TRANSCULTURAL ISSUES IN CHILD MENTAL HEALTH :WORKING WITH FAMILIES IN THE MIDWEST OF THE UNITED STATES

TRANSCULTURAL ISSUES IN CHILD MENTAL HEALTH: WORKING WITH CHILDREN AND FAMILIES IN THE MIDWEST OF THE UNITED STATES

First author. Martin Maldonado-Durán MD

Investigator, Child and Family Center, Menninger Clinic

Child psychiatrist, Family Service and Guidance Center

Adjunct professor, infant psychopathology, Kansas State University

Address. 325 Frazier Avenue

Topeka, Kansas USA 66604

Telephone 785 232 5005

Fax785 232 8611

Emailmaldo2000mor@aol.com

mmaldonado@fsgctopeka.com

2^nd Author. Velissarios Karacostas MD PhD. Child and adolescent Psychiatrist. Cincinnati Children’s Hospital. Cincinnati, Ohiio. USA

3^rd Author. Charles Millhuff D.O. Child and adolescent psychiatrist, Family Service and Guidance Center. Topeka, Kansas USA

SUMMARY.

Drawing from clinical experience in working with multiple settings in the Midwest of the United States, the authors explore a number of parenting strategies from a transcultural point of view. Parenting strategies that are clearly meaningful only within a certain cultural context, are sometimes presented as “scientific” more modern and advanced compared with practices used in traditional societies and Third World countries.We examine strategies of parents to promote self-reliance, individuation and independence in their children sometimes since they are very young.The importance of being strong, assuming one’s responsibilities and the consequences of one’s actions are very important cultural themes.We explore how parents deal with the cry of young children, how the approach feeding and sleeping, and the question of discipline. The cultural themes resonate across all these domains, where the strategies used by parents are the logical consequence of the need to be an individual from the beginning of life. We explore some possible reasons why in a highly industrialized capitalistic society, with high social mobility and progressive nuclearization of families, these strategies of parenting tend to foster emotional and character traits that are suitable to survive in such a society.

Key words:Transcultural. American culture. Individuality. Infancy. Early childhood.

TRANSCULTURAL ISSUES IN CHILD MENTAL HEALTH: WORKING WITH CHILDREN AND FAMILIES IN THE MIDWEST OF THE UNITED STATES

Introduction

We wish to present some of the most relevant transcultural issues that mental health professionals encounter when working with families in the Midwest of the United States of America.Our focus is on the cultural factors that have an impact on how parents deal with their children, their beliefs about child-rearing, their wishes and hopes for their future andhow these are translated in everyday parent-child relationships.

Our point of view is transcultural in the sense that we look at the observed themes and patterns “from outside” that is, without taking those practices as “natural” and without question. People within their own culture tend to see their practices as logical, rational and do not usually question them.Here, rather, we examine some parental beliefsand ways of dealing with children from a cultural framework, i.e. questioning how they make sense within their social group. Our goal is not to “compare cultures” or to suggest that some cultural practices are “better” than others, but simply to describe and reflect on the possible reasons for those actions and their impact on the child and the family as we see in our everyday clinical work. We position ourselves like other researches in the past have done with traditional societies, where certain myths, beliefs and practices and their meaning are discussed from an outsider’s point of view trying to understand why people do what is observed.

An important reason for our description and confrontation with these beliefs, myths and practices is that many are readily “exported” to other countries, given the role that cultural products from the United States have in many other parts of the world. Beliefs and practices thatare commonplace in the USA are often adopted elsewhere as if they were the “most scientific” or ”advanced” prescriptions. In this way, ideas, values and prescriptions about family relationships and child-rearing methods described in a number of books, journals, magazines,television programs, movies, etc. are presented sometimes as the latest advances in the field. These are adopted as “universal truths” for instance among mental health professionals, child developmentalists, etc.working in Third World countries, without questioning their applicability, relevanceor pertinence in other societal contexts.

The Midwest of the USA

In the Midwest of the U.S., much of the population is comprised predominantly of Euro American families, i.e. descendants of immigrants from Europe, in Kansas it is about80% of the population. In the area of the Midwest that includes Kansas, Nebraska, Oklahoma,Colorado, Nebraska and Missouri many immigrants moved to these plains several generations ago, primarily from Germany, but also from Britain. The majority of families are Christian, of the various Protestant denominations. This is slowly changing with increasing immigrants from Mexico, and some from Africa and Southeast Asia.

