Corporal punishment of children: discipline or abuse?

INTRODUCTION: Corporal punishment is a public health problem due to its impact on the physical, psychological, and social interactions of children.
OBJECTIVES: To determine the knowledge of pediatricians in Lebanon regarding corporal punishment, their preventive, educational, and legal role.
METHODS: A cross-sectional descriptive study conducted on 153 pediatricians in Lebanon, by a questionnaire distributed at the 12th Annual Congress of the Lebanese Pediatric Society and the North Lebanon Pediatric Society.
RESULTS: Less than 50% and less then 60% of pediatricians know the effects of physical punishment on the physical and psychic health of the child, respectively. About 74.2% and 23.2% of pediatricians disagree with Article186 of the Lebanese Criminal Code and Lebanese Law422/02 (Article25), respectively. Only 76.2% of Lebanese pediatricians always advise the abandonment of corporal punishment and 4.7% advise its use for discipline.
CONCLUSION: Pediatricians play a fundamental role in the abolition of corporal punishment, but this cannot be accomplished without improving their skills in this area. They are invited to seek legal reforms in Lebanon to abolish the use of corporal punishment as a means of disciplining children.

Introduction

Corporal punishment is the most common form of violence experienced by children. About 100 children die every year as victims of corporal punishment and many more suffer from disabilities [1]. In terms of health, physical punishment of children predisposes to physical illnesses such as asthma [2,3], cardiovascular disease, obesity, arthritis [4], neoplasia [3], decreased volume of cerebral gray matter [5], and increase in the frequency of hospital stays [2]. In addition, negative experiences in childhood are associated with metabolic diseases in adult age such as obesity, high blood pressure, diabetes, high total cholesterol, low high-density lipoprotein, high glucosylated hemoglobin, reduction in maximum oxygen consumption levels [6], chronic obstructive pulmonary disease, alcohol consumption, and liver diseases in adults [7].

In terms of psychological health, corporal punishment of children predisposes to aggression, delinquency and conjugal violence later in life [8], antisocial behavior [9], anxiety disorders, alcohol abuse or dependence, externalization problems [10], psychopathologies in adulthood such as depression, mania, personality disorders [11], suicide [12], disruption of the mechanisms of regulation of stress in the brain [13], and elevation of the level of cortisol [14]. Corporal punishment negatively affects the internalization of moral values by the child and his relationship with his parents [15]. Physical punishment is linked to a slow regression of cognitive development as well as negative effects on the academic pathway [16-20], noncognitive performance and executive functions [21] as well as alterations in the dopaminergic regions associated with substances and alcohol abuse [22]. In particular, negative experiences in childhood predispose later in life, to multiple sexual partners, sexually transmitted diseases, teenage pregnancies, unwanted pregnancies, and early initiation of sexual activity [23]. No studies have demonstrated a positive long-term effect of corporal punishment. Moreover, most studies have shown short-term and long-term negative effects of corporal punishment. It is only recently that children have been legally protected from corporal punishment in a growing number of countries. Our study aims to determine the knowledge of pediatricians about the long-term effect of corporal punishment and their role in family education. This study will specify in particular the preventive and educational role of pediatricians. It may pave the way for further social studies on the subject.

Materials and methods

This is a cross-sectional, descriptive study that has been conducted among pediatricians in Lebanon to determine their knowledge about corporal punishment and their role in family education. A questionnaire was developed to assess pediatricians’ knowledge of the physical and psychological effects of corporal punishment; their role in public education, prevention of corporal punishment by family education; their opinion about international, regional and national laws of corporal punishment; their suggestions about education, training, information, and legal changes, for better protection of children from corporal punishment.

