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Physical punishment and child outcomes: a narrative review of
prospective studies
Anja Heilmann,
Department of Epidemiology and Public Health, University College London, London, UK
Anita Mehay,
Department of Epidemiology and Public Health, University College London, London, UK
Richard G Watt,
Department of Epidemiology and Public Health, University College London, London, UK
Yvonne Kelly,
Department of Epidemiology and Public Health, University College London, London, UK
Joan E Durrant,
Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
Jillian van Turnhout,
Royal College of Physicians of Ireland, Faculty of Paediatrics, Dublin, Ireland
Elizabeth T Gershoff
Population Research Center and Department of Human Development and Family Sciences,
University of Texas at Austin, Austin, TX, USA
Abstract
Physical punishment is increasingly viewed as a form of violence that harms children. This
narrative review summarises the findings of 69 prospective longitudinal studies to inform
practitioners and policy makers about physical punishment’s outcomes. Our review identified
seven key themes. First, physical punishment consistently predicts increases in child behaviour
problems over time. Second, physical punishment is not associated with positive outcomes over
time. Third, physical punishment increases the risk of involvement with child protective services.
Fourth, the only evidence of children eliciting physical punishment is for externalising behaviour.
Fifth, physical punishment predicts worsening behaviour over time in quasi-experimental studies.
Sixth, associations between physical punishment and detrimental child outcomes are robust across
child and parent characteristics. Finally, there is some evidence of a dose–response relationship.
Correspondence to: Dr Anja Heilmann, Department of Epidemiology and Public Health, University College London, London WC1E
6BT, UK anja.heilmann@ucl.ac.uk.
Contributors
AH, RGW, and YK conceived of the study; all authors contributed to its design. AH and AM searched the literature, selected papers
for inclusion in the review, and extracted the data. AH, AM, RGW, and ETG interpreted the results and drafted the report. All authors
commented on and revised the report and approved the final version.
Declaration of interests
We declare no competing interests.
See Online for appendix
HHS Public Access
Author manuscript
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. Author manuscript; available in PMC 2022 January 24.
Published in final edited form as:
Lancet
. 2021 July 24; 398(10297): 355–364. doi:10.1016/S0140-6736(21)00582-1.
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The consistency of these findings indicates that physical punishment is harmful to children and
that policy remedies are warranted.
Introduction
The WHO–UNICEF-
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Commission1 on children has highlighted social, economic,
commercial, and environmental threats to child health and has called for urgent government
action to ensure that children grow up in safe and healthy environments. Yet the home
environments of most children worldwide are not safe because they include physical
punishment. The UN Committee on the Rights of the Child has definitively stated that
physical punishment is a form of violence that violates children’s rights to protection,
dignity, and physical security.2 The UN General Assembly has included the protection
of children from all forms of violence as Sustainable Development Goal 16.2.3 Such
human rights arguments, along with an aligned body of research indicating that physical
punishment is harmful to children,4–6 have led to a growing consensus among health
professionals that physical punishment of children is detrimental and ineffective,7–9 and
have led 62 countries to prohibit physical punishment of children in all settings and a further
27 countries to commit to doing so.10
Most of the world’s children live in countries where physical punishment is allowed by
law; as a result, 63% of children aged 2–4 years—250 million children—are regularly
subjected to physical punishment by their caregivers.11 The continued prevalence of physical
punishment suggests that parents are not receiving, or not believing, the message that it is
both ineffective and potentially harmful to their children’s health and development. This
lack of knowledge could be because the research to date is summarised in hundreds of
specialist research studies or in detailed meta-analyses5,12–14 that are not easily accessible
to health professionals whom parents consult for advice about discipline.15 Furthermore,
most countries have not prohibited physical punishment in homes or schools, or both.
Policy makers might not be aware of the strength of the research evidence against physical
punishment or of the likelihood that legislating against physical punishment would prevent
harm to children.
The purpose of this narrative review is thus to summarise the past two decades of research
on physical punishment in a format that is accessible to policy makers, community leaders,
and practitioners. Although psychological punishments such as yelling, humiliating, or
shaming children are also prevalent around the world11 and are harmful to children,16 we
focused our review on physical punishment in response to growing interest around the world
in legislating against its use.
Three strategic decisions guided our review. First, we began our review with studies
published in 2002, the year that the first comprehensive meta-analysis of research into
physical punishment was published.12 Second, we included only studies that examined
physical punishment specifically and excluded studies of severe assaults against children.
