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DOI: 10.1542/peds.2008-2374
; originally published online August 2, 2010; 2010;126;e701Pediatrics Beatriz Vizcarra and Isabel A. Bordin
Jain, Cristiane S. Paula, Shrikant I. Bangdiwala, Laurie S. Ramiro, Sergio R. Muñoz,
Desmond K. Runyan, Viswanathan Shankar, Fatma Hassan, Wanda M. Hunter, Dipty
International Variations in Harsh Child Discipline
http://pediatrics.aappublications.org/content/126/3/e701.full.html
located on the World Wide Web at:
The online version of this article, along with updated information and services, is
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
publication, it has been published continuously since 1948. PEDIATRICS is owned,
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
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International Variations in Harsh Child Discipline
abstract
BACKGROUND: Although the history of recognition of child abuse in
Europe and North America extends over 40 years, recognition and data
are lacking in other parts of the world. Cultural differences in child-
rearing complicate cross-cultural studies of abuse.
OBJECTIVE: To ascertain rates of harsh and less-harsh parenting be-
havior in population-based samples.
METHODS: We used parallel surveys of parental discipline of children
in samples of mothers in Brazil, Chile, Egypt, India, Philippines, and the
United States. Data were collected between 1998 and 2003. The instru-
ment used was a modification of the Parent-Child Conflict Tactics Scale,
along with a study-developed survey of demographic characteristics
and other parent and child variables. Women (N⫽14 239) from 19
communities in 6 countries were surveyed. We interviewed mothers
aged 15 to 49 years (18 –49 years in the United States) who had a child
younger than 18 years in her home. Sample selection involved either
random sampling or systematic sampling within randomly selected
blocks or neighborhoods.
RESULTS: Nearly all parents used nonviolent discipline and verbal or
psychological punishment. Physical punishment was used in at least
55% of the families. Spanking rates (with open hand on buttocks)
ranged from a low of 15% in an educated community in India to a high
of 76% in a Philippine community. Similarly, there was a wide range in
the rates of children who were hit with objects (9%–74% [median:
39%]) or beaten by their parents (0.1%–28.5%). Extremely harsh meth-
ods of physical punishment, such as burning or smothering, were rare
in all countries. It is concerning that ⱖ20% of parents in 9 communities
admitted shaking children younger than 2 years.
CONCLUSIONS: Physical and verbal punishments of children are com-
mon in high-, middle-, and low-income communities around the world.
The forms and rates of punishment vary among countries and among
communities within countries. A median of 16% of children experi-
enced harsh or potentially abusive physical discipline in the previous
year. Pediatrics 2010;126:e701–e711
AUTHORS: Desmond K. Runyan, MD, DrPH,
a,b,c
Viswanathan Shankar, MSc,
c,d
Fatma Hassan, MD, PhD,
e
Wanda M. Hunter, MPH,
a,c
Dipty Jain, MBBS, MD, MSc,
f
Cristiane S. Paula, MSc, PhD,
g,h
Shrikant I. Bangdiwala,
PhD,
c,d
Laurie S. Ramiro, PhD,
i
Sergio R. Muñoz, PhD,
j
Beatriz Vizcarra, Lic en Psic,
k
and Isabel A. Bordin, MD,
MSc, PhD
g
Departments of
a
Social Medicine,
b
Pediatrics, and
d
Biostatistics,
University of North Carolina, Chapel Hill, North Carolina;
c
UNC
Injury Prevention Research Center, Chapel Hill, North Carolina;
e
Department of Community Medicine, Suez Canal University
Faculty of Medicine, Ismailia, Egypt;
f
Department of Pediatrics,
Government Medical College, Nagpur, India;
g
Universidade
Federal de São Paulo, Escola Paulista de Medicina, São Paulo,
Brazil;
h
Universidade Presbiteriana Mackenzie, São Paulo, Brazil;
i
Department of Clinical Epidemiology, College of Medicine,
University of the Philippines, Manila, Philippines; and
j
Facultad
de Medicina and
k
Departamento de Psicologia, Universidad de
la Frontera, Temuco, Chile
KEY WORDS
child abuse, punishment, shaken-baby syndrome, child-rearing,
multicenter studies, cross-sectional survey
ABBREVIATIONS
WorldSAFE—World Studies of Abuse in the Family Environment
PC-CTS—Parent-Child Conflict Tactics Scale
www.pediatrics.org/cgi/doi/10.1542/peds.2008-2374
doi:10.1542/peds.2008-2374
Accepted for publication May 26, 2010
Address correspondence to Desmond K. Runyan, MD, DrPH,
Department of Social Medicine, University of North Carolina
School of Medicine, Campus Box 7105, Chapel Hill, NC 27599-
7105. E-mail: drunyan@med.unc.edu.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2010 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
SPECIAL ARTICLE
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Although there is global concern about
child abuse and neglect, there is less
global agreement about what consti-
tutes the abuse or neglect of a child.1– 4
Some define abuse or neglect by the
behaviors of the parents, whereas oth-
ers include physical consequences or
parental intention as part of the defini-
tion.5,6 Although parental intent may be
a legal criterion for child abuse or ne-
glect in some countries, discerning in-
tent can be difficult.7Nevertheless, an
approach to measuring occurrence
that permits international comparison
will facilitate efforts to respond to and
prevent child abuse.
