Children Physical Punishment - The perception of medical students

2013/2014 Tânia Marina Araújo Ferreira Children Physical Punishment - The perception of medical students março, 2014 Mestrado Integrado em Medicina Área: Medicina Legal Trabalho efetuado sob a Orientação de: Professora Doutora Teresa Magalhães Trabalho organizado de acordo com as normas da revista: Child Abuse & Neglect Tânia Marina Araújo Ferreira Children Physical Punishment - The perception of medical students março, 2014 1 Children Physical Punishment - The perception of medical students Authors’ names and institutional addresses: Tânia Ferreira1, Tânia Paias2,3, Cristina Silveira Ribeiro1,4,5, Teresa Magalhães1,4,5* 1Department of Legal Medicine and Forensic Sciences, Faculty of Medicine, University of Porto, Porto, Portugal 2 Faculty of Biology, University of Murcia, Spain 3Instituto Superior “Manuel Teixeira Gomes”, Portimão, Portugal 4National Institute of Legal Medicine and Forensic Sciences – North Branch, Porto, Portugal 5Forensic Sciences Center – CENCIFOR, Portugal. 6“Abel Salazar” Biomedical Sciences Institute, University of Porto, Porto, Portugal. *Corresponding author: Teresa Magalhães Email: [email protected] Department of Legal Medicine and Forensic Sciences, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro 4200-1319 Porto PORTUGAL Phone: +351 222073850 2 Abstract Objective: Physical punishment (PP) of children may constitute an abuse with severe consequences. Physicians have an important role in its detection, report and prevention. The aim of this study is to evaluate if medical students legitimate PP, and the influence that their personal past experience, certain personal features and training about violence and abuse during the medical course have on it. Methods: We applied a questionnaire to 502 medical students of the 1st and 6th years of the University of Porto - Portugal. It was constituted by 4 scales to evaluate the legitimization of PP, self-esteem, optimism/pessimism and social skills. Results: The PP legitimization totals mean score was 33.35 (range 14-70). PP was indifferent or accepted as an educational method by 37.2% of the students and 67.3% didn’t express opinion or disagreed that this practice should be legally repressed. Legitimization was higher in the 1st year when compared to the 6th (p=.006). Personal past experience, low self-esteem, low social skills and pessimism were positively correlated with legitimization of PP. Conclusion: Although the majority of the students seem to not legitimate PP, possibly representing a positive influence of the learning process during the course, it’s clear that a non-negligible number of them accept it or do not conceive any opinion. Thus, it will be necessary, during their medical training, to take into consideration the influence of the personal past experience as well as other personality features, highlighting the essential and privileged role of the physician in the prevention of child abuse. Keywords: Child abuse, Physical punishment, Legitimization, Medical students. 3 Introduction The choice of the best children educational method is a subject that concerns caregivers (namely parents) and causes big controversy even among scientific community (Donoso & Ricas, 2009). Physical punishment (PP) is one of the methods caregivers use to promote education and behaviour changes in children. It was defined by Straus (1994) as the “use of physical force with the intention of causing a child to experience pain but not injury for the purposes of correction or control of the child’s behaviour”. However, it is well known that some of these PP practices may cause physical injuries, mostly minor, but sometimes severe causing even death (Cavanagh, Dobash, & Dobash, 2007; Oates, 2011). Also it’s now fully accepted that PP does not bring benefits to children education (Ferguson, 2013), and can even generate adverse consequences, as behavioural and psychological harm (Gamez-Guadix, Straus, Carrobles, Munoz-Rivas, & Almendros, 2010; Gershoff, 2002). Therefore, there is increasing evidence that this method may consist in a sort of abuse, although sometimes it’s not understood as such. In fact, it is still a socially tolerated act, common among caregivers and associated to beliefs and other cultural aspects (Bell & Romano, 2012; Donoso & Ricas, 2009). The acceptance of this practice is often related to the fact that in most cases, there is no intention of hurting the child, but only the objective of punish/teach him/her (J. E. Durrant, 2008; Straus, 2000). Simultaneously, most cases of PP refer to demeanours which society consider as harmless (like spanking), or even as normal (Donoso & Ricas, 2009; Gracia & Herrero, 2008). According to Straus and Stewart (1999), in an American-population representative study, 94% of toddlers’ parents reported the use of PP in the 12 months previous to the time when questionnaire was applied. 