CME Author: Zeena Nackerdien
Study Authors: Melissa A. Blight, Sarah D. Lynne, et al.
Target Audience and Goal Statement:
Pediatricians, primary care physicians, nurses, and emergency department physicians
The goal was to learn more about the temporal association between school report card release and incidence rates (IRs) of physical abuse.
“Spare the rod, spoil the child” seems to be an adage that is embedded in the national psyche, with a 2016 study finding that corporal punishment is still legal in 19 U.S. states, mainly in the South. Nationally, corporal punishment is on the decline in the U.S. and this trend is replicated across the globe. Based on 2010 estimates, 112 countries have banned corporal punishment in schools and 24 countries have banned the use of corporal punishment against children in the home. While anecdotal evidence links report card release to punishment-initiated physical child abuse, there is no empirical evidence to back up those claims.
The investigators set out to answer the following questions:
- Is there a temporal association between school report card release and incidents of physical child abuse?
- Were there patterns in the timing of the abuse that would support anecdotal evidence?
Synopsis and Perspective:
Melissa Bright, PhD, of the University of Florida in Gainesville, and colleagues, collected data from the Florida Department of Children and Families child abuse hotline and recorded dates of report card release for Florida public schools across 64 counties. They observed a 265-day window (data collected from Sept. 8, 2015 to May 30, 2016) to account for summer, and limited their data to calls that became verified cases of physical abuse, including physical injury, bizarre punishment, asphyxiation, burns, bone fracture, or internal injuries.
The authors said they focused on children ages 5-11, because “this is the age range for which the child abuse pediatricians believed they observed increases in physical abuse after report card release,” and that of children who would receive report cards; primary school-age children have the highest rates of corporal punishment and physical abuse, they noted.
Of the 167,906 calls to a child abuse hotline, 2017 (6.7%) were verified as physical abuse cases. Among the 1,943 eligible cases, 58.9% (n=1,145) were boys, with an average age of about 8. Blacks and whites comprised 41.3% and 48.2% of the cases, respectively.
Mondays through Thursdays were not linked to an association between report card release and a rise in IR of child physical abuse on the same day, or the day after release. This pattern changed for Saturdays as there was nearly a four-fold increase in the IR of verified child physical abuse reports on that day after a Friday report card release vs non-release Saturdays (IR ratio 3.75, 95% CI 1.21-11.63, P=0.02).
In the final model, adjusted IRs were significantly lower on school holidays (IRR 0.41 95% CI 0.32-0.53, P<0.001). They were significantly higher in urban counties (IRR 1.80, 95% CI 1.11-2.90, P=0.02), in counties with higher rates of child maltreatment as of 2014 (IRR 1.36, 95% CI 1.15-1.61, P<0.001), and counties with higher grade retention rates (IRR 1.24, 95% CI 1.01-1.53, P=0.04), according to the authors.
Antoinette Laskey, MD, of the University of Utah in Salt Lake City, noted in an accompanying editorial that the 95% CI for the IR was quite large — a factor that does not negate the findings, but one that needs to be taken into account when proposing systematic policy changes.
“Children who receive poor grades or negative remarks on their school report card may be at risk of physical punishment if their performance is not to the parent’s standard or if they are reported misbehaving, inattentive, or disruptive in the classroom,” the authors wrote. “Importantly, short-term consequences associated with physical abuse include poor academic achievement, emotional and behavioral problems, and conduct disorders.”
A key strength of the study was the use of many data sources (16,960 observation days) and the granularity of the data (day-level time points). On the other hand, the study may not have sufficient statistical power to detect small associations of report card release with daily IRs.
Researchers wrote that the number of verified cases of physical abuse as well as the number of report card release days were small, and may limit the data. Additionally, they noted that the number of cases was limited to those that resulted in calls, and since many cases of abuse may go unreported, this number may in fact be underestimated. The data also only included children who attended public school and had hard copy report cards so it may not be generalizable to children in private schools, or those who receive online report cards.
Source Reference: JAMA Pediatrics, Dec. 17, 2018, DOI:10.1001/jamapediatrics.2018.4346
Study Highlights: Explanation of Findings
Currently, this is the only state-population sample of children of elementary school-age that measures calls of agency-verified cases of physical abuse, and the timing of report card release at county and day levels. Based on an analysis of data from 64 of 67 Florida counties with report card release dates available, an almost fourfold increase in the IR of physical child abuse was observed on Saturdays after a Friday report card release vs non-report-card-release Saturdays.
The authors noted two possible reasons for a lack of association on other days of the week. For example, administration of harsh punishment may be avoided on days when children will have access to mandatory reporters such as teachers. Also, work and other distractions may prevent caregivers from following through on negative reactions when report cards are released on a Monday through Thursday. However, this implies a deliberateness of forethought that is atypical when a caregiver crosses the line between “routine spanking” and physical injury, the authors noted.
Additionally, caregivers may have access to grades throughout the year via gradebooks and email updates, and they may have access to a child’s academic performance beyond report cards. The results need to be interpreted within the entire context.
Nevertheless, this study complements evidence from the literature identifying temporal variations in child abuse and neglect. Hong Kong researchers noted “a peculiar seasonal pattern and an alarming increasing trend in child maltreatment hospitalization” which they speculated could be partly due to school examination stress. Although causality cannot be inferred from the present study, Bright and colleagues pointed out that it is the starting point for designing future studies examining additional, potentially influential factors, such as days missed from school for children with verified cases of physical abuse after report card release, quality of report cards, and parental beliefs about corporal punishment.
Taken together with findings from other studies pertaining to the timing and other policy-level precipitants of abuse, the authors concluded that it was valuable to look at child abuse incidence and prevention at a macroscopic level. “To the extent that children who receive poor report cards are punished by their caregivers and that this punishment sometimes crosses the line to physical abuse, several school district-level or state-level policy changes could be made to reduce the likelihood of physical abuse,” they stated.
Laskey said that although no studies have shown that corporal punishment leads to positive behavioral change, and that physical abuse can have lasting effects on a developing child, the practice is still legal in the U.S. Prior research has shown that more extreme physical discipline may be used to cause desired behavioral changes in children when the perceived initial effectiveness begins to wane in the eyes of caregivers.
“These extreme forms lead to an increased likelihood of injury to a child which constitutes physical abuse,” she wrote. Additionally, parents who spank their young children usually do not change their disciplinary strategies when these children enter school and become teenagers.
“Changing a report card release date may cause some change in the number of physical abuse cases, but it will not solve the larger issue: it is still socially acceptable to hit a child to correct their behavior,” she wrote.
Original story for MedPage Today by Elizabeth Hlavinka
Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner