The use of physical punishment is controversial. Few studies have examined the relationship between physical punishment and a wide range of mental disorders in a nationally representative sample. The current research investigated the possible link between harsh physical punishment (ie, pushing, grabbing, shoving, slapping, hitting) in the absence of more severe child maltreatment (ie, physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, exposure to intimate partner violence) and Axis I and II mental disorders.
Data were from the National Epidemiologic Survey on Alcohol and Related Conditions collected between 2004 and 2005 (N = 34 653). The survey was conducted with a representative US adult population sample (aged ≥20 years). Statistical methods included logistic regression models and population-attributable fractions.
Harsh physical punishment was associated with increased odds of mood disorders, anxiety disorders, alcohol and drug abuse/dependence, and several personality disorders after adjusting for sociodemographic variables and family history of dysfunction (adjusted odds ratio: 1.36–2.46). Approximately 2% to 5% of Axis I disorders and 4% to 7% of Axis II disorders were attributable to harsh physical punishment.
Harsh physical punishment in the absence of child maltreatment is associated with mood disorders, anxiety disorders, substance abuse/dependence, and personality disorders in a general population sample. These findings inform the ongoing debate around the use of physical punishment and provide evidence that harsh physical punishment independent of child maltreatment is related to mental disorders.
Comments
Vanishing Sample
In their recent article Afifo, et al. set out to show that a significant proportion of mental disorders are attributable to the experience of physical punishment (1). While most pediatricians and child psychologists probably agree that physical punishment should be avoided and is not effective as a mode of discipline as it has no component of teaching desired behaviors, we are concerned that the conclusions drawn in this paper may not accurately represent the original data or general population.
The authors introduce a sample size of 34,563 adults from which they draw their data. They excluded from the analysis individuals who experienced child maltreatment as defined in the text. It was assumed that these abused individuals would inflate the rate of mental illness beyond what might be associated with more run-of-the-mill corporal punishment. However, we are told nothing else about the demographics of those excluded, which child maltreatment factors caused the exclusion, or the types and rates of Axis I and II diagnoses they exhibit. We note that the final analysis includes 20,607 subjects. Thus, over 40% of the sample was excluded. Was the original sample really representative of the US population, as stated? It is shocking to think that 40% of U.S. children experience child maltreatment. If true, that is a finding not to be excluded. Regardless, we wonder if we can trust that the 60% remaining in the analysis accurately represent the US population, possibly reducing the generalizability of the findings with regard to the burden of mental illness that physical punishment imparts on the U.S. We cannot begin to address these issues because there is no careful description or explanation that accounts for the nearly 14,000 individuals missing from the analysis. We wondered if the full study sample was characterized elsewhere and if we could learn the prevalence of types of child maltreatment within it. The NESARC data referred to in the paper as "a representative sample of civilian, non-institutionalized adults residing in the United States" (1) is a systematically selected sample in which "non-hispanic black and Hispanic housing units were selected at higher rates than other housing units"(5) to make up an initial sample of 43,093 adults, and young adults were intentionally sampled at a higher rate (2, 5). Of this initial sample, 34,563 participated in follow-up interviews and form the sample for the Afifi paper. The authors acknowledge that the sample needed weighting and adjusting to be representative of the U.S. population and avoid certain sampling biases, but they did not establish that those excluded are demographically or psychosocially similar or dissimilar from the sample analyzed.
We applaud the authors for taking on an important question; however, they should have provided more information on the specific reasons for excluding nearly 14,000 subjects. Of greater interest would be analysis of the 14,000 subjects who were categorized by the authors as having experienced child maltreatment compared with the 1,258 who merely experienced corporal punishment. Effective advocacy and policy-making should be evidence-based and will require more complete analysis.
Sincerely,
Bridget M. Wild, MD; Benjamin D. Kornfeld, MD; Sandra M. Sanguino, MD MPH; Robert R. Tanz, MD FAAP
References
1. Afifi TO, Mota NP, Dasiewicz P, MacMillan HL, Sareen J. Physical punishment and mental disorders: Results from a nationally representative US sample. Pediatrics. 2012;130(2):184-192.
2. Grant BF, Hasin DS, Stinson FS, Dawson DA, June Ruan W, Goldstein RB, Smith SM, Saha TD, Huang B. Prevalence, correlates, co-morbidity, and comparative disability of DSM-IV generalized anxiety disorder in the USA: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological Medicine. 2005 Dec;35(12):1747-59. Epub 2005 Oct 5.
3. Grant BF, Dawson DA, Frederick SS, Chou PS, Ward K, Pickering R. The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): reliability of alcohol consumption, tobacco use, family history of depression and psychiatric diagnostic modules in a general population sample. Drug and Alcohol Dependence. 2003: 71: 7-16.
4. Lazareck S, Robinson J, Crum RM, Mojtabai R, Sareen J, Bolton JM. A longitudinal investigation of the role of self-medication in the development of comorbid mood and drug use disorders: findings from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Journal of Clinical Psychology. 2012 May; 73(5): e588-93.
5. Alcohol Use and Alcohol Use Disorders in the United States, A 3- Year Follow-up: main findings from the 2004-2005 Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). In: US Alcohol Epidemiologic Data Reference Manual. Vol 8, Number 2. Bethesda, MD: 2010.
Conflict of Interest:
None declared
Harsh Physical Punishment, Physical Punishment, and Spanking: Methodology Matters
The authors of the recent article, "Physical Punishment and Mental Disorders: Results From a Nationally Representative US Sample" (1) have made a noteworthy effort to understand the relationship between harsh physical punishment and mental disorders. However, their study contains multiple methodological weaknesses, warranting more caution than the authors exercised in interpreting their results.
This was a cross-sectional case-control study utilizing secondary data--survey data collected from NESARC Wave II, a voluntary, paid follow- up survey to Wave I, which was initially designed to better understand the prevalence of alcohol use disorders and their associated disabilities in the general population (2). Problems with recall bias, selection bias, and various other confounders arose from using this particular data set.
While the authors acknowledge that the use of survey methods necessarily introduces recall bias, they downplay its magnitude in this study by referring to "evidence that supports the validity of accurate recall of adverse childhood events." In making this statement, they cite the work of Hardt and Rutter (3), who actually endorse a limited and cautious use of retrospective reports. While Hardt and Rutter reject the notion that all retrospective reports are unreliable, they do point out that only a few types are reliable enough to use, and that these are not entirely free from introducing bias into the results. When determining the validity of any particular restrospective data for research purposes, they suggest that certain criteria be used, namely, the extent to which the report can be objectively obtained and empirically confirmed (4). However, those steps could not be feasibly taken in this study. For example, while the specific terms "hit" and "kick" were used to assess the measure of interest, the answer scale used was notably vague and certainly open to judgment and interpretation (5). Further, responses could not be confirmed by independent records or other assessment methods. Hardt and Rutter also note a significant degree of under-reporting of serious adverse childhood events (false negatives), particularly in well- functioning adults compared to those suffering social impairments (6). It is possible that these biases may lead to greater differences in the events recalled between the comparison groups than actually exists.
Although the authors did exclude a number of confounders, including known associations with mental disorders such as parental psychopathology, criminality, and abuse/ neglect, and sought to control for various socio- demographic characteristics, they could not control for other studied associations, including parental loss, divorce, serious illness, etc.(7) Furthermore, given the existing literature suggesting the clustering of childhood adversities and the non-additive nature of how these individual adversities relate to mental illness, it is likely that the bias encountered in the inability to control for the above confounders may over -estimate whatever association is found for harsh physical punishment. The study also should have included information accounting for all the numbers relating to sample size and study groups. While the authors quote an initial Wave II sample size of 34, 653 adults, their results table contains an actual n of 20, 607 cases. Where are the other 14, 046? I presume that they were excluded (based on the study's exclusion criteria) but this is not clear. A breakdown of the numbers excluded in the various categories would be helpful in clarifying study results and elucidating methodological problems. Moreover, it is unclear exactly how the authors categorized respondents who answered "almost never" to harsh physical punishment. Were they included with the "no physical punishment" group, or were they excluded altogether from the study? This would be helpful in clarifying the study results.
Given the many methodological limitations of this study, it is difficult to make a strong association between harsh physical punishment and mental illness. However, not only do the authors matter-of-factly declare a "link" and "association" between the two without further qualification, they erroneously assume causation in several instances. They were also prematurely enthusiastic in their concluding statements, suggesting that "physical punishment (i.e., spanking, smacking, slapping) should not be used with children of any age." Yet, their study specifically defined and measured harsh physical punishment, not all physical punishment. Commenting on a measure not specifically analyzed can be viewed as irresponsible and potentially misleading. The authors ought to have concluded that, based on the severe methodological limitations encountered, a "possible" association between harsh physical punishment and mental disorders can be made, or, at least, that one "cannot exclude the possibility" of an association between the two.
