Cultural diversity poses challenges within the health care setting, particularly regarding the question of how health professionals can resolve the tension between respecting cultural norms or child-rearing practices and the importance of determining what constitutes harm and child maltreatment. Cultural competency and respect for cultural diversity does not imply universal tolerance of all practices. The United Nations provides a standard of universal child rights, protecting them from harmful practices. Pediatric providers must respect cross-cultural differences while maintaining legal and ethical standards of safety and wellbeing for children, promoting evidence-based prevention of maltreatment, and advocating for child wellness across all cultures.
Key points
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Culturally competent services, sensitive to diverse health beliefs and practices and to cultural and linguistic needs, are essential in achieving parity in care and facilitating positive health outcomes for children and families across all cultures.
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Cultural competence requires individuals and organizations to (1) appreciate diversity, (2) assess their own cultural perspectives and biases, (3) bridge cross-cultural differences, (4) acquire and disseminate knowledge regarding culture, and (5) continually address the changing needs of the culturally diverse population they serve.
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Owing to worldwide variability in resources and cultural/social norms, policies of child protection and definitions of child maltreatment vary.
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The use of culturally respectful models in the determination of child maltreatment does not mandate universal tolerance of all cultural practices.
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The United Nations Convention on the Rights of the Child (UN CRC) establishes universal principles for approaching child maltreatment and child protection.
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The application of the UN CRC requires an understanding of what is happening locally, including how a cultural group is situated within its social and political milieu, in addition to relevant laws and policies.
[T]he action most worth watching is not at the center of things but where the edges meet….shorelines, weather fronts, international borders. There are interesting frictions and incongruities in these places, and often, if you stand at the point of tangency, you can see both sides better than if you were in the middle of either one. This is especially true…when the apposition is cultural.
Globalization, technology, media, and human migration patterns have all contributed to creating a landscape of cultural diversity that is being increasingly recognized within health care delivery models. Groups have belief-systems that shape how they perceive health and illness, and whether and where they choose to seek out health care. Anne Fadiman’s pivotal documentation of the 1980s clash between a Hmong refugee family and their daughter’s health care providers in a Northern California community hospital highlighted what is now a well-recognized theme within the health care system. Importantly with regard to maltreated children, culture can affect their perception and disclosure of trauma, expression of symptoms, treatment-seeking behaviors, and attitudes toward treatment and recovery. Especially challenging is the question of how health professionals resolve the tension between respecting cultural norms or child-rearing practices and the importance of determining what constitutes harm and child maltreatment. Addressing this complex question necessitates an understanding of the culture of the child and the family, and also of the health care provider. In addition, consideration must be given to the social and cultural norms and policies of the society within which the circumstances are being evaluated. Moreover, there exists a universal standard of child rights that must be upheld to protect children of all cultures from harm and maltreatment.
Background: culture and cultural competency
Defining Culture
Culture is a set of “beliefs, attitudes, values and standards of behavior” that are passed down generationally, and are so entrenched within a cultural group that they are obvious and need not be overtly stated or challenged and defended. Key elements of culture are depicted in Fig. 1 . Culture is “not monolithic and static but variable and dynamic,” and is modified by time and continual interactions within its larger environment. Some of these dynamic processes are listed in Table 1 .

Enculturation | Process whereby a person is socialized into his or her own cultural group and learns its specific beliefs (eg, what a child undergoes as he or she is raised within one cultural group) |
Intergenerational tensions | Process whereby 2 generations within one culture challenge each other’s beliefs |
Acculturation | Process whereby an individual responds to his or her nonprimary culture, and vice versa |
Migration | Process of movement of an individual or a group to a separate or new geographic area (eg, immigrants seeking new opportunity; refugees fleeing persecution; Native Americans placed on reservations) |
Cultural Competence
An appreciation and understanding of cultural diversity is an essential component of clinical care. “Cultural competence refers to the process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, and other diversity factors in a manner that recognizes, affirms, and values the worth of individuals, families, and communities and protects and preserves the dignity of each.” Cultural competence is vital to reducing disparities and to achieving parity in delivery of services and care across a diverse population. Extensive guidelines have been published, giving providers and organizations a standard set of skills for culturally competent care. The Joint Commission has summarized 5 basic elements required of individuals and organizations, which are helpful for health care providers who seek to provide care that is deemed culturally competent ( Table 2 ).
Component | Examples |
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Appreciate and value diversity | Recognize and respect that communities are their own cultural experts |
Undergo continual self-assessment | Understand the impact of one’s personal cultural identity on how one practices health care Aware of stereotypes Aware that patients are influenced by their culture but are not defined by them |
Manage the dynamics of difference | Identify patients’ preferred language and provide trained language/communication assistance services Consider involvement of a patient’s family/cultural community in health-related discussions |
Acquire and institutionalize cultural knowledge | Support ongoing sharing of cultural knowledge Support effective communication among staff to address diverse patient needs |
Adapt to cultural diversity/community needs | Use population-level demographic data to determine community needs Collect feedback from patients, families, and the community |
Achieving cultural competence is not a linear process with a definitive end point of full competency. Rather it is an iterative, dynamic process whereby providers continually appraise their own cultural belief systems and practices in addition to the needs of the populations they serve. Some examples of providers’ cultural limitations in assessing child maltreatment are listed in Box 1 . Recognizing these limitations, and those of one’s beliefs, is referred to as “cultural humility,” and is vital to exercising a culturally respectful approach to child maltreatment.
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Stereotyping
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Fear of appearing racist
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Inadequate training
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Denial of abuse in ethnic minorities
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Communication difficulties (for example, the lack of use of interpreters, when indicated)
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Overidentifying with caregivers
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Fear of labeling a practice as maltreatment
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Lack of child-centered approach
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Cultural biases about disability and mental illness
Background: culture and cultural competency
Defining Culture
Culture is a set of “beliefs, attitudes, values and standards of behavior” that are passed down generationally, and are so entrenched within a cultural group that they are obvious and need not be overtly stated or challenged and defended. Key elements of culture are depicted in Fig. 1 . Culture is “not monolithic and static but variable and dynamic,” and is modified by time and continual interactions within its larger environment. Some of these dynamic processes are listed in Table 1 .
Enculturation | Process whereby a person is socialized into his or her own cultural group and learns its specific beliefs (eg, what a child undergoes as he or she is raised within one cultural group) |
Intergenerational tensions | Process whereby 2 generations within one culture challenge each other’s beliefs |
Acculturation | Process whereby an individual responds to his or her nonprimary culture, and vice versa |
Migration | Process of movement of an individual or a group to a separate or new geographic area (eg, immigrants seeking new opportunity; refugees fleeing persecution; Native Americans placed on reservations) |
Cultural Competence
An appreciation and understanding of cultural diversity is an essential component of clinical care. “Cultural competence refers to the process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, and other diversity factors in a manner that recognizes, affirms, and values the worth of individuals, families, and communities and protects and preserves the dignity of each.” Cultural competence is vital to reducing disparities and to achieving parity in delivery of services and care across a diverse population. Extensive guidelines have been published, giving providers and organizations a standard set of skills for culturally competent care. The Joint Commission has summarized 5 basic elements required of individuals and organizations, which are helpful for health care providers who seek to provide care that is deemed culturally competent ( Table 2 ).
Component | Examples |
---|---|
Appreciate and value diversity | Recognize and respect that communities are their own cultural experts |
Undergo continual self-assessment | Understand the impact of one’s personal cultural identity on how one practices health care Aware of stereotypes Aware that patients are influenced by their culture but are not defined by them |
Manage the dynamics of difference | Identify patients’ preferred language and provide trained language/communication assistance services Consider involvement of a patient’s family/cultural community in health-related discussions |
Acquire and institutionalize cultural knowledge | Support ongoing sharing of cultural knowledge Support effective communication among staff to address diverse patient needs |
Adapt to cultural diversity/community needs | Use population-level demographic data to determine community needs Collect feedback from patients, families, and the community |
Achieving cultural competence is not a linear process with a definitive end point of full competency. Rather it is an iterative, dynamic process whereby providers continually appraise their own cultural belief systems and practices in addition to the needs of the populations they serve. Some examples of providers’ cultural limitations in assessing child maltreatment are listed in Box 1 . Recognizing these limitations, and those of one’s beliefs, is referred to as “cultural humility,” and is vital to exercising a culturally respectful approach to child maltreatment.
-
Stereotyping
-
Fear of appearing racist
-
Inadequate training
-
Denial of abuse in ethnic minorities
-
Communication difficulties (for example, the lack of use of interpreters, when indicated)
-
Overidentifying with caregivers
-
Fear of labeling a practice as maltreatment
-
Lack of child-centered approach
-
Cultural biases about disability and mental illness
Culture’s influences
A foundational understanding of the influence that culture has on child-rearing practices, manifestations of symptoms of abuse, and health behaviors is essential to establishing a culturally competent practice of care.
