In spite of recent progress, there are still issues that are of particular concern to most black parents, black children, black physicians, and others engaged in the health and welfare of black people. A systematic approach to these concerns is developing. This article will attempt to outline some of the common areas in which black children and their parents experience psychologic and developmental difficulties and to make some recommendations concerning treatment and, more important, concerning primary prevention strategies for family physicians.
Psychologic and developmental difficulties in black children tend to have differing degrees of significance to their families depending on many variables, including their need to feel different. The most important issue is that the members of each black family and mixed racial family must be given the courtesy of being allowed to determine just how "different" they want to be. Each family must be appreciated for its uniqueness as well as its sameness within any given group with whom its members choose to live and form a society.
GENETIC AND POLITICAL BLACKNESS: A DEFINNITION
The more we learn about genetic variables, the more difficult it becomes to place people in one category. The terms "black" and "white" refer to very specific colors. Very few persons are black or white, and young children know this. Therefore, when we begin to teach a child that he is "black," we must also teach that this is a political definition in its pure sense, concerning itself with the socioeconomic state of a group of people with skins of varying colors. A person whose skin is literally black on a genetic basis must understand the meaning of "political blackness" and clarify his own identity in this regard. For example, one could be a politically black, genetically mixed American Indian-blackCaucasian. In any given situation, the choice is often up to the individual.
Every day new information is being uncovered about the role and function of genes and chromosomes in the determination of a variety of skin colors and physical characteristics. Understanding that people have both a political and genetic identity makes it much easier for physicians to work with parents and children of any color or racial extraction.
BLACK POLITICAL REALITIES AND INTRAPSYCHIC ISSUES
When speaking about the political realities of black life in the Western world, health and mental health professionals say, "But what about the intrapsychic problems?" When speaking about the intrapsychic problems, the political strategists say, "But you must consider the economic realities!" Both issues must be addressed, but in an organized, sensitive fashion. This is now beginning to occur. We are now thinking objectively about what were once extremely emotional issues.
Black Political Realities
Of particular concern are the following indicators of black life.1
. . . The proportion of Black children living with one parent, or no parent, was calculated by the Census Bureau (1974) at 49.3%.
. . . While there is no hard evidence that, when you hold economic factors constant, growing up in a fatherless family is necessarily detrimental to the psychological health of the children, . . . small children and harassed mothers without husbands can't hold economic factors "constant." On the contrary, one of the firmest predictors of poverty is to be born into a one-parent family - especially into a Black one-parent family.
. . . Children in Black two-parent families had a per capita income of $2,455.00 in 1973. That's 62% of per capita income in all American families, and a pretty fast increase from 56% in 1967. But children in Black families headed by women had per capita income of only $1,268.00. That's only 32% of the nationwide figure, and it's a slight DROP from the 33% of 1967.
". . . Half of the Black children below the official poverty line in 1967 lived in families headed by women. By 1974 this had risen to 70%. And the kids aren't catching up with the grownups: some 41% lived in poverty while only 25% of Black adults did.
. . . The birth rate among college- educa ted Black women is the lowest of any group in the nation.
. . . There is an "economic schism" in the Black community. The total number of Black children has diminished - the census data suggests that an outsized proportion of Black children are being born on the wrong side of the schism. But the number who are poor and in female-headed families rose from 2.3 million (24% of all Black children) in 1967 to 2.7 million (or 28% of all Black children) in 1974. AFTER YEARS OF STRUGGLE AND ACHIEVEMENT BY BLACK PEOPLE A LARGER PROPORTION OF THEIR CHILDREN FACE THE TRIPLE BURDENS OF PREJUDICE, POVERTY, AND FATHERLESSNESS.
Whatever one's theoretical position in reference to family life-styles, "one-parent families," "matriarchies," etc., one must agree with New York City's black Mental Hygiene Commissioner, June Jackson Christmas, M.D. In an address to the American Psychiatric Association almost 10 years ago, she stated that poverty makes things worse for one's mental health; in fact, it causes a form of mental illness.
