A qualitative study on corporal punishment and emotionally abusive disciplinary practices among mothers of children with ADHD

ABSTRACT OBJECTIVES The present study aimed to investigate actual disciplinary behaviours of Turkish mothers’ in the context of relational environment and to investigate ADHD as a risk factor on abusive disciplinary practices. METHODS Totally 120 children (children with ADHD; study group and healthy controls; control group) – and their mothers were interviewed with this aim. The interviews were qualitatively coded and analysed. T-test and Odds ratio were used for descriptive statistics with the aim of supporting the qualitative results. RESULTS According to the results of the study, emotionally abusive disciplinary behaviours (81% of all mothers 58% of all children) and corporal punishment (76% of all mothers and 65% of all children) were commonly used as a disciplinary method. Nevertheless, children with ADHD was shown to be at higher risk for both abusive disciplinary practices. The present study has also shown that children with ADHD and their mothers shared less positive activities compared to the control group. In addition to this, emotionally abusive disciplinary practices were found to be at least as hurtful as corporal punishment. CONCLUSIONS To our knowledge, the present study was the first one investigating Turkish mothers’ actual abusive disciplinary acts together with the relational environment between them and their children (including their relationship, positive sharing, problematic issues) by gathering information from both mothers and children of both study and control groups and then comparing these groups in terms of all these aspects. Qualitative nature of the study gave the opportunity of determining the actual disciplinary methods and the actual relational risk factors rather than attitudes and questionnaire scores about mother–child relationship. Therefore, it can be suggested that the results of the study provide important information about the abusive disciplinary behaviours of Turkish mothers and also provide the opportunity of predicting risk factors – keeping cultural context in mind – of these behaviours.


Introduction
Discipline is a process of learning and obeying the rules and this process is controlled first by the external sources (parents, teachers etc.), later by the internal sources [1,2]. However, there is a fine line between appropriate discipline and abusive disciplinary styles and childhood abuse is shown to have highly adverse effects both in the short [3,4] and long-term [5,6]. Risk factors related to childhood abuse are also widely studied [7][8][9]. However, child abuse does not always occur as a result of intentionally harming the child. Therefore, abusive behaviours for disciplinary purposes should also be explored in terms of parental (e.g. parenting stress, disciplinary attitudes, childhood abusive experiences …), child-related (e.g. mental retardation, aggression, attention or learning difficulties …) or societal (e.g. cultural approval …) risk factors.
Among the societal factors cultural approval is shown to be associated with abusive disciplinary attitudes. Studies conducted in different cultures widely reported that parents believe in the effectiveness of corporal punishment and approve using slight corporal punishment [10][11][12]. According to researchers who applied questionnaires related to abuse assessment, inappropriate attitudes such as shouting, physically punishing, and threatening were among the approved disciplinary styles for Turkish mothers [13][14][15]. While high parental stress and childhood maltreatment experiences are among the most commonly reported parental risk factors for abusive disciplinary attitudes, externalizing disorders such as Attention Deficit Hyperactivity Disorder (ADHD) is one of the riskiest child characteristics [8,16,17].
Preventing abusive discipline is also important for protective child mental health policies because it may disrupt children's appraisals about themselves, others and the world, accordingly, impairs and weakens their coping ability [18]. Especially when prolonged, abused children are at increased risk of developing lower selfesteem, learned helplessness, somatization, behavioural problems, posttraumatic stress disorder, externalizing and internalizing disorders, marital problems, eating disorders [19] and personality disorders [20,21].
Depending on these, this study investigates whether ADHD is a risk factor for abusive disciplinary practices and also manifest cultural factors associated with preferences of these disciplinary practices. With this aim, a qualitative study was constructed. Semi-structured interviews were conducted with children with ADHD diagnosis, children having no psychiatric diagnosis and mothers of all children. Interviews were about disciplinary practices of mothers and included 4 standard questions. Answers of both mothers and children are qualitatively analysed and discussed in the light of literature.