The questionnaire consists of four parts. The first part evaluate the pediatrician’s knowledge about definition and distribution of corporal punishment and its effect on physical health and behavioral disorders in children. The second part assesses the frequency of pediatricians who apply an actions (discussing and advising the parents) regarding corporal punishment. Additionally, it explores the frequency of pediatricians who use other nonviolent form of discipline at home and how frequently they provide resources to families, like information and referral to other specialties. In this part, the pediatricians were also consulted on the validity of the right to private life, liberty and religious belief. The third part of the questionnaire is designed to study the frequency of pediatrician’s seeking information regarding legal reforms in other countries to prohibit corporal punishment, their knowledge about committees that recommend the states to prohibit the corporal punishment of children. The opinion of pediatricians was evaluated using five questions regarding the legal concepts of international laws on corporal punishment (Article 19 of the Convention on the Rights of the Child, General Comment 13, Recommendation 1666 (2004) ‘Prohibition of corporal punishment of children in Europe’ of the Parliamentary Assembly of the Council of Europe, the 8th Conference of the Parliamentary Union of Member States of the Organization of Islamic Cooperation), As well as national legal concepts such as Article 186 of the Lebanese Penal Code and Lebanese Law 422/02 ‘Article 25’). Pediatricians were also asked if they agree with the legal concept of reasonable punishment and legitimate corrections. The last part of the questionnaire was about pediatrician’s views on their roles in education regarding punishment in the pediatric curriculum, their roles in information at clinics and hospitals, their roles in the Residency training as well as training by the Lebanese Pediatric Society and their legal roles (lobbying to amend the Lebanese Law 422/02, Article 25 plus Article 186 of the Lebanese Penal Code.

The questionnaire was distributed to 300 pediatricians at the 12th Annual Congress of the Lebanese Pediatric Society and the North Lebanon Pediatric Society, on 24–25 April 2015 at Hilton Habtoor Grand Hotel, Beirut-Lebanon. The questionnaire was completely anonymous. The data of the completed questionnaires were converted and calculated by percentages. Data were analyzed using SPSS version 20.0 for windows release (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY, USA).

Results

The questionnaire was completed by 153 pediatricians out of 300 to whom the questionnaire was distributed. About 71.2% of pediatricians know the united nation’s definition of corporal punishment. About 32.6% of pediatricians know that corporal punishment is widespread in homes, schools, health care facilities, and the state penal system. About 8.5% of pediatricians recognize committees that have recommended the prohibition of corporal punishment of children in states. Less than 50% of pediatricians are aware of the effects of physical punishment on the physical health of the child. Only 59.5% of pediatricians know the psychological effects of corporal punishment (Tables 1 and 2). Only 47% of pediatricians often conduct a discussion with parents about their difficulties in disciplining their children, and 45.7% of pediatricians do so from time to time. 76.2% of Lebanese pediatricians always advise the abandonment of corporal punishment, 4.7% advise the use of corporal punishment under certain conditions (see Figure 1). In assessing the role of pediatricians in family education, only 31.1% and 30.5% of pediatricians always discuss with parents, child rearing practices, and positive forms of discipline, respectively. While 6% of them, never do. In addition, only 17.9% of pediatricians provide information sheets to parents who need them. In fact, only 19.9% of pediatricians refer parents to other professionals to help them with their children’s disciplinary problems (Figure 2). Regarding the arguments for corporal punishment, 33.1% of pediatricians consider the right to privacy as a valid argument for the use of corporal punishment, while 62.3% of them totally disagree. Similarly, the right to liberty is considered a valid argument by 34.4% of pediatricians, while 60.9% of them totally disagree. Moreover, 34.4% of pediatricians find that the right to religious belief justifies the use of corporal punishment of children, but 60.3% of them totally disagree. It should be noted that only 8.6% of pediatricians consult legal reforms in other countries that prohibit corporal punishment (Figure 3). The number was shocking regarding the opinion of pediatricians about the legal concepts such as ‘reasonable punishment’ and ‘legitimate correction’, 73.5% of pediatricians agrees that these concepts are sufficient to protect children from violence. Only 0.7% of pediatricians totally disagree. Moreover, 95.2% of pediatricians are aware of the importance of their academic educational role, 96.7% of pediatricians are aware of their role in training pediatric residents and training by the Lebanese Pediatric Society. It should be noted that 87.4% of pediatricians consider themselves responsible for public information such as the distribution of brochures in clinics and hospitals. On the legal side, only 56.9% of pediatricians agree completely with the amendment of Lebanese law 422/02 (article 25), and 58.3% agree with the cancellation of article 186 of the Lebanese penal code (see Figure 4). The Lebanese law 422/02 (article 25) defines maltreatment as ‘the acts that affect .’, it stipulates that a child is endangered if ‘exposed to sexual abuse, and physical violence that exceeds the limits of ’. The Article 186 of the Lebanese Penal Code states the following: ‘The law permits the types of discipline inflicted on children by their parents and teachers ’

Table 1.

Pediatricians response to increased risk of physical health problems with corporal punishment.

