Development and Behavior: The Very Young Child

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Discipline in Early Childhood Barbara J. Howard, MD*

As pediatric practitioners we face questions about discipline for children daily. We are also in a key position to provide anticipatory guidance about discipline to prevent behavior problems from developing. Chamberlin3 found that 90% of mothers of 2-, 3-, and 4-year-olds have mild concerns about their children's behavior. Twenty percent of mothers of 4-year-olds had significant concerns. Most of those concerns had to do with discipline. Although discipline is a major issue for parents of preschool-aged children, it is actually also a focal point for parents from the birth of the child when using the definition that follows. Questions about helping infants get on a schedule, establishing bedtimes, and teaching manners for the table are as much a part of discipline as is handling aggression. This article presents a conceptual framework for discipline for the first 5 years of life and practical strategies for assisting families.

THE PEDIATRICIAN'S ROLE IN DISCIPLINE IN EARLY CHILDHOOD Pediatricians are often the only professionals who know children in the first 5 years of their life. Although other caregivers may know the children well, they may not have the expertise to help the children or family, the confidentiality in their relationship, or the intimate knowledge of the whole family. Pediatricians have at least three levels of involvement with families regarding discipline: primary prevention of problems or anticipatory guidance; secondary prevention or management of problems as they arise to prevent complications such as major behavioral or emotional dysfunction; and making effective needed referrals. Some pediatricians also train to manage more serious problems themselves. To fulfill these roles as pediatricians we need to understand the total context of child behavior, including the special characteristics of children such as developmental abilities and temperament as well as the family interaction patterns and dynamics that *Clinical Assistant Professor of Pediatrics, Duke University Medical Center, Durham, North Carolina

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make it susceptible to problems in child rearing. Knowledge of the dynamics is needed in order to offer interpretations to the family, choose appropriate strategies for intervening, and to have the credibility that facilitates referrals. We also need practical approaches for advising families on establishing discipline and solving problems that arise. All of this should derive from an understanding of current concepts from child development research on the factors affecting healthy emotional growth of children. This article offers an approach to all of these areas synthesized from parenting texts, intervention studies, and the author's clinical experience and provides references for further reading for discipline in the first 5 years. THE DEFINITION OF DISCIPLINE Discipline is the structure that the adult sets up for a child's life that is designed to allow him or her to fit into the real world happily and effectively. The discipline set up by parents is the foundation for the development of the child's own self-discipline later. It is within this structure that the child has real choices for behavior that take into account other people and are within the child's control. THE COMPONENTS OF DISCIPLINE Freud describes the basic human needs as "lieben und arbeiten"-to love and to work. Children have these same basic needs for healthy emotional development: to feel lovable and to feel capable. The structure of discipline should promote these goals for the child. To feel lovable children must experience affectional relationships in which they are held in positive regard, that endure over time, and in which the caregiver works to know the children. Observing children's activities, style, and patterns of emotional reactivity is basic to knowing them. Talking and listening to them to find out how they think and feel about things is central to understanding how they organize their experiences cognitively as well as emotionally once they are verbal. Above all, the structure of children's lives optimally requires the presence of a relationship in which the children want to please and be like the adult. The children give up some of their own inclinations to get the bigger pleasure of seeing a caregiver they care about be happy with them. Along with wanting to please, humans are also biologically designed to imitate the adults who raise them. An adult is most likely to be effective in setting a consistent structure of discipline for children that is loving and flexible if they have affection and commitment to the children as a person that goes beyond the children's day to day behaviors. Failure to have such a relationship often presents as discipline problems that require in-depth counseling or placement. Conveying a Sense of Being Lovable Some of the parenting actions that can help children feel lovable include attending to them, active listening, and talking in ways that convey positive regard (Table 1).

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Table 1. Conveying Positive Regard SKILLS FOR PROMOTING A CHILD'S SENSE OF BEING LOVABLE

Attending to the child Brief attention immediately Special time Sportscasting Red/Green Ignoring minor transgressions Active listening Conveying positive regard Label the act, not the child Specific feedback Emotional congruence Assistance with transitions Thank you messages Apologies

SKILLS FOR PROMOTING A CHILD'S SENSE OF BEING CAPABLE

Routines Models Instruction Progressive expectations Choices Role-taking opportunities Praise and rewards Appropriate consequences Natural consequences Logical consequences One request, then move Threats versus promises Whoever starts, finishes Time out

Attending to the Child. Being observed or attended to, especially by their most valued people, their parents, indicates to children from earliest infancy that they are important. Infants experience this careful attention when their signals of needs are acted upon promptly, contingently, and gently, e. g., responding promptly to the infant's crying. Fortunately, human beings are biologically prepared to respond to infants in these ways and almost cannot stop themselves if they are not overwhelmed by their own needs or problems. Parental problems that interfere with the ability to attend to children include depression, substance abuse, psychosis, environmental stress such as poverty, large numbers of dependents (either child or adult), physical illness, or marital stress. The parents' own personal histories can also interfere, for example, if they were neglected or abused as infants or were dealt with very inconsistently, possibly by depressed or alcoholic parents. If any of these factors are present, the parents may need assistance in obtaining appropriate mental health or social service support in order to attend to the child's needs. In many cases parents are healthy and well-motivated but still do not attend to their children in ways that promote the children's self-esteem. Some of these children could be called "The Hurried Child"8 because they are being rushed from one activity or day care situation to another and expected to adapt. Attention paid to children in groups, even simply two siblings together, may not be interpreted by the child as indicating individual importance. Children may learn to obtain the attention they desire through whining, begging for food, getting into fights with siblings, going into dangerous locations, biting, sulking, or using foul language. Even negative attention from parents is better than none at all! Pediatricians can help parents gain useful insight very quickly by pointing out these patterns. If parents wait to respond until children are acting negatively, the children learn to start with even more negative behavior the next time they seek attention, actually teaching them to act aversively.