In most countries, child maltreatment
rates are unknown. Only a minority of
episodes come to attention in those
countries where legal requirements
direct professionals or the public to
make reports.8The majority of coun-
tries have no mandatory child abuse
reporting or response systems. Per-
haps because much of the medical
literature about child maltreatment
has originated in Europe and the
United States, and the United States
in particular is known to have a high
homicide rate, there is a widespread
perception that child abuse and ne-
glect are more prevalent in Europe
and North America.9
Despite data limitations, both the 2002
World Health Organization Report on
Violence and Health10 and the 2006
United Nations World Report on Chil-
dren and Violence11 concluded that
child abuse is a serious problem every-
where. These reports noted that inter-
national comparisons are complicated
by conceptual and methodologic dif-
ferences in published research.12 For
example, some studies have presented
case series without denominators of
children at risk.13,14 Although some re-
searchers solicit child reporting,15,16
others ask for parental disclo-
sure.6,17,18 The good news is that data,
when collected, have suggested that
public and professional recognition,
intervention, treatment, and preven-
tion may be reducing child abuse in the
United States and Europe.19
Increasing clinicians’ attention to child
abuse will not be easy. Despite profes-
sional and public attention in the
United States, the skills required to
identify physical and sexual abuse are
not well taught in its medical schools.20
Poor or inadequate medical training in
child abuse may be a greater problem
outside the United States.21 It is impor-
tant to note that medical education pri-
orities are increasingly being directed
by epidemiologic data on the health of
the public.22 Medical schools in coun-
tries where recognition of violence
against children is low may be
prompted by data to add child abuse
and neglect recognition to their peda-
gogy. In the United States, medical rec-
ognition led to widespread policy and
societal recognition.23
Members of the International Clinical
Epidemiology Network24 designed par-
allel population-based surveys of fam-
ily violence and child discipline known
as WorldSAFE (World Studies of Abuse
in the Family Environment).25 To our
knowledge, this is the first report to
compare harsh punishment rates con-
ducted in a parallel fashion across
low-, middle-, and high-income coun-
tries. Individual community results
from Egypt,26 the Philippines,27 Chile,28
Brazil,29 and the United States8have
been published previously.
METHODS
After a 1996 Indian pilot study to test
feasibility,30 we conducted cross-
sectional studies in selected communi-
ties in Egypt, India, Chile, and the Phil-
ippines in 1998 –1999, and in Brazil and
the United States in 2002–2004. Re-
search protocols were reviewed and
approved by human subjects commit-
tees at each university. Detailed de-
scriptions of the WorldSAFE study sam-
pling, procedures, and measures have
been published.25,31
Sampling Strategy
The selection of countries and com-
munities began with expressions of
interest by International Clinical Epide-
miology Network members. Sample-
selection criteria and methodology
were standardized across studies ex-
cept for a deviation in the US study (see
“Methodologic Differences in the US
Study”). In all countries except India
and the United States, a single study
community was selected. In Brazil, the
selected community of Jardim Santo
Eduardo was sampled by using a
2-stage cluster-sampling design. In
southern Chile, a random sample of 8
clusters was selected from the 119
housing clusters in the community of
Santa Rosa. In the Philippines, a ran-
dom sample of 11 clusters or blocks
was selected from 43 blocks in the
community of Paco in metropolitan
Manila. The Egyptian community of El-
Sheik-Zayed was sampled by using
household census data from 18 neigh-
borhoods, followed by random selec-
tion of 3 neighborhoods for study. In
India, 7 medical schools* selected
samples from 2 of 3 possible strata
(rural, urban slum, and urban non-
slum). After the random selection
of communities, communities were
proportionately sampled to identify
households with a woman aged 15 to
49 years and at least 1 child under the
age of 18 years.
Procedures
Trained field interviewers selected eli-
gible households and recruited partic-
ipants. In sampled households, the in-
terviewer determined if more than 1
woman was eligible. If so, a random-
number table was used to select 1
woman for study. If that woman had
*Bhopal was included at the behest of the Interna-
tional Center for Research on Women, the funding
agency for India.
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more than 1 eligible child, a random-
number table was used to select the
“referent” child. If privacy could be en-
sured, after obtaining verbal informed
consent, interviewers conducted face-
to-face interviews in the home. If pri-
vacy was not possible, a private loca-
tion such as a community or health
center was used.
Methodologic Differences in the US
Study
The US study was described in this
journal previously.8We administered
an abbreviated version of the instru-
ment by telephone to 1435 mothers in
North Carolina and South Carolina.
Half the sample was selected ran-
domly from purchased lists of tele-
phone numbers of households. This
list was augmented with true random-
digit dialing to increase representa-
tion of lower-income families. The
telephone survey was conducted anon-
ymously (ie, respondent and house-
hold names were unknown). At the ini-
tiation of the interview, the computer
erased the telephone number from
view so that answers could not be
linked with the telephone number. This
approach solved some of the ethical
and legal constraints of the state man-
datory reporting laws that would have
otherwise made the US data com-
pletely noncomparable. Previous US
family violence surveys have demon-
strated that an anonymous telephone
survey is as likely to elicit positive re-
sponses to sensitive questions as a
face-to-face interview.32 The institu-
tional review board at the University of
North Carolina prohibited enrollment
of mothers younger than 18 years of
age in the US sample.
Measures
The WorldSAFE investigators jointly de-
veloped the core survey instrument in
English. Rigorous translation and
back-translation methods were used
to prepare the instrument in 7 other
languages: Arabic (Egypt); Hindi, Mar-
athi, and Tamil (India); Portuguese
(Brazil); Spanish (Chile); and Tagalog
(the Philippines). Discrepancies were
examined and resolved in discussions
between field staff, translators, and in-
vestigators before training staff. In ad-
dition to discipline practices, the in-
strument inquired about maternal
social support, the mother’s intimate
partner violence experience, alcohol
abuse, maternal depression, child
health, maternal experience with
childhood violence, and socioeco-
nomic characteristics. In this article
we present the child discipline data
from 19 communities in 6 countries.