Further illustration of the nature of the problem is the apparent inability of our public institutions - such as our schools, courts, and health-care facilities - to achieve effective integration, affirmative action, and quality service programs; to devote our resources meaningfully and responsibly to human services; and to hold the institutions responsible for not achieving their stated goals. "Cost effectiveness" too often means "Cut programs for poor people*' without attempting to give constructive and timely evaluations or recommendations about ways to improve programs. Large amounts of money continue to be given to favored programs with no proven success record of having "helped" a designated client population (based on standards set by the specific community).
One must understand the significance of the politics of "Who is well and who is sick and who will be treated by whom, for what, and at what cost, paid by whom?" Which child is minimally brain dysfunctional and which child is socially maladjusted (and placed in the understaffed, overcrowded "special" schools for the "socially maladjusted" - or simply dropped from school) ? Who can adopt a child and who cannot? Who is "mad" and who is "bad"?2*
Black Intrapsychic Issues
In The Black Child - A Parent's Guide,3 we wrote that the black child has five special problems:
The Black Child. He bears the White man's burden. Just by existing, he triggers the inherited shame and guilt that make it difficult for Whites to accept Blacks easily, to socialize, to empathize.
The Black Child. He bears the Black man's burden. He has to cope with his family's feelings of being different, of being discriminated against, of rage, of pride. His inheritance is his mother's and father's experience in a White world.
The Black Child. He is born to face a fight. He has to fight for his education. He has to face and conquer White hostility - and adult White hostility at that. (Remember those grown men in New York City who attacked Black and Puerto Rican junior high schoolers with iron pipes and dumped cans of oil on them? White hostility is not confined to Alabama or Mississippi.) The Black child has to fight his environment - the drugs, the below-standard living conditions, the below-standard average incomes, the fractured families, the violence of the angry and the emotionally deprived. And if he is one of the minority whose family is economically privileged (that's a very small minority), he has to fight the feeling of apartness from both the Black and White communities. The tragedy is that the Black boy child is usually raised to avoid a fight, a part of that crippling inheritance of the past.
The Black Child. To be his or her mother, to be his or her father, can be an exercise in frustration, in helplessness. But it need not be. Parents can learn how to instill courage and confidence and warmth and self-esteem in a child, to help him develop a positive self-image.
The Black Child. He is a child like any other. Like all others. Growing. Learning. Loving. The Black child is liberated in law. It is up to his parents to help him grow up liberated in fact and in mind.
And we wrote,
That is the reason for this book: To help parents counteract the pressures of a racist society on the upbringing of their children; to help them understand and counteract whatever ingrained psychological attitudes they themselves may have that may harm their children; to help them rear the children so that they achieve a proud sense of identity that is not based on Black or White, but on the inner person and the worth of that inner person.
So one can see that many parenting problems are the result of the combination of political and intrapsychic issues. It is obvious that skin color and physical appearance are only parts of a black child's identity. Emotional self-awareness and self-management are also essential. These must be taught. Adults "teach" emotional awareness and selfmanagement to children all the time, usually without even realizing what they are doing. Physicians must insist that it be done consciously and actively, at home and in the schools.4
INNATE SKIN COLOR PREFERENCE AND COLOR-RELATED PHYSICAL DIFFERENCES
Some infants are born squawking and very active. Others are quiet. They remain basically that way throughout life. Some like bright colors5 and lively music; others prefer subdued hues and soothing music. Is it so unusual to suppose that there may be a basic, innate preference for one color over another? On such a basic preference, might not prejudice or skin-color-related racist attitudes be developed as a result of an unfortunate combination of unplanned environmental events and the influence of the parenting figures? Assuming this to be true, one recognizes that even before a child is born, one should begin to consider deliberately working with the parents to prepare them to actively participate in the artitudinal development of the child, by being aware of concerns about skin-color differences at each developmental stage of the child and the hazards of equating a specific developmental difficulty with skin color.
A noted black psychiatrist, Dr. Chester Pierce, asks the question whether or not blacks think "differently" from whites; perhaps blacks do more audiovisual learning than audioverbal learning. Think of the significance, then, of television on the black child. Dr. Pierce notes that a black person, in his day-to-day activity, has to "think" about more trivia and indignities than a white person and probably, therefore, spends more time in just "thinking," "reacting," and becoming "fatigued."6 Is this a prelude to the development of essential hypertension, so common in adult blacks?
PSYCHOLOGIC THEORY AND THE DEVELOPING BLACK CHILD
Dr. Marjorie McDonald has written an excellent book on the impact of racial differences in a child's development within a psychodynamic framework, Noi by the Color of Their Skin.7 This author's experience in day-care centers and public and private schools - for rich and poor, normal and handicapped, segregated, desegregated, and integrated - empirically confirms her theories and observations. It must be read in its entirety. She sees the skin as a
. . . total sensory organ . . . which plays an important and specific role as the transmitter of the parent's warm and loving stimulation of the infant. . . . Through the parent's handling, the infant develops its earliest awareness of its own value. ... In the latter part of the first year the skin outlines, for the infant, the first awareness of its own body boundaries separate from those of the parenting figure. . . . Mental internalization of body separateness promotes the necessary beginning of a separation of the personalities of the parent and infant.
Parent-child color differences may catalyze this process, which is itself very erratic and highly sensitive. Dramatic color differences may foster too early or delayed separation between mother and child. Excessive stimulation, understimulation, skin conditions, orthopedic casts, etc., may interfere with normal development. ". . . Instead of a primary sense of well-being, [these conditions] foster a primary sense of pain and anger, . . . resulting in the fact that ... in later life one may reject an acceptable and even needed object relationship because of painful conditions of that early relationship."
Dr. McDonald has defined "skin color anxiety" as a separate and distinct developmental phase persisting for a while beyond the period of the better-known phase of "stranger anxiety" - i.e., six to 18 months of age.
. . . To recognize that another person has a different skin color can never be a meaningless discovery. The early and lasting psychological importance of the skin is such that this discovery must always have great import. ... In the midst of these developments [separation activities] we can only try to surmise what the infant's anxiety at the discovery of a new skin color would be about, and give it words which the child himself is not yet capable of assigning to it. The strangely colored person, so different in overall appearance from himself, his mother, or other strangers, must create a confusion about many of the recent achievements his primitive ego has tried to secure for itself. Looking at the new-colored person he might feel, "What is that? What does it have to do with me? Or with my mother? Will it change me? Will it change my mother?" . . . These primitive skin color anxiety reactions must be regarded as healthy responses to a disturbing new perception. Under favorable circumstances the primitive ego of the child can be expected to master the anxiety and as a result to gain a greater familiarity with the object world, an improved sense of his own body image with an added dimension of body color, and a strengthening of the ego itself.
By the time they reached the sexual phase of their development, many of these children had achieved an advanced stage of psychological racial integration. They knew each other as friends and had resolved many of their infantile conflicts about each other's skin colors. With this foundation they entered the sexual phase with the best possible protection against gross invasions Of skin color problems into sexual problems.
DEFINING THE BLACK ISSUES WITH YOUR PATIENTS
To Have or Not to Have a Child
College- educa ted black women are having fewer children than any other group. The more gifted black men and women choose a career over parenthood. This has long-term consequences. Parenthood must continue to be an attractive, fulfilling (not required) option for gifted blacks. Social and medical support systems should be available. Parenting instincts should be encouraged in both men and women.
The physician working with black families should be particularly sensitive to recognizing low self-esteem, irrational attitudes and fears, and expressions of depressive equivalents, such as "I'm not going to have children like all those other women and end up on welfare" or "Why bother to bring children into this world? It's too hard." A psychiatric or mental health referral may be indicated to explore the true meanings of these attitudes and depressive equivalents with the patient and help with the working through of the inner problems. The families should be helped to develop constructive defenses against the daily, defeating, and fatiguing indignities that befall black people.