4 In this perspective, there is a blurred line between PP and physical abuse (PA) (J. E. Durrant, 2008; Lansford & Dodge, 2008) which, in some cases, may be difficult to distinguish. In general, it is considered that a case of PP configures a PA when injuries result from it. However, we should be aware that PP (even without injuries) can also psychologically harm the child, which is an aspect that shouldn’t be slighted (Butchart, World Health Organization., & International Society for the Prevention of Child Abuse and Neglect., 2006; Gamez-Guadix et al., 2010). In fact, and given that almost 75% of PA cases are a consequence of PP, there´s an increasing concern to admonish this practice in order to prevent child abuse (J. Durrant et al., 2006; J. E. Durrant, 2008; Gracia & Herrero, 2008; Oates, 2011; Straus, 2000). In what the Portuguese population concerns, a retrospective study showed that 73% of parents experienced some kind of PA in their childhood (Figueiredo et al., 2004) and, according to another Portuguese study, 12.3% of parents admitted the use of some sort of PP in their children in the year previous to the study (Machado, Goncalves, Matos, & Dias, 2007). These aspects highlight the importance of helping caregivers that sometimes may be uninformed or may have doubts about the most suitable attitudes toward certain children behaviours (Keller & McDade, 2000). The relevance of the guidance given to caregivers by health professionals, mainly by paediatricians or general practitioners, is well documented. According to Taylor and collaborators (2013), paediatricians, in comparison with other professional groups, are the most commonly asked by parents in order to clarify what’s the most adequate educational approach, being their advices the most followed. In fact, an important way to promote the practice of most effective and less violent educational methods, like reasoning or removal of privileges and time-out, emerge from the intervention of health professionals, which should be informed in order to approach these questions in the best way 5 possible (J. E. Durrant, 2008; Knox, 2010). However, a questionnaire applied to United States American paediatricians revealed that they are not properly prepared to promote counselling about abuse prevention, since they have poor contact and training approaching this theme during the medical course (Borowsky & Ireland, 1999). According to a Tirosh study (Tirosh, Offer Shechter, Cohen, & Jaffe, 2003), more than 50% of paediatricians and general practitioners that were part of the studied sample approved the PP in several levels of severity, and in another study that included parents, paediatricians and medical students showed that approximately 56% of paediatricians and medical students believed that beating children is an acceptable way of educational discipline (Orhon, Ulukol, Bingoler, & Gulnar, 2006). These data reflect some of the gaps still existing among the medical community, where it’s necessary to intervene, instructing physicians and future physicians about appropriate discipline techniques, the discouragement of the PP, and how to detect and report PA (Tirosh et al., 2003; Trovão, 2012). Since medical students have big potential to intervene hereafter in the community and promote new strategies of violence detection and prevention, the goal of this study is to assess their degree of legitimization towards PP also studying the influence of their personal past experience, certain socio-demographic and personal features (e.g. self-esteem and social skills), and of the learning about violence and abuse during the medical course on that legitimization. Method Participants. This cross-sectional study was performed with medical students of the University of Porto - Portugal (Faculty of Medicine and “Abel Salazar” Biomedical Sciences Institute). There were included students of the 1st and 6th years, respectively the first and the last years of the medical course, with the goal of allowing the evaluation of the influence of 12 This evidence can conjoin with cultural question and even with personal experiences of these practices in the past since students can identify their personal upbringing with the less severe PP examples given and, in this way, not assume that certain behaviour