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The following principles can be helpful in teaching parents how to attend to their children successfully (see Table 1). Brief Attention Immediately. Children, especially toddlers, look to their parents every few minutes for signals of safety and interest. 9 • 20 If the caregiver does not respond to the first bid for contact, children may increase the bid by starting negative behaviors or they may withdraw and become depressed. By watching for children's first bid, making eye contact, perhaps touching the child, and commenting on their activity for 1 to 2 seconds, they are likely to be satisfied and return to play. Adults who are easily distracted may find it hard to get much other work done when they are supervising small children. Unrealistic expectations about this should be addressed. Special Time. Guaranteed time that the caregiver spends attending to an individual child without any interruption is experienced by children as a kind of "unconditional love," particularly when the adult remains interested but nonjudgmental and nondirective. In studies of children with conduct disorders, parents were found to interrogate or direct the children's activities more than in control families. 21 Children tend to resist this usurpation of their autonomy and react oppositionally. When parents are working outside the home yet have high expectations for their children's performance, they may spend their limited time with the children trying to make up for its brevity by teaching or correcting behaviors. Some parents also have personality structures in which they try to control most interactions in which they take part. Some useful guidelines for parents to help them establish regular positive individual time with their children can be summarized as "Special Time" (Table 2).

Table 2. Special Time (AU Ages) SPECIAL TIME SHOULD:

-Be given to each child every day regardless of behavior. -Be called "Special Time" or some other simple label so the child realizes he or she got it. -Be the child's choice for the activities (within reason). Older childen may choose activities that exceed the allotted time and require installments, with safe storage of materials between sessions. -Involve interactive activities between the caregiver and child rather than passive activities such as television viewing. -Be the caregiver's choice of time of day. It is not necessary or realistic for Special Time to occur at the same time each day. Activities can be promised, teaching delayed gratification. -Be a consistent, short length of time 10-15 minutes long to prevent boredom or avoidance, demarcated by a timer of which the child is aware to practice stopping. -Not be "saved up" and done at greater length another day. Children need daily attention. Extended periods of promised time tend to get postponed or shortened. -Be without interruptions of any kind from siblings, other adults, or phone calls. -If the parent wishes to spend more time it should be separated by several minutes from Special Time to prevent cajoling. -If the child refuses as a test, the parents should say they want Special Time with him or her and just follow the child around. -If the child is aggressive, he or she should receive time out or the selected consequence without stopping the timer.

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If the caregiver is not skilled in interacting with the child without becoming directive or intrusive, it may be necessary to teach sportscasting. I This involves describing the child's actions without asking any questions, giving suggestions or directives, or being directly involved in the child's play, similar to a sports announcer's role. Children respond to this as positive attention, although they are likely to be suspicious at first when there has been a pattern of overcontrol. It is often necessary to model sportscasting for the caregiver, get them to practice in your office, and give them feedback to be sure they perceive what is intrusive behavior on their part. Red-Green. The expression "catch him being good" encapsulates the important principle of rewarding positive behaviors in order to increase their frequency. This can be the mainstay of management even for children without major behavior problems. 18 Often the origin of a behavior problem is a combination of inadequate attention to desirable behavior and parentchild interaction in response to progressively aversive bids for notice. Simply instructing parents to attend to and acknowledge children more often when they are acting appropriately may not be enough. The redgreen technique (Table 3) can assist parents in monitoring their own role in attending to their child as well as differentially rewarding the children for their behaviors. Verbal praise, touches, or just looks can work just as well for parents who can do them consistently and children who are responsive enough to these low levels of acknowledgment. Ignoring Minor Transgressions. Some parents are so attentive to their

Table 3. Red-Green (Ages 3 to 6 Years) -For the first 3 days a green mark is put on the back of the child's hand each time he or she acts appropriately or positively, e.g., sharing, coming when called, asking without whining, etc. The parent, not the child, should place the mark. -Marks can be given during whatever period the parent is available to observe the child, from 10 minutes per day to aU day. -Six to ten marks per hour should be given. If fewer are given, the parent is not attending to the child closely enough or is not acknowledging small enough behaviors. -At the end of the designated period the child is rewarded for having more green marks than red ones. This is inevitable initially because no reds are given until the child is engaged in the game. Later, if reds exceed greens there is no reward. The reward can be a story, stickers, extra privileges, or whatever the family chooses. -Red marks are introduced after 3 days to be used for undesirable behaviors. Aggressiveness may earn reds but if time out is used by the family this should be implemented. If the child resists he or she can be caught. If marks on the body are unacceptable to the child or the parent they can be made on a notebook but this is less effective. Green marks only will be adequate in many cases. -Bonus greens or reds can be used for outstanding behavior. The parent can give greens freely when the child requests them if actions warrant them. At this stage the child is actually noticing and reinforcing him or herself, the desired result. -Red-green can be used for all children in the family or classroom or just some. Other children are likely to want to participate. -Marks can gradually be eliminated when the child's behavior has improved and the parent is practiced in acknowledging the child often enough. They can be restarted any time these behaviors slip.