Subjects
There were two main groups of subjects namely study group and control group. Study group consisted of 95 children diagnosed with ADHD and 95 mothers of these children. The study group consisted of three subgroups that included three subtypes of ADHD [Attention Deficit Disorder (ADD, n = 29), Hyperactivity Disorder (HD, n = 12), Combined Type of ADHD (n = 54)] taken among the first applications to University of Hacettepe Child and Adolescent Psychiatry Polyclinic. Control group consisted of 25 children having no psychiatric diagnosis and 25 mothers of these children. In all groups, the age range of children included in the study was between 71 and 158 months. The exclusion criterion was having neurological disorder and having scores below 80 on all Intelligence Quotient subtypes (Verbal IQ, Performance IQ, and Total IQ). Groups were matched on child age, parental age, paternal education, maternal education.
Existence of ADHD diagnosis and comorbid disorders were determined by a semi-structured instrument, named Schedule for Affective Disorders and Schizophrenia for School-Age Children: Present and Lifetime Version (K-SADS-PL). The instrument was originally developed by Kaufman and colleagues [22] and adapted to Turkish by Gökler and colleagues. [23] Intelligence of the children were measured by Wechsler Intelligence Scale for Children -Revised (WISC-R). The scale was developed by Wechsler in 1949 and revised in 1974 and was studied in Turkish by Savaşır and Şahin in 1995 [24].
In order to obtain more detailed information about the actual disciplinary practices of the mothers, all children and mothers were interviewed with open-ended questions. Four standard open-ended questions, regarding disciplinary practices of mothers, were prepared by the researchers and asked all mothers and all children by either a psychologist or psychiatrists. Answers gathered to form the participants were exhaustively written and child neglect and abuse were particularly detected.

Procedure
Prior to the study acceptance from Hacettepe University Ethical Committee was obtained. All children and parents were informed about the rationale of the study. Volunteer families were included in the study after signing the informed consent form. Among applications to the child and adolescent mental health department of Hacettepe University Child Hospital, 6-13-year-old children with ADHD diagnosis were included in the study in case they did not meet the exclusion criteria. All children, both in study group and control group, were screened for their intelligence and child mental health problems. With the aim of screening intelligence and mental health problems, WISC-R and K-SADS-PL were administrated to all children and K-SADS-PL was also administrated to mothers. Control Group was consisted of the children who were screened and found to have no mental health problems. In addition to the clinical interview, made for the decision of diagnosis (K-SADS-PL), a semistructured clinical interviewconsisting of standard open-ended questions asked to all mothers and childrenwas made. Questions were prepared for the present study and they covered the disciplinary practices of mothers with special emphasis to the possible existence of emotionally or physically abusive attitudes. All interviews are recorded.

Data collection and analyses
This is a single-center, case-controlled, cross-sectional, qualitative study. However, some results are supplemented with basic comparative analyses such as ttest (for differences on demographic variables) and odds ratio (for the corporal punishment and emotionally abusive disciplinary practices). Data related to the main variables (corporal punishment, emotionally abusive disciplinary practices, relational environment, disciplinary practices that affect children most negatively) of the study were qualitatively coded and analysed. During qualitative analysis, in accordance with Colaizzi's seven-step method, initially, all answers to each question were coded separately. Later, answers of each question were reviewed, statements that were relevant to the phenomenon of the study were identified, categorized around the common themes. Following these, the phenomenon was first exhaustively and then briefly described. Though Colaizzi's last step suggested gathering participants' verification, it was not possible for this study because of two reasons; (1) the sample size was too large for such method (2) it was expected that there will be significant differences between the researchers and participants' perspectives, as a course of the study nature. Hence, the compatibility between the themes and the statements was reviewed by other researchers instead of participants. The categorizations were first performed by one researcher and then checked by a second researcher. When a consensus is obtained between the two researchers categorization was reviewed by all other researchers. After all these steps, codes of mothers and children of both groups (namely; control group and the study group) were compared. Codes were also compared among three subgroups of the study group (ADD, HD, Combined Type of ADHD). Odds ratio values were used to indicate the statistical significance of the main findings and to support the qualitative results.

Sample characteristics
Control group constituted 21% (n = 25), children with ADHD constituted 79% (n = 30). In all groups the age range of children included in the study was between 71 and 158 months (Mean = 106.39). Thirty-one percent (n = 37) of the participants were girls and 69% (n = 83) of the participants were boys. In addition to the age and gender of the child there were eight more demographic variables of the study, namely; parental age, paternal education, maternal education, income of the family, number of siblings, duration of using pacifier, child's relationship with friends and family. Results revealed no significant group differences on demographic variables except for family income (t (116) = −3.005, p < .05). It was found that 40% (n = 38) of children had comorbid oppositional defiant disorder, 6% of the children (n = 6) had comorbid conduct disorder and 36% children (n = 34) other comorbidities (detailed information were given in Table 1).

