Association Between Harsh Disciplinary Methods and Child Functioning in Children Aged 7

Abstract

Despite having adverse physical and mental health outcomes, harsh disciplinary methods are commonly practiced all over the world. This study aims to measure the harsh disciplinary actions taken by parents and their association with child functioning in children, aged 7 to 14 years in Punjab, Pakistan. This study is based on secondary data obtained from the United Nations Children’s Fund (UNICEF’s) Multiple Indicator Cluster Survey, conducted in the Punjab province from 2017 to 2018. Parents/caregivers of 19,721 children were included in the analysis. Questionnaire-based interviews were conducted, and the data collection form included sociodemographic information, questions on different “Methods of Child Discipline” and the “Child functioning module.” The data was analyzed using STATA 15.0. Multiple logistic regression analysis was conducted to calculate the adjusted odds ratio and 95% CI exploring the association between harsh disciplinary methods and child functioning. More than 50% of children were exposed to severe physical, psychological, and emotional disciplinary methods. Exposure to severe physical aggression was associated with increased difficulty in learning (2.60 [1.27, 5.31]), remembering (2.83 [1.47, 5.44]), controlling behavior (1.63 [1.21, 2.18]), anxiety (1.98 [1.25, 3.13]), depression (2.57 [1.57, 4.22]) and making friends (1.94 [1.01, 3.79]). Whereas moderate physical aggression and psychological aggression were associated with (1.48 [1.19, 1.84]) and 1.5 times (1.20, 1.84) increase in difficulty in controlling behavior, respectively. Nonviolent actions were associated with protective odds for self-care (0.33 [0.17, 0.65]), communication (0.51 [0.27, 0.96]), learning (0.56 [0.33, 0.95]), remembering (0.62 [0.39, 0.90]), concentration (0.50 [0.31, 0.80]), anxiety (0.60 [0.46, 0.79]) and depression (0.67 [0.49, 0.92]). Severe disciplinary methods are detrimental to the child’s personal care, mental, social, emotional, and psychological well-being, whereas nonviolent actions are associated with positive child functioning. In a third-world country such as Pakistan, this topic is widely undiscovered and understudied, thus emphasizing the need for awareness and education of parents and healthcare providers.

Keywords

child discipline child functioning disciplinary methods physical aggression psychological aggression nonviolent actions

Introduction

Discipline plays a significant role in child rearing, growth and functioning. If properly and positively practiced, discipline can build excellent ethical values, morals, and can improve a child’s emotional intelligence and maturity. However, parents usually tend to revert to harsh disciplinary actions, which carry the risk of escalating to child abuse; hence, making it crucial to distinguish between constructive and harsh disciplinary actions. Harsh disciplinary actions are defined as the use of any verbal, physical or psychological force with the intention of causing physical or emotional pain for the purpose of correction or control of the child’s behavior, whereas constructive disciplinary actions relate to positive parenting techniques associated with optimum child development. Harsh disciplinary actions may unknowingly invade into abuse territory, as in cases where severe physical punishment and psychological discipline pose a continuous threat or stressor to the child, thus considered equivalent to physical or emotional abuse. (Leeb et al., 2008)

Global and Local Prevalence

The Multiple Indicator Cluster Survey, commonly known as MICS, is an international, regular survey conducted to measure the social indicators associated with women and child health. During the MICS 2010 to 2016 survey, data was collected from 49 low-middle-income countries (LMICs) to measure the national, regional, and global estimates for children aged 2 to 4 years exposed to various disciplinary actions. Utilizing the predictive modeling technique, the results were extrapolated to 131 LMICs and found that around 84% (296.2 million) of children were exposed to nonviolent discipline, whereas 62.5% (220 million) and 65.4% (231 million) children were exposed to aggressive physical and psychological disciplinary methods, respectively (Cuartas et al., 2019). However, Pakistan was not included in this survey.

The current study is based on the data from the Multiple Indicator Cluster 6 Survey (MICS 6), which has published research articles to highlight the condition of women and child health. (MICS 2017-18—Punjab | UNICEF Pakistan, n.d.). In the majority of the countries where MICS 6 was conducted, more than two in three children were subjected to violent discipline by their caregivers. The MICS-6 Punjab (Pakistan) survey reported that 74% of children in the age group 1—14 experienced psychological aggression as a form of discipline, while 71% experienced physical punishment (MICS Punjab 2017–18 | Bureau of Statistics, Punjab, n.d.). A report by Professor Zakar found that psychological (84%) and physical (74%) actions were the most common type and the use of violence for the sake of controlling and disciplining children contributed to further abuse and violence (Muhammad Zakria Zakar, 2016).

Factors and Consequences of Abuse

Various factors such as gender inequality, marital satisfaction, unemployment, drug abuse, cultural norms, and the methods that the parents themselves were exposed to during their own childhood affect the disciplinary actions taken by parents (Khuwaja et al., 2018; Lakhdir et al., 2021; Tang, 2006). Majority of the research studies have reported nonverbal disciplinary methods and severe physical punishments together and have only highlighted the negative consequences of harsh actions, which have over-shadowed the beneficial effects of nonviolent actions for child disciplining. Although described as part of a continuum, different levels of disciplinary actions (nonviolent, psychological, and physical) have varying effects on child behavior and functioning (Robertson, 2017).

