Effect
of High
School
Students’
Knowledge
of
Child
Development
and
Child
Health
on
Approaches
to Child
Discipline
Charles F. Johnson,
MD,
David
Loxterkamp,
MD, and
Mark
Albanese,
MA
From the Child Development Clinic and Department of Pediatrics, University of Iowa Hospital, Iowa City
ABSTRACT. Because there is an association between the
lack of knowledge of normal child development, high and
unrealistic expectations for a child’s performance, and
child abuse, a questionnaire about normal child develop-ment, child health maintenance, child discipline aspects of childrearing, and child development was given to a
representative sample of high school students in Iowa.
Though high school students in Iowa rank high in
aca-demic performance, the results of this study indicated
that students in grades 9 through 12 had apoor knowledge
of child development and child health maintenance.
Stu-dents whose highest probability of response to a child
discipline problem was either to punish or abuse knew
less about child development and child health
mainte-nance than their peers. Boys at all grade levels knew less
about child development and child health maintenance
and were more likely to choose punishment and abuse
than girls. Though the causes for child abuse are multi-factorial and complex, there is a need to guarantee that all who are at risk for parenthood be informed about child
development, child health maintenance, and child
disci-pline to minimize the effects that ignorance of these
factors may have on their approaches to discipline and
their potential for child abuse. Pediatrics 69:558-563,
1982; parenting education, child development knowl-edge, child-rearing knowledge, child health knowledge, child abuse prevention.
Currently, there is less concern about inadequate medical awareness of the existence of child abuse’
than when the concept was first described in 19532
Received for publication Nov 17, 1980; accepted July 16, 1981. When data were collected, Drs Johnson and Loxterkamp were at the University of Iowa College of Medicine, Iowa City.
Dr Loxterkamp’s present address: York Hospital, York, PA
17403.
Reprint requests to (C.F.J.) Child Abuse Program, Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205.
PEDIATRICS (ISSN 0031 4005). Copyright © 1982 by the
American Academy of Pediatrics
and was termed the “battered child syndrome” in
1962. Recently, the incidence of teenage pregnancy
has increased. These mothers may not be pre-pared technically or emotionally for pregnancy. Their infants are more likely to be subjected to
child abuse than babies born to older mothers be-cause teenaged mothers have a higher incidence of
out-of-wedlock births,7 a lack of maternal prepara-tion,8 and immaturit? and their babies have an
increased
risk of prematurity and mental and phys-ical defects.’#{176}’5Teenaged parents may demonstrate inappropriate child care responses.’6Studies have clarified the incidence of child
abuse’7 and described the personalities of battering parents.’8 Although a variety of personality
abnor-malities and low socioeconomic status were
de-scribed in one large series of the parents of abused children, youth and premature parenthood were associated features.’9 The demands and
expecta-tions of abusing parents have been reported as
beyond the ability of the infant to comprehend and respond appropriately.#{176}’2’ A lack of knowledge about childrearing and child development and un-realistic developmental expectations has been re-ported among teenaged parents who were impatient with and cruel to their children.22’23
The suggestion that there is a relationship
be-tween child abuse and teenage pregnancy and the findings ofunrealistic expectations and attitudes for
children among teenage parents and parents who
have abused their children were the impetus for this study. It was hypothesized that there was a
general lack of knowledge about childrearing
tech-mques and child development among high school
students and that students whose knowledge of
child development was poor would tend to select
harsher disciplinary methods in simulated
METHOD
Questionnaire Design
To assess the knowledge of normal child
devel-opment, child health maintenance factors, and child discipline approaches by high school students in the
state of Iowa, the Iowa Child Development Test (ICDT) was developed from the results of a survey
sent to 27 prominent professionals with expertise in child development and child health. Several
na-tional experts in child abuse and health curriculum
design were also contacted. They were asked to
indicate the minimal amount of knowledge about
child development, childrearing, and child health maintenance that a high school student should
pos-sess by the time of graduation. These objectives were used to develop the ICDT.