Third, we restricted our review to longitudinal studies that followed up children
prospectively and took initial levels of the outcome into account, thereby meeting the
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minimum criterion for causality that physical punishment must precede the measured
outcome in time and addressing concerns regarding the possibility of reverse causality.17
Findings
The database searches identified 3855 unduplicated records, of which 2198 were excluded
after initial title screening. An additional five studies were identified through Web of Science
search alerts and expert communication. After two independent reviewers assessed 1303
abstracts and 359 full texts, they identified 68 articles describing 69 studies (one article
reported on two samples) that met the inclusion criteria. These were retained for review
(figure).
The field is heavily dominated by research from the USA (60 articles), including a large
number of studies that used the same datasets—eg, 23 studies used the Fragile Families
and Child Wellbeing Study (FFCWS), and eight used the National Longitudinal Survey of
Youth (NLSY). The remaining eight studies came from Canada, China, Colombia, Greece,
Japan, Switzerland, Turkey, and the UK. No non-English studies met the inclusion criteria.
Characteristics of included studies are provided in the appendix pp 2–11.
We describe outcome measures using the terminology adopted by authors of the
original research. We grouped studies into nine broad categories: externalising behaviours
(behavioural difficulties that manifest outwardly and refer to acts towards the external
environment that violate social norms or are harmful to others, or both),18,19 internalising
behaviours (behaviours that are directed inwards, including symptoms of anxiety
and depression, withdrawal, fearfulness, and somatic complaints),18,19 total behaviour
difficulties (composite measures of both externalising and internalising), prosocial
behaviours, inattention or symptoms of attention-deficit hyperactivity disorder (ADHD),
cognitive abilities, interpersonal relationships, stress reactivity, and involvement with child
protective services (CPS).
The table presents an overview of the included studies. Many studies examined more than
one outcome, such that 98 effect sizes were presented across the studies. Additionally, some
outcomes were examined multiple times with the same dataset; to ensure the independence
of the findings within each outcome category, each dataset was counted only once per
outcome. When multiple studies from the same dataset had discrepant findings, the majority
finding was coded. For example, of the three studies that used data from the FFCWS to
examine cognitive abilities, one found a detrimental effect and two found no significant
association; the FFCWS was counted only once in the table in the row for cognitive abilities
as having no association. With each independent dataset counted once only per outcome, the
total number of effect sizes was 64.
Physical punishment was significantly (p<0.05) associated with worse outcomes over time
in 38 independent samples (59%). No significant associations were found in 15 independent
samples (23%). None of the studies reported main effects of beneficial child outcomes
associated with physical punishment. Mixed findings across studies using the same dataset
were found for 11 independent samples (17%); however, it is important to note that
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associations between physical punishment and beneficial outcomes were not found as main
effects for any study and were only found in four subgroups across all of the studies
examined (appendix p 2).
Externalising behaviours
Externalising behaviours were by far the most studied outcomes. 38 of 55 (69%) studies
used advanced statistical methods, including structural equation models, fixed effects
models, growth curve models, and propensity score matching. Almost all adjusted for a wide
range of covariates. Some studies examined the broad category of externalising behaviours
whereas others examined subcategories, such as aggression.
Externalising behaviour, typically measured with standardised questionnaires such as the
Achenbach Child Behavior Checklist,34 was the outcome in 27 studies from 19 independent
samples with follow-up periods of up to 12 years. These included five studies using
FFCWS data,35–39 two using the US Early Childhood Longitudinal Study–Kindergarten
Class of 1998–1999 (ECLS-K),40,41 and three using data from the US Child Development
Project.42–44 Apart from one Chinese,20 one Greek,22 and one Turkish45 study, all research
into externalising behaviour was from the USA.
In 13 of the 19 independent samples, physical punishment was associated with increases
in externalising behaviour over time.27,35–43,45–53 In three independent samples, no
associations were identified.44,54–56 Mixed findings were reported in another three
independent samples.20–22
Children’s aggressive behaviour was assessed in 20 studies and six independent samples.
