and Dr. Scholer is one of the authors of the program. The Play Nicely program can be viewed at no cost at www.playnicely.org. The study’s ClinicalTrials.gov identifier is NCT01459510. ∗ Corresponding author. 0145-2134/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.chiabu.2013.06.003
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Introduction Inappropriate discipline, including the use of physical punishment, is a risk factor for antisocial behavior, depression, anxieties, and many other adverse consequences (Durrant & Ensom, 2012; Durrant, 2008; Gershoff, 2002; Lansford, Chang, Dodge, Malone, Oburu, & Palmerus, 2005; MacMillan, Boyle, Wong, Duku, Fleming, & Walsh, 1999; Slade & Wissow, 2004; Straus, Sugarman, & Giles-Sims, 1997). Inappropriate discipline may lead to child maltreatment and be a form of toxic stress that has lifelong implications for adverse mental and physical problems (Shonkoff, Garner, Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics, 2012). Evidence is mounting that children who are physically punished are at increased risk of child abuse (Gershoff, 2002). As stated in an a report by the American Academy of Pediatrics (AAP), “The only way to maintain the initial effect of spanking is to systematically increase the intensity with which it is delivered, which can quickly escalate into abuse” (Stein & Perrin, 1998). To prevent violence, the World Health Organization (WHO) recommends that all parents learn appropriate methods to discipline their children (Krug, Mercy, Dahlberg, & Zwi, 2002). The pediatric primary care visit provides an excellent opportunity to teach parents appropriate methods to discipline and to discourage the use of physical punishment. The AAP and the Canadian Pediatric Society recommend that primary care physicians routinely encourage parents to use non-physical forms of discipline (“Effective discipline for children”, 2004; Stein & Perrin, 1998). Parents report they are ready and willing to learn discipline strategies that are alternatives to physical punishment (Olson, Inkelas, Halfon, Schuster, O’Connor, & Mistry, 2004; Taylor, Moeller, Hamvas, & Rice, 2013; Young, Davis, Schoen, & Parker, 1998), but there are missed opportunities within primary care to teach parents more effective strategies to discipline (Finch, Weiley, Ip, & Barkin, 2008; Olson et al., 2004; Young et al., 1998). Parents’ attitudes about physical punishment predict their actual use of physical punishment at home with their young children (Bower-Russa, 2005; Graziano, Hamblen, & Plante, 1996; Jackson, Thompson, Christiansen, Colman, Wyatt, & Buckendahl, 1996; Socolar & Stein, 1995; Vittrup, Holden, & Buck, 2006). There is evidence that parents develop their attitudes about discipline early in the lives of their children before children have time to display chronic behavior problems (Vittrup et al., 2006). A logical question is whether primary care interventions can help teach parents of young children to not use physical forms of discipline. Many parenting interventions have been studied in community and primary care settings (Barkin, Finch, Ip, Scheindlin, Craig, & Steffes, 2008; Dubowitz, Feigelman, Lane, & Kim, 2009; Fennell & Fishel, 1998; Minkovitz, Hughart, Strobino, Scharfstein, Grason, & Hou, 2003; Minkovitz, Strobino, Mistry, Scharfstein, Grason, & Hou, 2007; Olds, Eckenrode, Henderson, Kitzman, Powers, & Cole, 1997; Reich, Penner, Duncan, & Auger, 2012; Reid, Webster-Stratton, & Baydar, 2004; Scholer, Hamilton, Johnson, & Scott, 2010; Scholer, Hudnut-Beumler, & Dietrich, 2010; Sege, Perry, Stigol, Cohen, Griffith, & Cohn, 1997; Zubrick, Ward, Silburn, Lawrence, Williams, & Blair, 2005) and several studies of parenting interventions indicate that parental attitudes and behavior regarding physical punishment can be changed (Dubowitz et al., 2009; Fennell & Fishel, 1998; Minkovitz et al., 2003, 2007; Reich et al., 2012; Scholer, Hamilton, Johnson, & Scott, 2010; Scholer, Hudnut-Beumler, & Dietrich, 2010). Because it would be best for all parents to learn about appropriate methods to discipline, more work is needed to determine if parents’ attitudes can be affected using a population-based approach. The intervention in this study was the Play Nicely program, an educational program that was developed to help educate parents about discipline in primary care and early education settings. Developed at Vanderbilt University, the content of the program is based on material from the American Academy of Pediatrics, the National Association for the Education of Young Children, and the American Psychological Association (Scholer, 2010). Multiple evaluations of the program have laid the foundation for the population-based approach used in this study. In the setting of a general pediatric clinic, parents of 1–7 year old children were asked if they desired to learn more about discipline (Scholer, Mukherjee, Gibbs, Memon, & Jongeward, 2007). Of parents who agreed to participate, 30% spontaneously reported that they planned to use less spanking as a result of viewing the program (Scholer et al., 2007). In another study of parents in clinic and a preschool setting, we