Dear Dr. Murthy,

Congratulations on your confirmation in December, 2014, as the 19th Surgeon General of the United States. Among the many responsibilities of the Surgeon General is the communication of the best available scientific information to the public regarding ways to improve personal and public health.

A major public health problem which desperately needs your attention is physical punishment of children and the violence associated with it. The Centers for Disease Control and Prevention (CDC) has just come out formally (2016) with statements that physical punishment is child abuse (p. 8) and that physical punishment should be banned (p. 46). This is a significant public health development.

In addition, Dr. John King, the Secretary of Education of the United States, sent a letter Tuesday, November 22, 2016, to state leaders encouraging them to ban the use of corporal punishment in schools. The USA has no federal law prohibiting physical punishment, and 19 states still permit physical punishment in schools. All this is in contrast to the fact that there are now 51 countries which have banned physical punishment in all settings, and over 100 which have banned it in the schools.

In 2008, researcher Elizabeth Gershoff defined physical punishment as “the use of physical force with the intention of causing a child to experience bodily pain or discomfort so as to correct or punish the child’s behavior.” This includes spanking, hitting, swatting, slapping, and more. Physical abuse (the infliction of physical injury as a result of punching, beating, burning, and so on) is no longer conceptualized as distinct from physical punishment because most physical abuse occurs during episodes of physical punishment. Spanking is a euphemism for hitting. One is not permitted to hit one’s spouse or other adult; such actions are defined as the crime of assault. Nor should one be permitted to hit a small and more vulnerable child. Research documents that children who are hit identify with the aggressor, and are more likely to become hitters themselves – bullies and future abusers of their own children and partners. They learn to use violence as a way to deal with stress and interpersonal disputes.

Data

In our current evidence-based medical world, let’s discuss the data related to the public health problems associated with physical punishment. In the United States, studies show that approximately 65% of adults approve of physical punishment and about 50% of families use physical punishment to discipline children. The data documenting the associations between physical punishment and sociopathy are compelling. Pioneering national and international research has been conducted over the past decade by Elizabeth Gershoff, Susan Bitensky, Murray Straus, George Holden, Joan Durrant, and others.

What outcomes have been found to be associated with physical punishment? In 2014, Murray Straus and his colleagues summarized hundreds of studies, finding 15 major trends associated with physical punishment, including: increased antisocial behavior and delinquency as a child and as a young adult; poorer parent-child relationships; more crime perpetrated as an adult; higher probability of depression; more violence against marital, cohabitating, and dating partners; more violence against non-family members; more physical abuse of children; more drug abuse; and more sexual coercion and physically-forced sex. This growing body of research strongly suggests that a variety of poor outcomes—including increased violence and psychopathy—are associated with physical punishment.

Are there studies of outcomes in countries which have prohibited physical punishment? One such investigation was conducted in Finland by Karin Österman et al. and published in 2014. This was 28 years after the complete ban on physical punishment of children in Finland. Two findings stand out from this study of over 4,500 people. First, greater amounts of physical punishment were associated with greater alcohol abuse, depression, mental health problems, divorce, and suicide attempts. Second, and perhaps most strikingly, the decline in physical punishment was associated with a similar decline in the number of murdered children.

The International Community and Physical Punishment

Internationally, there is increasing consensus that physical punishment of children violates international human rights laws.  The United Nations Convention on the Rights of the Child (CRC or the Children’s Convention, adopted in 1989) presents one of the most comprehensive cases regarding the prohibition of physical punishment of children. In an attempt to stop what is called legalized violence toward children, and in response to the emerging data, the United Nations proposed a ban on physical punishment of children in the CRC.

Currently, 194 countries are party to the CRC, including every member of the United Nations, except Somalia, South Sudan, and the United States. The CRC states that all parties must “take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence.” In General Comment 8 in 2006, the Committee on the Rights of the Child stated there was an “obligation of all state parties to move quickly to prohibit and eliminate all corporal punishment and all other cruel or degrading forms of punishment of children.”

Such work has led to over 100 countries prohibiting physical punishment in schools and 51 countries banning physical punishment in all settings, including the home. Among the 51 are Sweden, Finland, Spain, Austria, Germany, Israel, Kenya, Tunisia, Venezuela, Argentina, and Brazil. The laws and consequences tend to be more educative (about development) than punitive.

The United States has not banned physical punishment, but approval of physical punishment in the United States has declined gradually and steadily over the past 40 years. The United States has signed, but not ratified, the CRC. Remarkably, 19 states in the U.S. still permit physical punishment in schools. These are: Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, and Wyoming.

Alternatives to Physical Punishment

What are the alternatives to physical punishment? Many medical and psychological organizations have outstanding Position Statements discussing the alternatives—e.g. the American Academy of Pediatrics and the American Psychoanalytic Association. For example, in 1998 the American Academy of Pediatrics concluded: “Corporal punishment is of limited effectiveness and has potentially deleterious side effects. The American Academy of Pediatrics recommends that parents be encouraged and assisted in the development of methods other than spanking for managing undesired behavior.”

There are three core alternatives which emerge from research, clinical work, and our understanding of human development and feelings. The first involves the idea of using words instead of actions; the second focuses on the behaviors of the parents/caregivers; and the third stresses use of positive, rather than negative, approaches. We will present them as one might in working with parents:

Use words to label your child’s feelings and words to explain your own feelings.