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children that they feel intruded upon and become oppositional for that reason. Minor misbehaviors are better ignored in many cases, e. g., experimentation with swear words, scuffles with siblings, or fooling around at meals. Ignoring behavior avoids secondary gain for children and eventually eliminates most minor negative behaviors. Children also feel less criticized. Whining and disputes with siblings are generally best ignored. With whining, the parent can actually say "I can't hear you when you're whining" and then respond to any improvement in tone. Sibling struggles very often become primarily designed to engage the parent. Parents can begin a sequenced approach for progressively more serious conflicts by (1) ignoring the squabbles; (2) entering but merely describing the situation and expressing confidence that the children can solve the problem; (3) entering, describing, and separating the children or the disputed object; and (4) entering, hearing the children's positions, and giving consequences to both. 11 Active Listening. After the first year of life it becomes more important for the adult to find out children's needs, wants, and feelings directly by asking and listening to them. This listening is most effective when done without initially judging either the content or the emotions of the children's message. Such active listening, well described by Gordon,14 Ginott,13 and Faber and Mazlish,lO also gives children the opportunity to answer their own questions and solve their own dilemmas as their development allows this (Table 4). Matching the child's affect by acting angry ("along with" not "at" the child) may seem counterintuitive but in fact it demonstrates nonverbally the listener's understanding of the child's feelings. 19 Adults who are uncomfortable with emotional expression themselves, especially anger, often find matching difficult. It is especially important for them to learn to do this because they usually are conveying to the children that their feelings are unacceptable. Young children are unable to hide their feelings (fortunately!) or do so at great cost. Their feelings may explode later; they may internalize feelings and develop somatic symptoms; or they may learn to act out emotions or threaten to as a method of getting their way. It is especially important to begin teaching labels for feelings so that words can substitute for action, as it must be in adulthood. Listening without intervening is usually the hardest part for parents who generally want to try to fix things Table 4. Active Listening (AU Humans, EspeciaUy >1 Year) 1. Describing the content with specific examples: "I hear you saying you had the truck first and Lucy grabbed it." 2. Guessing at and labeling the child's feelings, e.g., "You seem to feel angry at Lucy." If the adult guesses incorrectly the child may correct him at this point which further clarifies the situation. "No, I'm not mad at Lucy, I'm mad at you for not stopping her!" 3. Matching the child's body posture, tone of voice, etc., e.g., tense body, clenched fists, angry voice. It is important to do this without mocking by copying him exactly. 4. Not adding anything of one's own immediately; no judgments of the content or the child's emotions.

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either by consoling, teaching other strategies, or scolding the child, e. g., "If you didn't always grab her toys she wouldn't bother you when you're playing!" Such interventions are usually not useful while children are upset but instead cause them to feel misunderstood and angry at parents for interfering with them solving their own dilemma. Adults tend to use active listening naturally for positive emotions, but negative emotions, especially those directed towards the parent, take practice and are most beneficial. Family members should practice at least daily for the 2 to 3 weeks it takes to feel natural, at first notifying the other member that they are "practicing." Active listening actually satisfies children in many situations but is not intended to solve their dilemmas. Further problem solving, instruction, or actions are often needed after the active listening is completed, separated by at least 1 minute to be sure all the emotions have been expressed. Conveying Positive Regard. How adults speak to children is also central to the children's developing sense of being lovable. There are several important communication principles that help convey to children that they are held in positive regard. Label the Act, Not the Child. It is important to avoid labeling children either positively or negatively. The old adage "label the act, not the child" is a useful mneumonic, easier to state than to practice. One very useful principle is for caregivers to use ''I'' statements of the speaker's thoughts or feelings about the impact of the child's behavior on them rather than declaring their personal perception to be a general truth.1O For example, to react to shouting the adult might say "I don't like shouting. It hurts my ears" rather than "You are too loud." Labeling children as "bad" or "stupid" is insulting, demoralizing, and suggests a permanent condition without room for improvement. Children may react to these labels by being defensive, discounting everything the adult says to them, or striking back verbally or with actions. Some children succumb to labels, believing them to be true and living up to them. Perhaps surprisingly, good labels have similar problems. When children are called "good," they know they are not all good and may equally discount the speaker. They may even act badly to prove the adult wrong, show their other side, or test whether the adult still accepts them if their behavior is not totally positive. Even calling children "good" because of specific behaviors leaves the positive regard open for cancellation when the behavior changes. Specific Feedback. Children need feedback about their behavior frequently, approximately every 5 minutes for preschoolers. In addition to stating feedback in terms of ''I'' messages, it is most effective when given in short, simple, specific terms with emotion consistent with the message. 10 For example, it is preferable to say "I like this clean room. You cleaned up the blocks, the cars, and all the Legos." If comments are too elaborate, the point gets lost or the children believe it is either too good to be true (if positive) or excruciatingly overdone (if negative). Being specific provides instruction so that children learn from the experience and makes praise believable and unrefutable. Specific commentary avoids the hazards of generalizations in feedback, for example, "You never pick up your toys

