Ethical Challenges of Parenting Interventions in Low- to Middle-Income Countries

Abstract

This article explores ethical issues raised by parenting interventions implemented in communities in low- to middle-income countries (LMICs) with rural, subsistence lifestyles. Many of these interventions foster “positive parenting practices” to improve children’s chances of fulfilling their developmental potential. The practices are derived from attachment theory and presented as the universal standard of good care. But attachment-based parenting is typical primarily of people living Western lifestyles and runs counter to the different ways many people with other lifestyles care for their children given what they want for them. Thus, such parenting interventions involve encouraging caregivers to change their practices and views, usually with little understanding of how such changes affect child, family, and community. This undermines researchers’ and practitioners’ ability to honor promises to uphold ethic codes of respect and beneficence. Support for this claim is provided by comparing positive parenting practices advocated by the United Nations International Children’s Emergency Fund (UNICEF; with the world health organization [WHO]) Care for Child Development (CCD) intervention with parenting practices typical of communities with rural, subsistence lifestyles—the most common of lifestyles worldwide and largely observed in LMICs. As UNICEF has a considerable presence in these countries, the CCD intervention was selected as a case study. In addition, parenting interventions typically target people who are poor, and the issues this raises regarding ethics of fairness and justice are considered. Recommendations are made for ways change agents can be sensitive to the living conditions and worldviews of communities, and, thus, be appropriately effective and ethically sensitive to the diverse needs of different communities.

Keywords

parenting interventions ethics culture low- to middle-income countries

The reliance on early childhood development and education intervention programs (ECD/E) to positively influence children’s developmental achievements is a growing trend worldwide. The geographic distribution of these programs is impressive. ECD/E programs are in place in at least 88 countries where the United Nations International Children’s Emergency Fund (UNICEF) is active (Britto, Ponguta, Reyes, & Karnati, 2015), and similar programs are implemented by other intergovernmental organizations (IGOs) and by nongovernmental organizations (NGOs), governments, and civil society organizations. Many of these programs attend to the worlds’ most vulnerable children—the poor, the disadvantaged, and the disabled—in low- to middle-income countries (Mahon, 2010). One reason for this is that “More than 200 million children under 5 years of age in developing countries are not fulfilling their developmental potential” (Jolly, 2007, p. 145). Programs address factors that place children at risk for poor development in different ways (Putcha & van der Gaag, 2015). Interventions that deal with biological risk typically lessen the ill effects of nutritional deficiencies, infectious diseases, and environmental toxins. Those that deal with psychological risk typically promote “positive parenting practices” (Juffer, Bakermans-Kranenburg, & van Ijzendoorn, 2008) to optimize children’s cognitive and social-emotional competence. Sometimes, especially in low- to middle-income countries, interventions address both biological and psychological risk at the same time.

To be effective, interventions must change people’s views, practices, social norms, and/or lifestyles, and this can raise various ethical concerns (Guttman, 2017, p. 2). These concerns are legitimate when interventions take place in communities we know little about (e.g., Arnett, 2008; Henrich, Heine, & Norenzayan, 2010; Nielsen, Haun, Kärtner, & Legare, 2017), and when we assume that what we know about one group is universally applicable to children and families everywhere (e.g., Morelli et al., 2017; Rosabal-Coto et al., 2017). This article details our ethical concerns with parenting interventions that are implemented in communities in low- and middle-income countries to influence vulnerable children’s psychological development. We often do not know enough about these communities to understand which basic skills children need to survive and thrive, how to effectively intervene to enhance developmental outcomes, and how to evaluate short-term and long-term ramifications of any intervention. Much of what we know about positive parenting is based on research by scholars in U.S. academic institutions and in English-speaking countries on a small, select, percentage of the world’s people (Arnett, 2008; Henrich et al., 2010). And much of this research draws conclusions that overstate the extent of scientific consensus about favorable conditions for and features of children’s psychological development (Serpell & Nsamenang, 2014). In doing so, the research advances a particular view of parents and children (Keller & Kärtner, 2013) that is widely (but erroneously) accepted as universally applicable. This view dominates the scientific discourse on parenting on which decisions about risk and support are made.

The standards of care set by positive parenting advocates are held primarily by people in Western lifestyle communities, which are typified by living in service-based economies, in nuclear families with few children, with a high degree of formal education, and relative financial security. Yet most of the people in the world lead other, diverse lifestyles. The most prevalent of them, and widespread in low- and middle-income countries, is represented by people who have in common certain sociodemographic characteristics. They (a) tend to live in rural, subsistence-based (farming) economies, (b) tend to have a basic level of formal education, (c) tend to live in extended families with many adults and children, and (d) tend to experience income or wealth insecurity. (We refer to this sociodemographic cluster as rural, subsistence lifestyles for ease of reference.)

People with similar lifestyles, based on these sociodemographic clusters, are likely to be similar as well in community practices and views about good parenting and good child development (Keller & Kärtner, 2013). These practices and views are often a part of, and complementary to, a community’s larger cultural system. They make sense to the community, often intuitively. And, for the most part, they are successful in promoting children’s health and well-being in light of their cultural considerations and ecological affordances and constraints.

Parenting intervention programs rarely pay significant attention to community practices when they teach some Western lifestyle standards of care to people in communities with different lifestyles. The Reinforcement of Parental Practice intervention program, implemented by the Senegal-based NGO Tostan, serves as an example (see Weber, Fernald, & Diop, 2017 for a description of the program). This intervention trains rural-living Senegalese adult caregivers (mostly mothers) to talk with their young children, one-on-one, in play situations using discourse styles that are both prevalent and valued in Western lifestyle communities. However, this way of engaging with children runs contrary to standards of good caregiving in these Senegalese communities (Morelli et al., in press). In this case and others, practitioners problematize certain care practices (e.g., reliance on nonverbal communication) and, in their efforts to change them, may stigmatize the caregivers who practice them (Guttman, 2017). In turn, changing “problematic” practices may alter social dynamics and disrupt family or community life, or even increase the likelihood of exposing children to dangers from which they would otherwise be protected by their community’s care practices (e.g., Nsamenang, 2007; Serpell, 2011). Thus, well-intentioned parenting interventions can create ethical quagmires.