Listen to and talk with your child. As linguist Jeanine Vivona highlights, the influence of language begins long before the child can talk. One of the most useful ways to achieve healthy child development is to promote using words instead of actions. Increasing the child's capacity to put words to feelings and actions results in increased tension regulation (awareness of feelings and ability to tolerate them without having to act), self-awareness, and thoughtful decision-making. Charles Zeanah and his colleagues have compiled many effective interventions on individual, group, and community levels which address the issue of violence toward children. The foundation of all of these is understanding the feelings of the child and parent/caregiver and connecting them with language.

Set a good example.

Act and talk as you would want your child to act and talk. Your child strives to be like you. As psychoanalyst John Gedo notes, these identification and internalizing processes—preverbal and verbal—are among the most important factors in the formation of character structure and psychological health.

Use positive reinforcements rather than negative approaches.

Rewards and praise will enhance the child's self-esteem when appropriate standards are met. Positive reinforcement is more effective in obtaining long-term behavioral compliance than punishments that evoke feelings of fear and shame.

The American Psychoanalytic Association’s Position Statement (Revised 2013) and the American Academy of Pediatrics Guidance for Effective Discipline (1998) are useful in expanding the discussion on alternatives to physical punishment.

Verbal Abuse

In addition to physical punishment, verbal abuse also has a destructive impact on children. Remember the old ditty? “Sticks and stones will break my bones, but names will never hurt me…”  How untrue is this. And how poignant that such a ditty exists as a way to fend off the pain of verbal abuse, bullying, taunting, and the like. Of course words can hurt. They can massively disrupt one’s sense of self, self-confidence, self-cohesion—child or adult. This problem of verbal trauma involves the entire field of psychoanalysis and psychotherapy. The differences between verbal support and verbal abuse can be understood when one asks if the words are eliciting positive or negative feelings.

Physical Punishment and Public Health

To summarize, there are three crucial areas of intervention on the public health level to aid in preventing physical punishment of children:

1. Education about the psychological problems caused by physical punishment and about alternative approaches to discipline. Educational efforts should be directed towards parents, caregivers, educators, clergy, legislators, and the general public;

2. Legislation to protect all children from physical punishment and help parents and children at risk; and

3. Research about alternative methods of disciplining and managing children and about the best ways to communicate these methods to parents, educators, and caregivers. 

To paraphrase Abraham Lincoln, if hitting a child is not wrong, then nothing is wrong. If we truly want to decrease violence in our society, not hitting our children is a good place to start.

We wonder where violence comes from -- like so much else, it often begins early, and it often begins at home.

Thank you for your consideration,

Paul C. Holinger, M.D., M.P.H.

Professor of Psychiatry, Rush University Medical Center, Chicago IL

Faculty, Chicago Institute for Psychoanalysis,

                Training and Supervising Analyst,

                Child and Adolescent Supervising Analyst

paulcholingermd@aol.com   

30 North Michigan Avenue

Suite 1101

Chicago, IL 60602

Telephone: 312/726-6611

paulcholinger.com

Ms. Mary Morgan

(Mrs. Benjamin Spock)

Marymorgan1268@gmail.com

Documentation

American Academy of Pediatrics—Committee on Psychosocial Aspects of Child and Family Health (1998). Guidance for Effective Discipline. Pediatrics 101: 723-728.

American Psychoanalytic Association Position Statement on Physical/Corporal Punishment (2013). www.apsa.org.

Bitensky SH (2006). Corporal Punishment of Children: A Human Rights Violation. Ardsley NY: Transnational Publishers, Inc.

Durrant J, Ensom R (2012). Physical punishment of children: lessons from 20 years of research. Canadian Medical Association Journal 184: 1373-1377.

Fortson BL, Klevens J, Merrick MT, Gilbert LK, Alexander SP (2016). Preventing Child Abuse and Neglect: A Technical Package for policy, norm, and programmatic activities. Atlanta, GA: National Center for Injury Prevention and Control Centers for Disease Control and Prevention.

Gedo JE (2005). Psychoanalysis as Biological Science: A Comprehensive Theory. Baltimore: The Johns Hopkins University Press.

Gershoff ET (2002). Physical punishment by parents and associated child behaviors and experiences: A meta-analytic and theoretical review. Psychological Bulletin 128: 539-579.

Gershoff ET (2008). Report on Physical Punishment in the United States: What Research Tells Us About Its Effects on Children. Columbus OH: Center for Effective Discipline.

Österman K et al (2014). Twenty-eight years after the complete ban on the physical punishment of children in Finland: Trends and psychosocial concomitants. Aggressive Behavior (online, Wiley Periodicals, Inc.) 40: 568-581.

Straus MA, Douglas EM, Medeiros RA (2014). The Primordial Violence: Spanking Children, Psychological Development, Violence, and Crime. New York: Routledge.

Vivona JM (2012). Is there a nonverbal period of development? Journal American Psychoanalytic Association 60: 231-265.

Zeanah CH ed (2000). Handbook of Infant Mental Health: Second Edition. New York: The Guilford Press.

http://www.usnews.com/news/education-news/articles/2016-11-22/education-secretary-urges-states-to-end-use-of-corporal-punishment

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