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when I ask," suggesting that the undesirable behavior is a character trait. This may also color the parents' dealings with future incidents and children's view of themselves. If told that they never clean up, they have nothing to lose by confirming this impression. Being specific with feedback avoids comparing children to others or to themselves at other times, demoralizing at worst and emphasizing a competitive world view. Skills in different areas can be quite uneven and even vary from day to day, particularly for tasks at children's maximal ability. Comparing performance to prior feats may shame children as though they were not really trying. Writing down feedback or even symbolizing it with smiley faces impresses children a great deal at any age. Some children who have received very little correction in the preschool years become distressed when corrected in the average school setting. Routine correction, albeit kindly, along with praise makes adults more believable and helps children build needed tolerance. Emotional Congruence. It is very important that adults communicate with children in emotional tones consistent with the message and their true feelings. When the emotional tone is incompatible with the rest of the message it is confusing for the child because of the primacy of nonverbal communication. Some caregivers have difficulty conveying anger to their children out of a desire to be perfect parents or to be friends with their children. The result can be a child on the verge of hitting his baby brother with a hammer being told sweetly "Please be gentle, Joey!" Joey is deprived of a gauge of the degree of danger in his actions and is taught incorrect information. Parents who act more excited than they really are when praising similarly deprive as well as become unbelievable. When feelings are accurately conveyed immediately the parent is also less likely to harbor resentment and have it emerge unpredictably. Assisting Transitions. Preschool-aged children have relatively little choice in the sequence and timing of activities in their day. It is respectful of children as individuals to give them notice before requiring them to change activities, especially for highly persistent children or those with lower degrees of adaptability. 28 The caregiver should observe the children to see at what point they are in their activity, wait for an appropriate pause, catch their attention, and inform them of what is going to happen next and when. A kitchen timer can be helpful as an audible reminder of the minutes remaining until the change occurs. Although this approach will not avoid all upset, the children feel more respected and the parent is less ambivalent and more able to carry out transitions without negative emotions. Thank You Messages. Acknowledging children for their contribution to the adult tells them that they matter. Thanking children also models appreciation and courtesy. It is especially powerful when they are thanked for ordinary actions often taken for granted. It is central to moral development for children to be aware of their impact on others in the world. A useful format for thank you messages is: "Thank you for (specific example). It makes me feel (how)." For example, "Thank you for helping feed the dog. It makes me feel that you want to be helpful." Apologies. Apologizing to children tells them that their feelings count. It models humility and the ability to resolve conHicts and change views as well as gives children a chance to experience forgiveness. Hearing an adult

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apologize is a better way to teach these things than demanding that children apologize when they have acted inappropriately in anger. At that moment it is usually a lie for a child to say"!, m sorry." Instead, the adult can apologize to the victim. An adult can apologize to a child for incidents long past. Reminiscing about an interaction later gives both parties some perspective and calm. It also tells children that the adult has been thinking about them. Some parents make the error of apologizing after punishing children and even offer treats to compensate. This cycle is most likely to develop if the parent is too impulsive in punishing, too harsh, or does not assign thoughtful, appropriate consequences. They then feel regret and apologize or even retract their punishments. Conveying a Sense of Being Capable The other major need of human beings is to feel capable. To experience a feeling of capability, children need guidance in learning what the rules are, how things work, how to do things well, and the opportunity to practice in real ways. A system of discipline should include this guidance over a long period of time, flexible enough to adjust to the children's changing developmental needs and abilities. The parts of discipline that promote a sense of capability include routines, models, instruction, progressive expectations, choices, role-taking opportunities, and praise as well as consequences (see Table 1). Routines. Routines are regularly occurring patterns of activities, e. g., regular times and rituals for meals, sleep, and chores. Through routines children have a sense of security, that all is right with the world. Toddlers often establish routines for themselves, for example, a certain order for preparing for bed with a story before a song before three kisses. Routines can be especially helpful to children who are temperamentally irregular. Thomas et aP7 note that such irregular children have fewer problems in school when raised by parents who impose a regular structure for them in the preschool years. Wachs and Gruen 29 found that components of orderliness of the home correlated significantly with intelligence at 5, 6, 31, 36, and 54 months of age. Sprunger et aP6 found family routines to be correlated with both the mother's sense of competence and with overall family adjustment. Greater rhythmicity was found with greater family income even within their middle socioeconomic class sample. Less rhythmicity also has been documented among psychiatrically disturbed adults and low socioeconomic class inner city populations. Routines thus may be a product of higher functioning adults but are a beneficial component of discipline accessible to all. Models. Models of appropriate behavior are terribly powerful teaching tools. These encompass models of manners, cooperation, emotional expression, and conflict resolution as well as how to do specific tasks. Even toddlers copy adult behavior in excruciating detail. "Actions speak louder than words" is a verity not to be taken lightly. First-time parents are often embarrassed to discover how many habits they need to change in order to provide the models they want for their child. Instruction. Instruction in what the rules are and how to do things well is optimally given in steps that are reasonable to the abilities of the

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given child and respectful of their needs for independence and practice to accomplish them. Effective instruction is clear, simple, and direct without distracting, long, convoluted verbiage. 2 It should avoid judgments either positive or negative, for example, "If you had just done this earlier you wouldn't have to be rushing now!" Vagueness is also detrimental, for example, "Do you suppose it's sleepy time?" Clear instructions let the child know who wants what done when. For example, a father might say "Joseph, I want you to pick up all of these cards before dinner!" Studies of families of children with conduct disorders have shown parental instructions characterized by long strings of orders, judgments, and mixed emotional messages. 21 Clear instructions help avoid the development of defiance. Children with learning disabilities especially need clear instructions that are within their abilities. For children of normal intelligence with a receptive language problem, for example, a combination of short sentences with demonstrations may be needed although the final task is well within their abilities. 22 Certainly children should not be shamed or berated as part of instruction. Progressive Expectations. Discipline should include progressively increasing expectations appropriate to the children's developmental progress. The pieces of behavior that lead toward the desired result should be acknowledged separately with attention, praise, touches, or other rewards. Expectations of doing more of one task or more tasks successfully need to be increased very gradually so children have an ongoing experience of success. Parents above all must accept the need for teaching the same behavior repeatedly. Some parents with unrealistic expectations may com- . plain "She knows the rules, she should be minding by now!" Even when a task has been accomplished at one level of sophistication the child (and adult) begin to want to perform it more expertly almost immediately. When caregivers do not request adequately demanding tasks of their children the children may conclude that they are not capable of more advanced performance, for example, having the only chore of a 5-year-old be combing her hair. This can be a self-fulfilling prophecy because the child does not try and the parent does not instruct. It can damage self-esteem as much as excessively high expectations with repeated failures can. Choices. The opportunity to make choices teaches the skill of decision making and also respects children's individuality and need for autonomy. Choices can be overwhelming for a child, however, if they are too complex, emotionally charged, or inappropriate to the child's abilities. For example, toddlers can choose foods and toys; preschoolers can decide what to do first or which program to watch. Parents need to offer choices when there is actually time to choose, things to choose among (all of which are acceptable to the parent), and selections that are relevant to the child, such as which shirt to wear. Offering choices makes adult directives more acceptable for adults and for children. A structure that includes opporunities to choose adjusts automatically to children's progress in managing situations themselves and shows how much responsibility the children are able to assume. Role-taking Opportunities. Children acquire greater understanding of others and the dilemmas of group living by being in different social positions. For example, by being the one to replace a broken toy, children