We examine the ethical challenges of parenting intervention programs using the code of ethics most researchers and practitioners agree to honor when they work with children and families. We rely on this code to frame our inquiry into intervention programs designed to teach positive parenting practices that are based on the caregiving of people in Western lifestyle communities. This care closely mirrors the kind of parenting advocated by attachment theory (see Juffer et al., 2008), which has been the dominant discourse on parenting for decades but remains insensitive to cultural diversity in child care practices. We illustrate this by juxtaposing positive parenting training by professionals associated with UNICEF’s Care for Child Development (CCD) intervention with parenting associated with rural, subsistence lifestyles. We show how the two lifestyles differ in their care of children and in their conceptions of what it means to be an acceptable, good, and moral child (Ramaekers & Suissa, 2011). We advocate for acceptance of more diverse and inclusive views of parenting beliefs and practices, clarity in distinguishing these local beliefs and practices from conditions of poverty that independently affect child rearing, and heightened attention to ethical responsibilities of agents involved in interventions that teach caregivers different ways to care for children. We end with specific examples of ways to meet our ethical responsibilities and to improve the validity (and thereby enhance the benefits) of interventions designed to improve the well-being of the world’s children.

Code of Ethics and Standards of Conduct

Professional organizations, government agencies, universities, researchers, and practitioners are expected to honor codes of ethics and standards of conduct when they work with children and families in all communities. The codes and standards vary somewhat with the mission of the institution, but most of them include a version of the core principles established in the Belmont Report (United States National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1978): respect for the person, beneficence, and fairness and justice. These principles set standards for the ethical conduct of research, but they can serve as the foundation for practice as well (e.g., Berman et al., 2016; Guttman, 2017; Miller, Goyal, & Wice, 2015).

The principle of respect for the person asks that we consider people as autonomous agents capable of making their own decisions based on their values and preferences. To respect people in this way, we need to understand that a person’s decisions may relate in complex ways to his or her socioculturally situated relationships; that making decisions implies making choices; and that people must be aware of the choices available to them.

The principle of beneficence asks that our actions promote the well-being of people, communities, or societies as a whole. If the benefits to all are not clear, we should reconsider what we do. Our actions should minimally do no harm, or minimize harm if there is a greater benefit, whether on a physiological, psychological, or sociocultural level.

The principle of fairness and justice asks that we select people for study or intervention in ways that are equitable (e.g., fair in opportunities for involvement, just in determining who actually benefits), and avoid exploiting vulnerable populations.

There are widely shared standards of conduct that translate these principles into practice, for example, obtaining informed consent, protecting privacy, maintaining confidentiality, avoiding conflict of interest, determining noncoercive forms of compensation, and following procedures and using assessment instruments whose validity and reliability have been established for the people involved in the study or intervention. However, the application of the ethical principles in these and other ways is often complex. It requires that researchers and practitioners understand the people with whom they are working by learning about their perspectives. They must understand the lived experiences of people as they reflect the intersections of cultural worldviews, economic resources, ethnic background, age, gender, social status, linguistic practices, religion, and other factors, and they must become aware of and avoid acting on their biases. This is likely when there is wide-ranging representation of cultural perspectives in research and practice, especially perspectives of scholars and experts from communities that are not well represented.

Without such information, the ethics of research and practice are compromised. Miller et al. (2015) give an example of this. The Strange Situation, a procedure to assess the quality of a child’s attachment to his or her caregivers, was developed based on child care assumptions of people primarily in Western lifestyle communities. But, it is considered “ethical” by institutional review board standards even though research documents the extreme stress (harm) mothers and infants in non-Western lifestyle communities may experience in this procedure (e.g., Gaskins et al., 2017).

Care for Child Development Intervention

We illustrate our ethical concerns about parenting interventions by considering the CCD intervention that is implemented by UNICEF (with WHO) directly or indirectly through alliance networks. We single out UNICEF’s CCD intervention to make our case because of UNICEF’s considerable presence in low- and middle-income countries. This intervention, in 2015, was reported in 23 sites in 19 UNICEF-active countries (Lucas, 2016). Even this figure does not tell the entire story, as the CCD intervention is carried out by many other agencies.

The CCD intervention was implemented in the late 1990s to promote positive parenting defined as “effective, sensitive, and responsive child rearing and caring practices” (Britto et al., 2015, p. 1). The assumption was that this style of care best allows caregivers to raise children to become successful members of the community. UNICEF has a long history of promoting children’s well-being, and it is the only intergovernmental agency devoted exclusively to children. In the early days of its inception, UNICEF provided emergency and health care to children (Watt & Roosevelt, 1949). It widened its scope to include mothering practices, perhaps, as LeVine and LeVine suggest, “on the assumption that the mothering practices of the poorer countries with high infant mortality rates must be putting babies at risk psychologically as well as medically” (LeVine & LeVine, 2016, p. 47).

The ethical concerns we have about this intervention extend to all interventions that aim to change the child care practices of people, especially in communities whose lifestyles are poorly understood. Our critical examination of the difficult ethical dilemmas this parenting intervention faces is not a critique of all the other interventions and programs UNICEF has put into place over the years. We appreciate and cherish all efforts to help families. However, as we detail, the CCD intervention and other similar interventions worry us because their goal is to modify how people with certain lifestyles care for children by training them in positive parenting practices of people with different, Western lifestyles. We extend our critique to attachment theory because of its universal claims regarding positive parenting and its impressive influence into real-life situations worldwide (Rosabal-Coto et al., 2017).