Pathophysiology Between Harsh Disciplinary Actions and Brain Development

Stress as a result of childhood abuse, can result in high levels of cortisol, which can destroy brain cells, interrupt neuronal connections, and impair the child’s behavioral development. De Bellis and Zisk (2014) literature has consistently shown that exposure to childhood maltreatment affects the structural integrity of the brain and the region most commonly involved is the fronto-limbic circuit, which includes the pre-frontal cortex, anterior cingulate cortex, hippocampus, amygdala, corpus callosum, and the cerebellum. Hart and Rubia (2012) state that the pre-frontal cortex develops between the ages of 8 and 14 years and plays a significant role in the cognitive control functions and the working memory organization of an individual. It is involved in conducting executive functions such as planning, insight, and foresight and the presence of dopamine allows it to have the ability to pay attention and influence impulse inhibition (Lupien et al., 2009; Klein et al., 2019). Any harm to these structures may cause irreplaceable damage to the child’s inner and outer personality and cause long-term negative mental health consequences and, thus, impact the well-being of the child.

Studies Reporting Harsh Disciplinary Actions

Research has also shown that early exposure to harsh physical punishment in young children aged 8 to 14 years old results in a significant decline in cognitive abilities. Furthermore, all forms of physical punishment are also shown to be associated with declines in school engagement and harsh disciplinary punishment with increased peer isolation. (Font & Cage, 2018). A cross-sectional study conducted on primary school students in Tanzania in 2016, found a strong relationship between exposure to harsh discipline and internalizing problems (β = .47). These students also had a lower working memory capacity (β = −.17) and a lower school performance (β = −.17). (Hecker et al., 2016) A meta-analysis regarding the association between parental punishment and several child behaviors was conducted by Gershoff and concluded that while subjecting to disciplinary actions may result in short-term compliance, it can decrease moral internalization (taking over socially acceptable behavior due to intrinsic motivation) and is also a strong contributor to increased aggressive and hostile behavior in children and adolescents. Due to its significant detrimental effects on parent-child relationships, harsh disciplinary actions also increase the risk for delinquent, criminal, and anti-social behavior (Gershoff, 2002a). A study conducted in Khyber Pakhtunkhwa in Pakistan concluded that students subjected to harsh punishment by their teachers were less motivated and less active in class participation as compared to the rest of the students. Even though this study did not examine harsh disciplinary actions by parents, it is evident that maltreating children to control their behavior decreases their motivation and learning attitude (Ahmad et al., 2013).

Studies Reporting Nonviolent Disciplinary Actions

While, on one hand, severe punishment has a clear association with child functioning, it is difficult to comment on the impact of nonviolent actions on child functioning and growth. This is because nonviolent actions vary widely. Also, parenting style, culture, age, and educational status also determine nonviolent actions. Contradictory findings have been reported for nonviolent actions, with some studies mentioning its ineffective and harmful impact (Gershoff, 2013), whereas others suggest minimal impact of nonviolent actions on a child’s behavior and cognitive growth (Ferguson, 2013).

Rationale

Abuse against children is already an under-reported topic in Pakistan and the magnitude of the problem further amplifies when abuse is considered a “disciplinary method.” According to the Pakistan Bureau of Statistics 2017, around 10% to 11% of the population of the province of Punjab comprises 7 to 14 years old children. (Final Results of Census-2017 | Pakistan Bureau of Statistics, n.d.). During the crucial developmental stage of 7 to 14 years, children start attending school and are exposed to a new environment, which necessitates a period of adjustment.

The debate regarding the ideal guidelines to discipline a child varies in different cultures and ethnicities. In the Pakistani population, many parents struggle with developing an encouraging environment in their households, and the taboo associated with this topic has discouraged open discussion. Children are considered mere possessions of their parents, who not only believe that harsh and severe actions are necessary for establishing authority but also misuse their authority wherever they deem necessary. This recurring cycle of violence has been justified by parents, caregivers, and teachers based on their own childhood experiences (Greene et al., 2020).

Hence, we hypothesized that, i. More than 50% of children aged 7 to 14 years will be exposed to harsh disciplinary actions, ii. Harsh disciplinary actions will be associated with behavioral, cognitive, and mental health issues in children. iii. Nonviolent disciplinary actions will be positively associated with child functioning.

Over the history of studying child disciplinary methods, there have been several arguments and theories, which have tried to explain whether the benefits of such actions outweigh the risks. (Gershoff, 2010; The State of Research on the Effects of Physical Punishment - Ministry of Social Development, n.d.). While it is impossible to generalize the results for setting a “threshold limit” beyond which caregivers are harming a child rather than promoting positive behaviors, the prevalence of harsh disciplinary actions in our population, coupled with the significant risk factors and the detrimental consequences justify exploring the association between various disciplinary actions and child functioning.