found that viewing the Play Nicely program was associated with a change in parents’ attitudes toward using less physical punishment in an intervention group; however the study did not find a difference comparing the intervention and control groups (Scholer, Hamilton, Johnson, & Scott, 2010). These earlier studies were limited in that parents agreed to participate, resulting a selection bias. Additional studies of the Play Nicely program were needed to demonstrate that it is possible to use a population base based approach to teach parents about discipline. In a general pediatric clinic, one group of parents was invited (i.e. parents had to opt in) to view information about discipline and another group was instructed (i.e. parents had to opt out) to view the material as part of the well visit (Scholer, Walkowski, & Bickman, 2008). Regardless of the group assignment, 100% of parents were pleased that the program was provided in the office (Scholer et al., 2008). In a randomized controlled trial of consecutive parents of 1–5 year old children presenting for a well visit, parents in an intervention group were 12 times more likely to revise their plans to discipline compared with a control group (83% vs. 7%; p < 0.001) (Scholer, Hudnut-Beumler, & Dietrich, 2010). Parents in the intervention group were more likely to verbalize that they planned to use less spanking (9% vs. 0%; p < 0.001) (Scholer, Hudnut-Beumler, & Dietrich, 2010). Although these evaluations are promising, studies are now needed to confirm that brief programs can actually affect parents’ attitudes toward using less physical punishment. The objective of this randomized controlled study was to determine if a brief intervention, integrated into the primary care visit, can affect parents’ attitudes toward using less physical punishment. The results of this study have implications for how to improve primary care offerings, the prevention of child abuse, and the prevention of violence.
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Methods Overview The study design was a randomized controlled trial conducted in a pediatric primary care clinic at Vanderbilt University from June to August in 2010. Participants were parents of infants and children between the ages of 6 months and 24 months presenting for a well visit. Parents were excluded if they could not speak English or Spanish. We used an atypical methodological approach by randomizing participants without their knowledge to an intervention before the clinic visit. After the visit, parents were invited to participate in a research study in the form of a personal interview; all participants provided verbal informed consent. The participant flow is illustrated in Fig. 1. The pediatric clinic is staffed by pediatric residents with supervision by attending pediatricians. Most children seen in the clinic have TennCare, Tennessee’s government sponsored health care insurance program that is similar to Medicaid. The average age of the participants was 28 years and almost half of the participants had at least some college education. The majority of participants were White, Black, or Hispanic. The ages of the children tended to be between 8 and 17 months. There were no statistically significant differences between the groups for any of these characteristics (Table 1).
Randomization A research assistant (RA) randomized eligible parents to an intervention or control group by opening an opaque envelope. As recommended by the CONSORT guidelines designed to improve reporting of data in randomized controlled trials, “Informed consent by study participants is typically required in intervention studies.” Although typically required, it is not mandatory if there is justification. In the IRB proposal, we provided our rationale for randomizing parents without their knowledge. First, the experiences in the study are very similar to what parents experience as part of a routine primary care clinic visit. Second, advance knowledge of the purpose of the study would likely bias the results by creating a demand characteristic for a socially desirable response. Finally, without using this approach, we would not be able to answer the research question about the effect of an intervention that has been integrated into the visit because we have learned that many parents, if asked, will decline to view educational material about discipline (Scholer et al., 2007, 2008). In a study in which parents were invited to view the intervention immediately after the clinic visit, approximately 50% declined (Scholer et al., 2007). In a separate study, we asked parents in the waiting room if they would like to spend a few minutes learning about how to discipline their child while they were waiting to be checked into the triage area; 60% of parents declined (Scholer et al., 2008). This is in contrast to another group of parents who were instructed that the next part of the clinic visit was to view strategies to discipline their child; 100% of parents in the “required” group agreed (Scholer et al., 2008). We submitted the rationale for our approach and the study was approved by the Vanderbilt Institutional Review Board (IRB).