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learn the impact of their actions. Such perspective-taking requires both a certain level of cognitive development and practical experience.23 Moral reasoning has been found to be more advanced in children raised with roletaking opportunities. 16 Praise and Rewards. Motivation by positive feedback, especially selfgiven, is preferable to that given by criticism or punishment. A smile, increased attention, praise, or material rewards all serve to reinforce a child's actions, as discussed earlier. For many children these non-material forms of feedback are sufficient rewards. Often children who are less responsive or those who have been in cycles of negative behavior and criticism from their caregivers need concrete results to help them attain or maintain positive behavior patterns. Concrete rewards may range from the green marks described earlier to stickers, extra privileges such as an extra story, trip to the park, or a toy. Parents often see these as bribes, which are to be avoided. It can be helpful to remind parents that we all reward ourselves daily, for example, by giving ourselves a coffee break after we complete a section of a project. Concrete rewards should be accompanied by attention, praise, and good feelings, which then become sufficient in preschool children after 1 or 2 months. Praise is best given in small, specific forms, as described earlier. Rewards should be small, immediate, and appropriate to the situation. Smaller rewards are better for several reasons: adults are more likely to give them promptly, frequently, and without resentment, and children are less likely to move to requests for very costly rewards. When parents promise a $50 fire truck as a reward, they may be unwilling to acknowledge the small steps toward the desired behavior. The ultimate goal, self-praise, is promoted by asking children to assess their own performance as well as by modeling specific praise. Appropriate Consequences. Although behavior can be managed with positive feedback, the world actually provides innumerable consequences to children naturally. Consequences also change behavior more quickly than simple positive feedback, which is often important. Natural Consequences. Much of a child's behavior results in natural consequences and instruction, particularly effective because it is completely impersonal and without interfering emotions. Gravity is one of the best examples of a natural consequence. If children run too fast on a slippery floor, gravity instructs them. They accept this lesson without resentment. Children can learn that if they spend their money on a toy there is none left for candy. Parents can allow children to learn many things from natural consequences but have to protect children from damage, social disgrace, and some of their own impulses. Clearly no one can let a child learn about cars by running into the street but they may be able to let a cat teach the need for gentle handling. Protection from social disgrace is needed because of children's limited social perception. For example, children need to be stopped from overt sexual exploration of others because of the potential reaction of peers and their parents. Children also need protection from their own impulses. For example, they should not be allowed to hit their parents. Children feel very bad about themselves and they fear for their survival if allowed to hurt the people on whom they depend for everything. Logical Consequences. When caregivers provide consequences they

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need to be logically related to the offense, graded in degree, given with emotional congruence, and given promptly. One Request, Then Move. The simplest consequence for young children is losing the freedom to do a task at their own speed. Common parental complaints include "I have to tell her 100 times" and "He won't listen." Because adults know the children can understand, they assume that verbal mediation is effective without action. Parents actually teach children to ignore their requests when they give repeated commands without following up with action. Following a simple principle of "One request, then move" improves most behavior of young children. Parents should observe what children are doing, watch for a break in their activity e. g., the end of a TV show, get their attention by words or touch, and give the instruction clearly (as described earlier). If a child does not move to do as requested in 10 seconds, the parent should go toward the child, grasp an arm if necessary, and shepherd him or her to the task without speaking further. The adult should perform the task with or without child participation. As long as the adult does not talk (to avoid lectures, criticism, nagging, or diversion) the child has the experience of complying. If the children help with the task they can be acknowledged for this. If children act in a way they clearly know is forbidden, most commonly aggression, they should receive no requests before action is taken. No further consequence is needed for most defiance in preschool children. It is essential that the adults limit their requests to ones they are Willing to complete physically, at least in the beginning of new efforts to improve compliance. They may need to limit requests to one part of the day, e.g., from after work to before dinner, to prevent exhaustion or inconsistency. Threats Versus Promises. Using only one request also avoids the common problem of accelerating consequences. In this scenario the parent tells the child to do or not do something, e.g., "come in the house." When the child ignores this, the parent threatens, e. g., "If you don't come in right now, you'll be in big trouble." If the child continues to ignore, the parent increases the consequence, e. g., "If you don't come right this minute you'll go to bed without dinner." The first problem here is that no action is taken after the initial request. The second problem is the use of threats that tend to be vague, fear-promoting, and without instruction as to what the person can do to avoid the consequence. Threats tend to raise tension, freeze problem-solving skills, divert attention away from the requested task to responding emotionally, and transmit desperation, giving children the message that they are monsters; a prophecy they may fulfill just to relieve tension. Instead of threats the parents should make promises that are clearly stated, with congruent emotion, in specific terms, and are logical consequences. For example, for throwing sand out of the sandbox a child could be promised that if he or she does it again, he or she would not be allowed to play in the sandbox for the next 30 minutes. The child can be said to "choose" this consequence if the misbehavior continues. Excessive consequences are usually promised when parents feel out of control. When they recover, they may regret the consequences and not enforce them, e.g., sending the child to bed without dinner, teaching the child not to believe

