Many indications clearly predict a population of Spanish-surnamed children of considerable size in the United States. This group's youthfulness (their median age is approximately 10 years less than that of Anglos), their low academic attainment (in the Southwest only 27 per cent finished high school), their high unemployment (twice the national rate), their traditional Catholicism, and the presence of large numbers of recent immigrants are all factors associated with high fertility. This population's rapid growth, from 9.2 million in 1970 to 10.6 million in 1973, and the presence of an estimated additional 5 million undocumented residents provide ample evidence for practicing pediatricians to consider their special needs.
What special needs should the pediatrician or other health counselor consider? A serious concern is the absence of research to document the existent health hazards affecting this population. We know that higher maternal and neonatal mortality, premature and lowweight infants, toxemia, tuberculosis, maternal and neonatal malnutrition, birth defects, brain damage, and retardation, as well as other conditions that seriously threaten life and quality of life, are poverty linked. Yet we do not know the incidence of these unfavorable conditions among the Spanish surnamed. We know that numerous federal programs have been created to minimize these hazards. However, we do not know to what extent this population is aware of, participating in, or benefiting from such programs.
Another serious concern is the nonexistence of empirical research specific to parenting behaviors among the Spanish surnamed. Poverty-prejudice concomitants - such as inappropriate and insufficient education; early, frequent, and prolonged childbearing; marital disharmony and disruption; father absence due to incarceration; lack of employment and family stresses; overcrowded and dilapidated housing; low levels of health, health care, and health information; and insufficient resources - can and do influence child-rearing practices. To what degree are these factors promoting child abuse and neglect; delaying, distorting, or preventing developmental progression; and perpetuating the vicious cycle of poverty?
Still another concern is that many romantic and prejudicial notions have been written about this population's cultural values and practices. Few of these stereotypes can be supported by large-scale, methodologically sound research. Very questionable evidence exists in support of the popular notion that this population has a stronger and more frequently extended family and that its members are nonmaterialistic, noncompetitive, superstitious, passive, and dependent. Further, it is highly questionable that "machismo" is a cultural rather than a poverty or father-absence variable.
A conference sponsored by the U.C.L.A. Spanish- S peaking Mental Health Research Center in August, 1976, described research on Mexican- Ameri can families as highly inadequate, promoting of stereotypes, and generally not helpful. These conclusions are supported by many authors. For example, Peñalosa1 notes that the Mexican-American family has not been subjected to any systematic analysis. Montici2 observes that the theories and concepts used to investigate this population are "methodologically unsound" and "quasi-psychoanalytic," emphasizing a "pathological perspective." He further asserts that the uncritical acceptance and consistent repetition of unverified quasi-psychoanalytic notions by social scientists do not constitute an empirical reality. Romano10 refers to the social scientists' treatment of the MexicanAmerican family and other minority poor as "mere tribal rhetoric and fiction" and recommends "discarding the teleological-cultural-tribal-mystical interpretation of the historical process."
In addition to the nonexistence of quality health, parenting, and cultural research, this population's wide inter- and intragroup differences constitute another special need. There is much heterogeneity among members of the various Hispanic groups, as well as among members of the same group. For example, Karno and Edgerton4 found a cluster of differences among English-dominant Mexican Americans compared with those who were primarily Spanish speaking. Peñalosa5 describes Mexican Americans as one of the most heterogeneous groups ever studied, while Romano6 describes wide cultural differences even within families.
Still further, the intervening influences of prejudice, social class, nativity, biculturation, family differences, and presence of physical and mental pathology must also be considered.
The health counselor must be sensitive to these important considerations and should avoid destructive "helper" behaviors, such as myth building, mass stereotyping, culture blaming, and insensitivity to the consequences of social conditions that victimize the Spanish surnamed and promote destructive parenting. Even though empirical research specific to parenting behaviors among this population is nonexistent, certain indicators provide reasonably sound inferences concerning the need to improve these behaviors. For example, the prejudice-poverty concomitants previously specified affect child-rearing practices. Such child-rearing practices can become culturally sanctioned and later attributed to cultural variables. Consider the following.
Maternal deprivation. The child may be exposed to a higher rate of maternal deprivation because of the higher mortality in povertyminority mothers. This poverty also forces them to work outside the home. In addition, some children are left in their country of origin with members of the extended family while their parents establish themselves in the United States.