	Strongly Disagree N (%)	Disagree N (%)	Agree N (%)	Strongly Agree N (%)	No Answer N (%)
Chronic obstructive pulmonary disease	25 (16.6)	58 (38.4)	48 (31.8)	15 (9.9)	5 (3.3)
Ischemic heart disease	56 (37.1)	49 (32.5)	23 (15.2)	15 (9.9)	8 (5.3)
High blood pressure	41 (27.2)	34 (22.5)	29 (19.2)	43 (28.5)	4 (2.6)
Hypercholesterolemia	42 (27.8)	67 (44.4)	8 (5.3)	27 (17.9)	7 (4.6)
Obesity	27 (17.9)	14 (9.3)	57 (37.7)	50 (33.1)	3 (2.0)
Non-alcoholic fatty liver disease (NAFLD)	68 (45.0)	27 (17.9)	19 (12.6)	14 (9.3)	23 (15.2)

Table 2.

Pediatricians response to increased risk of behavioral disorders with child physical punishment.

	Strongly DisagreeN (%)	DisagreeN (%)	AgreeN (%)	Strongly AgreeN (%)	NoAnswerN (%)
Smoking	15 (9.9)	1 (0.7)	38 (25.2)	93 (61.6)	4 (2.6)
Alcoholism	15 (9.9)	2 (1.3)	35 (23.2)	96 (63.6)	3 (2.0)
Illicit drug use	15 (9.9)	0 (0)	37 (24.5)	96 (63.6)	3 (2.0)
Early initiation of sexual activity	15 (9.9)	2 (1.3)	51 (33.8)	77 (51.0)	6 (4.0)
Sexually transmitted diseases	15 (9.9)	4 (2.6)	37 (24.5)	89 (58.9)	6 (4.0)
Teenage pregnancies	15 (9.9)	7 (4.6)	51 (33.8)	73 (48.3)	5 (3.3)
Multiple sexual partners	0 (0)	19 (12.6)	40 (26.5)	87 (57.6)	5 (3.3)
Domestic violence	0 (0)	16 (10.6)	37 (24.5)	96 (63.6)	2 (1.3)
Unwanted pregnancies	15 (9.9)	8 (5.3)	39 (25.8)	83 (55.0)	6 (4.0)
Depression	15 (9.9)	0 (0)	35 (23.2)	100 (66.2)	1 (0.7)
Suicide	15 (9.9)	2 (1.3)	33 (21.9)	99 (65.6)	2 (1.3)

Figure 1.

Frequencies of the disciplinary advises given by the pediatricians to the parents.

Figure 2.

Role of pediatricians in family education.

Figure 3.

Pediatricians’ opinions on international and national laws of corporal punishment.

Figure 4.

Pediatricians’ views of their role in education, information, training, and legal matters in order to protect the child from corporal punishment.

Discussion

According to the results obtained, it is noted that the knowledge of pediatricians in the field of corporal punishment is not satisfactory. To our knowledge, it is the first study that asses the skills and knowledge of Lebanese pediatricians in corporal punishment. There is a significant deficit in the knowledge of Lebanese pediatricians about the effects of corporal punishment on the physical and psychological health of the child: less than 50% of pediatricians are aware of the effects of physical punishment on the physical health of the child; only 59.5% of pediatricians know the psychological effects of corporal punishment. This lack of knowledge may be due to a lack of pediatricians’ training in this area. Therefore, the fight against corporal punishment should begin first with the education of pediatricians about corporal punishment and its effects and training in this area, ranging from university courses, to training during their residencies, and a continuation of training by the Lebanese Pediatrics Society.

Then, once pediatricians are well trained, their role is fundamental in public education, especially in family education, by discussing with them the difficulties of disciplining children, the various positive forms of discipline, advising them to abandon corporal punishment, providing them with fact sheets and directing them to other professionals even helping them to understand the natural development of their children. We compare our survey with that of the American Academy of Pediatrics (AAP), Division of Child Health Research, on Pediatric Attitudes and Clinical Advice on Corporal Punishment, initiated by the Committee on Psychosocial Aspects of Child and Family (COPACFH), in 1998; of 602 pediatricians[24]: only 49% advised the abandonment of corporal punishment of children in the family discipline, while in our survey 76.2% of pediatricians in Lebanon always advise the abandonment of corporal punishment. In addition, 42% of pediatricians in the AAP survey advise the use of corporal punishment under certain conditions versus 4.7% in our survey. According to the AAP, 43.7% of pediatricians discuss the difficulties and means of discipline used by parents, versus 92.7% in our study. This discrepancy in results can be attributed to the age of the AAP study done in 1998 when corporal punishment was a silent public health problem, but nowadays many studies have put the short-term and long-term effects of corporal punishment, and even many legal reforms have prohibited the use of corporal punishment, hence pediatricians today are more aware of this problem. However, long time ago, pediatricians have advised families to use positive forms of discipline, 97.8% of pediatricians according to the AAP in 1998, versus 93.4% of pediatricians in our survey.