Relational environment of mother and child
Study group mothers and children reported less joyful moments and more conflict areas whereas the opposite was true for the control group. When groups were compared with each other, study group mothers reported that they had significantly less joyful moments together which included social sharing with their children (odds ratio: 2.91, p < .05). Similar results were obtained on conflict areas. Issues related to academic performance and doing homework seemed to be the most frequent problems experienced by mothers (n = 47, 49%; n = 9, 36%; for mothers in the study group, for mothers in the control group) and children (n = 23, 24%; n = 3, 12%; for children in the study group, for children in the control group) of both study and control groups.
Two other issues that mothers of the study group experienced trouble were behaviour problems of the children (n = 22, 23%) and not doing things they were told to (n = 31, 33%). Children in the study group complained about the restriction for watching TV and playing computer (n = 24, 25%). Together with the time spent across the TV or computer, children stated that their attention deficit or their hyperactive (restlessness) behaviours (n = 25, 26%) were also among the important factors that frequently become a problem between their mothers and themselves. Eating problems, behaviours to siblings or friends, timing for playing and sleeping, were among other issues labelled by mothers and children as problem areas between them.

Corporal punishment
When corporal punishment was investigated, 76% of all mothers and 65% of all children reported that corporal punishment was accepted as a discipline method in their houses. Specifically, participants in both groups, mostly mothers, reported that hitting was used as a discipline method in their family. When study and control groups were compared, data gathered from both mothers and children indicated that mothers of the study group were more likely to use corporal punishment than the mothers of control group (odds ratio: for mothers; 3.36, p < .01, for children; 4.44, p < .001).
In addition to these, 6% (n = 6) of study group mothers and 8% (n = 2) of control group mothers and 15% (n = 14) of study group children reported that there were also other things used for hitting in their family (e.g. hanger, rolling pin). Whereas, none of the control group children confirmed this. Some participants also reported that there were other physical discipline methods like shaking or nipping the child, pulling hair, pulling ear, etc. Among these parents, one mother from the study group reported that she was putting pepper to the tongue of her child when s/he does something wrong and another one reported that she slatted her child's throat when she gets angry at him/her. Parents generally told that the methods were generally used by parents when in order to discipline the child without hitting. However, almost all of the families who used these methods first, also reported that the process mostly resulted in hitting. In general, parents reported that they were trying to discipline their children by first trying to talk to them, then they shouted and used emotionally abusive discipline, and when they thought that none of them worked, they resorted to corporal punishment. A mother of an 8-year-old boy in the ADHD group explained her helplessness about handling her son's behaviour problems as: I tried to talk, I even tried tell him my expectations by writing … None of them worked … When he makes me angry I try to stay far away from him by washing the dishes, making some house cleaning … However, he mostly continues misbehaving and eventually I have to beat him even though I don't want … In order to understand which problems specifically increase the likelihood of being exposed to corporal punishment, the ratios of study group are also studied among 3 subgroups of the study group (ADD, HD, Combined Type). The results indicated that hitting was used as a discipline technique mostly in the Hyperactivity Disorder group according to both children and mothers in this group. The ratios of children and mothers of ADD group and Combined Type group were almost the same. Odds ratios did not indicate significant difference among three groups but the corporal punishment risk of control group was significantly lower than all three children groups and mothers in two subgroups of study group (namely; Hyperactive Group and Combined Type Group). Results are given in detail in Table 2.
When the frequency of corporal punishment was investigated, 44% of the mothers in the study group and 12% of the mothers in the control group reported using corporal punishment more than two times in a week. The information about frequency could be gathered only from the mothers because as expected, based on characteristics of their developmental stage, the children aged between 6 and 13 years had great difficulty about telling the time or the frequency of anything they have experienced or they were exposed to.

