Preschoolers and kindergarten-age children (three years to five years)

At three years to five years of age, most children are able to accept reality and limitations, act in
ways to obtain others’ approval, and be self-reliant for their immediate needs. However, they
have not internalized many rules, are gullible, and their judgment is not always sound. They
require good behavioural models after which to pattern their own behaviour. The consistency
should apply not only in the rules and actions of the primary caregiver, but in other adults who
care for the child.
Reliance on verbal rules increases, but still the child requires supervision to carry through
directions and for safety. Time-out can be used if the child loses control. Redirection or small
consequences related to and immediately following the misbehaviour are other alternatives.
Approval and praise are the most powerful motivators for good behaviour. Lectures do not work
well and some consider them to be counterproductive.
Example: The preschooler draws on the wall with crayons. Use time-out to allow him to think
about the misbehaviour. Consider using also logical consequences, eg, take the crayons away and
let the child clean up the mess to teach accountability.

School-age children (six years to 12 years)

The child’s increasing independence may lead to conflicts. School-age children tend to act
autonomously, choose their own activities and friends, and, to some extent, recognize other than
parental authority. Parents should continue to supervise, provide good behavioural models, set
rules consistently, but also allow the child to become increasingly autonomous. Parents should
continue to make the important decisions because school-age children cannot always put
reasoning and judgment into practice.
Praise and approval should be used liberally, although not excessively, to encourage good
behaviour and growth into a more mature human being. The use of appropriate motivators
should be encouraged; for example, buy a keen reader his or her favourite book.
Acceptable means of discipline include withdrawal or delay of privileges, consequences and
time-out.
Example: The child destroys toys. Instead of replacing these toys, let the child learn the logical
consequences. Destroying toys will result in no toys to play with.

Adolescents (13 years to 18 years)

Conflicts frequently ensue because the adolescent adheres increasingly to the peer group,
challenges family values and rules, and distances himself from the parents. Parents can meet
these challenges by remaining available, setting rules in a noncritical way, not belittling the
adolescent, and avoiding lectures or predicting catastrophes. Contracting with the adolescent is
also a useful tool. Disciplinary spanking of adolescents is most inappropriate.
Despite their challenging attitudes and professions of independence, many adolescents do want
parental guidance and approval. Parents should ensure that the basic rules are followed and that
logical consequences are set and kept in a nonconfrontational way.
Example: The adolescent defiantly takes the car and has an accident. The logical consequence
would be that there is no car to drive and that the teenager has to help pay for the repairs. This
teaches accountability.
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SETTING RULES AND APPLYING CONSEQUENCES

Rules are established for children so they can learn to live cooperatively with others, to teach
them to distinguish right from wrong, and to protect them from harm. Children raised without
reasonable limits will have difficulty adjusting socially. The following are some ways that
parents can use rules and limits to promote effective discipline:
 Reinforce desirable behaviour. Praise positive behaviour and “catch children being
good”.
 Avoid nagging and making threats without consequences. The latter may even encourage
the undesired behaviour.
 Apply rules consistently.
 Ignore unimportant and irrelevant behaviour, eg, swinging legs while sitting.
 Set reasonable and consistent limits. Consequences need to be realistic. For example,
grounding for a month may not be feasible.
 State acceptable and appropriate behaviour that is attainable.
 Prioritize rules. Give top priority to safety, then to correcting behaviour that harms people
and property, and then to behaviour such as whining, temper tantrums and interrupting.
Concentrate on two or three rules at first.
 Know and accept age-appropriate behaviour. Accidentally spilling a glass of water is
normal behaviour for a toddler. It is not willful defiance. On the other hand, a child who
refuses to wear a bicycle helmet after repeated warnings is being willfully defiant.
 Allow for the child’s temperament and individuality (goodness of fit). A strong-willed
child needs to be raised differently from the so-called ‘compliant child’.
In applying consequences, these suggestions may be helpful:
 Apply consequences as soon as possible.
 Do not enter into arguments with the child during the correction process.
 Make the consequences brief. For example, time-out (see Forms of discipline) should last
one minute per year of the child’s age, to a maximum of five minutes.
  Parents should mean what they say and say it without shouting at the child. Verbal abuse
is no less damaging than physical punishment.
 Follow consequences with love and trust, and ensure that the child knows the correction
is directed against the behaviour and not the person. Guard against humiliating the child.
Model forgiveness and avoid bringing up past mistakes.
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FORMS OF DISCIPLINE
Three forms of discipline, in particular, are discussed in the current scientific literature:
 time-out;
 reasoning, or away-from-the-moment discussions; and
 disciplinary spanking.