Child discipline was measured with a
modified Parent-Child Conflict Tactics
Scale (PC-CTS).6The PC-CTS asks about
specific discipline practices according
to frequency over the previous year
and if ever used. In this study, mothers
were asked how often they and/or
their husband or partner had used
specific disciplinary acts. The range of
responses was reduced from the orig-
inal 8-point scale to a 3-point scale (not
at all, 1–2 times, ⱖ3 times in the pre-
vious year) to facilitate translation and
use. We added 4 disciplinary practices
on the basis of focus group discus-
sions in Chile, Egypt, and India: putting
hot pepper in the child’s mouth; forc-
ing the child to kneel or stand with a
burden (such as in hot sand or while
holding bricks); twisting the child’s
ear; and hitting the child on the head
with the knuckles. One PC-CTS item
(smothered or choked) was separated
into 2 items (see Appendix).
The WorldSAFE investigators classified
child discipline practices as fitting into
1 of 6 categories: (1) nonviolent disci-
pline; (2) moderate verbal discipline;
(3) harsh verbal discipline; (4) moder-
ate physical discipline; (5) harsh phys-
ical discipline without using an object;
and (6) harsh physical discipline in-
cluding hitting with an object (see Ta-
ble 1). Because there was not consen-
sus among the investigators that
hitting with an object should be consid-
ered “harsh” in all countries, we re-
port harsh physical discipline both
with and without the 2 items that de-
scribe hitting with an object such as a
stick, belt, cane, or broom. Shaking a
child ⬍2 years old was classified as
harsh discipline.
TABLE 1 Definitions of Derived Categories of Severity of Child Discipline Practices
Type Child Discipline Practices
Nonviolent discipline Explained why; took away privileges; told child to start or stop doing something; made child stay in one place; gave child
something to do
Moderate verbal discipline Shouted; screamed or yelled; refused to speak to child; withheld food
Harsh verbal discipline Cursed child; called child names such as “stupid,” “ugly,” or “useless”; threatened to abandon child; threatened to
invoke ghosts/evil spirits; locked child out of the house or threatened the child with a knife or gun
Moderate physical discipline (includes
hitting with an object)
Slapped face; spanked with hand on buttocks; hit head with knuckles; pulled hair; pinched; twisted ear; forced to kneel
or stand in one position; hit buttocks with an object such as stick, broom, or belt; hit elsewhere other than buttocks
with an object; put hot pepper or spicy food in child’s mouth; shook child aged 2–18 y
Harsh physical discipline without
including hitting with an object
Kicked; choked; smothered with hand or pillow; burned/scalded or branded; beat (hit over and over again with object or
fist); shook child aged ⬍2y
Harsh physical discipline including
hitting with an object
Adds hitting child with an object on the buttocks or anywhere else on the body to the scale “harsh physical discipline
including objects”
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Data Management and Analysis
Except for the US data, all data were
entered into a common entry system
within each country.33 US telephone
survey data were entered directly into
the SAS data file.34 US data were
weighted to match 2000 census statis-
tics for the 2 states according to race
and income by using SUDAAN.35 The
other countries’ samples were not
weighted. The Indian data are pre-
sented from individual communities in
the absence of weighting to produce a
summary estimate.
Simple descriptive statistics present
the discipline practices experienced by
the children. Inferential statistical analy-
ses were not thought necessary. For
each study child, we included all re-
ported types of discipline. All analyses
were performed by using SAS 9.1.3.34
Human Subjects
Institutional review boards at each
of the participating universities ap-
proved the study.
RESULTS
Survey-Participation Rates
Nineteen community samples were
identified, and 14 239 women were in-
terviewed. Table 2 presents partici-
pant characteristics and participation
rates according to community. In half
of the communities, participation
rates were ⬎90%. In the United States,
52% of the mothers reached by tele-
phone completed the interviews by us-
ing the conservative American Associ-
ation for Public Opinion Research
standard definition response rate type
3 standard to guide interpretation of
nonresponsive telephone numbers.
This rate is comparable to that of other
US telephone surveys.27 Although re-
fusal rates in a few communities were
high enough to be concerning, refusals
would likely lower the reported rates
from the true rates and produce con-
servative estimates.
We present the participating commu-
nities in rank order of mean maternal
education in all tables and in Fig 1. In-
spection of the data suggested that
lower maternal years of education
were associated with higher rates of
harsh physical punishment, and no
compelling alternative order of pre-
sentation emerged. Sample character-
istics appear in Table 3. Mothers in the
urban nonslum sample of Chennai, In-
dia, had the highest level of education
of any community at 15.4 years. It is
significant that 72% of the respondent
TABLE 2 Distribution of Respondents per Study Site, WorldSAFE
Specific Study Site No. of
Respondents
Participation
Rate, %
Brazil, Embu, São Paulo 813 82.5
Chile, Santa Rosa district of Temuco 422 96.0
Egypt, El-Sheikh Zayed district of Ismailia 631 93.5
India
Delhi, urban slum 550 80.1
Delhi, nonslum 850 55.7
Lucknow, nonslum 506 81.0
Lucknow, rural 906 89.8
Nagpur, urban slum 905 91.2
Nagpur, rural 526 92.4
Bhopal, urban slum 700 98.9
Bhopal, rural 700 90.6
Chennai, urban slum 1000 56.1
Chennai, nonslum 400 38.8
Thiruvananthapuram, nonslum 700 83.3
Thiruvananthapuram, rural 765 91.1
Vellore, nonslum 716 90.4
Vellore, rural 714 85.9
Philippines, Paco, Manila 1000 90.6
United States, North Carolina and South Carolina 1435 52.0
FIGURE 1
Patterns of child discipline types found in selected communities in 6 countries. HITS indicates that
hitting the body, including the buttocks, with an object during punishment was included as harsh
physical punishment.
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mothers in the Delhi, India, urban slum
had no schooling. The mean age of the
children ranged from 5.8 to 9.5 years,
and the oldest mean was in El-Sheikh
Zayed, Egypt, and the youngest in the
urban slum of Delhi. The percentage of
girls in the sample ranged from 42.7%
in the Delhi slums to 51.5% in Chennai.
