Pediatricians providing anticipatory guidance to parents from diverse cultural backgrounds need to understand the different value systems operating in individualistic and collectivist societies. Questions about child behavior, development and parenting are central to well-child visits, and pediatricians will encounter a range of parenting styles and beliefs that may be at odds with their personal beliefs as well as recommendations by the AAP. Though most doctors today receive some “cultural competency” training during medical school, the focus is typically on how different cultures interpret and treat illness. There is far less training on how culture drives family dynamics and informs essential differences in child rearing practices. (Johnson, Radesky, & Zuckerman 2013).

Two Fundamental Patterns in Child Rearing

 Based on attitudes towards autonomy vs. interdependence, most all cultures in the world can be divided into two basic patterns of child rearing (though notable differences between cultures that share the same pattern do occur). There can be considerable disapproval across two such fundamentally different value systems, and this disapproval often surfaces in childcare and health care settings.

 

Individualistic Cultures

 In study after study, cultural anthropologists have found that the overriding goal of American parents is to make a child independent and self-reliant. (Small 2002) Every culture has its ideal smart, well-functioning child. The ideal is so ingrained in the culture that few question its validity. In America, that ideal is a highly verbal, independent, emotionally controlled, and self-reliant child. These social skills are seen as essential to success in an individualistic society. (Small 2002) Most American parents believe a child has an inborn temperament, a set of personality traits that can be molded by parenting and society. Babies are bundles of potential and a good parent is one who can uncover the latent abilities and talents in their child, encourage the good while discouraging the bad (Small 1998). American parents are concerned about the self-esteem of their children; the word self-esteem can’t be easily translated into other languages because the trait is not part of the value system in many cultures. Of course American mothers are acutely aware that success in society depends on having good people skills. Being individualistic to the point of overt selfishness is problematic. Successful children achieve a balance between self-maximization and consideration of others.

 

Collectivist Cultures

 In the majority of cultures in the world children learn to think of themselves as part of a “we”-group or in-group. Collectivist cultures actually downplay independence and promote dependence on a core group of people. This strengthens the relationships that hold the fabric of a collectivist society together. Reciprocity of responsibility and favors between members of an in-group allows people in an extended family to get things done – in other words, it allows them to negotiate cooperation.

 Families in some collectivist cultures actually train children in dependent behaviors. The idea is to teach children to engage in appropriate levels of relatedness – to have an obedient, calm, polite and respectful demeanor. One has to learn to both give and receive graciously. A person has to feel responsible for his behavior and avoid, at all costs, shaming not only himself but also the family, tribe, and community. The worst thing that can happen to a person is to be left alone. Rejection by the in-group is a terrible punishment. Compare this to the American icon the cowboy – he is usually depicted as being a loner by choice. He rides the range on his most faithful companion – his horse. He is a model of self-sufficiency.

Individualism vs. Collectivism in Three Child Rearing Practices

 Sleeping, feeding, and toilet training issues make great examples of autonomy vs. interdependence in the earliest stages of parenting.

 Sleeping Solitary vs. Co-sleeping

At well-child visits with pediatric doctors in the U.S., questions about the schedule of both feeding and sleeping are used as markers of the child’s development and well-being. Parents from other cultures may not understand these questions and may not agree with the concepts being emphasized by health care providers.

 In an individualistic culture that promotes autonomy, an infant sleeps in his or her own crib or room, which requires the infant to self-regulate and self-soothe. American babies tend to sleep solitary and, in general, spend much more of their time alone than babies do in more collectivist cultures. They spend considerable time sitting in playpens or play seats with their toys. Many parents feel that social time is stressful for babies and that infants need “downtime” to rest and recover. Babies very quickly learn that social interaction is spaced between times of solitude. (Small 1998)

 Though some American parents do sleep with their babies for “pragmatic” reasons (presumably for breast-feeding and comforting a fretful baby), many express the concern that co-sleeping fosters attachment. Many move their babies out of the parental room as soon as possible, usually by six months; They express the need to guide the child down a path of independence as well as a desire for their own privacy (Small 1998). Mothers in collectivist cultures rarely raise concerns about children having attachment issues.

 In many cultures, putting the infant in another room is considered unacceptable, and due to traditional practices or physical constraints the infant shares a bed with the mother or parents. ( Johnson, Radesky, & Zuckerman 2013) In fact, for the overwhelming majority of mothers and babies around the globe today, co-sleeping is an unquestioned practice – in much of southern Europe, Asia, Africa and Central and South America. Mothers from these cultures believe co-sleeping to be the best and most natural practice because the mother is more tuned into their baby’s arousal during the night. For U.S. pediatricians working with immigrant and refugee populations it is important to know that infant sleep patterns are one of the last traditions to change under pressure from the adopted country. (Farooqi 1991)

 Tips On Communicating About Co-Sleeping

  • Explore sleeping practices with immigrant and refugee families especially. Ask parents and grandparents about their cultural preferences for putting babies to sleep. Expect some parents to politely listen to concerns about co-sleeping safety without any intention of actually changing the practice.
  • Be prepared to negotiate. One helpful alternative is room-sharing without bedsharing, such that the infant’s bassinet is placed next to the parents’ bed. The child and parents can there-fore see, hear, and often touch each other, which promotes closeness and parental responsiveness.
  • Ask if your guidance about sleeping make sense to families. Can they follow your recommendations?

 Feeding

Parents from cultures oriented toward interdependence may spoon-feed children through toddlerhood and beyond. Spoon feeding supports interdependence as it teaches a child to be patient and cooperate with a caregiver in the process of eating. It also models connectedness via helping behaviors; the child being helped learns how to help others when it comes time for him to do so.