The MICS study 2017 to 2018 has vastly reported the prevalence of harsh disciplinary actions and child functioning. However, the age range included all children from 1 to 14 years, and no associations were explored between disciplinary methods and child functioning in the previous reports. To address this gap, the current study has used data from the MICS-6, for the age range of 7 to 14 years. Majority of the parents and teachers in Pakistan believe that the early years of schooling require strict disciplinary actions; thus, a child is burdened with over-expectations and humiliation at this tender age, which may leave a negative mark on the child’s growth and functioning (Zakar, 2016). This study aimed to determine the association between various methods of harsh disciplinary actions (ranging from nonverbal, and psychological aggression to acts of moderate and severe physical punishment) on the physical, mental, emotional, and social functioning of children aged 7 to 14 years in Punjab, Pakistan.

Methodology

Data

Secondary data obtained from UNICEF’s MICS 6, Punjab 2017 to 2018, was used in this study. The MICs household survey has been conducted in approximately 116 countries and uses a two-stage cluster sampling survey. The sample selected included participants from all 36 districts of Punjab, and from each district, urban and rural areas were defined as the main sampling strata and from each stratum, enumeration areas were systematically selected with probability proportion to size. The list of households was obtained from the Census 2017 of the Pakistan Bureau of Statistics and 20 households were then further selected from each enumeration area. The total number of households included in the data set is 53,840 and the total number of clusters included are 2,692. For this study, the focus was on children aged 7 to 14 years, which were 19,721 in number. Furthermore, sample weights were reported in relevant data files.

The data was collected through in-person interviews, and interviewers received training for administering the questionnaires and filling in the information through digitalized technology. The survey included eight questionnaires, but the primary questionnaire we will be using is the one specifically designed for the population of children aged 5 to 17, among which the target age group is 7 to 14. From the data set, the categories relevant to our study are the following: Child Information Panel (FS), Child’s Background (CB), Child Discipline 5 to 14 (FCD), and Child Functioning (FCF). The questionnaire was modified according to cultural context, and the questions were answered by the mothers or primary caregivers of the children.

The inclusion criteria of the study were children aged 7 to 14 years old, and the exclusion criteria of the study comprised children with some form of disability (those who wore glasses/contact lenses or were not able to see at all or had a lot of difficulty in seeing, children using hearing aids or who could not hear at all or had a lot of difficulty in hearing and finally, children who were using equipment or those who required assistance for walking) as these can affect the normal functioning of children.

Measures

Disciplinary Actions: The “Methods of Child Discipline” module of the MICS 6 questionnaire included 11 questions (FCD2A-FCD2K) regarding disciplinary practices and has been adapted from the Conflict Tactile Scale (CTS) (Cotter et al., 2018; Straus et al., 1998), which is based on the WorldSAFE survey questionnaire (Sadowski et al., 2004). Regarding the “Child Discipline MICS Questionnaire,” the respondents were introduced to the module with the following statement: “All adults use certain methods to teach children the right behavior or address a behavior problem. I will read various methods that are used, and I want you to tell me whether you or anyone else in your household has used each method with (child’s name) in the last month.”

The questionnaire has been used cross-culturally in several countries worldwide. Following the recommendations from CTS and MICS UNICEF (Monitoring the Situation of Children and Women Division of Policy and Planning, n.d.), we have categorized the disciplinary actions taken by parents/caregivers as follows:

Nonviolent discipline: This included: Taking away privileges, forbidding something that they liked or not allowing him/her to leave the house (FCD2A), explaining to the child why his/her behavior is wrong (FCD2B), and giving the child something else to do (FCD2E). Each question was answered as “yes” and “no” and coded as “1” and “0,” respectively. The responses were summed together giving scores ranging from 0 (meaning zero exposure to any nonviolent acts and it was taken as a reference category) to 3 (exposed to all three types of nonviolent actions).

Psychological aggression: This included: Shouted, yelled, or screamed at him/her (FCD2D), called him/her dumb, lazy or another name like that (FCD2H). Each question was answered as “yes” and “no” and coded as “1” and “0” respectively. The responses were summed together giving scores ranging from 0 (meaning zero exposure to psychological aggression and was taken as a reference category) to 2 (exposed to both types of psychological actions).

Physical aggression (PA): This included: Shook him/her (FCD2C), Spanked, hit, or slapped (him/her) on the bottom with bare hand (FCD2F), hit or slapped (him/her) on the face, head or ears (FCD2I), hit or slapped him/her on the hand, arm, or leg (FCD2J). Each question was answered as “yes” and “no” and coded as “1” and “0,” respectively. The responses were summed together giving scores ranging from 0 (meaning zero exposure to physical aggression and was taken as a reference category) to 4 (exposed to all four types of aggressive actions).

Severe physical aggression (SPA): This included: Hit him/her on the bottom or elsewhere on the body with something like a belt, hairbrush, stick or another hard object (FCD2G), beat him/her up, that is, hit him/her over and over as hard as one could (FCD2K). Each question was answered as “yes” and “no” and coded as “1” and “0” respectively. The responses were summed together giving scores ranging from 0 (meaning zero exposure to severe physical aggression and was taken as a reference category) to 2 (exposed to both types of severe physical actions).