Research assistant approached consecuve parents of 6-12 month old children presenng for a well visit (n=263)
Exclusion criteria: Parent who could not speak English or Spanish
RANDOMIZATION Control group received standard offerings in primary care (n=132)
Mulmedia Intervenon Viewed intervenon (n=131) Declined (n=0)
Accepted (n=128) Declined (n=3)
RECRUITMENT Parent invited to parcipate in a brief survey immediately aer clinic visit. Informed consent Open ended queson 10 item scale Fig. 1. Participant flow.
Accepted (n=130) Declined (n=2)
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Table 1 Demographic characteristics of participants. Characteristic
Study group Control (n = 130)
Intervention (n = 128)
p-value
Age of caregiver, years median (IQR) Gender of caregiver, female
28.0 (23.0, 32.0) 112 (86.2)
28.0 (23.0, 32.0) 109 (85.2)
0.494 0.819
Caregiver relationship to child Mother Father Other
106 (81.5) 17 (13.1) 7 (5.4)
103 (80.5) 18 (14.1) 7 (5.5)
Education
21 (16.3) 47 (36.4) 38 (29.5) 23 (17.9)
20 (15.7) 55 (43.3) 33 (26.0) 19 (15.0)
Race White Black Hispanic Asian Other
35 (27.1) 60 (46.5) 23 (17.8) 5 (3.9) 6 (4.7)
28 (21.9) 61 (47.7) 32 (25.0) 5 (3.9) 2 (1.6)
Marital status Now married Never married Divorced Separated Widowed
51 (39.5) 70 (54.3) 7 (5.4) 1 (0.8) 0 (0.0)
48 (38.1) 72 (57.1) 4 (3.2) 1 (0.8) 1 (0.8)
Gender of child, female Age of child (months) median (IQR) Total no. of children median (min, max)
69 (52.3) 12.0 (8.0, 15.3) 2.0 (1, 3)
56 (43.4) 12.0 (9.0, 16.8) 2.0 (1, 3)
0.972
0.628
0.360
0.681
0.152 0.587 0.320
All data presented as n (%) unless indicated otherwise. IQR indicates inter-quartile range.
Intervention The intervention, viewed in the examination room, was the Play Nicely program, a multimedia program that teaches how to manage childhood aggression and appropriate strategies to discipline children (Scholer, 2010). The program can viewed on a CD ROM or on the internet and is available in English and Spanish. In one part of the program, viewers are presented with the hypothetical situation of one young child hitting another and provided with a list of 20 options to respond. When the viewer clicks on a specific option, he/she views approximately 1 min of multimedia material that explains whether the option is (1) a great option, (2) a good option after others have been tried and failed, or (3) an option that is not recommended (see Table 2). The focus of the study was to determine if an intervention could affect attitudes about physical punishment. When parents clicked on the option, “Spank your child”, English-speaking parents heard the following script accompanied by bulleted points: “Spanking may seem to help in the short run, but it can actually make matters worse in the long run. Spanking may get a child’s attention, but it does nothing to explain why the behavior is wrong. You are your child’s role model. If you spank them, they will learn from you that physically hurting someone else is an acceptable way to deal with a challenging situation. It does not make sense to teach a child not to hit by hitting them. It is much better to use other ways such as redirecting to teach your child how not to hurt people. Because there are much better options to consider, spanking is not recommended as a form of discipline. Some justify spanking by quoting the Biblical phrase that says, “Spare the rod, you spoil the child”. However, shepherds usually used a rod to guide sheep, not to hit them. Children should not be guided with being hit or spanked; rather they should be guided by setting the rule, redirecting behavior, teaching why hurtful behavior is wrong, and getting them to think about the feelings of others. It is likely that if you spare the guidance, your child will develop behavior problems.” Readers who are interested can view the actual multimedia program, including the Spanish version, at www.playnicely.org. Intervention group The RA approached all parents allocated to the intervention group (n = 134) after their child was triaged and instructed them that the next part of the clinic visit was to view at least 4 of the interactive options in the Play Nicely program. Viewing