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the parent. If large consequences are given, parents are more likely to disagree and contradict each other, children may believe that the parents are mean, harsh, or unreasonable, which decreases cooperation generally, and they have no opportunity to work their way back into favor or have no time in the day to practice correct behavior. Shorter and smaller consequences are better; a simple scowl often suffices. Red marks are also useful for minor misbehaviors (see section on Red-Green). Choosing an appropriate response may take time, especially as children get older and present more complex dilemmas. After the misbehavior is stopped and the child notified that there is a consequence, the caregiver can take time to choose a response without diminishing its effect. This also allows adults to regain composure, confer with their spouse for major problems, or collect more information if needed. This is not the same as "waiting until Daddy gets home," which implies weakness on the mother's part and sets the father up as a fearsome person. It is desirable but not essential for all caregivers to give similar consequences for similar behaviors although children can distinguish different rules for different people or situations. The bigger mistake to avoid is having one parent interfere with how the other has already started to handle a given situation. This suggests weakness of one parent, raises tension between parents as well as between parent and child, and distracts from settling the problem so that no consequence or a delayed consequence may be given. As long as no caregiver is abusive it is better to let the person who starts finish handling a given situation. The aJults should discuss management strategies later out of the child's hearing. In problem cases, regularly scheduled meetings of all caregivers, perhaps with the pediatrician, are needed. Time Out. Just as attention is the most powerful positive feedback for a child, removal of attention is the most effective aversive consequence. 5 Time out serves to stop a misbehavior, convey disapproval, give both parties opportunity to regain composure, and decrease the .likelihood of repeated misbehavior. It is important to use time out properly for it to be effective (Table 5). If many behaviors result in time out, children may have little time left for "time in." In these cases time out may be sought by children for the attention it gives them. To assure that time out is truly nonreinforcing and to make it immediate, it is important that as little discussion occurs as possible. Older children may be allowed to present their views of the problem, but prolonged discussion or debates should be avoided because they postpone the consequence and put the adult in the position of judge. Similarly, long harangues by the adult postpone the consequence, distract from the instructional value of the event, and cause children to feel angry at the adult rather than sorry for what they did. Children need instruction regarding behavioral expectations and problem-solving strategies but these should be given at a separate time. Use of a chair for time out has several advantages; one can tell if the child is in the chair and the child can see what is going on. This is important in sibling rivalry because if separated, a child imagines that the sibling is receiving valued privileges and experiences even more jealousy. Keeping

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Table 5. Time Out (>9 Months) Time away from reinforcement and attention accompanied by disapproval, loss of freedom, and loss of interesting things to do. Principles of time out: 1. Only 2 to 3 priority behaviors should result in time out; often only aggression to people or things. 2. Only one warning should be given; no warnings for aggressive behavior. This avoids invalidating time out by using it as an empty threat. 3. A brief statement of the offense should be given. 4. Time out should be in a noninteresting but also nonscary place, preferably a straight-backed chair near the parent, if the adult can refrain from interacting. 5. Time out is best when brief: 1 minute per year of age to a maximum of 10 minutes measured with a timer the child can hear. 6. If the child leaves the chair he or she should be replaced without talking and restrained, if necessary. Toddlers may be placed in playpen or crib. 7. After time out the child's first positive or neutral hehavior should be attended to; no lectures or discussion of the offense.

the child nearby also symbolizes the fact that it is the child's behavior, not the child, that is unacceptable. In cases in which the adult cannot refrain from interacting they may need to leave the room or have time out occur elsewhere. If peers or siblings interact with the child they may be put in time out also. As for other consequences, shorter is better for time out. Studies have shown no additional effect after 10 minutes, even in older children. 18 If the time is longer, children are more likely to forget the offense and parents are more likely to forget the children, allowing them to drift out on their own. Initially, any behavior in the chair is accepted, including screaming; later, quiet is required, with the timer reset until the full time has been served in silence. If silence were required during initial teaching the child could be in time out for hours, defeating the purpose. Restraint can be by hands on the thighs or holding the child in the adult's lap facing away, with arms, legs, and head held as needed to prevent injury to the adult. Rather than keeping a specific time, toddlers may be released at the first lull to avoid teaching them to cry in order to be let out. 5 Some authorities suggest one spank each time the child gets out of the time out chair. 1 I have very rarely found this necessary as long as the parents are able to remain silent. If children are too strong to restrain they may be put in their room with the door knob held, not locked. These cases of persistent failure of time out deserve family counseling. Prompt attention and distraction after time out is important. Reminders of the offense or lectures may increase the likelihood of repeated misbehavior. Comforting children may be appropriate and does not invalidate the time out. If time out took place when the children had been asked to perform a task, they should go back to that task immediately. Some authorities allow the children to decide when time out is over, either because they have calmed down or because they can state what they have done wrong. For preschoolers this often results in children coming out while still angry and labile, however, and misbehaving again immediately.