Attachment Theory

Attachment theory is psychology’s most influential theory of relationships, and it has dominated developmental accounts of children’s close relationships in the last decades. From the start of the 20th century, psychologists of different orientations studied the attachments that infants form with their main caregivers and offered different explanations for those ties. John Bowlby (an English psychiatrist and psychoanalyst) along with his colleague Mary Ainsworth (a U.S.-Canadian psychologist) made the case that infants have an innate need to attach to their mothers (if the mother is not available, a child will attach to a mother-figure: for example, Ainsworth & Bowlby, 1991), but the quality of the attachment stems from the way a mother cares for her child (Ainsworth, Blehar, Waters, & Wall, 1978). When care is sensitive and responsive, a child feels secure in the presence of his or her mother, is able to explore the environment with confidence, and thus, is able to master the physical and social world. When care is not sensitive and responsive, a child is less able to do this. For these reasons, the security that care engenders is seen by attachment theorists as paramount to the child’s social and emotional development, to the child’s ability to learn about the world on his or her own and from others, and to all of the child’s future relationships (e.g., Cassidy & Shaver, 2016).

The sensitive and responsive care described by Bowlby, Ainsworth, and researchers who continue with their intellectual tradition is accepted as the gold standard of care by which all care, worldwide, is compared and evaluated. This is so despite the fact that attachment theory has received numerous criticisms since its inception (Vicedo, 2017).

Implementation of the Care for Child Development Intervention

The CCD intervention trains caregivers in positive parenting skills, based on attachment theory, that should maximize children’s ability to achieve their full potential (Britto et al., 2015; Lucas, 2016). (This intervention takes place as part of existing health, nutrition, and other family-support services.) Caregivers practice these skills primarily in the context of play and talk. The assumption is that positive parenting, especially when it takes place in these contexts, will promote secure attachment relationships. With this, children are believed to be more likely to develop stronger social (e.g., cooperation), cognitive (e.g., language), and emotional (e.g., regulation) skills (UNICEF, 2012; UNICEF/WHO, 2012b).

In this intervention, caregivers are taught to treat the child as a separate person, to see the world from the child’s point of view, and to respond contingently and appropriately to the child’s explicit signals (Lucas, 2016; UNICEF, 2012; UNICEF/WHO, 2012b). Accordingly, caregivers practice:

Exclusive and intensive dyadic exchanges with the child that rely on distal senses, for example, caregivers are instructed to look closely at the child, into the child’s eyes when communicating with the child; to take turns with the child; and to talk with the child whenever possible (especially while breastfeeding), starting on the first days of life.

Child-centered ways of engaging with the child, for example, caregivers are instructed to focus on the child’s interests and not to change the child’s focus; to respond to their child’s words, actions, sounds, interests, and so on; to not correct the child; to give the child choices rather than saying “don’t”; to notice and praise what the child does; and to wait for the child to make a response before responding.

Affectionate and affectively engaging ways to interact with the child, for example, caregivers are instructed to encourage the child to smile, and to smile and laugh with the child.

The CCD intervention sensitizes children to pay attention to their own personal qualities and preferences, and to use both as a primary point of reference to relate to and with others; to see themselves in control of events and therefore able to change them in ways most suited to their needs and wants; and to define and negotiate relationships from their point of view.

These positive parenting skills, and the children they aim to raise as self-contained and self-focused, accord with what the UN Convention on the Rights of the Child (CRC) expects of parents and children. We draw attention to the CRC because it serves as the basis of all of UNICEF’s work (UNICEF, n.d.-a, n.d.-b). Children’s rights are based on what childhood is believed to be like, the leading assumption being that it is uniform across the world in the ways imagined (e.g., Burman, 1996, pp. 51-53 for a recounting of the political agendas that attended its writing—especially the undue influence of the U.S. delegation in its drafting). Taken together, the 42 CRC Articles that spell out children’s rights make clear that “The child is entitled to care, security and an upbringing that is respectful of his or her person and individuality” (Pečnik & Lalière, 2007, p. 23). Parents (or guardians) are expected to ensure these rights, and, as a result, they should receive the assistance they need to do so (Hodgkin & Newell, 2007). A notable feature of the CRC is that children’s rights have priority over parents’ rights. However, this priority is unfamiliar for many communities where children are not viewed as separate individuals outside of their families, but are, instead, nested within the identity of their parents, wider kin group, or community at large. In such contexts, the notion of separating the rights of children from the family or community circle would be deeply and structurally—indeed, ethically—problematic.

The Case for Ethical Concerns

The CCD intervention is burdened by assumptions about child rearing that are widely held by people with Western lifestyles. One is that primary caregivers (usually mothers) typically and regularly play and talk with children, and they do so in certain ways (e.g., face-to-face, mutual gaze). These are presumed to be important contexts for maternal expressions of sensitive and responsive care, and, therefore, critical learning opportunities significant to a child’s attachment and, thereby, a child’s development (UNICEF, 2012; UNICEF/WHO, 2012b). The cross-cultural record shows, however, that adult–child play and talk are less common among people in rural, subsistence communities, and when they take place, they usually do not follow the typical interactional script (e.g., exclusive, distal, dyadic exchanges) of Western lifestyle communities (Lancy, 2007; Paradise & Rogoff, 2009). Consider this example of talk. Adults tend to use talk judiciously with children, and a lot of talk between adults and children is in the service of carrying out an ongoing activity (Morelli, Rogoff, & Angelillo, 2003). Children, on the other hand, talk a lot with one another, and, indeed, they may spend more time talking with one another than they do with adults (Rogoff, Morelli, & Chavajay, 2010; Scheidecker, 2017). Children mostly chit-chat among themselves as they relax and hang out, or talk as they play, do chores, and help out.

Another assumption is that the child’s primary caregiver, usually the mother, is the person with whom the child spends most of his or her time and who provides the widest range of care for the child. As such, the mother is the person who provides that child’s primary learning experiences. But mothers may spend less time with their children than the combined collective input of all other caregivers (e.g., Morelli & Tronick, 1992; Weisner et al., 1977), and mothers may care for children in circumscribed ways (e.g., in rural Madagascar, mothers only attend to their children’s physical needs; Scheidecker, 2017). Thus, with an exclusive focus on mother and child, important learning experiences provided by many other social partners, especially children (e.g., Weisner et al., 1977), would be missed.