was wrong. Also, it seems hard for students to judge their caregivers (mostly parents) and consequently who practice the PP, by having committed a violent act. These facts were observed in this study, since that, and as referred previously, 67.3% of the students didn’t support or have no opinion regarding the legal repression of PP, giving the idea that they really believe that a certain degree of punishment was useful on their education (Bell & Romano, 2012; Labbe et al., 2012) – although only 8.4% assumed it completely. In fact, the influence of past experiences in the validation of PP was also reassured by the statistically significant differences (p = .000) observed between the PP legitimization mean score and the answer’s groups to the question “When you were a child, physical punishment was a common practice and that practice showed to be important for my upbringing”. So, there was evidence that the past experiences truly influence the answers regarding this educational method. We found that a lower self-esteem, a lower social skills and a higher pessimism, evaluated by RSES, SSI and MOP Scale, respectively, were correlated with a greater legitimization of PP (p = .006; p = .047; p = .025, respectively). Another evidence concerns the fact that we found statistically significant differences between the 1st and the 6th years regarding PP legitimization: we globally observed a lower validation in the 6th year students, being this present in all the statistically significant affirmations (9 out of 14 affirmations). However, when we refer to RSES and SSI, only the first showed a statistically significant difference. Although there is scientific evidence that a lower self-esteem and anti-social attitudes, as well as a poor emotional and behavioural control are risk factors associated to abuse (Ateah, Secco, & Woodgate, 2003; Seng & Prinz, 2008; Straus, 1994), according to Stith and 13 collaborators (2009), self-esteem is related more with neglect than with PA. In this way, it’s valid to consider that the statistically significant difference for legitimization between the university level (1st/6th year) cannot be entirely explained by the difference found in selfesteem. It might be thought that in this case the medical school program on violence and abuse, during the 5th year, can have positively influenced the PP validation, leading to a lesser degree of legitimization. In spite of these general results, students seem to be still contradicting themselves in opinions given concerning PP, particularly when it comes to consider it an eventual crime. Although in Portugal PP is legally repressed since 2007, our study showed that only 32.7% of the sample answered that it should be legally repressed because it constitutes a violent act, but afterwards, only 5.2% considered that it should be a crime only if injuries come out of it and only 2.6% believed that it doesn’t cause psychological harm. Also, regarding shaken baby, approximately 26% totally disagreed or disagreed that the act of shaking violently a baby should be considered a crime, although 88.5% knew it can cause serious injuries. These results show us that there is still need for intervention in some professional groups – such as physicians - towards the prevention of acts of violence against children, namely concerning PP. Conclusions Results of this study allow us to conclude that: a. Globally, medical students of the University of Porto show a low degree of PP legitimization, although 37% hadn’t disagree with its practice; b. PP legitimization is less observed when we refer to apparently more severe punishment, for example, making use of objects; 14 c. Students of 6th year legitimate PP less than 1st year ones, supposedly due to the positive influence that specific information and adequate training on this subject can have; d. A higher legitimization of PP is linked with PP personal past experience and correlated with lower self-esteem, lower social skills and a higher pessimism scores; e. Approximately 67% of the students didn’t support or have no opinion regarding the legal repression of PP; f. 12% of this differentiated population (college students) doesn’t have a specific or consistent opinion about this topic. Although the majority of these future physicians doesn’t seem to legitimate PP, what might represent a positive influence of the learning process during the medical course, it’s clear that a non-negligible number of them accept it or don’t conceive any opinion. In future studies it will be necessary to ensure that the influence of the PP personal past experience and the