There is some controversy as to the inevitability and irreversibility of the effects of mother deprivation. It is also not known what specifically influences the negative effects, because the complex and interwoven deprivation variables are difficult to disentangle and study. Nevertheless, disruption in maternal care is likely to have negative effects that may be associated with psychiatric impairment, as Langner and his colleagues7 have demonstrated.
Father absence and stressful fathering. The Spanish-surnamed child may frequently experience father absence because marital disruption and incarceration are associated with poverty, the father usually immigrates to the United States first, and the lack of local employment encourages father absence. Even though 10 per cent of the children in the United States are being raised in fatherless homes, the poor quality of the existing research prevents specification of the consequences of father absence to personality and intellectual development. Nevertheless, we can logically assume that father absence places a tremendous burden on the mother and that this added stress may interfere with healthy child-rearing practices. We can also assume that older children may be placed in inappropriate adult roles and that they and the younger children will be deprived of needed paternal identification, nurture, and guidance. The child may also be placed under stress by the presence of his father, whose powerless social position and damaged role as a provider may encourage maladaptive behaviors.
Degrading of one parent by the other or by other family members. The child needs to retain positive beliefs and memories concerning both parents. The "offended," "deserted," "neglected," or "abused" parent at times uses the child to vent feelings of disappointment, anger, or grief concerning the other parent. This practice can have unfavorable emotional consequences for the child.
Excessive attachment between mother and child, combined with detachment between father and child. This pattern is usually associated with marital disharmony and parental instability. The mother becomes excessively attached to her children, refusing to leave them even for a few hours. This exclusive association discourages needed involvement with the father, extended family, and others.
Early burdening of the older child with rearing of younger siblings. Because of poverty and high fertility, the older children may be deprived of needed play, school activities, and even regular school attendance because of the need to assist in the care of their younger siblings.
Use of children as interpreters. Low-income Spanish-speaking children, even when very young, may be used as interpreters by their parents, who may have limited English-speaking ability. These children are kept out of school and deprived of other enriching activities that could disrupt the vicious cycle of poverty. Also, they are exposed to emotionally sensitive adult matters and concerns. Failure by the various institutions to provide trained interpreters reinforces this practice.
Excessive or inappropriate work requirements. The family's poverty, high fertility, and low educational attainment make it essential that as many family members work as possible, including children. Appropriate work can create a sense of responsibility, self-mastery, and industry in the child. However, inappropriate work can discourage and physically exhaust the child and prevent him from participating in enriching opportunities. Insufficient or inappropriate sex education. Marital disharmony, insufficiently educated parents, overcrowded housing conditions, and father absence may have a profound effect in teaching and perpetuating disturbed sexual attitudes in the child. Negative "machismo" characteristics attributed to Latin males and the masochistic subassertiveness attributed to Latin females may represent poverty-related sexual attitudes that degrade men and women. The mother is usually the most available to educate the children sexually. However, many mothers are poorly prepared for the difficult task of providing gradual, accurate sexual information in a tranquil, accepting manner. Their own insufficient or inappropriate sexual education and traumatic experiences encourage them to respond with embarrassment and to discourage or even punish the child's inquiries and curiosities. The lack of sex information written in English and Spanish in a basic, concrete style prevents the low-income Spanish-speaking parent from improving their own sexual education.
In addition to these influences, poverty, combined with low educational attainment, can also reinforce certain types of discipline styles that injure, frighten, degrade, depress, or confuse the child. The following are examples.
Frequent and severe physical punishment. The parent may shake the child; pull his hair, ears, or arms; slap his face, head, and ears; and use belts, shoes, clothes hangers, electrical connections, broom handles, and sticks to hit him.
Degrading punishment. This consists of calling the child "stupid," "idiot," "animal," and "burro"; using belittling sermons; scolding and belittling the child in front of friends or others; indicating that the child is bad, rotten, or sinful; comparing him unfavorably with others; and equating him with the family's "black sheep."
Frightening punishment. This includes telling the child that the devil, ghosts, or other frightening magical figures will take him; telling the child that he will be given away or will no longer be loved; locking the child in a closet or dark room; dangling the child out of a window or from another high place; and making other frightening threats.
Punishment that discourages the expression of emotions. Expressing emotions, such as anger, may be punished by the parent, who may view this as disrespectful and contrary to expectations of compliance. The expression of grief, sorrow, or sadness (especially by male children) may be discouraged, ridiculed, or punished by the child's parents, who may view this as unmanly behavior.