Similarly, a 1992 study by McCormick KF; in the United States; assessing doctors’ attitudes towards corporal punishment of children [25]; shows that 59% of pediatricians advocate the use of corporal punishment as a means of disciplining children versus 4.7% of pediatricians in our survey. However, the number of pediatricians who discuss the various forms of discipline with parents has been 90%, a figure very close to our survey of 92%. On the other hand, the study by Wissow LS, Roter D., in 1994, entitled ‘Toward Effective Discussion of Discipline and Physical Punishment in Primary Care’ [26], shows that only 18% of pediatricians discuss the use of corporal punishment with parents and this is due to parents’ fear of being accused of child abuse, and parents often rely on the disciplinary advice given by their families, rather than the advice of pediatricians.

Another similar study, conducted in 2003 by Tirosh E1, on 107 doctors including 95 pediatricians to assess their attitudes toward corporal punishment; shows that 58% of pediatricians still advise the use of corporal punishment, which was still a form of discipline acceptable at that time [27]. While in our study, only 4.7% still advise corporal punishment as a form of discipline. This is encouraging in the mission of the abolition of corporal punishment, in which pediatricians play a fundamental role. However, the advice given by the pediatrician to parents to abandon corporal punishment in the discipline of children is not sufficient on its own to protect the child from this form of violence. Pediatricians are encouraged to provide parents with better education regarding the discipline of children such as providing them with fact sheets and referring them to other professionals.

On the legal level, in our study 74.2% and 23.2% of pediatricians disagree with Article 186 of the Lebanese Penal Code and Lebanese Law 422/02 (Article 25), respectively. In Lebanon, legal concepts include up to now concept of reasonable punishment and legitimate corrections, thus allowing the corporal punishment according to common usage. Hence, corporal punishment remains a widespread concept that is socially and culturally accepted in Lebanon, which needs a social and cultural legal reform. Pediatricians are invited to ask governments to amend these laws on corporal punishment that violates children’s rights.

Study limitations

The results of our study are to be interpreted keeping in mind of some limitations. The response rate was low; however, the sample may be representative since the pediatricians were from all the regions of Lebanon, different religions, different cultural and social habits, and graduated from different universities. In the other hand, our study presents some strength. The questionnaire used was formulated by the team of this study and was adapted to the Lebanese population.

Conclusion

The abolition of corporal punishment constitutes a social and public health emergency. Pediatricians play a fundamental role in this process. The abolition of corporal punishment can be achieved by family education, which cannot be accomplished without improving the skills of pediatricians and issuing legal reforms in Lebanon to abolish the use of corporal punishment as a means of disciplining children.

	Strongly Disagree	Disagree	Agree	Strongly Agree
Chronic obstructive pulmonary disease
Ischemic heart disease
High blood pressure
Hypercholesterolemia
Obesity
Nonalcoholic fatty liver disease (NAFLD)
Early death

	Strongly Disagree	Disagree	Agree	Strongly Agree
Smoking
Alcoholism
Illicit drug use
Early initiation of sexual activity
Sexually transmitted diseases
Teenage pregnancies
Multiple sexual partners
Domestic violence
Unwanted pregnancies
Depression
Suicide

	Never	Rarely	Sometimes	Usually	Always
Use of corporal punishment
Abandon the use of corporal punishment

	Never	Rarely	Sometimes	Usually	Always
Child-rearing practices
Nonviolent forms of discipline to practice at home

	Never	Rarely	Sometimes	Usually	Always
Information sheets
Referral to other professionals

	Strongly Disagree	Disagree	Agree	Strongly Agree
The right to a private and family life or family
The right to freedom
The right to religious belief

	Education	Information	Training		Legal: lobbying for:
	university courses on child abuse in the pediatric curriculum	distribution of brochures in clinics and hospitals	pediatric residents	Lebanese Society of Pediatrics	Modify law 422	Cancel article 186
Strongly Disagree
Disagree
Agree
Strongly Agree