The ICDT is composed of four sections. The first section assesses knowledge of normal child devel-opment. The answers are designed to reveal expec-tations that are above or below normal as well as normal. The second section deals with child health maintenance factors and includes basic health
knowledge about immunization, nutrition, and ge-netics. The third section, child discipline ap-proaches
(CDA),
is constructed
to provide fiveman-agement alternatives for dealing with common child discipline situations at various ages. Several of the
questions are based on situations in which
expec-tations for performance are inappropriate for the
child’s chronologic age. Because there are no
uni-versally accepted appropriate child discipline
meth-ods, all options were placed in one of six mutually
exclusive categories: reinforcement, isolation,
ig-nore, lecture, punish, and abuse.
For each examinee, six CDA scores were obtained
to indicate the percentage of items chosen in that
discipline category. For example, six items had op-tions categorized as abuse. If a student selected
abuse options in three of the items, his abuse score
would be 50%. For each student, the child discipline category with the highest percentage was deemed the student’s Characteristic Child Discipline Ap-proach
(CCDA).
The CCDA
category
was
consid-ered a student’s highest probability response to a
child
discipline problem.The purpose of the fourth section of the test is to determine
demographic
variables
that
can affect
performance on the examination. It surveys
oppor-tunities for childrearing experiences in the home,
community, and class room; attitudes about where childrearing should be taught; family size and
or-dinal position; desire for a family; and future edu
cational goals. Other variables that might be asso-ciated with performance on the test, such as sex and grade, were obtained from data
collected
whenthe Iowa Testing Program administered the test as a trial unit with the Iowa Test of Educational
Development.
Population Studied
By utilizing the resources of the Iowa Testing Program, located at the University of Iowa, the test was administered in conjunction
with
the annualstate-wide regular high school testing program, the Iowa Test of Educational Development (ITED).
The test was distributed among grade 9 through 12
students who were randomly selected from a rep-resentative sample of 20 high schools from around the state. A total of 1676 students provided usable
tests.
Statistical Analysis
Two-factor completely crossed analyses of
van-ance were computed to examine the relationship of
sex and grade to CDA scores. Three-factor
com-pletely crossed analyses of variance were computed
to examine the relationship of sex, grade, and
CCDA
to scores on the first two subtests of theICDT (normal child development and child health maintenance factors). Disproportionate cell
fre-quencies were accommodated by partiallying out confounding effects.
RESULTS
Performance on Child Development and Child Health Maintenance Sections
The 12th grade students generally answered more
items correctly on these two sections. Of the 12th grade students, 54% correctly identified
develop-mental landmarks at birth, 6 months, 1 year, and 2 years of age; 76%
correctly
identified
the landmarks
of a 6-year-old child.
Of
the 12th grade students, 13% had expectations for a newborn that were beyond the capacity of a newborn-1.5% expected a newborn to roll over andsit alone. At the 6-month-old level, 10% of the students had performance expectations that were higher than appropriate; 5% of the 12th grade stu-dents expected a 6-month-old child to stand without help and 1.5% expected a 6-month-old to scribble with a crayon.
For the 1-year-old child, 39% of seniors had ex-pectations that were higher than a normal
devel-opmental level; for the 2-year-old child, 15% had
excessive expectations, and 12.5% had excessive
ex-pectations for a 6-year-old child.
ques-tions was better than on the child development
section. Among the 12th grade students, 60%
rec-ognized all the parental factors associated with child abuse, 80% recognized normal oral temperature,
and 75% selected all the correct diseases for which
a child can be immunized; however, only 36% an-swered the question about infant feeding correctly
and 38% answered the question about inherited conditions correctly. Knowledge about pregnancy
jeopardy was also poor with 47% of 12th grade students believing that pregnancy could not take place during a woman’s “safe” period and 12% be-lieving that pregnancy was not possible for a 14
year old who has had only one menstrual period.
Although more students answered health items cor-rectly, some of the answers are cause for concern. For example, 5.5% of seniors believed that normal oral temperature was 104 F (40.0 C); 23% believed that the primary effect of television viewing was to
increase imagination; 6.5% believed that a 1-month-old infant should be fed hourly; 7% cited that a 1-month-old infant needed some solid food; 5% an-swered that bottle milk was better food than breast
milk for the baby; 3.5% believed that bottle milk
caused less allergy; 5.5% believed that the safest age for pregnancy was when the mother was less than 21 years of age.