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This may be a reasonable option for older children who have greater selfcontrol and insight. Physical Punishment. Punishment or aversive reinforcement that decreases the target behavior should only be a small part of the structure of discipline for children. A system using mainly punishment leads to inhibition of many behaviors, possibly without any clues as to alternatives or what acceptable behaviors would be. Often punishment is used as a kind of revenge by caregivers who are angry, embarrassed, fearful, or out of control, more to relieve their tension than to teach anything. Because of this, the punishment may be excessive and poorly modulated. The use of physical punishment increases aggression in the child, can lead to deviousness and lying to avoid it, and may result in fear of the parents or anger towards them, which can last a lifetime. 15 By regular use of physical punishment children are taught that power is paramount, decreasing their self-esteem. When punishment of any kind is the mainstay of family discipline the parents are likely to feel bad about their interaction with children, may feel like abusers, may give in or reverse themselves, and be inconsistent. If they give punishments they may coddle the child afterwards or apologize, confUSing the child. Punishment may also replace other forms of management that would be more instructive and effective. Punishment, although effective in the short term, loses effectiveness with older children, particularly continued use of physical punishment, which can cause them to lose respect for the parent or even run away. Often pediatricians are in the position of advising parents on discipline when one or both already use and believe in physical punishment and even strike children while in the office. This is an opportunity to begin teaching the parents alternatives. The physician can start by commenting on observations of the child's behavior, such as "He's really into things, isn't he! What is it like for you at home?" After ventilation, most parents are open to the offer that the physician can help them. It is possible to teach time out and coach parents in doing it during the visit, praising them for steps they accomplish. With explanation of the disadvantages of physical punishment and coaching in time out, most parents contract with the physician to use it exclusively for at least 2 weeks. It is optimal for both parents to attend visits about discipline because they need to work together. A personal phone call to absent parents often brings them in for the next visit. When parents declare that they were raised with the switch and came out fine, it is worth asking how they felt when they were hit. Usually the answer is "angry." Asking how their relationship is with their parents now may reveal persisting anger that they want to avoid with their own children. If one or both parents are unwilling to give time out a trial, they may at least agree to certain limitations on the use of physical punishment. Schmitt25 suggests limiting hitting to one spank on the child's hand or buttocks with the adult's hand only. This should be accompanied by notice of the offense and used consistently for only certain extreme behaviors. The possibility of the presence of abuse should be kept in mind and reports should be made if there is concern about excessive physical punishment. Physical punishment, although not optimal, can be associated with

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good parent-child relationships if it is not excessive and occurs only contingently to children's behaviors rather than arbitrarily when parents are angry.4 In fact, 70% of middle-income American families still use physical punishment, and higher percentages of low-income parents do. Harsh or arbitrary punishment is associated with higher rates of depression and alcoholism in later young adulthood, however. 17 Even teenaged mothers are able to master time out, learning in 1 hour to decrease the dangerous behavior of their I-year-oIds from 40% to 6%.5 Portes et al24 documented that teenaged mothers participating 5 half-days per week for 2 years in parent training were less punitive. Their style of discipline correlated 0.3 with the child's scholastic achievement, reading, and language scores. Dornbusch et al6 similarly found that a reasoning style of discipline correlated significantly with school grades in adolescents across cultural groups. BARRIERS TO EFFECTIVE DISCIPLINE Some children are more difficult to manage because of temperament, autism, emotional disturbance, mental retardation, or a history of being abused or neglected. The principles described in this article are even more important to these children and are effective. Most problems with discipline reflect parental difficulties, however. Any number of intrapsychic and family issues can make creating the structure of discipline more difficult. 12 Parents who are depressed or overwhelmed by their life situations may have little energy to follow through or may be too angry to do the required work. They are also likely to offer inadequate attention to their children who may then respond by eliciting attention in negative ways. Parents who are overidentified with their children, believing them to be part of themselves to an abnormal extent, may be too critical or have excessively high expectations of their children as they do of themselves. The children may respond to this pressure with negativism and oppositional behavior. On the other hand, parents who overidentify may believe any restrictions they place on their children as a restriction on themselves and thus fail to set adequate limits, or interfere with the other parent's discipline, even if it is reasonable, because they take it so personally. Parents who underidentify with their children may instead project traits of others onto them, such as those of an alienated ex-spouse. They may treat the children accordingly by being harsh or not offering enough positive interaction. This is also more common with step or foster children. Marital discord is frequently associated with discipline problems, either primarily or secondarily. For some, children's misbehavior serves to act out their anger or frustration and is therefore covertly encouraged. Couples who disagree on many issues are more likely to disagree and interfere or undermine each other in child management. Children are very sensitive to their parents' tension and react by being demanding or oppositional. Marital strife can also model aggression for the children. Children even purposefully misbehave to distract parents from fighting with each other. Other family stresses can produce similar tension, including the burden of retarded or physically or emotionally ill relatives, overcrowding, poverty, or conflict

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with grandparents or neighbors. If neighbors threaten to call the police when children cry, options for discipline seem limited. Parents who live with their own parents or in-laws may have additional contradictory input complicating the structure of discipline. Although these stresses may be impossible to eliminate, the pediatrician can arrange meetings of all family members to develop alternatives within their reach. Probably the single most important influence on parents' disciplinary style is how they perceive the way they were raised. We all learn how to parent primarily from how we were parented at the same age. Parents who were raised in a laissez-faire style may have done well, but this same kind of structure may not be adequate for one or more of their children who are temperamentally different. Parents who believe that they were harshly treated are more likely to parent in an extreme way. Some overcompensate for their own pasts by setting up very little structure for their children. They may never set limits or, when the children push them, they may react violently from the patterns in their past but then regret it, waver, and give in again. Others seek not to repeat history but respond harshly despite themselves. Interestingly, recent studies have shown that mothers who had problems in their upbringing but recognize and have accepted it have children with the normal distribution of types of attachment. Mothers who remain bitter or are unable to recall their upbringings have children more likely to show an insecure attachment pattern. 7 Although one is not inevitably tied to one's past, it may require psychologic work to be free of it. Pediatricians can help by referring for individual or family therapy parents who are struggling with their own pasts as they raise their children.