Emotionally abusive disciplinary practices
According to data related to the emotionally abusive discipline, both mothers 81% of all mothers (83%, n = 79 for study group, 72%, n = 18 for control group) and 58% of all children (60%, n = 57 for study group, 48%, n = 12 for control group) reported that emotionally abusive discipline was used in their houses. Answers given by all groups were categorized and 6 categories were obtained namely; cursing, refusing, comparing, threatening, and arousing pity, insulting. According to the results; the study group mothers, control group mothers and study group children mostly reported that insulting and arousing feeling of pity were commonly used with disciplinary purposes in their homes. However, most of the children in the control group did not report being yelled at and being exposed to emotionally abusive discipline. Results are given in detail in Figure 1.
Results also indicated that according to the children insulting is more common in the study group compared to the control group (odds ratio: 6.7, p < .01). Nevertheless, generally mothers stated that they resorted to several emotionally abusive disciplinary practices from more than one category. For example; A mother of a 9 year-old boy reported that she used the following words/sentences: "don't you understand, are you not listening, are you stupid, are you mentally retarded, are you idiot, I hope you die and I get rid of you, I wish you were not born, where did you come from, you cause the fights of me and your dad. We have no peace left, we are continuously fighting because of you." She also stated that she and her husband closed their son to the toilet, they forbid him go out and play with his friends, and they sometimes did not give meals to punish him.
In order to understand which problems specifically increase the likelihood of being exposed to insulting, the ratios of study group are also studied among 3 subgroups of the study group (ADD, HD, Combined Type). According to the information gathered from mothers, insulting was used as a discipline technique mostly in the Hyperactivity Disorder group. However, the information given by children indicated that children in Combined Type Group were mostly exposed to insulting. Results are given in detail in Table 2.
When the frequency of the emotionally abusive discipline was investigated, among the control group 28%, among the study group 52% of the mothers reported that they were using emotionally abusive discipline at least 2-3 times a week. The information about frequency could be gathered only from the mothers because as expected, based on their developmental characteristics, the children aged between 6 and 13 years had great difficulty about telling the time or the frequency of anything they have experienced or they were exposed to. When insulting was specifically investigated, it has been seen thatin both study and control groupswords related to the mental capacity of the child (ex., stupid, moron) were highly used (54%, n = 51 for study group and 44%, n = 11 for control group). Among the children 26% (n = 25) of the study group told being called with these insulting words whereas 8% of the control group children reported to be called with these words. Other insulting types were; wishing not having given birth to that child (doğurduğuna i1işkin pişmanlık dile getirmek), calling the child with animal names (hayvan yakıştırması yapmak), swearing saying handicapped, dishonourable (şerefsiz demek).
Disciplinary practices that affect children most negatively 47 children (39 study group, 8 control group) mentioned that among two types of these abusive attitudes (verbal and physical), one of them hurt their feelings more than the other. Children in both study and control group stated that they feel worse about the insulting words they hear from their mothers. For example; an 8-year-old child, from the study group, reported that his mother was frequently using words like moron and that eventually after their quarrel he asked her if she really meant those words. The boy also added that sometimes he was also questioning "if he is so," but he was not doing this too much. Results are given in detail in Table 3.