A third assumption is that children should develop a sense of self as independent and self-contained individuals. As we discuss next, many in communities with rural, subsistence lifestyles hold different views. Often, children in such communities are expected to develop a sense of self as connected with others, and the care that best accomplishes this is usually at odds with positive parenting practices. Despite that, positive parenting is the care model used by the CCD intervention to teach caregivers how to care for children, with little appreciation for their communities’ lifestyles. This inattention to local circumstances undermines efforts to uphold the principle of respect and thereby renders honoring the principle of beneficence difficult if not impossible.

Ways of Caring for Children in Rural, Subsistence Lifestyles

People living rural, subsistence lifestyles expect children to be fundamentally connected to others such that they are “defined and made meaningful in respect to such others” (Markus & Kitayama, 2010, p. 423). Accordingly, care in these communities sensitizes children to pay attention to the needs and interests of others, and to the community as a whole; and it encourages children to see themselves and the world as others do. People are children’s primary referent for action, and control is about changing oneself in the interest of others to meet relational and other social obligations (Rothbaum, Morelli, & Rusk, 2011).

Caregivers support children’s learning of this relational sense of self by helping children fit into the social goings-on in the moment, and into the social group as a whole. Fitting-in goes hand-in-hand with children’s keen awareness of and inseparable connection to others that defines them and their reality. Children can learn this sense of connectedness in various ways, and there is a great deal of diversity among communities in how this learning is supported. One way takes advantage of the great amount of time children typically spend nearby or in physical contact with the (sometimes many) people with whom they keep company. Physical closeness provides regular and plentiful opportunities for children and caregivers to use touch, posture, gaze, gestures, facial expressions, and other nonverbal ways to communicate (Keller et al., 2009). These valued, proximal modes of communication are inclusive of other activities as well as other people, and they make it possible for children to engage in multiparty, ongoing, simultaneous activities (Rogoff, Mistry, Goncu, & Mosier, 1993). In this manner, children engage others as expected, without interrupting, dominating, or monopolizing whatever else caregivers are doing (Otto & Keller, 2015).

Children who fit in are often expected to be calm, well-behaved, well-mannered, respectful, and obedient (Harwood, Miller, & Irizarry, 1995; Morelli, Ivey Henry, & Foerster, 2014; Otto & Keller, 2014; Quinn & Mageo, 2013). Caregivers may dampen or discourage expressions of emotions—positive as well as negative ones—to support these qualities (e.g., Diener, 2000; LeVine & LeVine, 2016). The emotional expressiveness as encouraged in the CCD (e.g., affectively engaging), however, is seen, oftentimes, as undermining them, and, by doing so, disrupting relational harmony (Kitayama, Karasawa, Curhan, Ryff, & Markus, 2010).

Children’s inseparable connection with others is amplified in other ways. For one, children’s attention and activities are usually other-centered—blurring, at times, self–other boundaries. This happens in many ways. Caregivers orient children outward by placing them in the same direction in which they are facing (Ochs & Izquierdo, 2009). Caregivers lead children in activity, and children follow their lead (Keller, Borke, Lamm, Lohaus, & Yovsi, 2011). Caregivers speak on children’s behalf (Gottlieb, 2004; Schieffelin & Ochs, 1986). And caregivers rely on children’s subtle cues (e.g., postural shifts) to address children’s needs, or to anticipate them, rather than waiting for children to make them explicit (Chapin, 2013; deVries & deVries, 1977; Friedlmeier & Trommsdorff, 1999; Harwood, 1992; Keller, Kärtner, Borke, Yovsi, & Kleis, 2005).

In these care contexts that support children’s fitting-in with and orienting to others, children develop a heightened sense of self as connected with others, and children learn to see themselves as others see them. In other care contexts, in other communities with rural, subsistence lifestyles (e.g., various Amerindian groups), practices support the development of self as distinct, independent, and autonomous. However, even in these communities, the sense of self is never a starting or ending point in development, and corresponds to an individual autonomy that permits and is embedded in social relationships (Course, 2011; Murray, Bowen, Segura, & Verdugo, 2015; Overing, 1989, 2003).

Parenting Intervention Programs Raise Ethical Concerns

Ethical principles require practitioners to respect people and their values, perspectives, and beliefs, and to do no harm and to benefit children’s welfare. So, it is worrisome that parenting interventions, such as the CCD intervention, implemented in low- to middle-income countries in communities with rural, subsistence lifestyles encourage caregivers to radically shift their care from one kind of care to another kind of care. These caregivers typically direct children to notice and attend to others, accentuate children’s social interdependencies, direct children to be part of events—often many at the same time, lead children in activity, and rely often on nonverbal forms of communication. But, instead, this intervention trains caregivers to give children their full and undivided attention, to treat children as distinctive, to follow children’s leads in activities, to respect children’s wishes and needs, and to talk with children on topics of interest to them. And, by extension, to raise children who have their own interests and needs in mind, even when they are growing up in a community of people who may instead prioritize the interests and needs of others.

Improving the life chances of children in low- and middle-income communities is a worthy goal. But do parenting interventions accomplish this, and, if so, at what risk to child, family, and community? There is the view that children’s “lack of early learning opportunities and appropriate caregiver–child interactions contribute to loss of developmental potential” (Walker et al., 2011, p. 1330). However, evaluations of parenting interventions that aim to provide significantly better learning opportunities and more appropriate child–caregiver interaction in these countries are inconclusive at best; indeed, they are mostly neutral with regard to documenting even short-term social (and cognitive) gains (Morelli et al., in press; Weber et al., 2017; Yousafzai, Rasheed, Rizvi, Armstrong, & Bhutta, 2014). Even if evaluation research was able to claim intervention “success,” it is difficult to figure out what success actually means in terms of the lived lives of these children and families. More so, it is difficult to figure out how social and relational dynamics between children and others change as a result of these programs, or the effect this change may have on community functioning. The information we need to understand how parenting interventions “fit” into (or not) community life is insufficient, difficult to gather, or ignored.