There is not a“Midwest culture”as a uniform entity- andindividual families vary vastly in their beliefs, practices and traditions. It is clear that any given family’s ancestors and “myths”vary and are quite specific depending on their history of migration, the unique blending of traditions and beliefs, and the degree of acceptance of “modern values”. Also, individual factors like the unique life histories of parents and children determine their practices, as well as socio-economical status. Despite all this, some common themes are fairly pervasive, particularly among the more disadvantaged or poor Caucasian families.

Poverty is a relative term, as what is considered poverty here might not be so in Third World countries.In the U.S. the definition of poverty corresponds to an income level for a family is below a threshold: spending above a third of the family’s total earnings to buy basic food items (Huston, 1991. Huston et al, 1994).

One of the frequent observations with parents of young children is their relative lack of exposure to parenting. Many children have grown up only in nuclear families, with little contact with other relatives who are raising infants or young children. The traditional transmission of parenting strategies from one generation to the next may be interrupted by the nuclearization of families, by the high social mobility and an emphasis on modernity. Therefore new parents may find themselves without a behavioral repertoire to deal with problemsand having to rely on books or experts tosolve problems related to children and parent child relationships (Maldonado-Duran et al, 2002).

Commonparental beliefs about children, child rearing and relationships

Self-reliance and independence.

A major theme, reflected in many parental practices, is the encouragement of the child to become an individual and to rely on him or herself as early as possible (Small, 2002). Many families in the Midwest idealize themes like taking care of one’s own problems, not depending on other people and not to become a burden to anybody: i.e. to be self-sufficient, responsible, truthful and strong. These same themes and values are conveyed to children, since they are very young.These themes are related to a strong Protestant ethics that values work, being self-sufficient, fiercely independent and relying on oneself (DeLoache et al. 2000)

In general, parents are very concerned about preparing their children for their future. They want to ensure that the child will be strong enough to resist life independently as an adult. This is more pronounced when parents themselves have experienced a difficult upbringing. In those circumstances, early losses, disruptions in attachment and disappointment force the child to be less sensitive to emotions, to “weakness” andinterested in self-reliance. The adultshope may be that their son or daughter will attain enough independence and leave home by the time they are 18 years old.

Another worry isthat children should not be “ spoiled” or made weak by beingindulged, as this does not teach them self discipline and how to do things for themselves. In a somewhat extreme version of this with families of toddlers in our infant mental health clinic, we commonly hear parents complain that their toddlers “do not pick up their toys” or that a preschool age child does not “clean up his room”.Often the expectations for self control are very high (Maldonado-Duran et al, in press). The problem with these high expectations is that many children who are more impulsive or have less self-control cannot live up to those standards.

To illustrate the cultural theme with a somewhat extreme example:

Ms. M. a 23 year old woman comes to a parent support self-help group with her two-month old daughter Ariel. Several members of the group speak about the issue of child behavior and discipline.Ms. M. then says that her daughter is now throwing temper tantrums and she is eager to talk about how to discipline her. She said that these tantrums had to be eliminated soon because the baby might become spoiled if allowed to have those rages. When other women said that perhaps she was too young to be “disciplined” Ms. M. indicated that Ariel had to learn to control herself, even if the hard way. She was worried that the child, if allowed to get her way all the time, would become a “wimp”.

As the mother talked about her own life history, she spoke of multiple disappointments in her childhood and of how she had to be very tough to cope with multiple attachment disruptions, placements in foster homes, and one imprisonment for theft

The topic of “toughness” and becoming strong is particularly important for families who live in poverty, in troubled inner city areas, where there is more violence and where many children are exposed to very crude circumstances, many of them witnessing acts of violence or experiencing losses. Therefore, being tough prepares the child to deal with violence, disappointments and losses. This is particularly important for boys. On multiple occasions we have observed that when a toddler boy falls down or has a small accident, the mother or father tell the child “don’t cry, you are tough” so they learn to cope with these situations by absorbing inward their pain and fear while not showing any fear externally.

Recently a 3 year old child- Nicholas- who is in foster care came to the consulting room to be evaluated for “hyperactivity and non-compliant behavior” by his foster mother. He had been in three prior foster homes because of frequent temper outbursts and hyperactivity. He had been taken away from his parents because of neglect related to drug abuse.As Nicholas came into the room he had a bewildered look, eyes wide open and was clearly shaking. He seemed utterly frightened of what might happen in the office. As the child psychiatrist asked him if he was a little afraid, he said (more to himself) with a reassured tone “I am never afraid. I am afraid of nothing…I am tough”.