Most were undertaken in early childhood. In five of the six samples, physical punishment
predicted increases in aggressive behaviour over time. 15 studies used FFCWS data with
consistent findings of detrimental effects of physical punishment across different analytical
methods and age groups.57–71 Associations with increases in aggressive behaviours were
observed in four of the remaining five independent samples, including in Canada,72
Switzerland,73 and the USA.30,74 Only one study found no association between physical
punishment and aggressive behaviour.75
Antisocial behaviour and conduct problems were assessed in eight studies from five
independent samples. Follow-up periods ranged from 2 to 12 years. Four studies analysed
NLSY data, with conflicting results: physical punishment predicted increases in antisocial
behaviour in two studies,23,24 whereas the other two studies found no associations.25,26
The remaining four studies on independent samples found associations between physical
punishment and increases in antisocial behaviour,76 conduct problems,72,77 and oppositional
defiant disorder symptoms.78
Internalising behaviours
Internalising behaviour was the outcome in 15 studies from ten independent samples.
Apart from one study that measured depressive symptoms,77 all studies reported on an
overall measure of internalising behaviour symptoms. Six studies analysed data from the
FFCWS.38,39,59,64,66,67 Most studies were undertaken in early childhood, although some
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followed up children into early adolescence. Overall, the findings were mixed. Physical
punishment predicted increases in internalising behaviour over time in five of the ten
independent samples, including all six studies using FFCWS data.38,39,52,53,59,64,66,67,76,77
Three independent studies found no associations.47,54,55 One study reported mixed findings
from subgroup analyses,22 and another reported beneficial associations from age 3 years
to 5 years but detrimental associations for physical punishment at age 5 years predicting
internalising outcomes in middle childhood (age 9 years).27
Total behaviour problems
Six studies from five independent samples examined total behaviour problems, a
combination of internalising and externalising behaviours.28,29,31,79–81 All were undertaken
with young children, with a baseline age of 2–4 years and follow-up periods of 2–6
years. Physical punishment was related to increased behaviour problems over time in four
independent samples.31,79,80,81 The fifth sample was the NLSY; of the two studies using this
dataset, one found that physical punishment predicted increased behaviour problems over
time28 and the other reported mixed findings.29
Prosocial behaviour or social competence
None of the five included studies on prosocial behaviour or social competence found any
evidence that physical punishment affected these outcomes.30,53,55,57,72
Inattention and ADHD
Physical punishment was unrelated to later inattention in a sample from the US Head Start
Impact study.30 However, data from the ECLS-K suggested that physical punishment at 5
years of age increased the risk of both moderate and severe symptoms of ADHD and the risk
of severe symptoms of ADHD-conduct disorder 8 years later.82
Cognitive abilities
Cognitive abilities were assessed in eight studies using data from six independent
samples.30–32,36,37,67,83,84 Outcomes included children’s vocabulary, literacy, reading and
mathematics skills, school readiness, school engagement, and approaches to learning.
Findings were highly heterogeneous. Two independent studies showed that physical
punishment was associated with poorer cognitive abilities in early childhood.83,84 Of three
analyses of FFCWS data that used the same vocabulary test but at different ages and with
different follow-up periods, only one found an association between physical punishment and
lower vocabulary scores,36 whereas the other two studies did not.37,67 Three studies reported
mixed results with detrimental effects for some but not all cognitive outcomes.30–32 One
study reported associations with better cognitive performance but weaker school engagement
in middle childhood and adolescence.32
Interpersonal relationships
Cross-lagged path models showed reciprocal associations between physical punishment and
the parent–child relationship: physical punishment at 36 months was associated with lower
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quality of observed parent–child interaction 1·5 years later, and better interaction quality at
36 months was associated with less physical punishment over time.51
Peer isolation among young children (such as having nobody to talk to at school) was
assessed in a study using the National Survey of Child and Adolescent Well-Being and was
unrelated to physical punishment.32
Data from an evaluation of a US dating violence prevention programme found mixed
results, with no overall associations between child-reported physical punishment at age 14
years and self-reported initiation of dating violence assessed 7 and 19 months later for
the subsample of single mothers. However, the study found a detrimental association for
physical punishment by married mothers and a non-significant association between physical
punishment by married fathers and dating violence.33
Stress reactivity
One small US study measured physical punishment at 1 year of age and children’s cortisol
production during a laboratory visit between ages 1 and 2 years, after exposure to a stressful
situation (introducing a stranger and separating the child from the mother).85 A higher
frequency of physical punishment at 1 year of age predicted increased cortisol levels post
separation after controlling for baseline cortisol, indicating a heightened stress response.85
Involvement with CPS
When a family reports that they are involved with CPS, such involvement is typically
an indication of suspected child maltreatment. Three US studies assessed associations
between physical punishment in early childhood and subsequent involvement with CPS
for suspected child abuse or neglect. We did not require that a study controlled for previous
maltreatment or involvement with CPS because we would not expect reciprocal associations
between physical punishment and CPS involvement. Additionally, we felt that any future
maltreatment was of concern, regardless of whether it had happened in the past. In fact, one
of the studies did control for previous CPS involvement,86 whereas two studies using data
from the FFCWS did not.87,88 In both samples, physical punishment increased the risk of
subsequent CPS involvement87,88 and of CPS-reported neglect after controlling for previous
CPS involvement.86
Thematic overview
We identified seven themes from our review of the longitudinal research into physical
punishment and change in children’s outcomes over time.