Some studies, however, hint at the types of changes we might expect when caregivers in rural, subsistence lifestyles adopt positive parenting practices prevalent among people with Western lifestyles. Much of this research examines the role of social change on children’s psychological competencies, characterized typically as a transition from rural, subsistence to Western lifestyles. Education, as part of this change, is often a factor of interest. This is relevant to parenting interventions in low- and middle-income countries because components of positive parenting (e.g., talking to children) are implemented to foster children’s success in Western-style schools (Weber et al., 2017), which most children attend. Success in these schools is measured by gains in a child’s cognitive skills and knowledge acquisition (Serpell, 2011). But this metric, and dominant school discourse (e.g., communication style, competitiveness, individual achievement: see Rogoff, 2003), may undermine the socially responsible intelligence (e.g., respect, obedience, cooperation) that is expected of children and supported by people in many rural, subsistence lifestyle communities (e.g., Serpell, 2011). Jukes and colleagues found evidence of this in their study of Mandinka and Wolof adolescents of Gambia (Jukes, Zuilkowski, & Grigorenko, 2018). Adolescents, who as children dropped out of Western-style primary school and remained in their villages, were rated as less respectful and obedient by adult community members. In addition, Chavajay and Rogoff (2002) and Jukes, Zuilkowski, Okello, and Harris (2013) observed a relation between maternal education (in Western-style schools) and child engagement. In the former, Guatemalan Mayan indigenous mothers with less schooling were more likely to participate in multiparty, collaborative engagements with their children than were mothers with more schooling. In the latter, in the Kwale district of Kenya, parents with less schooling were more likely to favor adult authority over children than parents with more schooling.

In our view, a deep and comprehensive understanding and appreciation of people’s lifestyles, and the care of and aspirations for children these lifestyles represent, is a necessary precondition to designing and implementing interventions in ethically responsible ways. Without core knowledge of local beliefs and practices, how can we respect people and how can we determine harm or benefit? We say this mindful that UNICEF and WHO (and other agencies) have policies in place to help ensure culturally relevant programming, in part, by including community involvement in planning, implementing, monitoring, and evaluating programs (e.g., UNICEF/WHO, 2012b; UNICEF/WHO, 2012a, 2012b). Even so, as we have shown, the CCD intervention is unlikely to honor these ethical codes. How can this be? We suspect that positive parenting is deeply rooted in the practices of these agencies because of their steadfast institutional support of the CRC and because there is little reason to question claims made by attachment theorists that positive parenting supports strong child developmental outcomes. We have shown that these claims are not universally relevant.

Is It Fair to Target Poor Communities for Parenting Interventions?

So far, our primary concern about the ethics of parenting interventions has been the unintentional lack of respect and potential harm inherent in encouraging caregivers to adopt practices that are prevalent among Western lifestyle communities but that are not predominant in their own communities. We turn now to the ethical principle of fairness and justice as relevant to the people who are targeted for such interventions. Even though the CCD intervention is meant to improve the life chances of all children in low- and middle-income countries who are considered vulnerable, it is regarded as being “another tool to reduce the cycle of . . . poverty which passes from one generation to another. . .” (WHO/UNICEF, 2013, p. 5). Therefore, poor people and impoverished communities are often the target of parenting intervention programs, maybe unfairly so.

In trying to change parenting practices mostly in poor communities, are those programs making the following two unproven assumptions: one, that poor parents parent poorly, and two, that these interventions will be beneficial despite the fact that they do not address the underlying causes of poverty in the community? Even if agents of change do not make those assumptions, their focus on poor communities can lead to the stigmatization of poor people in regard to their parenting abilities.

To illustrate the risks of targeting poor communities in parenting intervention programs, we turn to a previous historical episode examined by medical historian Michal Raz in her 2013 book What’s Wrong with the Poor? Psychiatry, Race, and the War on Poverty. Here, she shows that child psychologists played a key role in supporting a “cultural deprivation” framework to conceptualize the needs of children from low-income homes in the United States during the 1960s. But, she argues, the belief that poor children suffered from cultural deprivation was based on White middle-class views about maternal deprivation.

The notion of maternal deprivation was introduced by John Bowlby (1951) in his widely influential WHO report “Maternal Care and Mental Health”. Bowlby argued that children deprived of maternal care and love would later suffer from profound psychological and emotional problems. Vicedo (2013) has shown that Bowlby was criticized for relying on a small number of studies, conflating cases of maternal separation and deprivation, and extrapolating results from children under conditions of severe sensory and maternal deprivation to everyday family conditions. In fact, in 1962, the WHO published a volume revealingly titled Maternal Care: A Reassessment of Its Effects (WHO, 1962), which included various criticisms of Bowlby’s ideas.

Yet, as Raz has documented, the concept of deprivation continued to be widely employed by researchers and reformers who examined the effects of sensory deprivation and often equated it with maternal deprivation. After some scholars questioned the exclusive focus on mothers, the framework was expanded to include “cultural deprivation.” The basic idea was that children in culturally deprived communities did not receive sufficient intellectual stimulation and educational opportunities. The seemingly common-sense view that cultural deprivation existed mostly in poor communities led reformers to focus on “two overlapping sections of American society: poor and black” (p. 6). As a result, the discourse of cultural deprivation stigmatized Black families. However, as Raz shows, “Much of the theory of cultural deprivation relied on race- and class-specific interpretations of normative mothering and what constituted maternal deprivation” (p. 40).

By faulting caretaking practices that deviated from the White middle-class norm for not providing for children, the specific interventions promoted in the 1960s helped perpetuate the Euro-American middle-class family as “the scientifically sanctioned approach to child rearing” (Raz, 2013, p. 74). The focus on deprivation emphasized what was missing in a specific community rather than on what was provided or what worked well. This approach often led to see differences as deficiencies. But as Raz concludes, many of the programs designed by well-intentioned researchers and policy makers aimed “to provide the poor with things they in fact did not lack or did not need” (Raz, 2013, p. 170).