Considering the magnitude of all these factors, what can the individual practitioner do to improve the life and quality of life for lowincome Spanish-surnamed families? To whatever degree it is possible, the pediatrician can direct his energies at improving the health and social conditions that victimize this population. The recruitment, training, and hiring of Spanish-speaking professionals can also be facilitated. He can also attempt to assist the family itself. Let us consider some familyspecific recommendations.
Cultural sensitivity versus cultural stereotyping. The practitioner can respond to his patients in a way that allows them to have beliefs and practices similar to or different from his own without imposing on them preconceived "Latin," "Mexican," or "Puerto Rican" ways. Polite, respectful rituals, demonstrations of friendliness and concern, and clearly verbalized expectations are essential to the treatment of this population. Encouraging the patient to verbalize questions, concerns, and doubts may greatly facilitate adherence to a treatment procedure that may not have credibility among the patient's relatives and friends. Use of well-trained bilingual, bicultural staff can help the busy practitioner to discourage treatment failures, broken appointments, and treatment dropouts.
The implications of poverty. Poverty not only profoundly affects behavior but also requires appropriate interventions. Sensitivity and respect should be utilized in making referrals for needed legal, social, and supportive services. The practitioner and his staff should identify and improve available community resources.
The implications of limited education combined with limited ability to speak English. Attempts should be made to speak English and Spanish in a concrete, simple style that may be more appropriate to the restricted linguistic code attributed to the poor.8 Office staff who speak English and Spanish fluently and clearly should be hired. These staff members can make appropriate referrals, reinforce treatment plans, call to inquire about broken appointments, and in general support and encourage families whose stresses are contributing to their dysfunction. Weekly, informal meriendas educativas (educational kaffeeklatsches)9 child management and family health classes could be held in the office or at some central meeting place. These discussions can be facilitated by bilingual materials10 and by Spanish-language educational video and audio tapes.11*
Discipline styles. It is essential to attempt to identify and discourage discipline styles that can injure, frighten, degrade, depress, or confuse the child. The doctor, nurse, and other professional staff members are in positions of prestige. The low-income Spanish-speaking person is likely to be highly influenced by prestigious professionals whom he respects. Consejos ("advice") delivered clearly and concretely, yet with respect and affection, are likely to be well received.
The role of the father. Poverty, prejudice, insufficient education, unemployment, and insensitive helper practices serve to weaken and discourage the Spanish-surnamed father. Attempts should be made to counteract these destructive influences. Sensitive, caring inquiries concerning the father could be made. The mother should be encouraged to relay pertinent information and to involve her husband. The father should be encouraged to call, and the importance of his opinions and decisions should be emphasized. In situations of father absence or dysfunctional fathering, appropriate referral should be made. The family should be encouraged to utilize available healthy extended-family members, compadres ("godparents"), neighbors, and friends.
Cultural strengths. Even though the Spanishsurnamed population is culturally very heterogeneous, attempts should be made to understand and accept the patient's specific cultural values and practices. Many of these practices are very constructive when they are viewed from the patient's perspective. The extended family and compadres, when available and functional, can constitute a powerful supportive network as well as a source of cultural continuity. Cultural pride, knowledge of Spanish, and in-group cohesion are tremendously useful sources of identity, support, and enrichment. Spanish-speaking parents can be encouraged to teach their children the richness of their Cuban, Puerto Rican, Mexican, and other Hispanic cultures. Their songs, traditions, dichos ("proverbs")» and chistes ("jokes") constitute a system of cultural wisdom that is shared with each oncoming generation. Failure to perceive the importance of retaining and cherishing this group's cultural heritage can produce dysfunctional behaviors by overtly and covertly encouraging these parents to culturally deprive and historically isolate their young. The practitioner must also be aware of the client's tendency to attribute to culture behaviors that may be destructive to the family's well-being. This practice should not be accepted. When it is, pathologic behaviors are reinforced and the culture is polluted and distorted.
In summary, intervention strategies with the low-income Spanish-speaking or Spanish-sumamed population must be based on the reality that we currently know very little about their core culture, family, and childrearing values and practices. Inappropriate generalizations derived from poorly designed studies, anecdotal reports of isolated enclaves, authors' romantic or deprecatory prejudices, and reports of the victim's acceptance of stereotypes are the essence of our current knowledge. The pediatrician or family counselor must avoid cultural generalizations if he hopes to work effectively with these families. Instead, the practitioner must consider individual cultural values and practices and the povertyspecific concomitants that can influence child care.
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