The mean number of children per
household ranged from 1.6 to 3.1.
Discipline practices reported by the
mothers varied widely (Table 4). Virtu-
ally all mothers indicated that they and
the child’s father/father-figure used
verbal explanation as a discipline
strategy. The strategy of taking privi-
leges away ranged from a low of 3% in
Paco to ⬎84% in the United States. Re-
stricting the child to a particular place
for a specified time (“time-out”) was
used by more than half of the parents
in 7 of the 19 communities.
Moderate and Harsh Verbal
Discipline
Screaming or yelling at children was
frequent; rates ranged from 70% to
95%. Threatening the child with aban-
donment varied widely across coun-
tries from rare to quite common.
Threatening a child with a knife or a
gun was rare; the highest rate (4%)
was reported in Thiruvananthapuram,
India.
Moderate Physical Discipline
Rates of spanking (hitting the buttocks
with an open hand) ranged from 26%
in Vellore, India, to 76% in Paco. Hitting
the buttocks with an object was a
highly variable form of discipline: the
highest rate (70.5%) was reported in
the Thiruvananthapuram rural sam-
ple, and the lowest rate (5.6%) was re-
ported in the urban nonslum part of
Delhi. This form of punishment was
used by approximately one-quarter of
the respondents in the US sample.
Slapping on the face or head was asso-
ciated with the widest variation of any
form of discipline; Indian communities
reported both the highest and the low-
est rates. The lowest rate of slapping
(4%) was in Thiruvananthapuram, and
the highest rate (80%) was reported in
the Delhi urban nonslum. Overall, in In-
dia, rates of slapping on the face or
head exceeded spanking as a disci-
pline practice.
Harsh Physical Discipline
Beating the child up (hitting over and
over again with a closed fist) was re-
ported at high rates in 2 communities:
rural Bhopal, India (29%), and El-
Sheikh Zayed (24%). Beating-up was
rare in 5 communities. Choking, burn-
ing, and smothering were rarely re-
ported in any community (⬍5%).
Observed Rates According to the
PC-CTS/WorldSAFE Scale
Table 5 presents summary rates for
the different categories of discipline
according to WorldSAFE site. The over-
all rates of moderate physical acts to
punish children varied from 55% to
89%. The rates of harsh physical disci-
pline, our proxy measure for child
abuse, were dramatically higher in all
communities than published rates of
official physical abuse in any country.
For example, 28% of the mothers in El-
Sheikh Zayed reported using harsh
TABLE 3 Description of Sample in Each WorldSAFE Community
Community
a
nMaternal
Education,
Mean (SE), y
Mothers
With no
Education, %
Maternal
Age, Mean
(SE), y
Mother
Employed,
%
Child
Gender,
% Female
Child Age,
Mean
(SE), y
Index Child
⬍2y,%
Total No. of Children
in Household, Mean
(SE)
Chennai (NS) 400 15.4 (0.1) 0.3 32.5 (0.3) 6.5 51.5 7.3 (0.2) 8.3 1.6 (0.03)
United States
b
1435 13.7 (0.1) 0.0 — 70.8 47.4 9.0 (0.2) 8.1 —
Delhi (NS) 850 12.9 (0.2) 5.3 32.9 (0.2) 19.2 46.8 7.3 (0.1) 14.1 1.9 (0.03)
Philippines 1000 10.0 (2.6) 0.1 33.3 (0.3) 31.1 50.6 6.9 (0.2) 15.7 2.7 (0.1)
Thiruvananthapuram (NS) 700 9.7 (0.1) 1.0 33.5 (0.3) 23.3 47.1 8.2 (0.2) 13.0 1.7 (0.03)
Chile 422 9.6 (0.1) 0.5 39.3 (0.4) 34.8 47.9 7.5 (0.2) 14.2 1.9 (0.1)
Egypt 631 8.7 (0.2) 25.6 36.8 (0.3) 39.0 47.3 9.5 (0.2) 9.0 2.2 (0.04)
Thiruvananthapuram (R) 765 8.3 (0.1) 1.6 32.0 (0.2) 17.0 50.2 7.7 (0.2) 14.0 1.9 (0.02)
Lucknow (NS) 506 7.3 (0.3) 34.2 32.4 (0.3) 16.2 48.0 7.3 (0.2) 11.7 2.9 (0.1)
Chennai (US) 1000 7.3 (0.1) 10.8 30.5 (0.2) 18.3 46.4 7.3 (0.2) 14.3 2.0 (0.03)
Brazil 813 7.1 (0.1) 2.7 33.4 (0.3) 51.9 50.1 7.7 (0.2) 9.5 1.8 (0.03)
Nagpur (US) 905 6.8 (0.1) 12.2 29.8 (0.2) 27.3 47.0 6.8 (0.2) 18.8 2.3 (0.04)
Vellore (NS) 716 5.6 (0.2) 25.3 31.2 (0.3) 34.5 50.3 7.4 (0.2) 18.4 2.2 (0.04)
Vellore (R) 714 5.4 (0.1) 25.6 30.2 (0.3) 39.1 46.9 7.5 (0.2) 16.7 2.1 (0.03)
Nagpur (R) 526 4.3 (0.2) 34.0 29.9 (0.3) 51.1 47.1 6.6 (0.2) 23.0 2.4 (0.1)
Bhopal US 700 3.2 (0.2) 55.1 29.9 (0.3) 27.1 49.1 6.6 (0.2) 20.9 2.7 (0.1)
Lucknow (R) 906 2.7 (0.1) 64.7 31.4 (0.2) 19.8 48.7 6.3 (0.2) 15.5 3.1 (0.1)
Bhopal (R) 700 2.1 (0.1) 68.3 30.4 (0.3) 41.1 45.4 6.4 (0.2) 22.0 2.8 (0.1)
Delhi (US) 550 1.7 (0.1) 71.8 28.3 (0.3) 21.6 42.7 5.8 (0.2) 18.7 2.9 (0.1)
Indian communities were classified according to official designation as rural (R), urban slum (US), or urban nonslum (NS). — indicates data not available.
a
Communities are listed according to the mean number of years of education reported by maternal respondents.
b
Weighted percentages.