Attitudes about the need to compliment and
re-ward children were negative in 20% of seniors.
Toi-let training would be started at age 1 year by 41%
of seniors; 15% would use spankings at 1 or 2 years
of age for “accidents.” The need to hold a baby
“very little” was expressed by 33% of 12th grade
students. Only 54% recognized the danger of
shak-ing a young child as a disciplinary method; 64% saw
thumb-sucking in a 3-year-old as abnormal and
requiring action.
In responding to management situations in which
slapping and spanking was offered as one
alterna-tive discipline approach, depending on the question, that answer was selected by 1% to 13% of senior students. They selected spanking less often for the
child more than 2 years of age, and concerning
curfew for a 13 year old, 31% preferred parental “firmness” over compromise (59%).
Teenagers expressed some degree of tolerance in their approach to child abusers: 40% would take the
abused child away from the parents, 50% would
offer help to the parents, and only 2% would jail the
parents.
Girls scored higher than boys on both subtests (P < .01). Test scores increased in a linear fashion
with grade for the Child Health Maintenance Fac-tors subtest (P < .0003). A similar, although
nonsig-nificant, trend was found for the normal
develop-ment subtest (P < .09).
Performance on Child Discipline Approaches Section
Abuse was the least frequent CCDA; 37 (2.2%) of the students were characteristically abusive in their
choice of childrearing approaches. Positive
rein-forcement was the most frequent CCDA: 1,005
(59.9%) of the students used positive reinforcement as their characteristic response to child disciplinary
situations.
More boys than girls tended to have punish and abuse CCDAS. Only the punish CCDA in the 12th grade reversed this trend. More girls than boys
possessed positive reinforcement CCDAS at all
grade levels.
For both subtests, Child Development
Knowl-edge and Child Health Knowledge, differences were found in ICDT subtest scores for students with
different CCDAs (P < .01). On both subtests, stu-dents with reinforce CCDAs scored the highest. Students with lecture CCDAS had the second high-est scores. Next came students with ignore or isolate
CCDAS. The lowest scores were achieved by
stu-dents with punish or abuse CCDAS. A statistically
significant grade by CCDA interaction complicates the interpretation of the CCDA means for the Child
Health Maintenance Factors subtest. The pattern
of change in the child health factors subtest scores as the grade level increased varied dramatically depending on the student’s CCDA.
Students with abuse and punish CCDAs were the
most deviant. The most pronounced change was
manifested by the 23% decline in ICDT Health
Maintenance Factors subtest scores from grades 9
to 10 for students with punish CCDAS. Compared
with the 5% increase for students with positive
reinforcement CCDAS over the same period, this decline was statistically significant at the .05 level. The small number of responses contributed to the lack of significance of score differences for other CCDA groups from grades 9 and 10.
To explore further child discipline approaches,
scores from the six CDAS were submitted to a
two-factor analysis of variance. Sex and grade served as the independent variables. Girls generally increased the percent of ignore options selected as grade level
increased whereas the reverse was true for boys. The effects of grade level on positive reinforcement
and abuse CDAS were statistically significant at the .05 level. Positive reinforcement CDA scores con-sistently increased as grade level increased; abuse CDA scores were erratic but tended to decrease as
grade level increased.
There were statistically significant differences be-tween boys and girls for the punish, positive rein-forcement, lecture, and abuse CDA scores (P <
respec-tively). Boys were more likely to select punish and
abuse options whereas girls were more likely to select isolate and positive reinforcement options.
Family Size, Ordinal Position, Educational Goals, and Childrearing Experiences
Students indicated that their knowledge about
children and childrearing care came primarily from
their families; 43.6% of the students responded that their family was the primary source of such
infor-mation. However, the next largest group (26.5%)
admitted to a lack of knowledge of these areas. A
majority (58.5%) of the 12th grade students had
never taken a class in childrearing or child
devel-opment; a similar percentage believed that these
subjects should be taught to all students in schooL
Of the 12th grade students, 36.5% were from families of five or more, 3% were the only child, and
24% were the youngest child; this indicates that 73%
should have had some experience dealing with a
younger sibling in the home. However, the number
of siblings was unrelated to knowledge of child
development or child health maintenance (P < .02
and P < .5, respectively).