Time-out
Time-out is one of the most effective disciplinary techniques available to parents of young
children, aged two years through primary school years (5). The time-out strategy is effective
because it keeps the child from receiving attention that may inadvertently reinforce inappropriate
behaviour. Like any other procedure, time-out must be used correctly to be effective. It must be
used unemotionally and consistently every time the child misbehaves. Research on why time-out
works effectively has been published in detail (2–5). How time-out is initiated is important, as is
what the child does during this time, how time-out is terminated, and what the parent does when
it is over.
Some suggestions for parents on effective time-out include the following:
 Introduce time-out by 24 months.
 Pick the right place. Be sure the time-out place does not have built-in rewards. The
television should not be on during time-out.
 Time-out should last 1 min per year of the child’s age, to a maximum of 5 min.
 Prepare the child by briefly helping him or her connect the behaviour with the time-out.
A simple phrase, such as “no hitting,” is enough.
 Parents should avoid using time-out for teaching or preaching. When the child is in time-
out, he should be ignored.
 The parent should be the time keeper.
 After time-out is over, it is over. Create a fresh start by offering a new activity. Don’t
discuss the unwanted behaviour. Just move on.
As with other disciplinary techniques, parents should refrain from hurting the child’s self-esteem
by instilling shame, guilt, loss of trust or a sense of abandonment.
If used properly, time-out will work over time. It may not necessarily eliminate the unwanted
behaviour, but it will decrease the frequency. If time-out does not work after repeated tries, a
consult is recommended.
Parents should be advised that these general guidelines may need to be adjusted to suit the
particular temperament of the child. Parents may have to experiment with the length of time-out,
because 1 min per year of age may be too long for some children.
Physicians may want to have a handout available that teaches parents how to use time-out
procedures correctly according to the child’s age, personality, level of development, and so on.

Reasoning or away-from-the-moment discussions

Discipline involves teaching positive behaviour as well as changing unwanted behaviour. That is,
children need to know what to do as well as what not to do. In general, it is more effective to
anticipate and prevent undesirable behaviour than to punish it. ‘Away from the moment’ refers to
dealing with the difficult behaviour not in the heat of the moment, but rather in advance or away
from the actual misbehaviour. An away-from-the-moment discussion can help prevent
undesirable behaviour by giving parents the opportunity to teach the child the desirable
behaviour in advance. This technique is not appropriate for use in children younger than three
years to four years of age (6).

Disciplinary spanking
The Psychosocial Paediatrics Committee of the Canadian Paediatric Society has carefully
reviewed the available research in the controversial area of disciplinary spanking (7–15). The
existing research is not in the form of double-blind, randomized controlled trials, as such studies
would be impossible to conduct. Moreover, no modern ethics committee is likely to approve
research that involves violence against children. The research that is available supports the
position that spanking and other forms of physical punishment are associated with negative child
outcomes.
The Canadian Paediatric Society, therefore, recommends that physicians strongly discourage
disciplinary spanking and all other forms of physical punishment. Physical redirection or
restraint to support time-out or to prevent a child from harming himself or others may be
necessary, but should be done carefully and without violence.
Physical harm to a child inflicted by a parent out of control and in a rage is completely
inappropriate and dangerous. During periods of anticipatory guidance on appropriate discipline,
physicians should also remind parents to take a time-out for themselves before they lose control.
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SUMMARY
Discipline is about changing behaviour, not about punishing children. Discipline allows children
to develop self-discipline, and helps them become emotionally and socially mature adults. There
are many effective techniques that can help parents teach and guide their children, and some
forms of discipline will always remain controversial.
The physician’s role is to take an anticipatory approach to discipline, which involves asking
questions about techniques used in the home. Physicians should actively counsel parents about
discipline and specifically discourage all forms of physical punishment, including the use of
spanking.
The physician, while taking a complete psychosocial history, should include a discussion on
effective means of discipline. A balanced view should be offered to families. The physician
should be an advocate for the child as well as a resource for the parent in offering counselling
and anticipatory guidance. Inappropriate forms of discipline should be identified and corrected.
Special attention should be given to the child’s age, level of development and temperament when
giving advice on effective means of discipline.
Consideration should be given to cultural differences, and adjustments should be made for a
developmentally challenged child. It is essential to emphasize to parents the importance of being
consistent, being a good role model and avoiding empty threats, ie, not following through with
consequences.
Effective discipline should be based on academic facts rather than subjective opinion. The
conclusions and recommendations in this statement should, therefore, be viewed as subject to
revision and clarification as data continue to accumulate.
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Footnotes
PSYCHOSOCIAL PAEDIATRICS COMMITTEE (2003–2004)

Members: Drs Kim Burrows, Kelowna, British Columbia; Anthony Ford-Jones, The Burlington
Professional Centre, Burlington, Ontario; Gilles Fortin, Hôpital Sainte-Justine, Montreal, Quebec; Sally
Longstaffe, Children’s Hospital, Winnipeg, Manitoba (chair); Theodore Prince, Calgary, Alberta; Sarah
Shea, IWK Health Centre, Halifax, Nova Scotia (board representative)

Liaisons: Drs Jane Foy, Wake Forest University School of Medicine, Winston-Salem, North Carolina,
USA (Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics);
Rose Geist, The Hospital for Sick Children, Toronto, Ontario (Canadian Academy of Child Psychiatry);
Anton Miller, Sunny Hill Health Centre for Children, Toronto, Ontario (Developmental Paediatrics Section,
Canadian Paediatric Society)

Principal authors: Drs Peter Nieman, Calgary, Alberta; Sarah Shea, IWK Health Centre, Halifax, Nova
Scotia

The recommendations in this statement do not indicate an exclusive course of treatment or procedure to
be followed. Variations, taking into account individual circumstances, may be appropriate.

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