In addition, reformers’ focus on poor communities had other detrimental consequences. One, it created a negative image of the parenting abilities of Black families and thus led to their stigmatization. Two, as their critics pointed out, “emphasizing the pathological home and family life of individuals from low-income backgrounds” became “a method of shifting blame and responsibility onto the poor” (Raz, 2013, p. 40). That is, this approach blamed the victims, and justified interventions to change the victims of social injustice, rather than changing society itself.

We have presented this historical case at some length because it provides a “cautionary tale about the risks of using seemingly neutral theories of child development and mental health in attempts to address social problems” (Raz, 2013, p. 175). With the benefit of hindsight, we see the problems with those interventions in the 1960s. They tried to modify parenting practices in groups without respecting their own parenting goals and social visions. They stigmatized poor communities. And they helped governments and societies avoid their responsibility in addressing the complex socioeconomic causes of poverty.

More recent parenting intervention programs in poor communities are also perceived as quite problematic. For example, analyzing interventions in the United Kingdom, Val Gillies has argued that,

Without help, poor parents are seen as destined to transmit their cultural deficits . . . through an intergenerational “cycle of deprivation” (ODPM 2004). In pursuing this reasoning, policies have been orientated towards reforming the lifestyle and conduct of the poorest and most vulnerable in society in order to “save” the next generation. (Gillies, 2008, p. 1081)

In sum, parenting interventions targeting poor communities raise difficult ethical issues. We need to make sure they respect the principles of fairness and justice toward groups with different lifestyles. Many questions remain: How can researchers avoid compromising the cultural sovereignty of people? Do parenting interventions dilute the rights of families and reach beyond the agenda of poverty alleviation? Can welfare agencies guarantee that their parenting interventions, and the subsequent changes that they claim to make, do not in fact compromise the adaptive mechanisms that people develop in particular contexts to survive? After all, the structural contexts of poverty or disadvantage cannot change as quickly as individual behavior might. Moreover, changing specific practices can, in fact, predispose families and children toward unanticipated vulnerabilities. The confidence of counselors and change agents undoubtedly derives from a background of relative affluence, compared with the poverty of the people with whom they work. But an unintended consequence of this gap is that, in participating in interventions imposed on them by wealthy and elite outsiders, the poor also lose their rights to privacy and self-determination on account of being poor.

Situating Change Agents in Cultural Context

In addition to the assumptions about positive parenting and children in poverty that change agents make, we have another equally grave concern. As social scientists, we find that change agents’ interventions are routinely initiated in the absence of sufficient scientific evidence. One reason for this tendency is the lack of local ethnographic research that would challenge intentions to uphold ethic codes.

We have argued that change agents do not know enough about the child rearing practices of the local communities they hope to change—and specifically about the putative “psychological risks” that these practices might entail—to intervene effectively in them. What must we know about children and their families to decide which, if any, interventions into child rearing in these families should be undertaken? We have suggested paying attention to the different cultural beliefs and practices concerning the care of children, the local contexts for such care, including what may be labeled child care “ideologies” or “ethnotheories” about such care, and the “lifestyles” that surround it. Why are such beliefs, ideologies, practices, and lifestyles important to understand?

Psychological anthropologists recognize that beliefs and practices are typically, perhaps always, embedded in what these practitioners call “cultural models,” or what other social scientists sometimes refer to as “cultural logics” (e.g., Fisher, 1999; Lareau, 2011) and what are sometimes also called, in keeping with current neurobiological theories of the organization of the brain, “cultural schemas” (e.g., Fisher, 1999). Cultural models are thus more or less tight clusters of associations that have become linked through recurrent experience, and can include (or not) not only knowledge (e.g., what you believe, how it is labeled, or how to perform a related practice) but also motivations, emotions, and any other embodied experiences that have co-occurred. Cultural models for child rearing are typically held especially dear among all the cultural knowledge that people living in a given group or society accumulate in the course of their lives. This is because these are models for the all-important task of turning children into the kind of adults valued in that group or society. Therefore, models for child rearing are crucibles of key cultural values, or what LeVine has characterized as a “culture’s model of virtue” (LeVine & Norman, 2001, p. 84).

It follows that to understand any given belief or practice, one must appreciate the cultural model that is the context in which that belief or practice is embedded, and that gives it its local meaning. It is axiomatic in cultural anthropology that, however poor, however out-of-the-way, or however different from what change agents accustomed to Western lifestyles may expect, every group’s culture is just as complex as every other—just as every distinct linguistic group speaks a fully grammatical language. This is true, ipso facto, for the cultural model of child rearing believed in and enacted by that group. This is not to say that differences of opinion and debates do not arise about how to raise children, just as they can in all societies about any aspect of culture. These opinions and these debates about child rearing are likely to be especially intense just because significant cultural values are at issue in raising children.

For the same reason—that is, the significance to change agents of the cultural model of child rearing they believe in—it is easy for them to misconstrue child rearing in a cultural context other than their own. They may do so because the virtues of their own cultural model of child rearing seem so obvious to them. A good example of this is the Reinforcement of Parental Practice intervention that the NGO Tostan implemented in rural-living Senegalese communities that we referenced earlier. The intervention taught mothers to speak more often one-on-one with their children, with the laudable intention of enhancing these children’s future success in school and thereafter in the global economy, but without regard for what might have been a very different local understanding of adult speech with children. How do we know whether these outcomes are met, or even if their goals are reasonable? A host of considerations are up for debate, including ethical criteria, better living conditions, better grades at school, and maintenance of increased speech output. This training program has been positively evaluated in Weber et al. (2017), an article critiqued by Morelli and colleagues (Morelli et al., in press).