Child functioning: Previously, for the MICS 2 to 4 Report, child disability had been measured using the Ten Questions Screen. However, this measure was discontinued and the Washington Group on Disability Statistics-WGDS (Module on Child Functioning: Questionnaires—UNICEF DATA, n.d.) has now developed a new module. This module aimed to identify children with functional difficulties and relevant domains were selected as the ability to perform various tasks. The conceptual framework for these variables was provided by the International Classification of Functioning, Disability, and Health for Children and Youth, WHO, ICF-CY 2007 (International Classification of Functioning, Disability and Health: Children and Youth Version: ICF-CY, n.d.), which was originally derived from the International Classification of Functioning, Disability and Health, WHO, ICF 2001 (International Classification of Functioning, Disability and Health [ICF], n.d.; WHO Disability Assessment Schedule [WHODAS 2.0], n.d.). The ICF 2001 gave rise to the World Health Organization Disability Schedule (WHODAS 2.0), which captured the domains of functioning in six main domains: Cognition, Mobility, Self-Care, Getting along, Life activities, and Participation.

After extensive review by other experts and testing in several countries, the “Child Functioning” module for MICS 6 was finalized. Respondents were asked to answer all the questions in comparison to other children of the same age and the data collected was included in the variables FCF1 to FCF26. Amongst these, the following 11 variables have been considered in this study: self-care (ability to feed/dress—FCF16), being understood inside the household (FCF17), being understood outside the household (FCF18), learning (FCF19), remembering (FCF20), concentrating (FCF21), accepting change (FCF22), controlling behavior (FCF23), making friends (FCF24), anxiety (included being nervous or worried—FCF25), and depression/sadness (FCF26) that were further compressed into 9 domains, namely, Self-care (FCF16), Communication (FCF 17, 18 and 24), Learning (FCF 19), Remembering (FCF 20), Concentrating (FCF 21), Accepting change (FCF 22), Controlling Behavior (FCF 23), Anxiety (FCF 25) and Depression (FCF 26). The responses to these variables were answered on a rating scale according to the degree of their severity and were recorded according to the guidelines mentioned in the MICS 6 Report. (MICS Multiple Indicator Cluster Survey Punjab Multiple Indicator Cluster Survey, n.d.). Each of the outcome domains was converted to a binary variable by summing up the Likert responses “cannot perform at all” and “lot of difficulty” and “some difficulty” and coded as “1” and labeled as “having functional difficulty”/limitation” versus “no difficulty” coded as “0.” The domain “communication” comprised of three functions, that were added together and further divided into a binary variable. The occurrence of anxiety (FCF25) and depression (FCF26) were measured in terms of frequency as daily, weekly, monthly, a few times a year, never, and no response. The response category “daily” was considered a functional disability and coded as “1” versus the remaining considered as “0.”

Statistical Analysis

The analysis was carried out using STATA 15.0 (manufactured in the United States of America) under complex survey compounds. Different disciplinary actions namely nonviolent behavior, psychological aggression, and physical and severe physical aggression, were considered categorical variables (independent variables). The dependent variables were also treated as binary categorical variables and included 9 domains, namely, Self-care (FCF16), Communication (FCF 17, 18 and 24), Learning (FCF 19), Remembering (FCF 20), Concentrating (FCF 21), Accepting change (FCF 22), Controlling Behavior (FCF 23), Anxiety (FCF 25) and Depression (FCF 26). Each of the outcome domains was converted to a binary variable by summing up the Likert responses “cannot perform at all” and “lot of difficulty” and “some difficulty” and coded as “1” and labelled as “having functional difficulty”/limitation” versus “no difficulty” coded as “0.” The domain “communication” comprised of three functions, that were added together and further divided into a binary variable.

Age, gender, area of residence, mother’s education, and wealth index were also treated as categorical variables. Frequency percentages were calculated for all the variables. Initially, bivariate analysis was conducted using the cross-tabs to measure the association between sociodemographic variables, disciplinary actions, and the child functioning domains. Multiple logistic regression analysis was conducted to calculate the adjusted odds ratios along with a 95% confidence interval. The factors adjusted for during the analysis included the area that the child belonged to (rural or urban), the gender of the child (male, female), the child’s age (7–8, 9–10, 11–12, and 13–14), the child’s education level (none/pre-school, primary, middle, secondary and higher), mother’s education level (none/pre-school, primary, middle, or higher) and the wealth quintile index of the household (poorest, second, middle, fourth, and richest).

Results

Sociodemographic Characteristics of Children

The MICS survey included 60,000 children aged 0 to 14 years; however, for this paper, 19,721 children, aged 7 to 14 years were included in the analysis, whereas 1,063 were excluded due to missing data. Table 1 displays the sociodemographic characteristics of the study participants. Almost equal number of children were in each age category except for the 7 to 8 years age group that comprised 28.5% (n = 5,610) of the sample. Similarly, both genders were almost equally represented in the sample (males 50.76% vs. females 49.24%). Around 60% of the children had primary-level education, whereas only 4.4% (n = 862) received secondary-level education. The wealth index found that 26% (n = 5,164) belonged to the lowest-poorest quintile, and only 15% (n = 3,009) belonged to the highest-richest quintile.

Table 1.

Socio-Demographic Characteristics of Children in Punjab, Pakistan (MICS 2017–2018 Survey).