DISCUSSION
Three basic conclusions result from this study: high school students of all grades and both sexes had relatively little knowledge of child development
and child health maintenance factors; ninth and
tenth grade students knew substantially less than 11th and 12th grade students and boys in all grades knew less than girls.
The mean score on the child health maintenance
knowledge section of the best performers, 12th
grade girls, was 64% correct; for boys it was 55.8%
correct. The performance by 12th grade students on the child development section was poorer; the percentage of correct answers for girls was 53.7 and
for boys 49.2.
The lack of knowledge of normal child develop-ment is a factor in high and unrealistic expectations for a child’s performance, and has been cited as a major variable in child abuse.24 In this study
stu-dents whose highest probability of response to a
child disciplinary problem was either to punish or
abuse knew less about child development and child
health maintenance factors (Scheffe: F5,,0 = 115.86, P < .01) than their peers. In contrast,
stu-dents for whom positive reinforcement was their CCDA tended to possess the highest level of knowl-edge about child development and health mainte-nance factors of any of the CCDA groups. The relationships ofthese findings to actual childrearing practices is unknown.
It is encouraging to note that there was an im-provement in knowledge as adolescents progressed through high school. The factors influencing this progress are uncertain. It is also heartening to know that for the majority of students (59.9%), their
highest probability of response to a child discipline situation was to give positive reinforcement for appropriate behavior and that the percentage of
abuse responses selected by both boys and girls
declined as grade level increased (except for the
11th grade in which the percentage increased by 1.1). In addition, the percentage of positive
rein-forcement responses selected by both boys and girls
increased with grade level.
Of concern is the poorer performance by boys at all grade levels. The average tenth grade girl knew more about normal child development (50.5%) than
the average 12th grade boy (49.2%) and the average ninth grade girl knew more about child health main-tenance factors (57.9%) than the average 12th grade
boy (55.8). In addition, except for a slight decline in
the 11th grade, the percentage of ignore responses
in childrearing situations selected by girls increased with grade level; whereas for boys, the percentage decreased as grade level increased. Concern about
the
future
parenting
role
of these high school boysis amplified by the findings that boys were more
likely
than
girls
to use punishment and abuse as ameans of child discipline (P < .0001). This lack of
knowledge and tendency toward violent discipline
choices for teenage boys may contribute to their
potential for child abuse.
The poorer performance of younger teenagers would appear to place them in most jeopardy for
being abusive parents with younger boys having the
highest potential for an abusive response to a child
disciplinary situation. There was an upward trend
in the percent of abusive CCDAS from 3.5% among ninth grade boys to 5.1% in 11th grade boys; 3% of
12th grade boys had an abusive CCDA. The poten-tial for abuse in a real situation under stress may be even higher.
The fact that any of the students chose abuse as
their most likely response to a child discipline
sit-uation is cause for concern, especially in such an emotionally uninvolved situation as a pencil and
paper questionnaire. It is possible that this may
translate into actual behavior when these students
are confronted by a real child discipline situation. The effects of Iowa high school students’ high academic achievement on the results of their
per-formance on the ICDT are uncertain. If students
experiencing the socioeconomic factors that are
known to be associated with early parenthood and
child abuse could have been identified as a group,
abusive CCDAS and other approaches to discipline.
The students (26.5% of the 12th graders) admitted to a lack of knowledge in these areas, despite cited
opportunities to learn about children from their
families. Only 11% of the seniors claimed the
class-room as a primary source of knowledge about
childrearing and child development. Of the senior
students,
58.5% believed that these subjects shouldbe taught to all students in school; 58.5% also never had a class in child development.
In the past, knowledge about childrearing and
child development was expected to come from the home. The decrease in family size and the increase in the number of mothers in the work force may
have a detrimental effect on the knowledge of
childrearing and child development that can be
learned from role models in the home, although one study concluded that experience with younger
brothers and sisters has not helped in
understand-ing of child development and the need for pa-tience. The same study indicated that limited help
for teenage parents came from grandparents and
physicians.