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Table 2 List of discipline options in the intervention.a Great options Set the rule by firmly saying “No hitting” Redirect by giving your child an example of how to be helpful with his hands Redirect by asking your child what should be done with his hands Ask your child how the other child feels Later in the day, praise your child for playing nicely Discuss why hurtful behavior is wrong Tell your child that you expect the right choice next time Role play at another time Good options after others have been tried Place your child in Time-Out Take away a privilege Say “No” to your child Tell your child what to expect if he is hurtful again (i.e. give warning) Hold and give hugs to your child At another time, encourage rough and tumble play Ask your child about his feelings Leave the area There are better options Spank your child Ignore the behavior Yell or speak angrily at your child Tell your child that he is hurtful child a Parents in the intervention group were asked to view at least 4 of options in this list. After the parent chooses an option, he/she learns if the option is a great option, a good option, or if there are better options. Each option is described in more detail with multimedia content (approximately 1 min/option). Spanish-speaking parents viewed the Spanish version.
each option takes 1–2 min, resulting in a viewing duration ranging from 5 to 10 min. If the parent indicated that he/she did not want to view the program or he/she wanted to stop viewing for any reason, the research assistant had been instructed to discontinue the viewing experience; however, no parent declined to view the intervention. Parents whose primary language was Spanish viewed the Spanish version. All parents in the intervention group were asked to view at least 4 discipline options from the interactive section of the program. The RAs did not track which options were viewed. For a minority of intervention parents (approximately 20%), we experimented with a variation of this introduction by asking parents to find 2 great options to discipline and 2 options that are not recommended. The RAs did not record which parents experienced this variation in introducing the intervention. Control group The control group participants (n = 132) received routine primary care with their resident physician. Recruitment After the clinic visit with their pediatrician, all parents were invited to participate in a 2 min research study. Parents who provided verbal informed consent were enrolled in the study. The RA who recruited the parent was different from the RA who introduced the intervention and was blinded to the intervention allocation. See Fig. 1 for a description of the participant flow. Measures Demographic information included parents’ age, gender, marital status, education level, ethnicity/race, relationship to the child, and number of other children. The first measure was parents’ response to a hypothetical scenario of one young child hurting another. Parents were asked to consider the following scenario: “Assume you are the parent of a 2 year old boy and you see him hit another child.” Parents were then asked two open-ended questions: (1) “list at least 2 things that you might do to respond” and (2) “list at least 2 things that you would not do to respond.” The parents’ responses were reviewed by the authors. The authors developed definitions for each of the eight most common responses. Then, one of the researchers, (AC), blinded to the group allocation, coded the responses based upon the following definitions: 1. Spanking: parent reported that they would spank, pop, hit, slap or use other “physical” punishment. Does not include vague references such as using “discipline” or “punishment”. 2. Time-out: parent used the term “time out”. Does not include pulling child away or removing child from situation.
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Table 3 Parents’ report of how they would respond to a hypothetical scenario of a child with aggression. Response Spank Time-out Remove from situation Set limit Explain Redirect Stop child from hitting Apology
Control (n = 130)
Intervention (n = 128)
p-value
22 (16.9) 40 (30.8) 24 (18.5) 61 (46.9) 36 (39.1) 4 (3.1) 10 (7.7) 24 (18.5)
9 (7.0) 34 (26.6) 10 (7.8) 56 (43.8) 56 (60.9) 23 (18.0) 8 (6.3) 7 (5.5)
0.015 0.455 0.011 0.609 0.007 <0.001 0.649 0.001
All data presented as n (%). Note: Columns do not sum to 100% because more than one response was possible.