In the U.S., babies are encouraged to take part in the feeding process as soon as possible. Parents encourage the child to hold the spoon and try to get food from the mouth to the plate. The inevitable mess involved is just part of the process. It is seen as a developmental milestone of significance when the child gets a significant proportion of a meal into her mouth. This supports feelings of independence, and also develops skills in using the hands. Some experts even encourage letting children touch and “play” with their food as a sensory experience.

Feeding practices can be an interesting theme to explore with immigrant and refugee families especially. A U.S. pediatrician might be surprised to learn that in some cultures food is revered. It is never a plaything, especially to people who have survived severe famines. Other relevant examples of cultural influences on feeding practices include breastfeeding duration, acceptance of breastfeeding in public, and timing of introducing complementary food. (Johnson, Radesky, & Zuckerman 2013)

  • Ask about who is living in the household – tension between cultural beliefs across generations of a family can create conflict, affecting the health and well-being of children. Food is central to culture. Ask parents and grandparents about their culture’s dietary and feeding practices for infants and toddlers.
  • Ask what the family’s views are on independent feeding?
  • As children get older, family mealtimes set a good example; studies indicate that family
    mealtimes can be important in preventing childhood obesity.
  • Ask if your guidance about feeding makes sense to families. Can they follow your recommendations?

The Move Toward Consistent Schedules is based on Americans’ Focus on Time Control.
Studies of culturally-based infant feeding and sleeping practices consistently show that American mothers and the pediatricians who advise them believe it is important to move a baby toward a consistent feeding and sleeping schedule. The importance of establishing a regular feeding and sleeping schedule exemplifies the tendency Americans have to manage and structure “their” time. Time is a personal commodity in American culture, something to be used planfully. Any disruption in set infant feeding and sleeping schedules concerns parents because it appears to be a regression or setback that often results in a baby becoming fussy. Easy babies are those that adjust well to routines. Americans focus on bedtime rituals to reinforce infant sleeping schedules – lullabies, stories, special clothing, bathing, and toys encourage sleep-time, but in many cultures parents simply let babies fall asleep when they naturally do so.

Toilet Training
In American culture toilet training is an important step in teaching or encouraging the child independently to take care of his or her own toileting needs and the caregiver’s goal is to accomplish this as quickly and painlessly as possible once the learning process has begun. Many American parents do not begin potty-training until a minimum of age 2, and the Mayo Clinic even recommends that you don’t begin training your child until he begins to show an interest, and can get himself up and down from the toilet on his own.

 It becomes most obvious how this approach to toilet training reflects individualism when it is compared with the norm in collectivist societies. Consider the following advice taken from a popular parenting website babycenter.com. The language used here exemplifies how the experience of toilet training should be “individualized” for the child in America. The toddler is given a lot of leeway to make his own choices.

 “Let him help pick the potty out at the store, then let him play with it, look inside, sit his teddy bear on it. Then, ask him if he wants to sit on it — with his clothes on at first — so that he can get used to how the seat feels. If he wants to take a rain check on this, don’t push it. Explain how the potty is used in simple terms that he can grasp: “This is for making pee and poop in when you’re ready to stop wearing diapers.”

 The above recommendation would probably strike someone from a highly collectivist culture as strange indeed. In many societies, toilet training starts when the infant is just a few months old. The culturally accepted method of toilet training is to form a partnership between the child and the caregiver where they “sync up” signals when it is “time to go.” Babies in many non-western cultures are held almost constantly so that the caregiver(s) can respond immediately to signals that the baby needs to urinate or have a bowel movement. This reinforces mutual dependence as the infant becomes accustomed to the caregiver’s involvement in the process. Traditionally in China, for example, this process is called elimination training. Babies and toddlers are encouraged to use the toilet on demand once the caregiver has noticed the “time to go” signals. The baby learns to go on demand while a caregiver is making whistling or shushing noises and the baby is being held over a toilet. Babies often wear slit-bottom pants called kaidangku and diapers aren’t used. Considerations about cultural variations in toilet training practices:

  • In an informal poll of pediatricians from the Child Health Clinic at Children Hospital of Colorado, it was generally agreed that toilet training conversation does not frequently come up at well-child visits, but when it does, it is usually initiated by middle-class European American parents seeking advice about developmental “norms”. Immigrant and refugee parents rarely raise questions about toilet training- and certainly not as a developmental milestone.
  • In collectivist cultures where “elimination training” is practiced, when mistakes happen they are the fault of the caregiver who failed to be tuned-in enough.  American pediatricians sometimes need to coach American parents not punish or shame a child for potty-training mistakes.
  • Toilet training can become a divisive issue between parents and day care providers. Parents from a variety of cultures may insist their infant is already toilet trained, but U.S. caregivers won’t accept the “sync up” method of elimination training as being toilet trained. Realistically, they can’t “sync up” with all the infants in their care.

 Sources

Gonzales-Mena, J. 2000. Multicultural Issues in Child Care. New York, NY: McGraw-Hill

Hofstede, G. 2001. Culture’s Consequences: Comparing Values, Behavniors, Institutions, and Organizations Across Nations. Second Edition. Thousand Oaks, CA:  Sage Publications

Johnson, L., Radesky, J.and Zuckerman, B. Pediatrics 2013;131;631; originally published online March 18, 2013

Small, M. F. 1998. Our Babies, Ourselves: How Biology and Culture Shape the Way We Parent. New York, NY: Anchor Books

Small, M. F. 2002. Kids: How Biology and Culture Shape the Way We Raise Young Children. New York, NY: Anchor Books

Mayo Clinic Staff. Potty Training – How to get the job done. Mayo Clinic. http://www.mayoclinic.com/health/potty-training/CC00060

 

Culturally-based Differences in Child Rearing Practices by Marcia Carteret M. Ed.

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