Dealing with crying.

A recent survey from Zero to Three, a national organization to promote the needs of infants and toddlers (Zero to Three) finds that a significant proportion of parents in the US ( about 40%) think that an infant, even a very young baby, should be left to cry for a while and not soothed “too soon”. They may fear that picking up the infant too soon will cause the baby to be spoiled. In contrast with what happens in traditional societies (Bensel, 2003) where parents tend to hold the baby when he/she cries or hold the infant constantly. In the United States it is common to hear the advice that the baby should be given a chance to first “calm himself”, then if the baby does not succeed, parents might want to try first showing their face, then talking to the baby and finally carrying the baby. From this point of view a baby is “more competent” if he succeeds in calming himself with his own resources, and without needing external intervention, for instance by sucking his thumb.

Crying is seen as a fairly undesirable behavior, particularly as the baby becomes older, as in toddlerhood or the preschool years where it is feared to revealtoo much neediness or demandingness.

As a result of these premises, parents are often advised by pediatricians and nursesto let the child cry by himself and not to be too quick to reassure or calm, , even if intuitively they would want to do it and would not mind picking up and holding their child. However, given the professional recommendations to do otherwise, parents think this is the best thing to do. Pediatricians trained in the United States tend to get very little instruction or trainingon child development and mental health (American Academy of Pediatrics, 1994). They tend to embrace and use a purely “behavioristic” approach to the elimination of problems or difficulties. For instance, in dealing with temper tantrums in a preschool age child, the “standardadvice” is for parents to ignore the tantrum. The hope is that the child will realize this does not achieve his goals and will abandon them. However, many children escalate and are unable to calm themselves, while their parents fear that intervening helping the child to recuperate will “reinforce” the negative behavior. Many parenting books use this same approach of purely behavioristic mean to abolish undesired behaviors (e.g. Christophersen et al, 2002).

To give an example of this “external view “ of the child that pays attention mostly to obvious behaviors, rather than his inner world. In many day care centers, parents are told that they should leave the young child there despite his protests and wanting to be with the parent. It is thought that if the child does not cry, then this is a sign that he is coping very well with the separation, even if the youngster is just suppressing his vulnerability and fear of separation.

Children and sleep

Sleep is a controversial issue, even in the United States. A recent study has found that despite the “cultural prescription” that children should sleep separately from their parents (not co-sleeping), a prescription that is supported by the American Academy of Pediatrics, many parents do co-sleep with their babies (Weimer et al, 2002), particularly Afro American and Latino families, and this is the predominant practice in traditional societies (Reimao et al, 1998, Yang et al, 2002). The majority of North American books for parents giving advice (e.g. Ferber, 1986), suggest that the baby or very young child has to learn to go to sleep by himself. That is, that even the very young infant should not need any participation from adults to fall asleep. Parents are then advised to put the baby in his bed when drowsy so that the baby then fall asleep on his own. If the baby cries parents should try to not intervene so the baby soothes himself to sleep. The same recommendation is usually given about dealing with waking during the night. In many parent-advice books, it is suggested not to respond to the infant waking up and crying by picking up the baby, etc. but letting the child cry for sometime after ensuring he is not sick, and induce the onset of self-soothing mechanisms (Anders, 1992). This practice would seem puzzling in traditional societies where children are routinely rocked to sleep on the parents’ arms and the placed to sleep by the parent on the bed, hammock, etc.It seems that the advice given commonly in US books is a representation of the value of self-calming, autonomy and doing things by oneself, as an individual and not in co-dependence with anyone.

In our clinical practice we often encounter parents who feel guilty because they have “given in” and allow their toddler or preschooler to go into their bed in the middle of the night or at sleep onset. They feel they have done something wrong. Very often we deal with sleep onset difficulties in children who need close physical proximity in order to calm and go to sleep (for instance because of difficulties in sensory integration) and parents who try to be very consistent and feel it they should not allow the child to be with them, even if they would not mind it. Some of our therapeutic interventions consist of an expert “giving permission” to parents toexercise their intuitive behaviors toward soothing and calming their children, for instance they are frightened or ill.

