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Association of physical punishment and health outcomes in early childhood: a population representative prospective study

Pediatric Research (2025)Cite this article

Abstract

Background

Physical punishment without maltreatment is still a common practice worldwide. However, there is a dearth of prospective evidence on the effects of physical punishment on children’s physical outcomes.

Methods

Data were derived from a 3-year cohort study of a representative sample of 3–6 years old Chinese children (n = 16715). Caregivers reported the usage of physical punishment, history of maltreatment, children’s physical health status (including recurrent sickness, general physical health status, and global sleep disturbance) and two measures of medical service utilization. A propensity score weighted model was used to evaluate the effects of physical punishment on physical health outcomes.

Results

Physical punishment without maltreatment was associated with higher risk of recurrent sickness (OR = 1·15, 95% CI: 1·03,1·28), poorer general health (OR = 1·30, 95% CI: 1·16, 1·47), global sleep disturbances (OR = 1·42, 95% CI: 1·29, 1·55), and increased number of clinic visits (B = 0·18, 95% CI: 0·10, 0·26), but not the number of hospitalizations (B = 0·03, 95% CI: −0·01, 0·06).

Conclusion

Even without a history of maltreatment, physical punishment adversely affects children’s physical health and increases medical service utilization. Any form of physical discipline should be avoided.

Impact

  • The first population-representative cohort study to prospectively investigate the effects of physical punishment on physical health outcomes during early childhood.

  • Innovatively focus on physical punishment without maltreatment, revealing that even in the absence of maltreatment, physical punishment was associated with adverse physical well-being. These effects were maintained after the propensity score weighting for sociodemographic characteristics, socioeconomic status, nurturing environment factors, BMI, physical health during the neonatal period, and baseline physical health indicators.

  • Provides the first evidence that non-maltreating physical punishment independently predicts increased medical service utilization in early childhood. It highlights the hidden public health costs of physical punishment practices.

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Fig. 1: Association of physical punishment and maltreatment at baseline (Wave 1) with recurrent sickness, general health, and global sleep disturbance at second follow-up (Wave 3).

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Data availability

The datasets generated during and/or analyzed during the current study are not publicly available due to shared ownership of Shanghai Municipal Education Commission but are available from the corresponding author on reasonable request.

References

  1. United Nations Committee on the Rights of the Child. General Comment No. 8: The Right of the Child to Protection From Corporal Punishment and Other Cruel or Degrading Forms of Punishment. Geneva, Switzerland (2007).

  2. United Nations Children’s Fund. A Familiar Face: Violence in the Lives of Children and Adolescents (UNICEF, New York, 2017).

  3. Jaffee, S. R. Child maltreatment and risk for psychopathology in childhood and adulthood. Annu. Rev. Clin. Psychol. 13, 525–551 (2017).

    Article  PubMed  Google Scholar 

  4. Miller-Perrin, C. & Perrin, R. Physical punishment of children by US parents: moving beyond debate to promote children’s health and well-being. Psicol. Reflex Crit. 31, 16 (2018).

  5. Oram, S. Child maltreatment and mental health. Lancet Psychiatry 6, 881–882 (2019).

    Article  PubMed  Google Scholar 

  6. Hughes, K. et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health 2, e356–e366 (2017).

    Article  PubMed  Google Scholar 

  7. Norman, R. E. et al. The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med. 9, e1001349 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  8. Heilmann, A. et al. Physical punishment and child outcomes: a narrative review of prospective studies. Lancet 398, 355–364 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  9. Dede Yildirim, E., Roopnarine, J. L. & Abolhassani, A. Maternal use of physical and non-physical forms of discipline and preschoolers’ social and literacy skills in 25 African countries. Child Abus. Negl. 106, 104513 (2020).

    Article  Google Scholar 

  10. Murray, A. S. & Mallie, J. P. Corporal punishment by mothers and development of children’s cognitive ability: a longitudinal study of two nationally representative age cohorts. J. Aggress. Maltreatment Trauma 18, 1–25 (2009).

    Google Scholar 

  11. Horn, I. B., Joseph, J. G. & Cheng, T. L. Nonabusive physical punishment and child behavior among African-American children: a systematic review. J. Natl. Med. Assoc. 96, 1162–1168 (2004).

    PubMed  PubMed Central  Google Scholar 

  12. Akmatov, M. K. Child abuse in 28 developing and transitional countries—results from the Multiple Indicator Cluster Surveys. Int. J. Epidemiol. 40, 219–227 (2011).