The notion that harsh physical punishment (e.g. face-slapping, kicking, punching, developmentally inappropriate hitting beyond early childhood even in the absence of marks and injury) may be associated with mental disorders makes intuitive sense. To my knowledge, the existing literature and all experts in the field agree that harsh physical punishment is detrimental to children's mental health and well-being (11). Since many of the methodologically crippling factors in this study arise from the use of secondary data, I encourage the authors to obtain a data set specifically tailored to test their hypothesis. Different approaches can be taken to minimize bias in a retrospective survey. For example, one can design multiple questions to measure a single variable of interest. When using answer scales, it is also desirable to standardize answers across individuals with specific numeric definitions if possible. If, however, the authors would like to understand whether or not developmentally-appropriate "conventional" spanking (e.g. two swats with the hand on the buttocks by a parent in emotional control between the ages of two and six, intended to teach, not harm) (12) may be associated with mental pathology, then I would encourage them to design a study specifically tailored to answer this other question, being very careful to exclude as many known associations with mental illness as possible. Furthermore, it is always more prudent to ask a well-defined, relatively narrow question that can be plausibly answered and make no broader conclusion beyond what a reasonable analysis of the data suggests. It is not that an association between harsh physical punishment (or all physical punishment for that matter) and mental disorders cannot exist a priori, it is just that, unfortunately, the methodological errors in this study preclude making any sufficiently strong associations.
1. Afifi, TO, Mota, NP, Dasiewicz, P, et. al. "Physical Punishment and Mental Disorders: Results From a Nationally Representative US Sample" Pediatrics. 2012; 130(2):1-9.
2. See, for example, Pulay AJ, Stinson, FS, Dawson, DA, et. al. Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Schizotypal Personality Disorder: Results From the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Prim Care Companion J Clin Psychiatry 2009;11(2); 53-67. Also see NESARC data on niaa.nih.gov.
3. Hardt J and Rutter M. Validity of adult retrospective reports of adverse childhood experiences: review of the evidence. J Child Psychol Psychiatry. 2004;45(2):260-273.
4. Hardt and Rutter state that "the conclusion that retrospective reports of serious abuse/neglect/conflict are sufficiently valid to be usable has to be accompanied by the crucial qualifier that this encouraging conclusion applies only to those open to reasonable operationalisation. The recall of experiences that rely heavily on judgment and interpretation have not been found to have satisfactory validity."
5. It would have been helpful to attempt some standardization of the answers by using a numeric definition with the Likert scale used (e.g. "sometimes" = 10-20 lifetime occurrences, or "sometimes" = monthly occurrences, etc.).
6. Hardt and Rutter looked at multiple studies reporting a tendency for healthier, well-functioning adults to under-report serious childhood adversities compared to poor-functioning adults. However, people with poor functioning were not found to exaggerate negativity (so false positives are not an issue). They estimated a false-negative rate of close to one-third, but caution against using any quantifiable/ mathematical model to adjust for that rate. This is distinct from their finding that mood states in and of themselves do not seem to affect the recall of early childhood adversities. For more regarding the effect of mood states on childhood memories, see also Brewin CR, Andrews B, Gotlib IH. Psychopathology and early experience: a reappraisal of retrospective reports. Psychol Bull. 1993;133(1):82-98.
7. Family history of dysfunction in the current study included: alcoholism, prison history, mental illness treatment or hospitalization history, and attempted suicide/ death by suicide of parents or any adult living in the home. However, associations of other childhood adverse events with mental illness have been shown. See, for example, McLaughlin, KA, Green, JG, Gruber MS, et al. Childhood adversities and adult psychopathology in the National Comorbidity Survey Replication (NCS-R) III: Associations with functional impairment related to DSM-IV disorders. Psychol Med. 2010 May; 40(5): 847-859.
8. Green JG, McLaughlin KA, Berglund PA, et. Al. Childhood adversities and adult psychopathology in the National Comorbidity Survey Replication (NCS-R) I: Associations with first onset of DSM-IV disorders. Arch Gen Psychiatry. 2010 February; 67(2):113.
9. For example, they state that the "main objectives...were to determine...what proportion of mental disorders...is attributable to physical punishment...the effect of physical punishment was examined..." (emphases added) However, the nature of their study design makes it impossible to "attribute" A to B, or determine that B is "the effect of" A. The authors continue with their causation-association confusion by making the mistaken claim that "an approximate reduction of 2% to 5% for Axis I disorders and 4% to 7% for Axis II disorders may be noted in the general population if harsh physical punishment in the absence of child maltreatment did not occur." PAF's are generally used to analyze prospective cohort studies (where causation can be plausibly established), not retrospective surveys.
10. In fact--and it is unclear as mentioned above--if the authors had placed the respondents answering "almost never" under the umbrella category of "no physical punishment," one may presume the opposite association: that non-harsh physical punishment (including mild, "conventional" forms of physical punishment as defined by the authors) may actually confer a lower risk of mental disorders compared to harsh physical punishment.