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TABLE 4 Specific Discipline Practices Experienced by Child ⱖ1 Time in the Previous Year According to Country/Community
Community
a
/variables nNonviolent Discipline Moderate Psychological Violence Harsh Psychological Violence
Explained
Why
Took
Privileges
Told to
Stop
Stay in
One Place
Gave
Something
to Do
Yelled or
Screamed
Refused
to Speak
Withheld
Food
Called Child
Names
Cursed Threatened
to Kick Out
Threatened
Abandonment
Threatened
Evil Spirits
Beat-up Threatened
With Knife/Gun
Chennai (NS) 400 91 6 66 34 31 85 9 0.3 23 3.8 8.9 22 4.7 0.8 0.0
United States
b
1435 — 84 — 78 — 75 13 0.4 4.2 21 6.8 3.1 2.7 0.4 0.0
Delhi (NS) 850 97 30 89 50 40 89 39 1.9 51 16 12 16 7.6 5.9 0.0
Philippines 1000 94 3 95 60 67 85 14 1.0 25 0.4 27 48 25 12 —
Thiruvananthapuram (NS) 700 95 31 97 20 11 87 26 2.0 52 18 16 35 22 6.8 4.8
Chile 422 92 60 88 40 72 84 17 0.2 16 3.3 5.5 7.8 13 1.7 0.0
Egypt 631 78 26 68 49 43 70 47 0.6 44 50 1.6 10 6.2 2.2 0.2
Thiruvananthapuram (R) 765 93 39 95 35 16 81 37 4.2 47 21 28 42 28 13 4.1
Lucknow (NS) 506 94 5 47 21 39 90 36 4.1 68 28 15 20 20 3.4 0.4
Chennai (US) 1000 94 17 78 52 45 86 17 3.3 34 16 17 27 17 3.0 0.4
Brazil 813 93 47 86 37 64 76 17 0.4 19 16 4.1 17 7.5 0.9 0.3
Nagpur (US) 905 99 51 65 42 52 95 45 4.4 48 1.9 38 45 27 3.8 1.2
Vellore (NS) 716 88 10 53 31 24 67 12 2.2 37 10 5.6 14 16 3.4 0.3
Vellore (R) 714 92 7 62 37 22 75 11 2.2 45 6.7 4.8 18 20 2.5 0.4
Nagpur (R) 526 94 31 60 34 40 92 35 3.9 37 5.3 37 45 34 1.4 0.6
Bhopal US 700 95 20 75 54 63 90 18 14 33 28 19 19 31 5.8 1.5
Lucknow (R) 906 98 8 55 15 46 94 32 6.6 72 39 15 18 27 2.0 1.0
Bhopal (R) 700 96 15 74 52 60 92 14 14 30 27 21 22 30 8.6 1.2
Delhi (US) 550 95 30 84 57 41 91 26 5.4 61 31 16 19 14 7.1 3.2
Community
a
/variables nModerate Physical Discipline (%) Harsh Physical Punishment (%)
Spanked
Buttocks
Hit Butt
With an
Object
Hit
Elsewhere
With an
Object
Slapped
Face
Pulled
Hair
Shook Child
(2–17 y)
c
Hit With
Knuckles-Head
Pinched Twisted
Ear
Forced to
Stand
Burdened
Put Hot Pepper
in Child’s
Mouth
Shook Child
(⬍2y)
d
Burned Beat-up Choked Smothered Kicked
Chennai (NS) 400 58 13 7.4 13 2.0 17 11 16 17 9.3 0.3 0.0 0.3 1.0 1.0 0.0 1.0
United States
b
1435 44 24 3.6 6.0 — 2.6 — 5.7 — — 0.3 2.6 0.1 0.3 — — 0.3
Delhi (NS) 850 16 6 5.4 72 5.7 21 2.6 1.4 13 0.5 0.1 12 0.0 0.1 0.1 0.0 1.1
Philippines 1000 76 51 20 21 23 21 8.3 58 30 4.1 0.9 19 0.3 2.7 1.0 0.2 5.8
Thiruvananthapuram (NS) 700 55 59 48 5.1 2.8 32 2.3 61 19 2.0 1.8 22 0.4 0.9 0.6 0.6 2.5
Chile 422 53 20 4.5 13 25 44 13 3.1 29 0.2 0.0 24 0.0 0.7 0.2 0.0 0.7
Egypt 631 29 29 27 42 28 62 26 45 32 7.3 2.9 12 2.2 24 0.8 0.6 5.4
Thiruvananthapuram (R) 765 72 71 52 4.3 1.7 34 1.8 66 25 4.9 3.5 17 0.9 2.5 0.4 0.7 2.1
Lucknow (NS) 506 34 27 25 64 20 47 65 22 34 2.8 2.3 53 0.2 9.8 1.7 0.4 7.8
Chennai (US) 1000 71 38 35 27 17 27 28 348 31 12 1.2 13 2.6 12 4.1 0.0 9.7
Brazil 813 55 15 4.7 4.8 8.1 25 9.2 13 20 1.6 0.6 10 0.0 0.3 0.5 0.0 0.7
Nagpur (US) 905 57 27 27 76 21 24 3.7 13 18 2.4 6.7 37 4.5 10 0.6 0.4 6.5
Vellore (NS) 716 29 29 31 40 7.2 15 13 18 14 2.2 1.3 9.7 1.0 8.7 1.4 0.0 6.2
Vellore (R) 714 26 31 32 38 8.1 16 11 14 11 4.1 0.9 12 0.9 11 1.0 0.1 5.4
Nagpur (R) 526 60 27 29 77 21 18 4.3 5.3 13 0.8 2.2 31 2.9 10 0.8 1.0 5.1
Bhopal US 700 68 26 25 80 21 62 21 26 40 2.5 3.6 49 2.0 19 2.5 0.2 11
Lucknow (R) 906 48 42 39 69 24 47 77 15 28 1.4 1.4 63 0.3 14 0.7 0.5 5.8
Bhopal (R) 700 68 33 29 77 28 68 30 33 48 1.5 4.3 61 1.8 29 3.3 0.3 12
Delhi (US) 550 30 21 19 79 19 43 13 8.8 22 2.9 0.6 23 0.2 3.0 1.1 0.0 11
Indian communities were classified according to official designation as rural (R), urban slum (US), or urban nonslum (NS). — indicates that the data were not collected.