    Article  PubMed  Google Scholar 

  13. Huang G. H. C. & Gove M. Asian parenting styles and academic achievement: views from eastern and western perspectives. Education. 135, 389–397 (2015).

  14. Afifi, T. O., Mota, N., MacMillan, H. L. & Sareen, J. Harsh physical punishment in childhood and adult physical health. Pediatrics 132, e333–e340 (2013).

    Article  PubMed  Google Scholar 

  15. Berger, R. P. & Zolotor, A. J. Is there an association between physical punishment in childhood and physical health in adulthood?. Pediatrics 132, e500–e501 (2013).

    Article  PubMed  Google Scholar 

  16. Wang, X. et al. Cohort Profile: The Shanghai Children’s Health, Education and Lifestyle Evaluation, Preschool (SCHEDULE-P) study. Int. J. Epidemiol. 50, 391–399 (2021).

    Article  CAS  PubMed  Google Scholar 

  17. Wang, H. et al. Types of on-screen content and mental health in kindergarten children. JAMA Pediatr. 178, 125–132 (2024).

    Article  PubMed  Google Scholar 

  18. Deng, Y. et al. Sleep disturbances and emotional and behavioral difficulties among preschool-aged children. JAMA Netw. Open 6, e2347623 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  19. Zhao, J. et al. Association between screen time trajectory and early childhood development in children in China. JAMA Pediatr. 176, 768–775 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  20. Chen, W. et al. The influence of home-rearing environment on children’s behavioral problems 3 years’ later. Psychiatry Res. 244, 185–193 (2016).

    Article  PubMed  Google Scholar 

  21. Shimada, K., Kasaba, R., Yao, A. & Tomoda, A. Less efficient detection of positive facial expressions in parents at risk of engaging in child physical abuse. BMC Psychol. 7, 56 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  22. Gan-Yadam A. Quality of Child Care Environment among the Parents of Children with Disabilities, in the case of Khovd Province, Mongolia. Research Square. Preprint https://doi.org/10.21203/rs.3.rs-3874982/v1 (2024).

  23. Anme T. et al. Validity and reliability of the index of child care environment (ICCE). Public Health Front. 2, 141 (2013).

  24. Salum, G. A. et al. Measuring child maltreatment using multi-informant survey data: a higher-order confirmatory factor analysis. Trends Psychiatry Psychother. 38, 23–32 (2016).

    Article  PubMed  Google Scholar 

  25. Shan, W. et al. Positive parent-child interactions moderate certain maltreatment effects on psychosocial well-being in 6-year-old children. Pediatr. Res 95, 802–808 (2024).

    Article  PubMed  Google Scholar 

  26. Shan, W. et al. Association between maltreatment, hair cortisol concentration, positive parent-child interaction, and psychosocial outcomes in Chinese preschool children. Eur. Child Adolesc. Psychiatry 33, 2719–2730 (2024).

    Article  PubMed  Google Scholar 

  27. Zhao, J. et al. Measuring early childhood development with The Early Human Capability Index (eHCI): a reliability and validity study in China. BMC Pediatr. 20, 323 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  28. Kenney, M. K. & Chanlongbutra, A. Prevalence of parent reported health conditions among 0- to 17-Year-olds in rural United States: National Survey of Children’s Health, 2016-2017. J. Rural Health 36, 394–409 (2020).

    Article  PubMed  Google Scholar 

  29. Owens, J. A., Spirito, A. & McGuinn, M. The Children’s Sleep Habits Questionnaire (CSHQ): psychometric properties of a survey instrument for school-aged children. Sleep 23, 1043–1051 (2000).

    Article  CAS  PubMed  Google Scholar 

  30. Li, S. et al. Development and psychometric properties of the Chinese version of Children’s Sleep Habits Questionnaire. Zhonghua er ke za zhi/Chin. J. Pediatr. 45, 176–180 (2007).

    Google Scholar 

  31. Wang, Y. et al. Effects of sleep disturbances on behavioral problems in preschool children with autism spectrum disorder. Front Psychiatry 11, 559694 (2020).

    Article  PubMed  Google Scholar 

  32. Chen, X., Ke, Z. L., Chen, Y. & Lin, X. The prevalence of sleep problems among children in mainland China: a meta-analysis and systemic-analysis. Sleep. Med 83, 248–255 (2021).

    Article  PubMed  Google Scholar 

  33. Li X., et al. Parent-preferred childcare environment styles: a latent class analysis and association with parental stress. Child. Youth Serv. Rev. 155, 107176 (2023).