Cultural Influences on Child Rearing
Cultures define “proper” and “improper” practices for parents. By understanding the diversity of culturally dictated factors influencing parenting and behaviors, health care providers are able to maintain cultural awareness and respect.
Factors influencing parenting practices and parental intent
Multiple factors and values influence how parents view and treat their children. Certain characteristics of children influence their risk of abuse within different cultures. For instance, the sex of a child may predispose or protect that child from abuse. An example is the strength of belief in male-child preference in regions of South Asia, which may influence the regional prevalence of female infanticide. Moreover, disabilities or health conditions in children may affect their value or burden. A child’s perceived economic utility or ability to preserve familial heritage may provide protection against maltreatment. In addition, unique consideration should be given to the vulnerability of lesbian/gay/bisexual/transgendered/questioning youth, given the wide range of cultural beliefs regarding sexual orientation. Cultural factors relating to the caregiver or family unit also affect the likelihood of maltreatment: these include family size and structure, sex roles, resources affecting stress and isolation, mental illness, and history of abuse. Furthermore, economic stress and intergenerational poverty significantly affect cultural beliefs and practices.
Collier and colleagues, in their study of Palauan teachers’ perception of child maltreatment, expose the gray area of parental intent. Parental behaviors were less often perceived as abusive if their intent was for discipline, which included such practices as children being beaten for not doing their homework. In addition, the practice of Palauan parents tying their toddlers by the leg to a post to keep them safe while they farmed was the scenario that was least likely to be viewed as abusive and reportable; this highlights the interface of local cultural values, practical considerations of daily responsibilities, and parental intent. Given that the intent was to protect, would providers with a Western cultural background also view this practice as acceptable? Although the practice is not deemed to be physically harmful within Palauan culture, the questions of the child’s subjective well-being and of whether the child may still incur psychological trauma as part of the practice are difficult to fully ascertain, especially using a Western framework.
Culture and parental discipline
Among the most contentious and perhaps the most germane topic within child maltreatment for primary care providers is that of parental discipline. “Child physical maltreatment most often results not from sadism or desire to harm, but from intent to punish or teach.” In particular, corporal punishment and its perception as either abusive or acceptable are varied across cultures and dynamics over time. Corporal punishment has historically been seen as acceptable, with most parents in the United States 2 decades ago reporting that they spanked their children, and with more than half of the medical providers in a survey supporting spanking in certain circumstances. In the United States, laws banning corporal punishment of children in schools and in the home vary by state. In their multi-country (6 countries, 19 communities) survey of parental discipline as part of the World Studies of Abuse in the Family Environment (WorldSAFE) project, Runyan and colleagues determined that a median of 16% of children in all countries surveyed experienced harsh or potentially abusive discipline in the prior year.
New studies and greater understanding of the impact of parental violence against children, and the increased recognition of children as bearers of rights, have led to a shift from regarding physical punishment as an effective and acceptable parenting practice to a risk factor for maltreatment. The American Academy of Pediatrics (AAP) Policy on Effective Discipline provides evidence that spanking can escalate: spanking increases the chance of physical injury to young children, may lead to more agitated or aggressive behaviors in children over the long term, and also may lead caregivers to perpetuate the use of physical punishment. Children who are spanked experience poorer behavioral and cognitive longitudinal outcomes. In recent years, the judicial systems evaluating corporal punishment cases in India, Israel, Italy, Fiji, Kenya, Namibia, Nepal, South Africa, and Zambia have ruled in favor of the rights of children. Nevertheless, only 2% of the world’s children, according to a UNICEF report, are protected from corporal punishment in the home. Thus, there is still a global acceptance across many cultures of physical discipline. Child rights advocates seeking legal protection of children from corporal punishment focus their efforts on changing cultural norms by motivating caregivers and educating the general public about the evidence-based negative health outcomes of this practice.