One of the questions is what can parents do if their child wakes up, cries at night and after trying to let him cry for a half hour or more the child still is crying, vomits and becomes exhausted while continuing to cry. Clearly many children cannot cope with the expectation of self-soothing and self-induced sleep and need more intervention from adults. However, the “expert advice” interferes with parents’ intuition and wisdom to help the child by physical proximity, holding, etc. In this case, the cultural value of self-reliance interferes with parental intuitive behavior and can exacerbate problems that could be easily remedied otherwise.

Feeding and children

In our clinical work we find a number of practices that are increasingly observable in many families.

First, there are considerable barriers to breastfeeding. In many hospitals, companies that produce powder milk make a “gift” to the newborn baby of several cans of milk before the baby goes home (Howard et al, 1994). Given that many mothers do not know how to breastfeed (and many grandmothers did not breastfeed themselves during the sixties and seventies), the difficulties involved, plus the availability of the formula might make bottle-feeding more “practical” and less problematic.

Breastfeeding is not commonly practiced in public in the US, and many mothersfind themselves having to “hide” (for instance in the bathroom of a shopping mall) in order to breastfeed the baby. As a result a minority of mothers (about 30% in the rural Midwest, Barton, 2001)continue breastfeeding (Li et al, 2003), particularly among Afro Americans. In this situation again, the “intuitive” behavior of breastfeeding is interfered with by societal prescriptions about where it is permissible to breastfeed, the interference of work hours and a space at work to breastfeed, and the ready availability of formula from the first hours after birth.

Older infants are often fed at a time separate from the time when their family eats. In fact, in a significant proportion of families, its members no longer eat together any of their meals, and at dinner time members eat separatelyat times in front of their respective televisions (Boutelle et al, 2003). Television viewing has been associated with the current “epidemics” of obesity in children in the United Sates which affects about 10% of all children and has an even higher prevalence in adults. The higher the number of hours of television viewing, the poorer the quality of the diet (Coon et al, 2002).In fact, in many of the homes there is very little cooking and a high reliance on “fast food” restaurants.

Perhaps associated with the lack of experience in taking care of young children and the diminished availability of parents or older adults to teach, many young parents do not know how to feed their baby, how to prepare the formula or deal with common eating difficulties, at times feeding too many juices (Dennison, 1996) instead of protein, filling up the infant with liquid and thus diminishing hunger, but with poor nutritional value (Hobbie et al, 2000), this is one of the causes of failure to thrive.

Finally, as the child gets older, parents have certain food traditions that may run counter to a positive experience during eating. For instance, many children are discouraged from talking during the mealtime, they are expected to “clean up the plate” (i.e. eat everything on the plate), or “taste one bite of everything”, even those items that they dislike. At times these rules only lead to a “battle of wills” and may be counterproductive. In most elementary schools in the US lunchtime is merely a matter of eating (not socializing) and only 20 minutes are allotted to it, and in many schools, it is forbidden to talk during the mealtime. The eating situation then is seen as a purely physiological phenomenon (initroducing calories), rather than as a social exchange.

Physicalcontact

By comparison with traditional cultures, in the US there is relatively less direct physical contact between a baby and his parents, and there is less timeofcarrying the child. Despite this, a number of new parents seem interested in learning about infant massage (if offered to learn), as traditionally this is not practiced as it is in other cultures. Usually the baby is carried only intermittently, rather than for extended periods of time. Many babies spend a long time sitting in “baby seats” or car-seats or swings in their home in front of the television.

In day care centers, caregivers are rather discouraged from touching young children for fear of accusations of child molestation. Also, children are discouraged from touching each other or to have much physical contact and are admonished to “keep their hands to themselves” despite ethological evidence about the importance of touch in child development (Eibl-Eibesfeld,1999). Some authors have linked the relatively lack of touch or skin to skin contact with problems like aggression (Field, 2000).Field and her group have actually compared the rate of physical contact between preschool children in the playground in France and the US. They find several times higher frequency of contact between French preschool children. At the same time there is several times a higher frequency of episodes of conflict and aggression between preschool children in the US compared with those in France. This same finding has been noted when comparing teenagers in both countries inside a fast food restaurant (Field, 1999. 2002).