3. Remove from situation: parent reported that they would remove the child from the situation. This could include pulling, taking, or moving the child. 4. Set limit: parent would say “No” or in another way, set rule that hitting is not allowed. 5. Explain: parent reported that they would “explain” to child why he child should not hit. For example, parent would tell the child that hitting is not right. 6. Redirect: parent reported that they would redirect the child toward a more positive behavior. 7. Stop child from hitting: parent reported that they would stop the child from hitting. 8. Apologize: parent reported that they would respond with an apology, either from themselves or from the child who hit. A second reviewer (SS), who again was blind to group allocation, independently reviewed parents’ responses; there was 95% agreement for all responses. For the category of spanking, there was 99% agreement. Coding by the first reviewer was used for the analysis. The second measure was the Attitudes Toward Spanking (ATS) scale, a 10 item scale that is correlated with parents’ use of physical punishment. Examples of items on the scale are “Spanking is a normal part of my parenting”, “Sometimes a spank is the best way to get my child to listen”, and “A spank is not an effective method to change my child’s behavior for the long term”. Participants respond to each item using a 7 point Likert scale ranging from 1 = ‘strongly disagree’ to 7 = ‘strongly agree’. A global ATS score is generated by summing the responses to the 10 items after reversing the scores for four of the items so that a higher score is associated with an increased likelihood of using spanking to discipline. Previous work has demonstrated the validity and psychometric properties of the ATS (Vittrup et al., 2006). Statistical analysis Sample size estimates were based on the desire to detect at least the difference in the ATS observed in a previous study (Scholer, Hamilton, Johnson, & Scott, 2010). In this previous study, parents viewed at least 8 interactive options, as compared with 4 options in this study, and we used a 5 point Likert scale for the ATS rather than a 7 point scale. Control participants in earlier work reported ATS mean values of ∼30 with SD = ∼14.5. A difference of ∼4 points between the control and intervention group was observed in a previous cross-sectional study (effect size ∼0.28). Given this expected high variability relative to the mean and a logistic distribution of scores, a sample size of 150 would provide 80% statistical power for detection of a change in ATS as small as 3.2 scale points (two-sided alpha = 0.05). This change translates into a standardized effect size of 0.22. After compensating for differences between the previous study and this study, we estimated that enrolling at least 200 families would be sufficient to detect differences as small as those noted above (less than a quarter standard deviation). We did not aim to enroll enough parents in this study to assess for differences in the ATS between sociodemographic subgroups. Frequency distributions were used to summarize the nominal demographic characteristics and parental responses to the hypothetical scenario. Differences in these distributions between these groups were tested using the likelihood chi-square statistic. The distributions of the continuous demographic characteristics and the ATS scores were skewed, therefore the median was used to represent the middle of these distributions and the 25th and 75th inter-quartile ranges (IQR) representing the middle 50% of the values are presented as the best summaries of variability in these measures. Mann–Whitney tests were used to compare the distributions of these variables between the two study groups. A p-value of less than 0.05 was used for determining statistical significance. Results Of the 263 parents who were randomized, 258 (98%) completed the survey. Parents’ responses to the hypothetical situation of one young child hurting another for each of the groups are summarized in Table 3. Parents in the control group were 2 times more likely to report that they would spank the child compared with parents in the intervention group (16.9% vs. 7.0%, p = 0.015). Parents in the control group were more likely to report that they would respond by removing the child from the situation and using an apology. Parents in the intervention group were more likely to report that they would redirect the child and explain why hitting is wrong.
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Table 4 Comparison of ATS scores for parents in the intervention and control groups. ATS median (IQR) Intervention
Control
All parents (n = 258)
24 (16,35)
30 (18,38)
Race White (n = 63) Black (n = 121) Hispanic (n = 55)
22 (16,35) 28 (20,36) 22 (16,29)
25 (16,34) 32 (20,39) 34 (16,46)
Education
19 (12,24) 24 (16,35) 25 (20,34) 34 (23,40)
31 (15,47) 28 (16,37) 34 (21,41) 24 (16,36)
Maternal age <25 (n = 88) 25–35 (n = 128) >35 (n = 42)
25 (16,36) 24 (17,34) 26 (17,32)
28 (17,37) 34 (19,39) 26 (15,44)
*
p = 0.043*
The p-value was not calculated for subgroups because the study was not powered to detect a difference in ATS scores between subgroups.