The expense and relative ineffectiveness of
sec-ondary
child
abuse
prsvention
has encouraged
efforts in primary
prevention
before abuse hastaken place. Classes in childrearing,
family
life,
andhealth education are not available in all school
systems.ss There are questions about the effective-ness of traditional educational experiences and
new programs that offer child management experi-ence3’ on actual childrearing practice. If potential parents are to be exposed to cognitive knowledge
about childrearing, child development, and child health maintenance, educational programs should
begin before the age when pregnancy is a possibility. These programs may be of low priority at a time when schools are emphasizing a return to basics.
For example, in 1978 the Iowa Department of Public
Instruction
reviewed
the educational
priorities
sub-mitted by 60 public and nonpublic schools. Practice
and understanding of health and safety and skills
of family living each had an average rank of 12.8.
Much parenting education takes place in the pediatrician’s office. As an advocate for children, the pediatrician has a responsibility to help
guar-antee the opportunity for children to develop
ade-quate parenting skills. The results of this study
suggest that it may be necessary to educate school systems about the need for comprehensive educa-tional programs in child development, child health
maintenance, and childrearing.
ACKNOWLEDGMENTS
The authors express appreciation to Leonard S. Feldt, PhD, Director ofthe Iowa Testing Program, for technical
assistance and to Gerald Solomons, MD, whose concern for handicapped and abused children was the impetus for
this study.
ADDENDUM
Copies of the ICTD test with results of each question
by grade level are. available from one of the authors
(C.F.J.). All tables including those that indicate CCDA distribution by grade and sex; analysis of variance with ICDT scores as dependent variables and sex, grade, and CCDA as independent variables; analysis ofvariance with
CDA scores as dependent variables; and discussion of the
psychometric properties of ICDT are also available from
one of the authors (M.A.).
REFERENCES
1. Heifer RE, Kempe CH (eds): The Battered Child, ed 2. Chicago, University of Chicago Press, 1974
2. Silverman FN: The roentgen manifestations of unrecognized skeletal trauma in infant& Am J Roentgenol Radium Ther
NuclMed69:413, 1953
3. Kempe CH, Silverman FN, Steele BF, et a!: The
battered-child syndrome. JAMA 181:17, 1962
4. Vaughan JH: Statement to Subcommittee on Health of the Committee onLabor and Public Welfare. School-age Mother and Child Health Act. US Congress, Senate, 94th Congress first session on S.2538, Nov 4, 1975, p 562
5. Zero Population Growth, Teenage Pregnancy: A Major
Problem for Minors. Washington, DC, 1976, p 1
6. 11Million Teenagers: What Can Be Done About the Epi-demic ofAdolescent Pregnancies in the United States. New York, The Alan Guttmacher InstitUte, Planned Parenthood Federation of America, 1976
7. Teenage Pregnancy. National Commission on the
Observ-ance of International Women’s Year, Department of State, Washington, DC, 1977
8. Hartley SF: Illegitimacy. Berkeley, University of California Press, 1975
9. Melnick B, Hurley JR Distinctive personality attributes of child-abusing mothers J Consult Clin Psychol 33:746, 1969 10. SmIth SM, Hanson R 134 battered children: A medical and
psychological study. Br Med J 3:666, 1974
11. Shriver BK: Statement to Subcommittee on Health of the
Committee onLabor and Public Welfare. School-age Mother
and Child Health Act. US Congress, Senate, 94th Congress, first session on 5.2538, Nov 4, 1975, p 361