existence of certain features of personality don’t contribute to a greater legitimization. Thereby, it’s important to approach these questions clarifying its definitions with practical examples of what PP and PA cases may be, as well as the physical and psychological harm that can arouse from them, highlighting the essential and privileged role of the physician in the detection, report and treatment of these cases. Integrity of research and reporting Ethical approval. It was ensured that personal information concerning students was protected, confidential and anonym in accordance with ethical rules. Ethical approval for the study was granted by the Ethics Committee of the Centro Hospitalar de São João. Funding. None declared. Conflict of interest. None. 15 References Ateah, C. A., Secco, M. L., & Woodgate, R. L. (2003). The risks and alternatives to physical punishment use with children. J Pediatr Health Care, 17(3), 126-132. Bell, T., & Romano, E. (2012). Opinions about child corporal punishment and influencing factors. J Interpers Violence, 27(11), 2208-2229. Borowsky, I. W., & Ireland, M. (1999). National survey of pediatricians' violence prevention counseling. Arch Pediatr Adolesc Med, 153(11), 1170-1176. Butchart, A., World Health Organization., & International Society for the Prevention of Child Abuse and Neglect. (2006). Preventing child maltreatment : a guide to taking action and generating evidence. Geneva: World Health Organization. Cavanagh, K., Dobash, R. E., & Dobash, R. P. (2007). The murder of children by fathers in the context of child abuse. Child Abuse Negl, 31(7), 731-746. Custódio, S., Pereira,A., Seco,G. (2010). Estudo de Adaptação e Validação das The Mehrabian Self-Esteem (MSE) And Optimism-Pessimism (MOP) Scales. Del-Prette, Z. A. P., Del-Prette,A. (2001). Inventário de Habilidades Sociais (IHSDel-Prette): Manual de aplicação, apuração e interpretação. Donoso, M. T., & Ricas, J. (2009). [Parent's perspective on child rearing and corporal punishment]. Rev Saude Publica, 43(1), 78-84. 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Machado, C., Goncalves, M., Matos, M., & Dias, A. R. (2007). Child and partner abuse: self-reported prevalence and attitudes in the north of Portugal. Child Abuse Negl, 31(6), 657-670. 17 Oates, K. (2011). Physical punishment of children: can we continue to accept the status quo? J Paediatr Child Health, 47(8), 505-507. Orhon, F. S., Ulukol, B., Bingoler, B., & Gulnar, S. B. (2006). Attitudes of Turkish parents, pediatric residents, and medical students toward child disciplinary practices. Child Abuse Negl, 30(10), 1081-1092. Santos, P. J. (2008). Validação da Rosenberg Self-Esteem Scale numa Amostra de Estudantes do Ensino Superior. On Avaliação Psicológica: Formas e Contextos. Braga: Psiquilíbrios Edições. Seng, A. C., & Prinz, R. J. (2008). Parents who abuse: what are they thinking? Clin Child Fam Psychol Rev, 11(4), 163-175. Stith, S. M., Liu, T., Davies, L. C., Boykin, E. L., Alder, M. C., Harris, J. M., Som, A., McPherson, M., & Dees, J. E. M. E. G. (2009). Risk factors in child maltreatment: A meta-analytic review of the literature. Aggression and Violent Behavior, 14(1), 13-29. Straus, M. A. (1994). Beating the devil out of them: Corporal punishment in American families. New York: Lexington Books. Straus, M. A. (2000). Corporal punishment and primary prevention of physical abuse. Child Abuse Negl, 24(9), 1109-1114. Straus, M. A., & Stewart, J. H. (1999). Corporal punishment by American parents: national data on prevalence, chronicity, severity, and duration, in relation to child and family characteristics. Clin Child Fam Psychol Rev, 2(2), 55-70. Taylor, C. A., Moeller, W., Hamvas, L., & Rice, J. C. (2013). Parents' professional sources of advice regarding child discipline and their use of corporal punishment. Clin Pediatr (Phila), 52(2), 147-155. Tirosh, E., Offer Shechter, S., Cohen, A., & Jaffe, M. (2003). Attitudes towards corporal punishment and reporting of abuse. Child Abuse Negl, 27(8), 929-937. 18 Trovão, J. N., Frazão,S., Magalhães,T. (2012). [Abuse against children. The physician's perception in the pediatric intervention]. Revista Portuguesa do Dano Corporal, 23, 161-173. 19 Tables Table1. Scales’ mean scores. Comparison between the 1st and 6th years. Year N Mean p PP Legitimization Scale (range 14-70) 1st 277 34.15 .006 6th 225 32.36 Total 502 33.35 Rosenberg Self-Esteem Scale (RSES) (range 4-40) 1st 277 31.84 .000 6th 225 33.52 Total 502 32.59 Mehrabian Scale Optimism (range 4-16) 1st 277 12.18 .643 6th 225 12.27 Total 502 12.22 Pessimism (range 4-16) 1st 277 9.57 .009 6th 225 9.22 Total 502 9.41 Social Skills Inventory (SSI) (range 4-28) 1st 277 20.10 .543 6th 225 20.34 Total 502 20.21 20 Table 2. Physical Punishment Legitimization. Comparison between the 1st and 6th years (%). Year TD1 D2 I3 A4 TA5 p It is acceptable to use physical violence as a form of selfdefense. 