Theme 1: physical punishment consistently predicts child behaviour problems over time
Physical punishment is commonly believed to be an effective method to improve child
behaviour. However, the overwhelming conclusion from the studies that we examined is that
physical punishment predicts an increase in behaviour problems over time. This finding is
consistent with three meta-analyses that have found parents’ use of physical punishment
to be associated with increased child behaviour problems, including aggression.5,12,14
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Therefore, physical punishment is ineffective in achieving parents’ goal of improving
child behaviour and instead appears to have the opposite effect of increasing unwanted
behaviours.
Theme 2: physical punishment is not associated with positive outcomes over time
Few studies of outcomes other than behaviour problems met our strict criteria in that
they examined potential outcomes of physical punishment prospectively while accounting
for initial levels of the child outcome. The results were largely mixed between findings
of detriments and findings of no association; across these studies, there was no evidence
of associations with positive outcomes related to children’s attention,30,82 cognitive
abilities,30–32,36,37,67,83,84 relationships with others,32,33,51 or stress reactivity.85 Physical
punishment also does not predict improvements in children’s prosocial behavior or social
competence over time.30,53,55,57,72
Theme 3: physical punishment increases the risk of child maltreatment
Three studies from two independent datasets, one of which took into account previous
involvement with CPS,86–88 found that parents who used physical punishment were at
heightened risk of perpetrating maltreatment that would trigger CPS involvement. This
finding is consistent with previous meta-analyses that have found physical punishment to
be significantly associated with higher risk of maltreatment,5,12 and with the finding from
a study of Canadian CPS records, not included in our narrative review, that 75% of cases
of substantiated incidents of physical abuse occur in the context of punishment.89 Taken
together, these findings indicate that physical punishment is linked with an increased risk of
maltreatment. They also call into question the arbitrary distinction between acceptable and
non-acceptable violence towards children.
Theme 4: the only evidence of children’s behaviour eliciting physical punishment is for
externalising behaviour
A criticism of past research into physical punishment is that cross-sectional studies
cannot determine whether physical punishment causes behaviour problems, in part
because observed correlations could reflect reverse causality—namely, children’s behaviour
problems eliciting physical punishment. We addressed this concern by including in our
review only prospective longitudinal studies that included initial levels of a child’s
behaviour; doing so allows us to be certain that we are examining whether physical
punishment predicts a change in children’s behaviour over and above their initial behaviour.
In addition, 15 studies in our review used a cross-lagged panel design, which
simultaneously models both the longitudinal association between physical punishment
and child behaviour as well as the association between initial child behaviour
and parents’ use of physical punishment at a subsequent wave. In the six studies
with independent samples,27,40,45,46,51,77 and the nine studies using data from the
FFCWS,35,57,59,60,62,63,67,70,71 physical punishment consistently predicted worsening
externalising behaviour problems over time, even after accounting for the tendency of
externalising behaviour to elicit physical punishment.
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In contrast, studies that used cross-lagged models to examine associations between physical
punishment and internalising behaviour found no evidence that internalising elicited
more physical punishment over time.59,67 Similarly, no reciprocal effects were found for
children’s social competence57 or for children’s vocabulary scores.67 The lack of evidence
of a child elicitation effect for these outcomes indicates there is little evidence of potential
reverse causation for outcomes other than externalising behaviour problems.
Theme 5: physical punishment is linked with worsening behaviour over time in studies
using quasi-experimental methods
The primary criticism of empirical studies of physical punishment is that they are largely
non-experimental, given that random assignment of children to a physical punishment
condition would be unethical, and thus cannot rule out other potential explanatory factors.41
However, several of the studies in our review used methodological designs that help to rule
out other potential explanations and thereby increase our confidence that the findings are
consistent with a causal conclusion.