Discussion
Results of the study indicated that mothers of children with ADHD had less communication with their children and were doing less activities that included sharing, more frequently used insulting words and hitting to their children as a discipline technique when they think that things are going wrong and feel that words are useless. According to these, ADHD children are at increased risk for physical/corporal and verbal disciplinary practices and low interaction is associated with  these. For example; A boy stated that his mother always did the housework but shared nothing with him and that his father did not spend any time with him either. Similarly, a mother of 12-year-old boy shared that she was bored when she stayed alone with her son and she really didn't know what to do at those moments. This result is congruent with the expectations because as the frequency of positive interaction between parents and children decrease, the risk of abusive disciplinary practices is known to increase [25]. Since both corporal punishment and adverse family relationships are reported to have negative outcomes on children's self-regulation and impulse control [26] it can be suggested that lower quality of parent-child relationship may lead to increased misbehaviour of children through the increased use of corporal punishment. Parenting to a child with ADHD can be stressful. This may be one of the reasons for the lower amount of social sharing activity between ADHD children and their parents. Likewise, less positive moments together may also increase the stress of parenting and decrease the buffering effect of relationship and attachment between the mother and the child. Depending on these, it may be suggested that teaching parents how to improve their relationship and how to share more positive moments with their children can be helpful.
This study also indicated that some abusive disciplinary practices are culturally accepted and used among both families of ADHD children and healthy control group children in Turkey. This result supports the relationship between the positive attitudes to corporal punishment and the use of it. Similarly, Clement and Chamberlend [27] conducted a survey with mothers and found that attitudes and practices are closely associated with each other and as maternal attitudes to corporal punishment decreased in last ten years the use of corporal punishment is also decreased. This result is also in line with a previous Turkish study applying International Child Abuse Screening Tools (ICAST) to students and reporting that Turkish parents accept "insulting the child" and "using corporal punishment" as appropriate ways for disciplining children [14]. The present study is conducted with both mothers and children and used qualitative interviews questioning disciplinary practices. For this reason, it can be suggested that the results of this study included both the mothers' and the children's perceptions and also revealed the actual disciplinary practices of parents rather than evaluating just the attitudes. This is an important finding because attitudes predict behaviours but they are not exactly the same and knowing the actual disciplinary practices of parents give the opportunity of organizing more effective training programmes for parents.
It was also determined that children diagnosed with ADHD were more frequently exposed to physically and emotionally abusive disciplinary practices. When ADHD is considered as a disability effecting the school functioning this result can be accepted as consistent with the findings of Lightfood, Hill and Laliberte [28] who suggested that disabled children are more frequently maltreated. Similarly, Gökten and her colleagues [13] applied Abuse Assessment Questionnaire to children with ADHD and their healthy controls and suggested that children with ADHD are at higher risk for physical and emotional abuse. When the results of the present study and the previous studies are considered altogether, the relationship between abusive disciplinary practices and ADHD seems to be bidirectional. Parenting to a child with ADHD diagnosis may be more stressful and this may be increasing the risk of abusive disciplinary practices [29]. Nevertheless, childhood abusive experiences are also indicated to cause ADHD [4]. In a prospective study, when investigating the relationship between parents' physical punishment and children's ADHD, it was suggested that physical punishment predicts ADHD even when the underlying ADHD and ODD, and other psychological problems of parents and children are controlled [4]. Consistently Briscoe-Smith and Hinshaw [8] stated that, compared to children without ADHD, children with ADHD were more frequently and severely abused, and also compared to girls with ADHD who are not abused, abused girls with ADHD exhibited higher externalization disorder.
One possible explanation for this relationship can be about the damage on brain that is related to stress occurring because of emotionally or physically abusive disciplinary practices [30]. Another explanation may be related to vicious cycle of aggression-corporal punishment. Externalizing behaviours have been shown to predict corporal punishment [16,8] but corporal punishment is known to be a kind of aggression and cause aggression as well [31,32] Researchers suggested that spanking the child increases the likelihood of the child's exhibiting aggression and externalizing behaviour [3,31,32]. Similarly, Taylor and his colleagues (2010) reported that frequent use of corporal punishment when the child was 3 years of age predicted higher levels of child aggression when the child was 5 years of age even after controlling for the child's level of aggression at the beginning [32]. As it is shown that people who report having experienced severe corporal punishment in their childhood are evaluating corporal punishment as more acceptable [33] it can be concluded as corporal punishment increases both the risk of being an aggressive child and being an abusive parent therefore the vicious cycle occurs. The reason for this cycle may also be about the learning process. Children -who are exposed to corporal punishment-may be learning aggression as a coping method in problematic situations. Corporal punishment is shown to decrease the child's problematic behaviour in the short time but also shown to increase these behaviours in the long period [34]. Children who are exposed to physically abusive discipline are reported to be more prone to aggression when solving their problems with their peers [35].
In addition to these, this study also examined the problematic issues that increase the risk of abusive disciplinary practices. Mothers in this study reported that the most problematic issues between them and their children were related to academic performance and listening to mothers' advice. Children added to more issues to their mothers' list: hyperactivity/restlessness and spending time on TV/computer. To our knowledge, the problematic issues increase the risk for abusive discipline are not widely studied, however, in some of the previous studies physically abusive disciplinary practices are shown to be reported as associated with higher rates of behaviour problems [36]. The present study has shown that in order to decrease the abusive discipline preventive programmes should include teaching the mothers how to handle children's academic issues, behavioural problems and how to establish rules with a positive manner.
Finally, 51% of the children reported that emotionally abusive discipline was more hurtful for them. This result indicates that emotionally abusive discipline is at least as hurtful as corporal punishment. Free from the its type childhood abusive experiences are known to have various adverse psychological consequences such as depression, anxiety disorders, post-traumatic symptoms, etc. [37]. Psychological disturbance related to childhood abuse is widely studied however, children's perceptions and emotions about abusive disciplinary practices are not reported much. This result is important because it shows that children are adversely affected in the same way from both types of abusive discipline. The present study revealed that mothers frequently insulted and used words arousing pity in their children. A mother expressed that "she asked her son if he was trying to kill her or make her ill, and that she was getting ill, having bad headaches because of his misbehaviors and wishing to die soon" and that these words upset him and later she felt sorry for saying these. Similarly, a child reported that he was frequently hearing words like stupid, moron, idiot and that sometimes he was questioning if he is so. According to these abuse in general, seems to damage self and, in turn, cause psychological disturbance. Children are found to be more likely to be adversely effected from the abusive behaviours (emotionally or physically) whichever s/he perceives that directly target her/his "self." A 12year-old boy summarized the situation as: "her words hurt me more, I have gained immune to be beaten but not to the words." This finding also seems to be consistent with the limited existing literature [18]. The child may begin to perceive him/ herself as more worthless, helpless and incapable of coping in a stressful situation, the others as angrier and threatening, the world as more dangerous. Mostly, parents are the primary caregivers of children and they are responsible to take care of the child, to protect him/her from the outside sources of threat, however, when the threat comes from the parent the child loses his/her shelter and the world seems more dangerous than ever.