Overall, the scores on the ATS were in the lower portion of the range of possible scores (median = 27.0, IQR = 17, 36, possible range = 10, 70). Parents in the intervention group had a lower ATS score compared with parents in the control group (median = 24.0, IQR = 16, 35 vs. median = 30, IQR = 18, 38; p = 0.043). ATS scores are listed in Table 4 for parents with different race/ethnic backgrounds, ages, and education levels [Note: the ATS scores for parents in different sociodemographic categories should be interpreted with caution due to an inadequate sample size for the analyses of subgroups (see Methods)]. In general, parents with different sociodemographic backgrounds had ATS scores that were lower in the intervention group compared with the control group. The one exception was parents with a college education in the intervention group had a higher ATS score compared with parents in the control group. Discussion These results of this study advance what is known about how to teach more parents that spanking is not a recommended form of discipline. We found that a brief, one-time, multimedia intervention can affect parents’ attitudes toward using less physical punishment. Compared with parents in a control group, parents randomized to a brief intervention had a lower ATS score. Compared with parents in the control group, parents in the intervention group were less likely to report that they would spank a child who was misbehaving. This study has implications for how to improve primary care offerings related to child abuse prevention and violence prevention. In this study, a brief intervention was integrated into the routine pediatric primary care visit because it is a logical step in determining how to educate more parents about not using physical punishment. It is known that parenting programs work (Barkin et al., 2008; Dubowitz et al., 2009; Fennell & Fishel, 1998; Minkovitz et al., 2003, 2007; Olds et al., 1997; Reich et al., 2012; Reid et al., 2004; Scholer, Hamilton, Johnson, & Scott, 2010; Scholer, Hudnut-Beumler, & Dietrich, 2010; Sege et al., 1997; Zubrick et al., 2005). Successes have been reported in the settings of homes, community classrooms, and primary care clinics. However, limitations of previous studies include selection bias (i.e. parents who enroll may be very different from the general population) and the challenges related to taking a comprehensive intervention to a larger scale. It would be best if all parents, not just parents who agree to be in a study, were aware that there are better options than using physical punishment. The intervention has some notable strengths that differentiate it from other parenting programs and, subsequently, lay the foundation for advancing the field. Using the interactive part of the program, the intervention is brief and can be easily integrated into the existing primary care schedule (Scholer, Hudnut-Beumler, & Dietrich, 2010; Scholer, Hudnut-Beumler, & Dietrich, 2012) The intervention takes advantage of the time between when parents are placed in an examination room and when the physician starts the well child visit. With the methodology we used, families are seen by their pediatrician immediately after viewing the intervention; thus the health care provider may answer parents’ questions and provide additional education as indicated. However the person who introduces the program to parents before the visit does not have to have any specific training in child development or parenting. Compared with the costs of providing parenting classes, digital program content is inexpensive; the internet version of the program is available at no cost through Vanderbilt University. Although the intervention was originally developed for parents of children between the ages of 1 and 7 years, we enrolled parents of children between the ages of 6 and 24 months. It is known that parents’ attitudes toward using physical punishment are relatively stable throughout the preschool years, indicating that parents’ attitudes about the use of physical punishment will not typically change on their own (Vittrup et al., 2006). It is also known that parents’ attitudes and behaviors related
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to the use of physical punishment become manifest during the first 6–12 months of their child’s life (Vittrup et al., 2006). Thus, to decrease parents’ use of physical punishment, interventions are needed early in the parenting process (e.g. prenatal period, parent of child < 2 years). We did not track which options were viewed by parents. Some parents may not have viewed the option that teaches why physical punishment is an inappropriate discipline strategy. Thus, it is not known what is driving the observed treatment effect. For example, was the driving force learning that physical punishment is inappropriate, that other options are better, or a combination of these factors? Graziano found that in a group of parents in which 93% justified spanking, 85% stated that they would rather not spank if they had an alternative in which they believed (Graziano et al., 1996). Thus, it is possible that many parents in our study wanted to learn alternatives. More studies are needed to determine what is driving parents’ change in attitudes. Parents’ response to the hypothetical scenario of one child hitting another corresponded with program content (see Table 2). Apologizing is not discussed in the program. Time-out is recommended as a second line option for older children after other options have been tried; this level of recommendation for time-out is consistent with material published by leading organizations (“Connected Kids”, 2005; “Time out for “Time-Out””, 1996). Because the scenario that parents viewed in the program consisted of one young child hitting another, it is possible that parents learned about managing aggression but did not learn about discipline in general. However, the ATS scale measures parents’ attitudes toward spanking related to discipline for misbehavior; there is no mention of aggression in the ATS. Also, in other studies, we have asked parents, after viewing the intervention, what they plan to do differently to discipline their children and results confirm that this intervention can be used as a platform to teach discipline strategies (Scholer, Hudnut-Beumler, & Dietrich, 2010; Scholer et al., 2007). The study has other potential limitations. This study was conducted at one medical center and, subsequently, is limited by a lack of geographic variability. However, the population that is served in the Vanderbilt pediatric primary care clinic is diverse, and we included a group of minority participants whose primary language was Spanish. Still, it is unclear how the results might differ in other settings such as private practice offices where the parent–physician relationship is more established or in communities in which baseline attitudes about physical punishment are different. No parent, whether in the intervention or control group, was made aware of their intervention allocation. Still, it is possible that some parents in the intervention group may have noted that viewing a video had not been a part of their primary care experience in the past; thus, the study was not a double-blind trial. We purposefully did not collect baseline data in this study so that participation could be maximized. Based upon previous studies, 50–60% of parents would have declined to participate in our study had we invited parents to be in our study before randomization and collected baseline data (see Methods) (Scholer et al., 2007, 2008). Our study is limited by not having longitudinal data. A change is attitudes about physical punishment immediately after an intervention may not result in sustained attitude changes. We did attempt a follow-up phone call with parents, but we were unsuccessful because of a high attrition rate (40%) and because many of the parents who were reached expressed an unequivocal lack of interest in completing the ATS questionnaire a second time in such a short period (2 weeks). There is some evidence that brief interventions can have an effect on parents’ attitudes for months post-intervention (Reich et al., 2012; Scholer, Hamilton, Johnson, & Scott, 2010). The current study advances the field by using a population-based approach. In the future, greater efforts (e.g. incentives for participation) will be required to capture longitudinal data with a high proportion of parents. We found a difference between the ATS score for parents in the intervention group compared with the control group but we did not measure behavior change. Although the 6 point difference was statistically significant and it is known that the ATS score is associated with parents’ use of physical punishment (Vittrup et al., 2006) it is unclear what a 6 point difference means in regard to an actual change in behavior of using less physical punishment at home after the intervention. Demand characteristics should be considered as a possible explanation for the findings. In other words, parents being interviewed in a pediatric clinic under the purview of their physician may respond more favorably than parents in another setting. That said, we feel that the potential for demand characteristics to have significantly affected our results is relatively small. First, both the control group and intervention group were recruited using a standard dialog and neither group was informed about the focus on physical punishment. Second, the RA asked the open ended question about how the parent might discipline their child before completing the ATS. Finally, parents were interviewed by a RA whom they had not met and who was unaware of the parents’ intervention allocation status. Other methods could be employed in future studies to reduce the effect of demand characteristics and other limitations of this study but these methodological changes may well result in biases that we sought to avoid. For example, a long-term study of parents’ behavior outside of clinic would likely decrease participation rates and result in a selection bias. This study may lay the foundation for larger and more complex studies. Larger studies are needed to determine whether there are certain subgroups of parents who are more or less likely to respond to the intervention. Because our study was not powered to detect differences for subgroups of parents, it is unknown whether parents of different backgrounds will respond similarly. Parents with a college education had an unexpected direction with their ATS score and it is currently unclear whether this is a true finding or merely a result of performing multiple comparisons. A stronger study design could include a second control group that was exposed to a parenting intervention void of explicit mention of physical punishment. It would be best if more parents were aware of non-physical forms of discipline. The results of this study indicate that an educational program, integrated into the primary care visit, can affect parents’ attitudes toward using less physical
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