Baseline Characteristic	Frequency	Percentage (%)
Child’s age
7–8	5,610.	28.45
9–10	5,003	25.37
11–12	4,704	23.85
13–14	4,404	22.33
Sex
Male	10,011	50.76
Female	9,710	49.24
Child’s education
None/Pre-School	3,497	17.73
Primary	11,747	59.56
Lower secondary	3,615	18.33
Upper secondary	862	4.37
Mother’s education
None/Pre-School	11,262	57.10
Primary	3,536	17.93
Lower secondary	1549	7.86
Upper secondary	1932	9.80
Higher	1442	7.31
Area
Urban	6,564	33.28
Rural	13,157	66.72
Wealth quintile index
Poorest	5,164	26.19
Second	4,301	21.81
Middle	3,661	18.56
Fourth	3,585	18.18
Richest	3,009	15.26

Proportion of Children Exposed to Various Disciplinary Actions

Tables 2 and 3 show the frequency percentages for different types of disciplinary actions as reported by the parents/caretakers. Our study indicates that among children aged 7 to 14 years old, the most common disciplinary method utilized by parents is psychological aggression (52.5%), followed by nonviolent disciplinary methods (50.5%), moderate (41.9%) and severe physical aggression (7%). Among the nonviolent actions, the majority (71%) of parents said that they provided reasoning to their children about wrong behavior. Among the psychologically aggressive behaviors, the most common were shouting and yelling at the child (72%). Under moderate physically aggressive behaviors, more than 50% of children were exposed to shaking (53%), followed by slapping (44%), spanking (37%) and hitting/slapping on the hands/arms etc. (34%). Only 19% were exposed to any one type of moderate aggressive action, whereas a significant 17% (n = 3,359) were exposed to all four types of moderate physically aggressive actions. Under the severe physically aggressive category, more than 90% of the parents mentioned that they do not subject their children to any severe physical punishments. However, around 9% of children were exposed to any one type of severe physical punishment, and around 3% were subjected to both severe actions.

Table 2.

Prevalence of Different Types of Physical Punishment Among Children Aged 7 to 14 in Punjab, Pakistan (MICS 2017–2018 Survey).

Type of Punishment	Yes		No
Type of Punishment	Frequency	Percentage (%)	Frequency	Percentage (%)
Severe physical aggression
Hit child on the bottom or elsewhere with belt, brush, stick, etc. (2G)	1,655	8.39	18,066	91.61
Beat child up as hard as one could (2K)	1,165	5.91	18,556	94.09
Moderate physical aggression
Shook the child (2C)	10,438	52.93	9,283	47.07
Spanked, hit or slapped child on bottom with bare hand (2F)	7,360	37.32	12,361	62.68
Hit or slapped child on the face, head or ears (2I)	8,661	43.92	11,060	56.08
Hit or slapped child on the hand, arm or leg (2J)	6,667	33.81	13,054	66.19
Psychological aggression
Shouted, yelled or screamed at child (2D)	14,214	72.07	5,507	27.93
Called child dumb, lazy, or another name (2H)	6,408	32.49	13,313	67.51
Nonviolent disciplinary acts
Took away privileges (2A)	7,641	38.75	12,080	61.25
Explained why behavior was wrong	14,003	71.01	5,718	28.99
Gave child something else to do (2E)	8,234	41.75	11,487	58.25

Table 3.

Frequency of the Number of Physical Punishments that Children Aged 7 to 14 have been Exposed to in Punjab, Pakistan (MICS 2017–2018 Survey).

Number of Punishments that the Child has been Exposed to	Frequency	Percentage
Severe physical aggression
None	17,449	88.48
Exposed to one type	1,724	8.74
Exposed to two types	548	2.78
Moderate physical aggression
None	6,112	30.99
Exposed to one type	3,811	19.32
Exposed to two types	3,437	17.43
Exposed to three types	3,002	15.22
Exposed to four types	3,359	17.03
Psychological aggression
None	4,879	24.74
Exposed to one type	9,062	45.95
Exposed to two types	5,780	29.31
Nonviolent behavior
None	4,148	21.03
Exposed to one type	5,711	28.96
Exposed to two types	5,417	27.47
Exposed to three types	4,445	22.54

Proportion of Children with Functional Limitations

Table 4 shows the percentage of children with different functional difficulties, ranging from self-care, communication, cognition, and behavior, to mental health. More than 30% of children were suffering from anxiety (38%) and depression (34%), whereas 29% (n = 5,782) had difficulty in controlling their behavior and 21% (n = 4,161) had problems in accepting any change. Around 7% to 9% of children suffered from various cognitive disabilities related to learning (7.4%); remembering (9%); concentrating (9%); and making friends (7%). Few parents also reported difficulty in self-care and in communicating with other people.

Table 4.

Frequency of Specific Functional Difficulties Among Children Aged 7 to 14 in Punjab, Pakistan (MICS 2017–2018 Survey).

Child Functioning	Limited/Present		Normal/Absent
Child Functioning	Frequency	Percentage	Frequency	Percentage
Self-care	437	2.22	19,284	97.78
Being understood inside the household	374	1.90	19,347	98.10
Being understood outside the household	492	2.50	19,229	97.50
Learning	1,459	7.40	18,262	92.60
Remembering	1,713	8.69	18,008	91.31
Concentrating	1,715	8.70	18,006	91.30
Accepting change	4,161	21.10	15,560	78.90
Controlling behavior	5,782	29.32	13,939	70.68
Making friends	1,443	7.32	18,278	92.68
Anxiety	7,551	38.29	12,170	61.71
Depression	6,765	34.30	12,956	65.70

Association Between Disciplinary Actions and Child Functioning Domains

Table 5 is showing the multiple logistic regression analysis with adjusted odds ratio and 95% CI for independent association between different types of disciplinary actions with various functioning domains in children aged 7 to 14 years. Severe physical aggression was shown to be significantly associated with impaired cognition, difficulty in controlling behavior, and declining mental health. Exposure to both types of severe physical aggression was associated with increased odds in problems with learning (2.60 [1.27, 5.31]), remembering (2.83 [1.47, 5.44]), and controlling behavior (1.63 [1.21, 2.18]), anxiety (0.98 [1.25, 3.13]) and depression (2.57 [1.57, 4.22]). Severe physical aggression was also associated with difficulty in making friends with an odds ratio of (1.94 [1.01, 3.79]). The moderate physical aggression category found that exposure to 3 or 4 types of simultaneous punishments was associated with (1.27 [1.03, 1.57]) and (1.48 [1.19, 1.84]) times increase in difficulty in controlling behavior. Psychological aggression as a form of punishment was associated with a 1.5 times (1.20, 1.84) increase in controlling behavior.

Table 5.

Multiple Logistic Regression Analysis Showing Association Between Various Types of Punishment with Child’s Mental, Behavioral and Social Health in Punjab, Pakistan (MICS 2014–2015).

Variables	Self-Care (FCF16)	Communication Outdoor/Indoor (FCF17,18,24)	Learning (FCF19)	Remembering (FCF20)	Concentration (FCF21)	Controlling Behavior (FCF23)	Anxiety (FCF25)	Depression (FCF26)
Severe physical aggression⁴
None	NS	NS	1.0	1.0	NS	1.0	1.0	1.0
One type			1.45 [.78, 2.70]	1.18 [.62, 2.01]		1.14 [.94, 1.37]	1.79 [1.31, 2.4]	2.12 [1.52, 2.95]
Two types			2.60 [1.27, 5.31]	2.83 [1.47, 5.44]		1.63 [1.21, 2.18]	1.98 [1.25, 3.1]	2.57 [1.57, 4.22]
Moderate physical aggression³
None	NS	NS	NS	NS	NS	1.0	NS	NS
One type						1.04 [.86, 1.26]
Two types						1.06 [.87, 1.30]
Three types						1.27 [1.03, 1.57]
Four types						1.48 [1.19, 1.84]
Psychological aggression²
None	NS	NS	NS	NS	NS	1.0	NS	NS
One type						1.17 [.97, 1.41]
Two types						1.49 [1.20, 1.84]
Nonviolent disciplinary acts¹
None	1.0	1.0	1.0	1.0	1.0	1.0	1.0	1.0
One type	.60 [.31, 1.12]	.51 [.27, .96]	.74 [.48, 1.16]	.62 [.39, 1.0]	.50 [.31, 80]	1.12 [.92, 1.36]	.77 [.59, 1.01]	.70 [.52, .96]
Two types	.31 [.15, .62]	.74 [.41, 1.33]	.68 [.42, 1.08]	.63 [.34, 1.18]	.81[.41, 1.60]	1.32 [1.09, 1.61]	.60 [.46, .79]	.67 [.49, .92]
Three types	.33 [.17, .65]	.58 [.29, 1.17]	.56 [.33, .95]	.61 [.33, 1.22]	.48 [.30, 2.2]	1.18 [.95, 1.46]	.80 [.60, 1.07]	.72 [.49, 1.04]

All significant associations are highlighted in bold.

All associations were adjusted for child’s age, gender, mother’s education, area of residence, and wealth index. NS = not significant.

Variable child’s educational level was not adjusted for due to multicollinearity;

p value = 0.05.

Nonviolent disciplinary acts include taking away privileges, explaining wrong behavior and giving child something else to do

Psychological aggression includes shouting and calling child dumb or lazy

Moderate physical aggression includes shaking, spanking, and hitting child

Severe physical aggression includes hitting on bottom with belt, brush etc. and beating child as hard as one could

Nonviolent actions such as “giving the child something else to do “or explaining to the child why his/her actions are wrong” were associated with an improvement in child functioning. The nonviolent actions were associated with protective odds for self-care (0.33 [0.17, 0.65]), communication (0.51 [0.27, 0.96]), learning (0.56 [0.33, 0.95]), remembering (0.62 [0.39,0.90]), concentration (0.50 [0.31, 0.80]), anxiety (0.60 [0.46, 0.79]) and depression (0.67 [0.49,0.92]). However, nonviolent actions were also associated with an increase in the odds for accepting change (1.62 [1.23, 2.15]), and controlling behavior (1.32 [1.09, 1.61]). The associations with “accepting change” are not shown in Table 5.

The age and gender of the child also showed protective results. Children aged 13 to 14 years were .32 (.13, 80) times at lesser odds for difficulty in self-care. Females were at lower risk of facing difficulty in accepting change (.78 [.66, .93]) and controlling behavior (.73 [.65, .83]). All associations were adjusted for mothers’ education, residence area, and wealth index.