Conclusions
The present study is one of the few studies examining the actual disciplinary practices in Turkish culture. Existing studies generally use questionnaires and assess attitudes, however, the data of the present study was gathered by qualitative methods. Therefore, it was thought that the results could provide information on the Turkish mothers' actual disciplinary practices as well. In addition to this, the present study includes children with ADHD and also normal controls. This characteristic of the sample gives the researchers opportunity of commenting on the abusive discipline risk among both children with ADHD (that is widely shown to be a riskier group) and among children who don't have any psychiatric disorder. Psychiatric disorders were screened by K-SADS -a semi-structured interview-and IQ of the group were determined by WISC-R (a structured interview). Structured and semi-structured interviews helped the researchers create a homogenous sample on the determined characteristics. Most studies in the literature are conducted retrospectively examining childhood abusive experiences with adults and the prospective studies or the cross-sectional studies generally do not involve mothers and children together. Qualitative nature of the study gave the opportunity of determining the actual disciplinary methods and the actual relational risk factors rather than attitudes and questionnaire scores about mother-child relationship. Therefore, it can be suggested that the results of the study provide important information about the abusive disciplinary behaviours of Turkish mothers and also provide the opportunity of predicting risk factorskeeping cultural context in mindof these behaviours. In addition, this study provides important information for prevention programmes regarding problematic situations that increase the risk of abusive discipline and about the mothers' difficulties of creating positive moments that include social sharing with their children. Also, it can be suggested that the results showing that emotional abuse negatively affects children as much as physical abuse is another contribution of the study. It can be argued that this result may be indicative of a fact such as "emotionally abusive disciplinary acts should not be ignored in the area of abuse related researches." Besides all its strengths this study has also some limitations. The present study focused on maternal disciplinary practices and gathered information from mothers and children. However, raising a child with appropriate parenting practices is under the responsibility of the whole family. Therefore, to examine abusive disciplinary behaviours and underlying problems, studies involving both mothers, fathers and children are needed. This study is based on mothers and children's statements and clinicians' observations during the interviews. Future studies may include home visits to increase the data and its objectivity. Children with three subtypes of ADHD and children with no psychiatric diagnosis were included in this study, future studies may also take a third control group consisting of children with another psychiatric disorder. The comparison of two groups with different psychiatric disorders may also provide information about the specificity of the relationship between abusive disciplinary practices and the psychopathology of interest. The sample of the study included children with comorbidities. Especially comorbid oppositional defiant disorder and conduct disorder may also be associated with parenting attitudes, future studies may be conducted with a sample of children having pure ADHD. Finally, researches conducted with larger samples may give more detailed results.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
The corresponding author of the study is supported by Young Scientist Outstanding Achievement Award Program (TÜBA-GEBİP) of Turkish Academy of Sciences.