1st 26.7 41.5 13.4 15.9 2.5 .001 6th 38.2 42.7 6.2 12.4 0.4 Total 31.9 42.0 10.2 14.3 1.6 PP can be acceptable for educational purposes. 1st 27.8 31.0 16.2 22.0 2.9 .053 6th 35.6 32.0 11.6 18.2 2.7 Total 31.3 31.5 14.1 20.3 2.8 PP should legally repressed since it constitutes an act of violence. 1st 12.6 35.0 21.7 20.9 9.7 .256 6th 13.3 27.1 24.4 24.0 11.1 Total 12.9 31.5 22.9 22.3 10.4 Pinch, pulling ears or spanking are ways to educate children. Used at the right time show to have educational purposes. 1st 11.2 19.5 18.1 33.9 17.3 .010 6th 16.0 27.6 15.6 25.8 15.1 Total 13.3 23.1 16.9 30.3 16.3 The pedagogic snap is very positive. 1st 30.7 24.5 22.0 16.2 6.5 .000 6th 37.8 37.3 12.0 9.3 3.6 Total 33.9 30.3 17.5 13.1 5.2 There are children with the capacity to irritate the progenitors until exhaustion. Using objects to hit them - belt, wooden spoon - makes them suppress their behavior. 1st 62.5 22.4 7.9 6.1 1.1 .018 6th 68.4 24.4 3.6 3.1 0.4 Total 65.1 23.3 6.0 4.8 0.8 Shaking a baby violently, even though the goal is to calm him/her up, should be legally repressed. 1st 16.2 10.8 17.3 33.9 21.7 .004 6th 13.8 11.1 7.1 27.1 40.9 Total 15.1 11.0 12.7 30.9 30.3 Shaking a baby violently can result in serious damage. 1st 2.5 3.6 7.6 37.5 48.7 .001 6th 4.4 1.8 2.7 16.4 74.7 Total 3.4 2.8 5.4 28.1 60.4 Parents should decide on the best way to educate their children and PP is one of such forms. 1st 30.7 36.5 16.2 16.2 0.4 .135 6th 37.3 36.4 11.1 14.2 0.9 Total 33.7 36.5 13.9 15.3 0.6 Parents should use physical force on their children so that they learn how to respect adults. 1st 36.1 31.8 12.3 17.7 2.2 .023 6th 39.6 37.3 12.0 10.2 0.9 Total 37.6 34.3 12.2 14.3 1.6 Some problems associated with raising children cannot be addressed by means of dialogue. 1st 30.7 35.7 15.9 13.7 4.0 .052 6th 38.7 34.2 12.9 12.0 2.2 Total 34.3 35.1 14.5 12.9 3.2 PP should be legally repressed only if traumatic injuries result from it. 1st 54.9 29.2 9.0 6.9 0 .001 6th 69.8 23.1 4.0 1.8 1.3 Total 61.6 26.5 6.8 4.6 0.6 PP isn’t liable to cause psychological harm because its goal is good. 1st 54.9 32.1 9.4 3.2 0.4 .002 6th 66.7 27.6 4.4 0.9 0.4 Total 60.2 30.1 7.2 2.2 0.4 When I was a child, PP was a common practice and that practice showed to be important for my upbringing. 1st 49.8 26.0 14.8 8.7 0.7 .210 6th 53.3 28.0 11.6 6.2 0.9 Total 51.4 26.9 13.3 7.6 0.8 1Totally disagree; 2Disagree; 3Indifferent; 4Agree; 5Totally agree ANEXOS Essential title page information • Title. 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Authors are responsible for ensuring that manuscripts conform fully to the Publication Manual of the American Psychological Association (6th ed.), including not only reference style but also spelling (see, e.g., the hyphenation rules), word choice, grammar, tables, headings, etc. Spelling and punctuation should be in American English. AFTER ACCEPTANCE Use of the Digital Object Identifier The Digital Object Identifier (DOI) may be used to cite and link to electronic documents. The DOI consists of a unique alpha-numeric character string which is assigned to a document by the publisher upon the initial electronic publication. The assigned DOI never changes. Therefore, it is an ideal medium for citing a document, particularly 'Articles in press' because they have not yet received their full bibliographic information. Example of a correctly given DOI (in URL format; here an article in the journal Physics Letters B): http://dx.doi.org/10.1016/j.physletb.2010.09.059 When you use a DOI to create links to documents on the web, the DOIs are guaranteed never to change. Proofs One set of page proofs (as PDF files) will be sent by e-mail to the corresponding author (if we do not have an e-mail address then paper proofs will be sent by post) or, a link will be provided in the e-mail so that authors can download the files themselves. Elsevier now provides authors with PDF proofs which can be annotated; for this you will need to download Adobe Reader version 9 (or higher) available free from http://get.adobe.com/reader. Instructions on how to annotate PDF files will accompany the proofs (also given online). The exact system requirements are given at the Adobe site: http://www.adobe.com/products/reader/tech-specs.html. 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