a
Communities are listed according to the mean number of years of education reported by maternal respondents.
b
Weighted percentages.
c
Denominator is mothers with children younger than 2 years old.
d
Denominator is mothers with children 2 years old or older.
e706 RUNYAN et al by guest on March 30, 2013pediatrics.aappublications.orgDownloaded from
physical discipline. The rates of harsh
physical discipline varied ⬎10-fold
within communities in India.
When we included the practice of hit-
ting a child with an object anywhere
on the body, the rates of harsh pun-
ishment increased dramatically in
every community, although the range
remained broad (from 9% in the
Delhi nonslum sample to 74% in
Thiruvananthapuram).
Discipline Practices According to
Age
The use of harsh verbal and physical
punishment varied according to child
age (see Table 6). Because we included
shaking children under the age of 2 in
the definition (⬎25% in 6 of the com-
munities and close to 25% in 2 more),
harsh physical punishment (without
hitting with an object) was observed
most frequently in this age group in 14
of the 19 communities. Harsh verbal
discipline was lowest among the
youngest children, although in a num-
ber of communities it was still at
⬎33%.
When hitting with an object was in-
cluded, the highest rates of harsh pun-
ishment were observed among 7- to
11-year-olds. This age group also re-
ceived high rates of harsh verbal pun-
ishment; ⬎50% of mothers in 16 of the
19 communities reported using harsh
verbal punishments (median: 71.5%).
DISCUSSION
Harsh punishment of children by par-
ents is not less common in communities
in low- and middle-income countries
than in the United States; it may be more
common. Our definition of harsh physi-
cal punishment was an attempt to esti-
mate child abuse; it included beating up,
choking, burning, smothering, and kick-
ing for all ages and shaking of children
⬍2 years old. Because some of the inves-
tigators in our consortium considered
hitting the child with an object such as a
stick to be abusive, we used an alternate
definition of harsh physical punishment
that included hitting with an object.
The burden of child physical abuse
seems high. Among the 14 239 mothers
interviewed, 2032 children (14.3%)
were subjected to 1 or more forms of
harsh punishment by a parent. The me-
dian community had a rate of harsh
punishment of 16.5%. When being hit
with an object was included, the me-
dian rate of harsh physical punish-
ment among our study communities
was 39%. These numbers (16.5% with-
out including all hitting with objects or
39% including being hit with an object)
provide a crude but chilling estimate
of the child abuse burden for the
world’s young people (and these esti-
mates include neither neglect nor sex-
ual abuse). To be cautious, our sam-
pled communities were not intended
to provide a statistical representation
of the world’s youth and dispropor-
tionately originate from 1 country: In-
dia. However, we believe that these
data are useful in informing public
health, medicine, and the public in
each country.
The patterns of discipline, reported by
mothers in these 19 communities, re-
flect the difficulties of parenting and
the variety of techniques that parents
use to modify child behavior. Culture
TABLE 5 Rates of Different Types of Child Discipline Practices Used on All Ages in WorldSAFE Countries/Communities
Community
b
/variables nNon Violent
Discipline, %
Moderate
Verbal
Discipline, %
Harsh
Verbal
Discipline, %
Moderate
Physical
Discipline, %
Harsh
Physical
Discipline, %
Harsh Physical
Discipline with
HITS, %
a
Chennai (NS) 400 91 85 40 65 2.8 17
United States
c
1435 92 76 26 55 1.0 25
Delhi (NS) 850 93 90 62 75 2.7 9.1
Philippines 1000 98 87 71 83 9.9 56
Thiruvananthapuram (NS) 700 97 88 70 84 6.4 63
Chile 422 97 85 32 69 4.5 25
Egypt 631 86 77 64 81 28 46
Thiruvananthapuram (R) 765 96 83 71 87 7.6 74
Lucknow (NS) 506 95 91 76 82 17 37
Chennai (US) 1000 94 87 57 78 20 48
Brazil 813 96 77 39 70 2.3 18
Nagpur (US) 905 99 96 75 83 21 38
Vellore (NS) 716 89 68 53 63 16 40
Vellore (R) 714 91 76 63 63 16 41
Nagpur (R) 526 96 92 72 81 20 39
Bhopal US 700 96 90 64 87 29 42
Lucknow (R) 906 98 94 81 86 21 48
Bhopal (R) 700 95 92 59 89 39 52
Delhi (US) 550 90 91 70 84 16 30
Indian communities were classified according to official designation as rural (R), urban slum (US), or urban nonslum (NS).
a
HITS indicates that hitting the body, including the buttocks, with an object during punishment was included as harsh physical punishment.
b
Communities are listed according to the mean number of years of education reported by maternal respondents.
c
Weighted percentages.