  34. Ruffolo, L. I. et al. Outcomes after child physical abuse and association with community-level social determinants of health. J. Am. Coll. Surg. 235, 810–818 (2022).

    Article  PubMed  Google Scholar 

  35. Kendall-Tackett, K. & Klest, B. Causal mechanisms and multidirectional pathways between trauma, dissociation, and health. J. Trauma Dissociation 10, 129–134 (2009).

    Article  PubMed  Google Scholar 

  36. Sachs-Ericsson, N., Cromer, K., Hernandez, A. & Kendall-Tackett, K. A review of childhood abuse, health, and pain-related problems: the role of psychiatric disorders and current life stress. J. Trauma Dissociation 10, 170–188 (2009).

    Article  PubMed  Google Scholar 

  37. Hornor, G. Childhood trauma exposure and toxic stress: what the PNP needs to know. J. Pediatr. Health Care 29, 191–198 (2015).

    Article  PubMed  Google Scholar 

  38. Liu, Y. et al. Do children evaluated for maltreatment have higher subsequent emergency department and inpatient care utilization compared to a general pediatric sample?. Child Abus. Negl. 134, 105938 (2022).

    Article  Google Scholar 

  39. Wang, S. et al. Characteristics of prescriptions and costs for acute upper respiratory tract infections in Chinese outpatient pediatric patients: a nationwide cross-sectional study. BMC Complement Med. Ther. 20, 346 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  40. Wu, P. et al. The economic burden of medical treatment of children with asthma in China. BMC Pediatr. 20, 386 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  41. Yang, J. et al. The economic burden of influenza-associated outpatient visits and hospitalizations in China: a retrospective survey. Infect. Dis. Poverty 4, 44 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  42. Wang, D. et al. Socio-economic burden of influenza among children younger than 5 years in the outpatient setting in Suzhou, China. PLoS ONE 8, e69035 (2013).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

This study was sponsored by Shanghai Pujiang Programme (24PJD070), Shanghai Jiao Tong University Medical-Industrial Interdisciplinary Research Fund (YG2025QNB09), National Natural Science Foundation of China (82103866), National Natural Science Foundation of China Joint Fund Project (U23A20170), Shanghai Municipal Education Commission (2024you1-1, D1502), Innovative Research Team of High-level Local Universities in Shanghai (SHSMU-ZDCX20211900), and Shanghai Key Laboratory of Child Brain and Development (24dz2260100).

Author information

Author notes

  1. These authors contributed equally: Wenjie Shan, Yihong Wang.

Authors and Affiliations

  1. International Medical Department, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China

    Wenjie Shan & Lei Zhang

  2. Child Health Advocacy Institute, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China

    Wenjie Shan, Yunting Zhang & Jin Zhao

  3. Department of Developmental and Behavioral Pediatrics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China

    Yihong Wang, Jin Zhao & Fan Jiang

  4. Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong SAR, China

    Patrick Ip

  5. Department of Pediatrics and Adolescent Medicine, Hong Kong Children’s Hospital, Hong Kong SAR, China

    Patrick Ip

  6. Ministry of Education-Shanghai Key Laboratory of Children’s Environmental Health, Shanghai, China

    Fan Jiang

Authors
  1. Wenjie Shan
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  2. Yihong Wang
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  4. Jin Zhao
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Contributions

Wenjie Shan (W.S.), Yihong Wang (Y.W.), Yunting Zhang (Y.Z.) and Fan Jiang (F.J.) took the initiative in conception and design. W.S., Y.W., and Jin Zhao (J.Z.) conducted the investigation, collected the data, and provided critical suggestions on data analysis. WS and YW analyzed the data, and W.S. completed the draft. W.S., Y.W., Y.Z., F.J., Lei Zhang (L.Z.), and Patrick Ip (P.I.) made substantial contributions to the interpretation of data and manuscript revision. WS, YW, and JZ directly accessed and verified the underlying data reported in the manuscript. All the authors accepted full responsibility for the finished work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

Corresponding authors

Correspondence to Yunting Zhang or Fan Jiang.

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Competing interests

The authors declare no competing interests.

Consent statement

The study received approval from the institutional review board of the Shanghai Children’s Medical Center, Shanghai Jiao Tong University (SCMCIRB-K2016022-01). Parents of the involved children signed the informed consent before participating in the study.

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Shan, W., Wang, Y., Zhang, Y. et al. Association of physical punishment and health outcomes in early childhood: a population representative prospective study. Pediatr Res (2025). https://doi.org/10.1038/s41390-025-04600-1

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