Three studies created quasi-experimental comparisons through propensity score matching
(PSM), which matches children on a range of individual and family background
characteristics so that the only observed difference between them is whether they
experienced physical punishment. Using PSM with data from the US ECLSK study (12
112 families), one study found that children who were physically punished increased their
externalising behaviour from age 5–8 years significantly more than did those who had not
been physically punished.41 A second study from Japan (29 182 families) used PSM to
determine that children who were physically punished exhibited more behaviour problems
over time than did their peers who were not.80 The third study, based in Colombia (1167
families), found that young children who were physically punished gained fewer cognitive
skills than did those who were not physically punished.83 The fact that these studies using
rigorous statistical methods with large samples from three different countries all found that
physical punishment predicted poorer outcomes over time lends considerable credence to the
conclusion that physical punishment is harmful to children’s development.
A second method of ruling out alternative explanations is fixed effects regression, which
uses difference scores for both predictor and outcome to control for time invariant
unobserved characteristics that could account for associations between physical punishment
and child outcomes. Two studies in our review used this method. One used data from
the NLSY to find that increases in physical punishment predicted increases in children’s
externalising behaviours.47 The other used fixed effects regressions with data from the
FFCWS and found that physical punishment predicted increases in child aggressive
behaviour.65
Finally, two studies in our review used data from randomised controlled trials of
interventions that reduced physical punishment; although the physical punishment was not
randomly assigned, the experimentally induced reductions in physical punishment predicted
improvements in children’s problem behaviours over time.30,48
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Theme 6: the associations of physical punishment with increases in detrimental child
outcomes are robust across child and parent characteristics
Many of the studies in our review considered whether the associations between physical
punishment and child outcomes might vary by characteristics of the child or parent. We
highlight the findings for the most commonly considered modifiers: sex of the child, race or
ethnicity, and parenting style.
With regard to the sex of the child, studies with four independent samples in the USA
found no modification of the link between physical punishment and increased behaviour
problems.35,37,42,74 Two US studies found a stronger association with problem behaviours
for boys than girls,24,69 whereas a Chinese study reported an association with externalising
behaviours for girls but not boys.20 A study in Canada found no modification by child
sex for the outcome of child aggression or conduct problems, but did find that physical
punishment was linked with improved prosocial behaviour, but only for girls.72 In a national
study in Greece, physical punishment predicted more externalising behaviours for boys but
fewer externalising or internalising behaviours for girls.22 Most of these studies thus found
physical punishment to be linked with increased problem behaviour for both boys and girls,
with differences only in the strength of the association.
Previous research has argued that the effects of physical punishment might vary on the basis
of the acceptance of physical punishment by the family’s culture, an argument referred to
as cultural normativeness theory.90 Several of the studies we reviewed accordingly tested
for effect modification by a family’s race or ethnicity. However, no modification of the
link to increased externalising behaviour was found in the ECLSK,40,82 the FFCWS,35,70
or five other independent samples.27,42,52,56,77 Findings with the NLSY for child behaviour
problems were mixed, with some finding modification by race or ethnicity26,29 but others
finding no modification.23,24,28
Another study with data from the NLSY found no modification by race or ethnicity for
achievement in mathematics or reading ability.84 Three studies did find modification, but not
in the direction predicted by cultural normativeness theory.27,33,50 Overall, these US-based
studies provided no support for the notion that the associations of physical punishment with
child outcomes are modified by the race or ethnicity of the child.
Some have argued that any negative effects of physical punishment are buffered when
parents have an overall positive parenting style. One study using data from the NLSY
did find evidence of a buffering effect of responsiveness for the link between physical
punishment and behaviour problems,28 but another study that used data from NLSY
found neither responsiveness nor cognitive stimulation buffered the links between physical
punishment and worse achievement in reading ability and mathematics.84 Three other
studies found that parental warmth did not buffer the effect of physical punishment on
an increase in behaviour problems.60,74,77 There is thus little evidence that parenting style
modifies the associations between physical punishment and detrimental child outcomes.