SUMMARY As pediatricians we have an opportunity and a responsibility to guide parents in the structure of discipline they set up for their children. The major goals of this structure are to help children develop a sense of being both lovable and capable. To feel lovable a child needs an enduring responsive relationship that conveys positive regard. Attending to children promptly, giving individual time daily, acknowledging positive behaviors, and ignoring minor transgressions all help them feel valued. Active listening without judgment demonstrates acceptance of children's feelings. Talking to children without labels or generalizations but with specific feedback about their actions and with congruent emotional tone is respectful and promotes self-esteem. Children also deserve assistance with transitions, thanks, and apologies as appropriate. To feel (and become) capable, children need a consistent structure of routines, good models, respectful instruction, and progressive expectations so that they have an ongoing experience of success. To grow as individuals they need opportunities to make choices relevant to their interests and role-taking opportunities to gain perspective on social interaction. Praise and rewards motivate as well as instruct children, but they also need to experience consequences to their actions. Natural consequences are optimal but parents also need to design logical consequences that are graded, related, prompt, and reasonable for a child's

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misbehaviors. Consequences are most effective when given after only one request, exactly as clearly promised by the adult involved without interference by others. Time out is one of the most effective consequences for young children when used properly. Physical punishment has multiple negative effects on a child's development, especially if used noncontingently. 1ntrapersonal and family factors predispose parents to predictable problems in establishing healthy discipline. Pediatricians can play an important role in promoting the emotional development of children by anticipating, guiding, and counseling families about discipline as well as referring them effectively.

REFERENCES 1. Barkley RA: Defiant children: A clinician's manual for parent training. New York, Guilford Press, 1987 2. Canter L, Canter M: Assertive Discipline for Parents. New York, Harper & Row, 1982 3. Chamberlin RW: Management of preschool behavior problems. Pediatr Clin North Am 21:33--47, 1974 4. Chamberlin RW: Relationships betweeen child-rearing styles and child behavior over time. Am J Dis Child 132:155-160, 1978 5. Christophersen ER: Anticipatory guidance on discipline. Pediatr Clin North Am 33:789--798, 1986 6. Dornbusch SM, Ritter PL, Leiderman PH, et al: The relation of parenting style to adolescent school performance. Child Dev 58:1244-1257, 1987 7. Eichberg CG: Quality of infant-parent attachment: Related to mother's representation of her own relationship history. Presented at Society for Research in Child Development. Baltimore, April 25, 1987 8. Elkind D: The Hurried Child. Reading, Addison-Wesley Publishers, 1981 9. Emde RN, Sorce JF: The rewards of infancy: Emotional availability and maternal referencing. In Call JD, Galenson E, Tyson RL (eds): Frontiers of Infant Psychiatry. New York, Basic Books, 1983, pp 17-30 10. Faber A, Mazlish E: How To Talk So Kids Will Listen and Listen So Kids Will Talk. New York, Avon Books, 1980 11. Faber A, Mazlish E: Siblings Without Rivalry. New York, Avon Books, 1987 12. Fraiberg S. Adelson E, Shapiro V: Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships. J Am Acad Child Psychiatry 14:387--421, 1975 13. Ginott H: Between Parent and Child. New York, Macmillan Co., 1965 14. Gordon T: Parent Effectiveness Training. New York, Peter H. Wyden, Inc., 1970 15. Grusec JE, Kuczynski L: Direction of effect of socialization: A comparison of parent's versus the child's behavior as determinants of disciplinary techniques. Dev Psychol 161:1, 1980 16. Hoffman ML: Moral development. In Mussen PH (ed): Carmichael's Manual of Child Psychology, ed 3. New York, John Wiley and Sons, 1970 17. Holmes SJ, Robins LN: The role of parental disciplinary practices in the development of depression and alcoholism. Psychiatry 51:24-36, 1988 18. Kazdin AE: Applying behavioral principles in the schools. In Reynolds CR, Gutkin TB (eds): Handbook of School Psychology. New York, John Wiley & Sons, 1982, pp 501-530 19. King M, Novik L, Citrenbaum C: Irresistible Communication. Creative Skills for the Health Professional. Philadelphia, W.B. Saunders Company, 1983 20. Mahler MS, Pine F, Bergman A (eds): The Psychological Birth of the Human Infant. New York, Basic Books, 1975 21. McMahon RJ, Wells KC: Conduct disorders. In Mash EJ, Barkley RA (eds): Treatment of Childhood Disorders. New York, Guilford Press, 1989, pp 73-132 22. Painting D: Helping Children with Specific Learning Disabilities. Englewood Cliffs, Prentice-Hall, Inc., 1983

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23. Piaget J: The Moral Judgment of the Child. New York, Harcourt, Brace, 1932 24. Portes PR, Dunham RM, Williams S: Assessing child-rearing style in ecological settings: Its relation to culture, social class, early age intervention and scholastic achievement. Adolescence 21:723-735, 1986 25. Schmitt B: Discipline counselling. In Levine MD, Carey WB, Crocker AC, et al (eds): Developmental-Behavioral Pediatrics. Philadelphia, W.B. Saunders Co., 1983, pp 1052-1054 26. Sprunger LW, Boyce WT, Gaines JA: Family-infant congruence: Routines and rhythmicity in family adaptations to a young infant. Child Dev 56:564-572, 1985 27. Thomas A, Chess S, Birch HG: Temperament and Behavior Disorders in Children. New York, New York University Press, 1968 28. Turecki S: The Difficult Child. New York, Bantam Books, 1989 29. Wachs TD, Gruen GE: Early experience and human development. New York, Plenum Press, 1982

Address reprint requests to Barbara J. Howard, MD Child Development Unit Duke University Medical Center 2213 Elba St. Durham, NC 27705