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TABLE 6 Rates of Different Types of Child Discipline Practices According to WorldSAFE Country/Community and Age Group of Child
Community
b
/variables ⬍2y 2–6 y
nNonviolent
Discipline,
%
Moderate
Verbal
Discipline,
%
Harsh
Verbal
Discipline,
%
Moderate
Physical
Discipline,
%
Harsh
Physical
Discipline,
%
Harsh Physical
Discipline
Including
Objects, %
a
nNonviolent
Discipline,
%
Moderate
Verbal
Discipline,
%
Harsh
Verbal
Discipline,
%
Moderate
Physical
Discipline,
%
Harsh
Physical
Discipline,
%
Harsh Physical
Discipline
Including
Objects, %
a
Chennai (NS) 33 60 40 15 12 0.0 0 167 91 86 38 76 1.8 16
United States
c
116 — 36 9 31 2.6 7.7 409 91 74 19 76 0.6 27
Delhi (NS) 120 51 65 26 36 11 12 288 98 95 69 88 0.4 5.9
Philippines 157 85 58 51 64 19 25 372 99 86 77 91 5.1 52
Thiruvananthapuram (NS) 91 70 52 36 56 22 34 189 100 95 78 96 2.7 77
Chile 60 83 56 19 39 24 25 140 100 90 34 85 0.0 24
Egypt 57 23 19 14 21 14 14 149 83 74 64 82 32 50
Thiruvananthapuram (R) 107 73 54 39 52 17 30 256 99 86 79 96 5.5 85
Lucknow (NS) 59 58 81 50 63 55 55 183 95 95 79 86 13 32
Chennai (US) 143 75 62 26 36 14 16 357 96 91 64 93 15 52
Brazil 77 86 51 18 46 10 13 308 100 84 35 91 1.0 16
Nagpur (US) 170 94 89 60 72 39 41 309 100 97 82 95 18 37
Vellore (NS) 132 63 49 38 42 12 19 209 90 68 57 79 15 50
Vellore (R) 119 70 50 44 30 15 21 216 95 78 70 75 16 46
Nagpur (R) 121 78 76 49 66 31 33 152 99 97 85 94 20 42
Bhopal US 146 59 69 38 70 48 48 236 99 95 73 97 23 38
Lucknow (R) 140 81 78 48 59 62 62 379 98 96 82 92 18 48
Bhopal (R) 154 76 73 38 81 62 62 230 97 96 66 95 35 49
Delhi (US) 103 43 67 38 48 23 24 248 98 96 75 94 14 30
7–11 y 12–17 y
Chennai (NS) 112 98 92 53 90 3.6 30 88 90 89 36 34 4.6 10
United States
b
394 97 84 29 67 0.1 37 513 88 80 34 37 1.5 19
Delhi (NS) 240 99 96 71 86 2.5 13 202 96 91 61 64 1.5 7.4
Philippines 256 100 94 72 98 13 73 214 100 92 68 83 10 54
Thiruvananthapuram (NS) 194 100 93 79 92 6.7 74 226 100 90 67 76 4 52
Chile 111 99 88 32 81 0.9 31 111 99 91 36 53 3.6 22
Egypt 159 96 89 74 93 31 58 256 95 85 68 85 29 45
Thiruvananthapuram (R) 183 100 86 78 95 4.4 89 219 100 90 73 86 8.2 72
Lucknow (NS) 146 97 92 81 85 19 40 118 99 86 74 77 14 35
Chennai (US) 236 98 95 67 95 31 71 264 94 86 55 67 21 40
Brazil 216 99 82 39 73 0.9 22 212 93 71 50 44 2.8 18
Nagpur (US) 216 100 100 80 90 22 50 210 100 97 66 66 13 26
Vellore (NS) 173 99 75 61 71 22 50 201 94 75 51 54 12 32
Vellore (R) 176 95 90 71 78 21 51 203 95 76 57 55 14 36
Nagpur (R) 129 100 98 77 92 20 49 124 99 94 67 66 11 31
Bhopal US 164 99 96 69 95 37 52 154 96 86 57 70 24 34
Lucknow (R) 231 100 94 84 90 21 56 156 99 96 81 73 14 31
Bhopal (R) 178 99 98 64 94 46 62 138 95 86 49 75 27 38
Delhi (US) 119 99 100 83 95 17 39 80 99 94 70 81 14 28
Indian communities were classified according to official designation as rural (R), urban slum (US), or urban nonslum (NS).
a
Hitting the body, including the buttocks, with an object during punishment was included as harsh physical punishment.
b
Communities are listed according to the mean number of years of education reported by maternal respondents.
c
Weighted percentages.
e708 RUNYAN et al by guest on March 30, 2013pediatrics.aappublications.orgDownloaded from
helps form parental attitudes about
how children should be disciplined. In
some communities, invoking evil spir-
its or threatening abandonment are
common, whereas children in other
communities are hit, pinched, hit on
the head with a parent’s knuckles, or
have their ears twisted. A community’s
sense of the appropriateness of a par-
ticular practice may depend on the
context within which the discipline is
used.
Our data converge with other sources.
Authors of a recent 13-state study of
child abuse in India interviewed 12 447
children between the ages of 5 and 18
years; children self-reported a rate of
69% for physical abuse (slapped,
kicked, beaten with staves or sticks,
pushed, and shaken).36 A comparison
of the data from common communities
in the 2 Indian studies reveals similar
rates. In both studies, the incidence of
harsh physical child abuse was high-
est in the 5- to 12-year age group.