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Theme 7: physical punishment shows a dose–response relationship with some child
outcomes
Seven studies measured the relationship between frequency of physical punishment and
level of the outcome variable. Five of these studies found evidence of a dose–response
effect—ie, the magnitude of the effect varied with the frequency of the punishment. Three
studies using data from the FFCWS found that the association with child aggression
became stronger as the frequency of physical punishment increased.37,61,64 Two studies
used data from the NLSY, one of which did not find a dose–response effect for antisocial
behaviour (both one instance and two or more instances of physical punishment predicted
antisocial behaviour).23 The other study found that the association with lower achievement
in mathematics and reading ability became stronger as the frequency of physical punishment
increased.84 Such findings of dose–response associations between physical punishment and
increases in detrimental child outcomes over time are indicative of a causal relationship as
per Hill’s criteria for establishing causality.17,91
Limitations
The purpose of this narrative review was to summarise and interpret the extant research
on physical punishment from prospective studies. Because it is not a meta-analysis or
systematic review, this narrative review does not take into account the number of participants
in a study or the magnitude of effect sizes. The vast majority of studies that met our
selection criteria were undertaken in the USA; only eight studies were from other countries
(one each from Canada,72 China,20 Colombia,83 Greece,22 Japan,80 Switzerland,73 Turkey,45
and the UK81). More research is needed in countries outside the USA, and in low-income
and middle-income countries in particular.
Implications for policy
The evidence is consistent and robust: physical punishment does not predict improvements
in child behaviour and instead predicts deterioration in child behaviour and increased risk
for maltreatment. There is thus no empirical reason for parents to continue to use physical
punishment. Moreover, the UN Committee on the Rights of the Child has explicitly stated
that physical punishment is a violation of a child’s right to protection and should be
prohibited.2
So far, 62 of the world’s countries have prohibited all physical punishment of children,
thereby ensuring that their laws protect children and adults equally. These prohibitions
are found throughout the world: ten in Africa, ten in Central and South America, six in
Asia-Pacific, 35 in Europe, and one in the Middle East.10 They are found across the world’s
cultures, faiths, levels of economic development, political leanings, and legal systems. Two
constituent countries of the UK, Scotland and Wales, also passed laws prohibiting all
physical punishment of children in 2019 and 2020, respectively.
Evidence is growing that such laws are associated with rapid and dramatic changes
in parents’ attitudes and behaviour, reducing both approval and prevalence of physical
punishment of children.92 Sweden, which prohibited all physical punishment of children
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in 1979, provides an example of how a prohibition can lead to steady declines in physical
punishment over time. In a study of three cohorts of young to middle-aged adults, the
proportion of participants who reported being slapped during childhood decreased from
83% in 1958, to 51% in 1981, and then to 27% in 2011—a two-thirds reduction over 53
years.93 Although public education can help to increase knowledge and shift attitudes, these
efforts are slowed and undermined when the law contradicts them. A study of five European
countries found that the greatest changes in attitudes about and use of physical punishment
occur when public education and law are consistent.94,95
There is no evidence that laws giving children full protection create an influx of caregivers
into the justice system. 5 years of police monitoring following the implementation of
New Zealand’s prohibition found that prosecution was limited to severe acts (eg, kicking,
holding by the neck, causing injuries) and none led to prison sentences. After passage
of the legal prohibition on physical punishment, police worked more closely with the
child protection authority, diverting cases from the justice system to agencies that could
respond supportively.96 Indeed, in almost all countries with prohibitions, these laws serve an
educational rather than punitive function, aiming to increase awareness, shift attitudes, and
clarify the responsibilities of parents in their caregiving role.92
In addition to national legal bans, communities and institutions can assist in preventing
and reducing physical punishment. One example is No Hit Zones, which have been
successfully introduced in many locations in the USA, particularly hospitals. No Hit
Zones prohibit the hitting of children in those settings and are effective in increasing both
hospital staff’s willingness to intervene in situations of parent–child hitting and parents’
acceptance of staff advice to avoid physical punishment.97 No Hit Zones are low-cost
interventions that can be instituted widely across communities and in a variety of settings
(eg, schools, libraries, supermarkets). A second strategy is for governments, stakeholders,
and practitioners to prioritise educational campaigns and interventions that teach parents and
caregivers disciplinary strategies that focus on enhancing children’s understanding rather
than enforcing their compliance, and that are based on children’s rights to protection and
dignity.98–100
Conclusions
Our review of prospective longitudinal studies has shown that physical punishment is linked
with increases in negative child outcomes. Many of these studies used statistical methods to
minimise potential confounding and selection bias. The review has documented compelling
evidence that physical punishment is harmful to children’s development and wellbeing and
has shown no evidence that it is beneficial for children. Given the high prevalence of
physical punishment around the world, there is no time to waste—all countries should heed
the UN’s call to uphold children’s human rights and promote their wellbeing by prohibiting
physical punishment in all forms and all settings.
Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
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Acknowledgments
ETG is supported by grant P2CHD042849 from the Eunice Kennedy Shriver National Institute of Child Health
and Human Development in the USA. YK is supported by the UK Economic and Social Research Council (ES/
R008930/1). The content is solely the responsibility of the authors and does not necessarily represent the official
views of the National Institutes of Health. We gratefully acknowledge Ms Caroline Fearn who assisted with
extracting the data.
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Search strategy and selection criteria
We undertook a literature search of MEDLINE, PsycINFO, and Web of Science in
June, 2020, and updated the search in October, 2020. The search terms were “physical
discipline”, “physical punishment”, “corporal punishment”, “physical chastisement”,
“smack”, “spank”, and “slap”. The search syntax for each database can be found in
the appendix p 1.
We searched for articles published from January, 2002, onwards, and did not restrict by
language or country. We also identified articles from reference lists of earlier reviews
and through expert authors. Included studies were peer reviewed; assessed one or more
outcomes measured in childhood (up to age 18 years); measured physical punishment
by a parent or parental figure (ie, not a teacher); included only parent behaviours that
fit our operationalisation of physical punishment; and reported empirical findings from
quantitative, prospective designs that adjusted for initial levels of the outcome(s) under
study.
We excluded studies that examined severe forms of physical punishment, such as: hitting
a child with an object; hitting or slapping on the face, head, or ears; throwing an object
at a child; beating; hitting with a fist; punching; kicking; washing a child’s mouth out
with soap; throwing down; choking; burning; scalding; and threatening with a knife or
gun. We also excluded studies that did not distinguish between physical and verbal forms
of punishment. When necessary, study authors were contacted for details to ensure that
inclusion criteria were met.
After initial database searches and removal of duplicate articles, all records were divided
between two reviewers (AH and AM), who did an initial title screen to exclude irrelevant
records that did not relate to physical punishment of children by a parent. Remaining
articles were subject to abstract and full-text screening through blind review by AH and
AM. Studies were included if both reviewers agreed that inclusion criteria were met. In
case of disagreement, consensus was reached through discussion and, when required, a
third reviewer (ETG).
For the included studies, data on key study characteristics and findings were extracted
(appendix pp 2–11). We then summarised these characteristics and findings for each
outcome category and analysed patterns to identify key themes. Given that some studies
used the same datasets, we report findings for independent samples or datasets rather than
individual studies.
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Figure:
Study selection
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Table:
Overview of included studies, by child outcome
Studies examining
outcome (n) Independent samples
examining outcome (n) Among the independent samples
Detrimental
outcomes Beneficial
outcomes No significant
associations Mixed findings*
Externalising behaviours
Externalising behaviour 27 19 13 0 3 3 (Det/NS)20,21 (Det/Ben)22
Aggressive behaviour 20 6 5 0 1 0
Antisocial behaviour or conduct
problems 8 5 4 0 0 1 (Det)23,24 (NS)25,26
Internalising behaviours 15 10 5 0 3 2 (Ben/NS)22 (Det/Ben)27
Total behaviour problems
(externalising and internalising) 6 5 4 0 0 1 (Det)28 (Det/NS/NS)29
Prosocial behaviour or social
competence 5 5 0 0 5 0
Inattention or ADHD symptoms 2 2 1 0 1 0
Cognitive abilities 8 6 2 0 1 3 (Det/NS/NS)30,31 (Det/Ben)32
Interpersonal relationships 3 3 1 0 1 1 (Det/NS/NS)33
Stress reactivity 1 1 1 0 0 0
Involvement with CPS
†
3 2 2 0 0 0
Total 98 64 38 0 15 11
Det=detrimental. Ben=beneficial. NS=not significant. ADHD=attention-deficit hyperactivity disorder. CPS=child protective services.
*
Differential findings across measures or subgroups within the same study or across studies within the same dataset.
†
Only one of the independent samples examining child abuse or neglect controlled for previous maltreatment.
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