Pediatricians, family physicians, and child psychiatrists should work to assure that as broad social policies are made, there is adequate recognition of the need for and development of the meaningful support systems for the potentially hypersensitive, hyperalert black parent. They should help design the means to alleviate stress and place strong emphasis on a good, balanced work/pleasure life-style to counteract the syndrome of the "super black."4 The patient must be offered psychiatric treatment, when indicated, in the manner most effective and appropriate for that person. Inadequate numbers of black mental health professionals should not lead us to accept the premise that less than adequately trained persons will be just as good, regardless of the ethnic background of the so-called therapist.
Black health and mental health professionals should identify crucial issues and develop educational materials for persons who care for black patients. They should encourage, by example and by forceful insistence, maximum self-development in black children and parents who seek their guidance and look to them as role models.
Color Consciousness Raising
When working with black families, it is always necessary to do some "color consciousness raising." When black parents consider having children, along with issues of sex preference, type of personality, and intelligence, they should be encouraged to think about skin-color preference. They should face their negative and positive or "absent" feelings about skin-color preference. They should be made aware of the variables. Pediatricians and family physicians should encourage parents to talk with their children about race and color and racial heritage - and to keep on talking about them. In The Black Child - A Parent's Guide,3 we list a variety of ways in which parents can continually work with their children in activities ranging from play with "integrating" toy chests to serious discussions about world populations as seen on TV and participation in educational games.
Black parents should be made aware of the fact that they are emphasizing attitudes toward color differences all the time. The most obvious example is the pleasure with which a parent responds when a child learns to differentiate between red and blue, green and yellow, or black and whitel Many white persons will say, "I don't think of you as black." Yet blackness is something that is a physical part of a black person right down to his genes. Black parents should not wait until the child asks about differences. By that time "the child has picked up the unspoken and spoken cues from significant people in the environment and has developed at least the precursors of a racial attitude. The objective of black parents and physicians working with black parents must be to prevent children from developing crippling racial attitudes and not to influence their color preference. We do not want children to feel inferior or superior on the basis of skin color. The longer it takes for a child to begin the task of working through attitudes about color, the harder it is. Just because a child does not ask, one must never assume that the bits and pieces of a very active fantasy life - which can form the foundation for prejudice, racism, and selfdefeatism - are not there. Or, on a more positive note, health and mental health professionals should assume that the potential to develop a healthy, happy, successful person is also there in bits and pieces to be supported, encouraged, and developed.
A SPECIAL NOTE TO WHITE PEDIATRICIANS AND DEVELOPMENTALISTS
Please make a strong effort to avoid making a strong effort to demonstrate that people are all very much basically alike. For the time being, allow black physicians, their patients, and their families and children to explore and learn about their similarities and their differences, to define their own identities, and to develop their own treatment styles. Black professionals should develop their own diagnostic categories and developmental stages as well, even if they turn out to be exactly the same as for whites. Remember the process of "working through"? There is much for us all to learn about early childhood development, primary prevention, and the expansion of human potential.
1. Malloy, M. T. National Observer, Nov. 5, 1975.
2. Harrison-Ross, P.. and Butts. H. T. White psychiatrists' racism in their referral practices to black psychiatrists. J. Nati. Meo. Assoc. (1969).
3. Harrison-Ross, P., and Wyden, B. The Black Child - A Parent's Guide. New Yoik: Peter H. Wyden/David McKay. 1973.
4. Harrison-Ross. P. Getting It Together: A Psychology Book for Today's Problems. New York: Learning Trends, a Orison of Globe Book Company, 1973.
5. Staples. R. The response of infants to colors. J. Exp. Psychol. 15 (1933), 119-141.
6. Pierce, C. R. Personal observation presented at the National Association of Postgraduate Physicians annual meeting, New York. May 20-22, 1977 (in a conference pertahing to the special medical problems of the black family).
7. McDonald, M. rVof by the Cotor of Their Skin. New York: International Universities Press, 1972.