Discussion

Findings and Comparison with Other Studies

Our study indicates that amongst children aged 7 to 14 years old, the prevalence of parental disciplinary methods ranged from 7% (severe physical aggression) to 52% (psychological aggression). Interesting associations were observed after exploring the association between various disciplinary actions with child functioning. Our findings are in consensus with a recently conducted systematic review that found a strong association between harsh disciplinary actions and child behavior and development. (Avezum et al., 2022) Our results are also in agreement with base estimates from a 2014 to 2015 meta-analysis, which showed that a minimum of 50% or more of children in Asia, Africa and North America experienced violence during the previous year and that globally over half of all children—1 billion children, ages 2 to 17 years—experience such violence (Hillis et al., 2016). Adolescents exposed to harsh discipline are less likely to promote a close relationship with their mothers and have decreased social and emotional functioning (Bender et al., 2007). Similarly, we also proved that increased exposure to psychological aggression negatively affects the child’s ability to accept change and control behavior. Verbally abusing the child initially decreases self-esteem and, eventually, inculcates the belief that aggression is an acceptable behavior in society. This results in several internalizing and externalizing behavioral problems in the child. Children’s internalization of values is compromised due to the defective communication between the caregiver and the child, and instead, aggressive and stubborn behavior is encouraged as a means for the child to socially interact (Gershoff, 2002b).

Our data also shows that as the number of nonviolent disciplinary methods increased, children can take care of themselves in a better way, face less difficulty in communication, making friends, and learning, and also show lower levels of anxiety and depression. Our findings are in support of an extensive overview of the effects of nonviolent disciplinary actions, including studies from all over the world. This study concluded the beneficial effects of nonviolent interventions on the child growth, functioning and cognitive behavior. The study has suggested the development of a tool-kit, which is acceptable by all cultures and ethnicities, in addition to being utilized in all settings like schools or at home. The toolkit should include multiple nonviolent, evidence-based interventions that can be used as an alternative to harsh disciplinary methods. The authors realize that one set intervention may not work due to multiple reasons, ranging from cultural differences to parenting style, number and order of siblings, etc. (Quail & Ward, 2020).

Policy Implications

Stopping abuse/violence is considered an international priority issue by the United Nations and the Sustainable Development Goals (SDG) target 16.2 aims to end all forms of violence against children by 2030. (Durrant, 2017) While global efforts and commitments are ongoing as an attempt to catalyze change, at a national level, the “Punjab Destitute and Neglected Children Act” was passed in 2007 and Child Protection Courts (CPC) were established. (Child Protection Courts | Child Protection and Welfare Bureau, n.d.) Unfortunately, our justice system is still favorable to the adults and primary caregivers of children, and Section 35 of the PNDC Act 2007 states that, “where some punishment is administered to a child by the person having lawful control or custody of the child, for any good or sufficient reason, it shall not be deemed to be an offence under this section.” Additionally, if the individual who is in charge of the child but is not their parent performs any maltreatment or neglect towards the child, they will be punished with imprisonment, which may extend to only 3 years, or a fine, which may extend to 50,000 rupees only or both (Rules and Regulations | Child Protection and Welfare Bureau, n.d.). As explained above, it is clear that our justice system fails to protect minors from parental abuse. The rules and regulations have not yet been able to define the line between the extent of punishment, which is considered legal and illegal. Results of our study should be used to modify the policy by increasing the repercussions of violent parenting and encouraging nonviolent disciplinary methods.

Parenting Practices

Baumrind has proposed three distinct styles of parenting: i- Authoritative parents, who are not intrusive and use reasoning rather than coercion to guide children’s behavior; ii- Authoritarian parents (“rigid ruler”) are harsh, power assertive and unresponsive to their children, and iii- Permissive parents use the indulgent style and allow free expressive of their children’s impulses (Baumrind, 1991). Later, a fourth style of parenting, “Uninvolved and Neglectful parent” was also identified and was characterized by little effort being put into interaction with the child (Kuppens & Ceulemans, 2019).

Most parents learn and develop the “art of parenting” through the practices they have observed in their childhood. While Western culture puts great emphasis on authoritative parenting, in countries like India and Pakistan, authoritarian parenting is culturally encouraged (Sahithya et al., 2019). Comparable association was discovered in a study from China, which commented on the aspect of normalization of harsh discipline. The perceived normalization of aggression by adolescents was found to buffer the negative association between exposure and outcome (Liu & Wang, 2018). In Pakistan, the use of “harsh” disciplinary methods has been cultivated for generations and parenting practices resemble a mixture of “authoritarian” and “neglectful.” A closer example to Pakistan is that of Bangladesh, where harsh disciplinary methods are considered a parental norm (Jasmine & Nduna, 2022). Although the majority of the population in both countries is Muslim, and Islam teaches tolerance and affection toward children, allowing them the freedom to play even when visiting mosques, the interpretation of religion is highly subjective (Giladi, 2014). Regarding the use of harsh disciplinary methods, various interpretations and schools of thought exist that attempt to justify such practices.