One concerning observation is the fre-
quency of self-reported parental shak-
ing of infants and young children. Seri-
ous outcomes in terms of death and
permanent disability can occur from
shaking.37 Our data indicate that this is
not just a low- and middle-income
country phenomena; self-disclosure of
shaking by mothers in the United
States is 150 times higher than the es-
timated prevalence of serious inflicted
neurotrauma.3Our query about shak-
ing did not ask about the force used in
shaking a child; it is possible that par-
ents in some communities are report-
ing milder jostling. However, 3 recent
focus groups conducted in Nagpur and
Vellore (D. Jain, MBBS and L. Jeye-
seelan, PhD, personal communication,
2008) suggest that the behavior de-
scribed as “shaking” in India is similar
to the construct in the child abuse lit-
erature. We note that shaking also was
reported in high rates for older chil-
dren in some of the Indian communi-
ties. Additional study of shaking is
warranted.
There are limitations to our data. We
did not collect representative samples
of any country. The samples were lim-
ited to geographic areas within the
countries, or to specific strata of soci-
ety in India; the data cannot be used to
ascribe rates to whole countries. De-
spite the high rates of harsh discipline
observed, our estimates may be low
because of the underreporting of be-
haviors that may trigger stigma or
shame. Nevertheless, the findings are
stark. Harsh treatment of children was
epidemic in all communities. Our data
provide empirical data that support
the conclusions of the 2002 World
Health Organization Report on Violence
and Health10 and the 2006 United Na-
tions World Report on Children and Vi-
olence that maltreatment occurs in all
nations.11,38 The data are a clarion call
to health professionals to be educated
about child abuse and neglect to im-
prove their recognition of child abuse
and develop effective prevention and
intervention.
ACKNOWLEDGMENTS
We thank the University of North Caro-
lina School of Medicine Faculty Small
Grants Program and LeBrun Founda-
tion (United Stated) and Oxfam for sup-
port of pilot studies in Nagpur, India;
the International Clinical Epidemiology
Network, Inc, for the surveys in Egypt,
Chile, and Philippines and the pilot
study in Brazil; the University of the
Philippines (Manila) for additional
support of the study in the Philippines;
the International Center for Research
on Women for support of IndiaSAFE
(Survey of Abuse in the Family Environ-
ment in India); Fundação de Amparo a
`
Pesquisa do Estado de São Paulo
(FAPESP 00/14555-4) for the study in
Brazil; Fundo de Auxílio aos Docentes e
Alunos (FADA 2001) from Universidade
Federal de São Paulo for additional
support of the pilot study in Brazil; and
the Duke Endowment for the survey in
the United States.
We acknowledge the following co-
investigators (and their institutions),
without whose assistance this study
would not have been possible: Maria
Lourdes E. Amarillo and Dr Bernadette
Madrid (University of the Philippines,
Manila, Philippines); Drs Antoinette
Laskey, Robert Agans, and Jen Jen
Chang (University of North Carolina,
Chapel Hill, NC); Drs M. K. Mitra, R. C.
Ahuja, and Savita Jain (King George
Medical College, Lucknow, India); Drs
R. M. Pandey and M. Lakshman (All In-
dia Institute of Medical Sciences, New
Delhi, India); Drs S. S. Bhambal and A. K.
Upadhaya (Gandhi Medical College,
Bhopal, India); Drs Saradha Suresh
and Shuba Kumar (Madras Medical
College, Chennai, India); Drs Abraham
Pedicayil, Thomas John, and L. Jeyas-
eelan (Christian Medical College, Vel-
lore, India); Dr M. K. C. Nair and Raj-
mohan Pillai (Thiruvananthapuram
Medical College, Thiruvananthapuram,
India); Dr Laura Sadowski (John H.
Stroger Jr Hospital of Cook County, Chi-
cago, IL); Rosimeire do Nascimento
and Dr Susane Rocha de Abreu (Divi-
sion of Social Psychiatry, Universidade
Federal de São Paulo, São Paulo, Bra-
zil); and Cristiane Seixas Duarte (Divi-
sion of Child and Adolescent Psychia-
try, Columbia University, New York,
NY).
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APPENDIX PC-CTS and Added WorldSAFE
Items
PC-CTS
a
Nonviolent discipline
A. Explained why something was wrong
E. Gave him/her something else to do instead
of what he/she was doing
Q. Took away privileges or grounded him/her
B. Put in “timeout” (or sent to room)
Psychological aggression
F. Shouted, yelled, or screamed at him/her
N. (Threatened to spank or hit but did not
actually do it)
J. Swore or cursed at him/her
U. Called him/her dumb or lazy or some other
name like that
L. Said you would send him/her away or kicked
him/her out of the house
Physical assault
Minor assault (corporal punishment)
H. Spanked him/her on the bottom with your
bare hand
D. Hit him/her on the bottom with a hard
object
P. (Slapped him/her on the hand, arm, or
leg)
R. Pinched him/her
C. Shook him/her: child aged 2 or older
Severe assault (physical abuse)
V. Slapped on the face, head, or ears
O. Hit some other part of the body besides
the bottom with a hard object
T. (Threw or knocked down)
G. Hit with a fist or (kicked hard)
Very severe assault (severe physical abuse)
K. Beat up, that is you hit him/her over and
over as hard as you could
I. Grabbed around neck and choked
M. Burned or scolded on purpose
S. Threatened with a knife or gun
C. Shook him/her: child under age 2
WorldSAFE added items
1. Threatened to invoke ghosts or evil spirits
2. Kicked him or her
3. Twisted ear
4. Hit him or her on the head with knuckles
5. Put chili or hot pepper in mouth
6. Locked out of house
7. Withheld food
8. Forced him/her to kneel or stand in one spot
with added burden
9. Smothered
Note that item O (hit some other part of the body besides
the buttocks with an object) was moved to minor assault.
a
1995 © Copyright 䡠䡠䡠䡠䡠䡠 (for permission to use this
instrument, contact Murray A. Straus at mas2@
cisunix.unh.edu).
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