11. See, for example, Baumrind D, Cowan PA, Larzelere RE. Ordinary Physical Punishment: Is it Hurtful? Psychological Bulletin. 2002;128(4):580-589.
12. See, for example, Friedman FB and Schoenberg SK. Consensus statements. The short-and long-term consequences of corporal punishment. Pediatrics. 1996;98(suppl):803-860.
Roxanne (Pan) Chang, M.D., Division of Hospital Medicine, Department of Pediatrics, Harbor-UCLA Medical Center
Conflict of Interest:
None declared
Harsh Physical Punishment and Appropriate Spanking Are Very Different
The article entitled "Physical Punishment and Mental Disorders" by Dr. Tracie Afifi (1) in the July Pediatrics takes a misleading "bait and switch" approach in opposing all use of disciplinary spanking with children. The authors discover an association (not causation) between an adult's retrospective recall of receiving "harsh physical punishment" and the presence of an adult mental disorder. The survey asked whether they were "pushed, grabbed, shoved, slapped, or hit by their parents" during their childhood. Remarkably, the survey neither included the term "spanking" nor limited the survey to the conventional definition of spanking: "striking a child with an open hand on the buttocks or extremities with the intention of modifying behavior without causing physical injury." (2)
Furthermore, participants in the study were most likely recalling experiences as teens, since retrospective reports correlate highest with events occurring at ages 12 to 14 years, more so than for earlier ages. (3) Adolescence is certainly not a recommended age for the use of spanking, let alone the use of harsh physical punishment.
Remarkably, the researchers gloss over their finding that "individuals with a family history of dysfunction were more likely to experience harsh physical punishment." That may be a better explanation for the mental illness association than the one they postulate. The use of harsh discipline is often a marker for troubled families and such an unhealthy environment takes its toll on a child. It is also suspicious that they control separately for gender (aOR-1 in their Tables 2 and 3) or this family history (aOR-2), but never together. It is possible that controlling for both reduces the odds ratios for most mental illnesses to a non-significant level.
After baiting the reader with an extensive and exclusive discussion of the use of "harsh physical punishment," the authors make the switch and conclude that all "physical punishment (i.e., spanking, smacking, slapping) should not be used with children of any age." So, they study the use of inappropriate harsh physical punishment with an inappropriate age group (teenagers) within dysfunctional families and then draw a conclusion that ordinary spanking of a young unruly child should be proscribed. In interviews following the release of this study, the authors failed to make the distinction between the harsh punishment studied and ordinary spanking of children leading the media to announce that "Children who are spanked, hit, or pushed as a means of discipline may be at an increased risk of mental problems in adulthood." (4)
This study by Dr. Afifi and her colleagues cannot draw any conclusion about whether the most appropriate kind of spanking (e.g., two open-handed swats to the buttocks) should remain an available option for parents when children of an appropriate age (about 2 to 7 years) defiantly refuse to cooperate with milder disciplinary measures, such as time out. That limited use of spanking, when directly compared to alternative disciplinary tactics, has actually been shown to lead to improved compliance and less aggression in children. (5) Sadly, this study says nothing about the effects of appropriate disciplinary spanking, adds to the growing confusion surrounding the topic of child discipline, and furthers an unscientific bias against corrective disciplinary measures employed by parents.
References:
1. Physical Punishment and Mental Disorders: Results From a Nationally Representative US Sample. Afifi T.O., Mota N.P., Dasiewicz P., MacMillan H.L., Sareen J. Pediatrics. 2012; 130:1-9.
2. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. Guidance for effective discipline. Pediatrics.1998; 101:723-728.
3. Stattin, H., Janson, H., Klackenberg-Larsson, I., & Magnusson, D. Corporal punishment in everyday life: An intergenerational perspective. In J. McCord (Ed.). Coercion and punishment in long-term perspectives. 1995; 315-347. Cambridge, England: Cambridge University Press.
4. USA Today News, July 2, 2012. http://www.usatoday.com/news/health/story/2012-06-28/spanking-mental- problems/55964610/1?csp=34news (accessed July 7, 2012).
5. Larzelere, R. E., & Kuhn, B. R. Comparing child outcomes of physical punishment and alternative disciplinary tactics: A meta-analysis. Clinical Child and Family Psychology Review. 2005; 8:1-37.
Den A. Trumbull, MD, FCP Pediatric Healthcare Montgomery, Alabama
Robert E. Larzelere, PhD, Professor Dept. of Human Development & Family Science Oklahoma State University Stillwater, Oklahoma
Peter Nieman, MD, FRCP (C), FAAP Clinical Assistant Professor University of Calgary Medical School Calgary, Alberta
Conflict of Interest:
None declared