Furthermore, the Pakistani culture also follows the mindset that the head of the family” that is, “the father” has authority and control over the parenting of his child and, thus, the right to use whatever disciplinary method he believes is needed. The misuse of such “power” is frequently observed, where a parent displaces their frustrations or anger upon a neutral or vulnerable person that is, their child. Some parents might also believe that “tough parenting” will lead to the development of resilient traits in their children, justifying the association with the parenting style practiced by their own parents. Self-awareness and healthy processing of one’s own trauma can help eliminate the vicious cycle of passing on negative practices.

While numerous studies have proved the detrimental effects of child abuse on the growth and health of children, our study was different in the sense that it examined nonviolent, psychological, and physical aggression, further categorized according to the number of nonviolent and violent acts the child was exposed to. By adjusting for several covariates, we were able to improve the reliability and authenticity of our results, which allowed us to better understand the outcomes of various parenting techniques in the Pakistani population. Our results are robust and generalizable as the sample comprises of children belonging to different sociodemographic classes with urban/rural representation.

Limitations

The data collected by the MICS regarding the child discipline and child functioning module was reported by the caregivers themselves. This poses a problem, as it raises concern about the social desirability bias, in which, the parents would only answer in a way that would be considered suitable to the cultural norms of the society. Also, the gender of the parent/caregiver was not adjusted for which may have introduced bias. In addition, we realize that our results are based on data collected before the Covid-19 outbreak. Several significant changes occurred during and post-Covid-19 pandemic. Internationally, studies have reported higher levels of harsh parenting and lower parental tolerance for children’s disobedience since the COVID-19 Pandemic (Sari et al., 2022). High parental stress was also found to be associated with a poor parent-child relationship, which subsequently impacted child well-being (Chung et al., 2022). Although MICS Data from 2019 to 2020 is available online, we were not able to find any published reports. It may take some time for both the parents and the children to resume their full-time activities as before Covid-19.

Conclusion and Recommendations

In this study, we have highlighted a significant association between disciplinary methods and child functioning. Our research suggests that exposure to physical and psychological aggression leads to impaired cognition, self-care, and communication, whereas nonviolent disciplinary actions seem to improve the child’s functioning and behavior. We recommend that government-funded programs should be introduced to raise awareness and educate parents regarding the adverse effects of harsh parental disciplinary techniques on child health. A community-based approach targeting community elders, teachers, and mosque leaders is a practical solution for the Pakistani population. Nonviolent disciplinary actions should be set as the “ideal” means to promote discipline in children as they do so without harming the child’s functioning. Additionally, efforts should be made to promote “tool-kits” for parenting techniques that highlight the importance of positive disciplinary methods and the consequences of harsh disciplinary methods (Quail & Ward, 2020).

Given the limited number of child psychologists, there is an urgent need for accessible mental health services for both children and caregivers. Promoting online therapy sessions can also foster healthy communication practices among family members and encourage parents to adopt positive disciplinary methods. Despite some challenges, both public and private sector organizations are investing in digital health, signaling a promising future for telehealth in Pakistan (Kazi et al., 2020). A recent study in Bangladesh assessed the feasibility and effectiveness of the Family United (FU) Program. The study concluded that the program positively improved child mental health, resilience, parenting practices, and family adjustment skills (Haar et al., 2023). Online healthcare services, including therapy sessions and tele-mental health counseling, have gained widespread popularity (Nadeem et al., 2020). Online counselling emerges as a more convenient solution to address mental health issues in Pakistan for several reasons. Many children and adolescents find themselves in restrictive home environments, making online support groups a viable and cost-free option. Moreover, online counselling alleviates concerns related to commuting costs and time.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflict of interest with respect to the authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research and/or authorship of this article.

ORCID iDs

Zaibunnisa Kamran

Ambreen Kazi

Author Biographies

Zaibunnisa Kamran, MBBS, is a Final-year Medical Student at the Aga Khan University Hospital, Karachi, Pakistan. Her research interests include understanding and improving child psychological and mental health, specifically, in the Pakistani community. Furthermore, she is very passionate about developing and implementing public health policies for the protection of children against domestic abuse.

Ambreen Kazi, FCPS, is a Family Physician and a Public Health Researcher. She has a special interest in the mental and social health of women and children. Dr. Kazi has conducted research and published papers on the sexual and mental health of adolescents. She has authored the development of a stress scale for measuring the condition and relation related stressors amongst pregnant women. In addition, she has taken lead in conducting largescale research studies on women health in Riyadh, Saudi Arabia.

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Association Between Harsh Disciplinary Methods and Child Functioning in Children Aged 7–14 Years in Punjab,Pakistan

Abstract

Keywords

Introduction

Global and Local Prevalence

Factors and Consequences of Abuse

Pathophysiology Between Harsh Disciplinary Actions and Brain Development

Studies Reporting Harsh Disciplinary Actions

Studies Reporting Nonviolent Disciplinary Actions

Rationale

Methodology

Data

Measures

Statistical Analysis

Results

Sociodemographic Characteristics of Children

Proportion of Children Exposed to Various Disciplinary Actions

Proportion of Children with Functional Limitations

Association Between Disciplinary Actions and Child Functioning Domains

Discussion

Findings and Comparison with Other Studies

Policy Implications

Parenting Practices

Limitations

Conclusion and Recommendations

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iDs

Author Biographies

References