Cultural Influences on Health Behaviors
Fadiman’s account of the Hmong family’s clash with their daughter’s Western health care providers illustrates innumerable manifestations of culture-related discordance of patients and clinicians. Specifically, cultural beliefs and practices can affect adherence to health care recommendations, health-seeking behaviors, and acceptance of medical treatment. For example, Fadiman describes how the Western medical ascription of seizures as a treatable medical problem stood in direct contrast to the Hmong belief that these seizures are a cherished unique and spiritual connection. If a cultural group does not accept the premise behind the need for a medical intervention, nonadherence to care or delay in seeking care is expected. Alternative cultural practices may be administered in addition to or in lieu of allopathic medical care.
Clinicians should acquire knowledge of traditional remedies that may result in findings that raise concern for maltreatment. In particular, many cultural healing practices result in patterned skin markings. Moxibustion, the application of a heated object to the skin at therapeutic points, is used in many cultures. For example, the Vietnamese practice of coining involves application of a hot coin to the skin. Cupping, the application of alcohol to the rim of a cup that is then heated and applied to the skin, may result in circular skin burns of varying severity. Maquas , deep burns to the skin near diseased organs, are seen in Arabic cultures. In addition, garlic is used in many cultures for healing in various manners and, if applied to the skin for prolonged periods of time, results in bullae or burn-like lesions. These findings may be misdiagnosed as abusive injuries by a clinician who has not considered these other potential practices. Such findings may present an opportunity for clinicians to illustrate alternative healing practices that may not cause physical injury.
Cultural and religious beliefs that caregivers cite to overtly refuse medical care pose a unique challenge for clinicians who must decide if refusal of treatment constitutes maltreatment. Circumstances can range from vaccine refusal to blood-transfusion refusal to prayer over a convulsing child. The central issue is the determination of whether the child’s health care needs are being met. In the United States, a review of child deaths caused by lack of medical care for religious exemptions over a 20-year period determined that nearly all deaths were preventable. Therefore, the AAP takes opposition to religious exemptions to medical care, stating that this disrupts society’s ability to equally protect every child and ensuring the fulfillment of their basic needs. Although this opinion is not universally upheld within regional United States legal systems, the US Supreme Court has ruled that the “right to practice religion freely does not include the liberty to expose the community or child to communicable diseases, or the latter to ill health or death.”
Cultural Influences on Manifestations of Abuse
When a child is maltreated within a family, cultural norms will dictate whether and how an individual or a family will disclose abuse, how they will seek help, and how they will respond to treatment and prevention initiatives. Disclosures of abuse can be discouraged by several factors that are weighted heavily in certain cultures: these include shame; taboos and modesty; sexual scripts; virginity; women’s status; honor, respect, and patriarchy; and religious beliefs. Some of these belief systems may limit open discussion about sexual matters, thereby limiting opportunity for disclosure, particularly of sexual abuse. Arab culture’s emphasis on collectivism and the benefit of the family over the individual, filial piety, hierarchical parent-child roles, and family honor and loyalty, in addition to a cultural stigma of mental health problems, may affect a victim and his or her family’s response to abuse. In addition, disclosure can be impeded by “reporting costs,” which are the consequences of a disclosure to an official source, such as loss of privacy, family support, or finances. The concepts of historical trauma, whereby there is societal transmission of trauma to subsequent generations, and of unresolved or disenfranchised grief, whereby such grief cannot be publicly acknowledged or mourned or supported, may also influence disclosure and help-seeking behaviors. Furthermore, the “model minority stereotype,” as experienced by South Asians within American culture, may cause them to internalize an excessively idealized identity and, therefore, not disclose circumstances that may dishonor that model minority myth. These examples illustrate the cultural variability in the disclosure of abuse.
In addition to disclosure, symptoms of abuse, for example, depression and suicidality or externalized symptoms such as anger or sexualized behavior, are variable depending on ethnic background. A survey of Taiwanese schoolchildren showed that children identified as victims of physical abuse had fewer symptoms of subclinical posttraumatic stress disorder in comparison with victims studied in Western cultures. This difference could be attributed, for example, to the fact that physical discipline by family elders is accepted in Chinese societies and that Chinese children therefore accept this as punishment for unwanted behaviors. African American sexually abused girls have been noted to demonstrate more symptoms of trauma-related avoidance or withdrawal than their Hispanic counterparts. Although the effects of each ethnic group’s level of acculturation cannot be measured, this increase in symptoms of avoidance and withdrawal can be potentially attributable to a history of disenfranchisement of African Americans within the child protective system in comparison with other ethnicities. Thus, practitioners must be aware of the ethnic and cultural variability that may exist in the presentation of symptoms following abuse.

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