12. Goldson E, Fitch MJ, Wendell TA, et al: Child abuse: Its relationship to birthweight, Apgar score and developmental
testing. Am JDis Child 132:790, 1978
13. Stern L: Prematurity as a factor in child abuse. Hosp Pract
8:117, 1973
14. Morse CW, Sahier OJZ, Friedman SB: Athree-year followup
study of abused and neglected children. Am J Dis Child
120’.439, 1970
15. Johnson B, Morse H: Injured children and their parents.
Children 15:147, 1968
16. Levenson P, Atkinson B, Hale J, et al: Adolescent parent
education: A maturational modeL Child Psychiatry Hum
Dev W.104, 1978
17. Segal J: Child abuse: A review ofresearch. Fam Today 2:577, 1979
18. Silver L Child abuse syndrome: A review. Med Times 96:803, 1968
19. Smith SM, Hanson H, Noble 5: Parents of battered babies:
A controlled study. Br Med J 4:388, 1973
21. Milner JS, Wimberley RC: An inventory for the identifies-tion of child abusers. J Clin Psychol 35:95, 1979
22. DeLissovoy V: Child care by adolescent parent& Child To-day 2:22, 1973
23. DeLissovoy V: Concerns of rural adolescent parents. Child
Welfare 54:167, 1975
24. Spinetta JJ, Rigler D: The child-abusing parent: A psycho-logical review. Psychol Bull 77:296, 1972
25. Task Force on Student Achievement in Iowa: Final report.
State of Iowa, Dept of Public Instruction, Des Moines, IA,
1979
26. Krugar, WS: Education for parenthood and the schools.
Child Today 2:4, 1973
27. Besharov DJ: Building a community response to child abuse
and maltreatment Child Today 42, 1975
28. American School Health Aseodation School Health in
America: A Survey ofState &hoolHealth Programs. Kent, OH, 1976
29. Morris HG: Parent education in wall-baby care: A new role for the occupational therapist. Am J Occup Ther 32:75, 1978
30. Cerreto MC: Parenting education The panacea for all ills?
J &h Health 49:537, 1979
31. Marland SP: Education for parenthood. Child Today 2:3,
1973
32. Loxterkamp D (reviewer): Iowa Department of Public
In-struction Files, Des Moines, IA
THE 12 GLOBAL INDICATORS TO BE USED FOR MONITORING AND
EVALUATION OF THE GLOBAL STRATEGY
(FOR HEALTH FOR ALL BY THE YEAR 2000]
The number of countries in which:
1. Health for all has received endorsement as apolicy at the highest official level, eg, in the form of a declaration of commitment by the head of state; allocation of adequate
resources equitably distributed; a high degree of community involvement and the
establishment of a suitable organizational framework and managerial process for national
health development.
2. Mechanisms for involving people in the implementation of strategies have been formed or strengthened, and are actually functioning, ie, active and effective
mecha-nisms exist for people to express demands and needs; representatives of political parties
and organized groups such as trade unions, women’s organizations, farmers’ or other occupational groups are participating actively; and decision-making on health matters is adequately decentralized to the various administrative levels.
3. At least 5% of the gross nationaiproduct is spent on health.
4. A reasonable percentage of the national health expenditure is devoted to local health care, ie, first-level contact, including community health care, health centre care, dispensary care and the like, excluding hospitals. The percentage considered “reasonable” will be arrived at through country studies.
5. Resources are equitably distributed, in that the per capita expenditure as well as
the staff and facilities devoted to primary health care are similar for various population groups or geographical areas, such as urban and rural areas.
6. The number ofdeveloping countries with well-defined strategies for health for all, accompanied by explicit resource allocations, whose needs for external resources are receiving sustained support from more affluent countries.
7. Primary health care is available to the whole population, with at least the
following: (a) safe water in the home or within 15 minutes’ walking distance, and
adequate sanitary facilities in the home or immediate vicinity; (b) immunization against
diphtheria, tetanus, whooping-cough, measles, poliomyelitis, and tuberculosis; (c) local
health care, including availability of at least 20 essential drugs, within one hour’s walk or
travel; (d) trained personnel for attending pregnancy and childbirth, and caring for
children up to at least 1 year of age.
8. The nutritional status ofchildren is adequate, in that: (a) at least 90% of newborn
infants have a birth weight of at least 2500 g; (b) at least 90% of children have a weight for age that corresponds to the reference values given in Annex I to Development of Indicators for Monitoring Progress Towards Health for All by the Year 2Ov’X.
9. The infant mortality rate for all identifiable subgroups is below 50 per 10(X) live-births.
10. Life expectancy at birth is over 60 years.
1 1. The adult literacy rate for both men and women exceeds 70%. 12. The gross nationalproductper head exceeds US $500.
Submitted by Student
From thirty-fourth World Health Assembly adopts global strategy for health for all. WHO Chronicle