Parentsare very busy, working long hours: in the U.S. there isno one year of paid maternity /paternity leave as in many European countries. The average maternity leave is of six weeks and it is not necessarily paid. Therefore, working parents have to additionally cope with housework, cooking, etc. after a long day in their place of employment. They try to find ways to give the infant comfort , such as swings, baby seats, play-pens, in order for the child to entertain himself without requiring as much physical contact with the parents and direct one to one attention.

In connection with the topic of touch, it must be remembered that until at the beginning of the XX century, the standard pediatric advice in the United States (e.g. Dr. Holt’s book for parents) was to not touch children except when it was absolutely essential. Touch should be restricted to changing diapers and changing positions. One should not play with children before age six or so, lest they became overstimulated. The behavioral psychologist Watson had similar recommendations on this issue. These admonitions still can be seen in the way many young children are approached by their parents.

Touch and physical contact can have a very positive effect in calming children, diminishing aggression and helping with physiological regulation.Clinically many parents benefit from learning about the importance of touch and using it to calm, develop intimacy and help regulate young children (Eibl-Eibesfeldt, 1999). When “given permission” many young parents are eager to have a closer contact with their child.

Discipline strategies

Parents tend to use a number of“distancing strategies” to deal with children in order to teach them self-control and discipline from very early on. For instance, even very young children(sometimes as young as 12 months old) are given “time outs” at home and at day care. Time outs are used very commonly to deal with many problems, from breaking rules to non-compliance, to deal with aggressive behavior, etc. A time out usually consists of having a child sit in one particular spot for a number of minutes, where he cannot get up from there and there is no interaction with other people during the duration of this “sentence” or while he “serves his time”.

The “common wisdom” is to give one minute of time out per year of the child’s age, even when there is no empirical evidence that this is adequate for the emotional development of children of various ages. Sometimes, sensitivechildren are very scaredby this strategy, as their natural bias is to seek proximity with their parent or teacher when they are in distress.In some centers, when the child is unable to remain silently sitting, the “count of minutes” starts all over again so the minutes aggregate.

The same can be said about other distancing techniques such as sending children to their room, not talking to them, “grounding”or withdrawing privileges.Not talking to the child consists of telling the child that one does not understand what he says when he is angry or “whining”, or that he cannot talk to the adult in that tone, and only will be listened to when he can “talk nicely”.

Grounding is used more commonly with older children and adolescents. In this strategy the child is cut off from contact with friends, the opportunity to go out,to talk on the telephone, etc. Unfortunately parents who are desperate to gain control of their child may use this technique. At times in anger they issue long “sentences’ of being grounded for several weeks or even months, during which particularly a teen age child is unable to be with friends after school. This creates a situation of great resentment and may well exacerbate the original problem. Occasionally adolescents are in a situation of long-term confinement andmay think of running away to escape those circumstances.

Things like toys, books, etc. can be seen as “privileges” and taken away as a consequence for misbehavior.At times this is labeled “ logical consequences”. For instance if a child throws a toy, a “natural” consequence mightbe to restrict the toy for a certain period of time that can go form one hour to one week or more. The message is that the child has to control himself at all times, and if he lost his temper he must pay the “logical” consequences in hopes that the next time he will not do this. In the case of the more impulsive, explosive or emotional child this strategy can be counterproductive.

Parents often worry more about the strategies to eliminate undesirable behavior in the short term and are advised to do so by professionals like pediatricians, psychologists, psychiatrists, etc.A cultural theme important to parents may be that no misbehavior should go unpunished.Often, they worry that if they do not give a negative consequence for every misbehavior, the child will “get away” with an offense and continuemisbehaving. In our clinical interventions we try to emphasize the importance of the long term relationship between parents an d children , and not to adhere rigidly to a “menu” of consequences for problem behaviors, but touse more empathic strategies that may involve proximity, such as talking and reasoning, modeling positive behaviortouching, holding, and problem solving. Compassion also can be taught to the child by the parent’s empathic attitude toward the child’s anger.

Each society reinforces the values that are important for the perpetuation of its structures. The emphasis on independence, on self-reliance, self-control and the message that the individual is alone from the start in this world tend to be strongly reinforced by many parents in the US. This is a country of very high social mobility where in contrast to traditional societies, people move comparatively more, families separate and there are multiple losses and high distance between families. About half of all marriages finish with divorce. One important question is whether this style of parenting prepares children to be individuals, to be able to form attachments and end relationships readily and to be able to cope with a social system that requires such mobility and fluidity in relationships and bonds.

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