Alternatively, change agents may perceive the practice they are criticizing as seemingly outlandish or counter-intuitive. A nice example of this is Japanese preschool teachers’ practice of mimamoru—roughly, “stay back and wait and observe,” as described by Tobin and colleagues (Tobin, Hsueh, & Karawawa, 2011, pp. 106-111)—rather than intervening preemptively in a squabble among the children under their care. When the researchers captured this practice on videotape and showed the tape to Chinese and U.S. teachers, both took exception to it, assuming that the Japanese teacher was just not paying adequate attention to the children’s interactions. But the Japanese teacher was monitoring the situation, as attested by the fact that she did intervene when she saw that some girls were scuffling dangerously close to a sharp corner of the piano. In fact, the teacher’s otherwise noninterventionist behavior was quite deliberate, “a performance intended to encourage the girls to relate to each other and solve their own problems rather than to turn to her” (Tobin et al., 2011, p. 110). This widespread Japanese practice is consistent, in turn, with the traditional Japanese theory of child rearing, in which young children are given the opportunity to be child-like, to learn to settle their own disputes, and to forge a peer group. Thus, the Japanese teacher’s laissez-faire response was difficult for the Chinese and American viewers to understand because they were not able to place the practice into a cultural context familiar to them.

Furthermore, change agents often misconstrue a child-rearing practice in another cultural setting because of prior commitments they have to a Western academic concept or theory. One such conceptual pitfall is the willingness of many social scientists to make an overly broad distinction between “Western” societies, deemed “individualist” in contrast to Asian (and sometimes all other) societies, thought of as “collectivist” (Miller et al., 2015). As Miller and her coauthors point out, such dichotomization obscures significant variation across class and ethnic groups in what is considered “individualist” or “collectivist” (see, for example, Kusserow, 2004 for a description of American “individualisms” across class, and Spiro, 1993 for a summary of variations in collectivism). Worse, it is an all-too-easy next step to characterize those raised in Asian societies and in others labeled collectivist as being entirely subject to a collective will—indeed, as having no individual self altogether, or, as Geertz (1984) put it regarding the Balinese, with “a view of the human person as an appropriate representative of a generic type, not a unique creature with a private fate” (p. 129). This is a stance that has been thoroughly debunked by Wikan (1987) for the Balinese and by Spiro (1993) more generally.

In another instructive instance, Chapin (2013) has critiqued attachment theorists’ overly narrow, ethnocentric definition of one of their key constructs, “maternal sensitivity.” This ethnography brings home the point that theoretical biases can obscure the meaning of local practices, making them seem improper or even pathological. As attachment theory counsels caregivers to be, those in the Sri Lankan village of Chapin’s ethnography were exquisitely attuned and responsive to the children under their care. However, the kind of responsiveness enacted by Sri Lankan caregivers departs radically from that advocated by attachment theorists. These theorists recommend teaching children to express themselves and their needs verbally, which is thought to contribute to their eventual autonomy. As Chapin (2013) reports,

The confident self-expression central to the achievement of “autonomy” was largely absent in child–caregiver interactions I observed in Sri Lanka. Children were not encouraged to express themselves in words, and caregivers did not model verbal expressiveness when they interacted with children. (p. 148)

Caregivers relied, rather, on nonverbal cues, for example, holding children over the toilet when they seemed to be about to eliminate. Moreover, these children learned to expect to be provided for—waiting passively with open mouths, for example, to receive balls of food at mealtime. Chapin tells us that these patterned interactions accord well with the local Sri Lankan model of nurturant hierarchy, in which “the person in the superior role determines what is to be done without soliciting or attending to the expressed wishes of the subordinate” (p. 149), and the junior in this situation waits patiently for his or her needs to be met. However, these precise practices contravene attachment theory principles.

Think Locally, Act Locally: Helping Families and Communities Support Children

What are some of the ways we might contravene such common misunderstandings by change agents who want to intervene in child rearing in other communities? A necessary first step, before even considering an intervention, is to learn all that can be learned about local models of child rearing, and then try to adapt the intervention to the existing beliefs and practices. We note several ways to investigate such cultural knowledge of local child rearing, and suggest that they are best used in combination.

Doing and Making Use of Ethnography

A first remedy for avoiding misunderstandings about child care is intensive fieldwork of the kind cultural anthropologists call ethnography. Even though ethnographic research is a challenging endeavor, the theoretical payoff is always immense. There is no other best way to come by knowledge of cultural models than to conduct ethnography. And that knowledge is crucial for constructing good theory, and it should be the first step in building such theory about child development, or indeed in any field. A fine illustration is the approach taken by Tobin and colleagues, described earlier (Tobin et al., 2011). These researchers systematically collected parent and teacher responses to the same videotaped scenes, to obtain multiple reactions to these interactions both within and across cultures.

If, as is likely, there is no time or opportunity to conduct fresh fieldwork, change agents should be aware that there are vast amounts of ethnography already available, including but not limited to the Human Relations Area Files (HRAF), a resource that has assembled and coded a wealth of ethnographic information collected on cultural groups worldwide, and is accessible online (Human Relations Area Files, n.d.). Change agents should check to see whether any ethnography exists for the area in which they are working or perhaps neighboring areas that are culturally related. For example, there is plentiful ethnography of the Wolof peoples of Senegal, if only the NGO Tostan personnel had thought to access it and learn from it before designing the “talk-to-your-child” intervention described earlier. Existing ethnography may not deal directly with cultural understandings of child rearing, of course, but may nonetheless suggest cultural differences in the way children are raised in this other society. The bottom line is that ethnographies are critical to practitioners who intervene in people’s lives to change what these people do, including how they raise their children. Ethnographic knowledge is necessary to bring about change that is respectful of people and their way of life, does no harm, and is just and fair.

Consulting Locals

It is also often useful to involve local experts on child rearing when recommending interventions in child rearing, though one must always be careful in recruiting such aid not to either unwittingly breach or reinforce lines of authority, nor to violate other culturally appropriate rules. The inclusion of indigenous scholars in research, theory building, and in international discourse on the research topic is another important step toward global understanding of cultural models. Another caution, especially relevant to consulting more educated local or national experts, is that they may have already become unwitting representatives of exogenous ideas and theories, even if just from having taken a course or been assigned a textbook containing such content.

But scholars with the educational credentials typically honored by Western change agents are not the only ones worth consulting on this topic. Change agents should consult child caregivers about planned interventions into child rearing. In some communities, older children, because of their crucial role not just in caring for younger ones, but in fostering their development, are child care experts in their own right. One program that successfully exploits this fact is the Child-to-Child (CtC) intervention program, which has mobilized children as agents of health education (Pridmore & Stephens, 2000). Serpell and Nsamenang (2014) explain that the widespread African practice of entrusting pre-adolescent children with the care of younger siblings was a major inspiration for the original proponents of the CtC approach (Pridmore, 1996; Udell, 2001), which has now been applied in more than 80 countries worldwide (Institute of Education, n.d.).

As Serpell and Nsamenang (2014) report, the impetus behind this program was the insight that pre-adolescent children can take on responsibility as agents of infant care and nurturance, within the context of primary health care and progressive social change. This indigenous understanding of pre-adolescence was re-appropriated by the African teachers at Kabale Primary School in Mpika, Zambia, and incorporated into the formal educational process (Serpell & Jere-Folotiya, 2008). It is worth noting, also, that in this approach, the cultural model of child care and its agents differ from the expectations of many in Western lifestyle communities. Hence, as we reported, such a cultural emphasis on promoting social responsibility in pre-adolescent children can be undermined by Western-style schools (Jukes et al., 2018).

Thus, more attention should be paid to the traditional parties responsible for children and their care in the design of parenting interventions. This is true not only in Africa but elsewhere, and not only with regard to health education, but more broadly. Moreover, such programs need to be designed not only for older children but also for knowledgeable adults, with attention to local understandings of who these local child rearing “experts” are.

Attending to Local Codes of Ethics Where These Exist

The African Charter on the Welfare and Rights of the Child, from the Organization of African Unity, shows us yet another way forward in providing for the best interests of children that is at the same time sensitive to local cultural standards (African Commission on Human and Peoples’ Rights, n.d.). As already observed, the Western countries and particularly the United States dominated in the drafting of the CRC. This circumstance prompted the drafting, in 1990, of this independent charter for African countries (Goonsekere, 1997).

A key feature of this charter is that, although broadly based on the CRC, it also recognizes distinctive aspects of African society, as reflected in its Preamble, which states that “the virtues of their cultural heritage, historical background, and the values of the African civilization” should be taken into consideration. Article II of the document further specifies that the child’s education should include “the preservation and strengthening of positive African morals, traditional values and cultures.” Such statements are important in the adoption of universal guidelines. Implementation of the charter is the responsibility of the partners—local, national, and global. However, it does provide a framework for recognizing cultural knowledge systems and the social situation of children within them, and for seeing that these understandings are incorporated into local programs.

Indigenous people, including the San of South Africa and Canada’s First Nations, have also designed their own codes of ethics. Another such code comes from the Australian Institute of Aboriginal and Torres Strait Islander Studies, a government agency with a long history and ample contemporary record of indigenous representation and consultation. These three codes lay down ethics for research projects, not for programs of intervention. They do not specifically address childhood or child rearing, although they often do include caveats applicable to these topics. All of these codes of research ethics contain guidelines that are relevant to the interventions of change agents. Most importantly, all speak directly to the need for consultation with local communities and respect and appreciation for local knowledge, which would of course include knowledge of children and child rearing. Here, for illustration, is a portion of what these codes have to say about consultation: The 2009 document, Ethics in First Nations Research, published by the Environmental Stewardship Unit of the Assembly of First Nations, declares in its “Introduction” that First Nations participation in research, among other advantages, “can provide direction for dealing with key challenges facing communities” (Assembly of First Nations, 2009, p. 3). The 2012 Guidelines for Ethical Research in Australian Indigenous Studies, published by the AIATSIS, reads, under Principle 4, that “. . . researchers must have a good understanding of the nature of indigenous traditional knowledge systems. . .” (Australian Institute of Aboriginal and Torres Strait Islander Studies, 2012). Similarly, the 2017 San Code of Research Ethics, from the South African San Institute, specifies under the subheading “Respect” that “We require respect for our culture, which also includes our history. We have certain sensitivities that are not known by others” (South Africa San Institute, 2017). The need for change agents to observe each of these slightly differently inflected directives is registered at various points throughout this article. These agents would do well to familiarize themselves with any such documents that exist for the communities in which they plan to work.

Summary

This article explores ethical issues raised by parenting intervention programs. We frame our inquiry by first examining the code of ethics most researchers and practitioners agree to honor when they work with children and families. We use UNICEF’s Care for Child Development intervention, designed to teach positive parenting practices, as a case study to exemplify ethical concerns some of these interventions raise. Typically, positive parenting interventions are embodiments of attachment theory. Our first objection is that this theory is based on research carried out primarily among people living Western lifestyles. The parenting practices advocated by many attachment theorists have been wrongly assumed to have universal validity. We show that those practices are not common among many other communities living in different economic, social, and ecologies conditions. Second, since many interventions focus on poor communities, we worry that poor people will be stigmatized as poor parents. We believe that in many cases, we do not know enough about specific communities to understand which basic skills children need to survive and thrive, how to effectively intervene to enhance their well-being, and how to evaluate short-term and long-term ramifications of any intervention. Given the ethical dilemmas that parenting interventions encounter, we propose ways to make sure that agents of change are sensitive to the living conditions and worldviews of different communities. First, change agents must pay attention to cultural models for child rearing, the local contexts for such care, and the lifestyles that surround it. The best way to do this is to obtain firsthand knowledge of the community by conducting ethnographic research or to rely on reputable, ethnographic, historical accounts. Ethnographic inquiries also help change agents to notice and deal with personal biases that make it easy for them to misconstrue cultural models. Second, change agents should consult with local experts and community members, including children, from the inception to the evaluation of the intervention and dissemination of findings. Finally, change agents should respect local ethic codes and support community efforts to develop them. Only when change agents approach interventions in the ways we describe will they be able to better the lives of children and families that are fair, just, and respectful of them and the community of which they are a part.

Footnotes

Acknowledgements

We are deeply grateful to Dr. Kim Bard for her thoughtful and insightful comments on this manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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