Two children visit their doctors: Social class in the USA

Rick Santorum, responding to Obama’s statement that “the middle class in America has really taken it on the chin,” said that he would never, ever, stoop to using the word “class.” (Dorothy Wickenden in The New Yorker)

Sociologist Annette Lareau has done extensive field work that involves unobtrusively inserting herself (or her field-worker assistants) into the homes and daily lives of families (treat us like “the family dog,” she recommends). Her observations have led her to identify a difference in the parenting styles of families from different social classes. Middle-class families practice what she calls concerted cultivation: parents teach their children skills that prepare them to engage successfully with the social institutions of adult, middle-class life. Working class families value natural growth: parents give their children a great deal of unstructured time in which they must use their own creativity to plan and execute their activities.

Lareau’s work is described in her book Unequal Childhoods: Class, Race, and Family Life. Originally published in 2003, it was updated for a 2011 edition. It’s a wonderful book. I think of it whenever people argue – as they frequently do in the US – that America is the land of equal opportunity, therefore those who fail to exert themselves sufficiently have only themselves to blame.

I’d like to cite two stories from Lareau’s book that relate to health care.

Learning to be important and entitled

The first is about Alex Williams, an African-American child of middle-class parents. Prior to a routine doctor’s appointment, his mother (Christina Williams) prepares him for the visit.

In interactions with professionals, the Williamses, like some other middle-class parents in the study, seem relaxed and communicative. They want Alex to feel this way too, so they teach him how to be an informed, assertive client. On one hot summer afternoon, Ms. Williams uses a doctor visit as an opportunity for this kind of instruction. During the drive to the doctor’s office, the field-worker listens as Ms. Williams prepares Alexander to be assertive during his regular checkup:

“As we enter Park Lane, [Christina] says quietly to Alex, ‘Alexander, you should be thinking of questions you might want to ask the doctor. You can ask him anything you want. Don’t be shy. You can ask anything.’ Alex thinks for a minute, then says, ‘I have some bumps under my arms from my deodorant.’ Christina: ‘Really? You mean from your new deodorant?’ Alex: ‘Yes.’ Christina: ‘Well, you should ask the doctor.’ “

Alex’s mother is teaching him that he has the right to speak up (e.g., “don’t be shy”; “you can ask anything”). Most important, she is role modeling the idea that he should prepare for an encounter with a person in a position of authority by gathering his thoughts ahead of time. During the office visit, both mother and son have the opportunity to activate the class resources that were evident during the conversation in the car.

During the office visit, the doctor mentions that Alex’s height is in the 95th percentile for a 10-year-old boy. Alex interrupts to assert that he is not ten (he’s nine years and ten months). Lareau comments:

The act of interrupting a person of authority is a display of entitlement. It is also indicative of middle-class child-rearing priorities: the incivility of interrupting a speaker is overlooked in favor of encouraging children’s sense of their individual importance and of affirming their right to air their own thoughts and ideas to adults. The casualness with which Alexander corrects the doctor (“I’m not ten”) is a further indication of this child’s easy assumption of his rights.

Alex does indeed remember to ask about the bumps under his arms. And when he does so, “he gets the physician’s undivided attention and an implicit acknowledgment that this condition is a valid subject and worthy of consideration in the exam.”

Lareau concludes:

At the end of the office visit, when the doctor turns to Alex’s mother to ask, “Any questions or worries on your part?” Ms. Williams replies, “No … he seems to be coming along very nicely.” This statement succinctly captures her view of her son as a project that is progressing well. The exchange also underscores the relative equality of status between Ms. Williams and the doctor — the tone implies a conversation between peers (with the child as a legitimate participant), rather than a communication from a person in authority to persons in a subordinate position.

You get the picture. Contrast this with the visit of a child from a working class/poor family and note the difference in what children learn about interacting with doctors.

Learning not to be assertive with authority figures

Harold McAllister is a white, fourth-grade student who lives in a housing project with his mother, Jane. He visits a clinic to receive a physical (the visit is a prerequisite for attending Bible camp). During the visit,

the normally boisterous Ms. McAllister is quiet, sometimes to the point of being inaudible. She has trouble answering the doctor’s questions. In some cases, she does not know what he means (e.g., she asks, “What’s a tetanus shot?”); in others, she is vague:

DOCTOR: Does he eat something each day — either fish, meat, or egg?

JANE (her response low and muffled): Yes.

DOCTOR (attempting to make eye contact but failing as mom stares intently at paper): A yellow vegetable?

JANE (still no eye contact, looking down): Yeah.

DOCTOR: A green vegetable?

JANE (looking at the doctor): Not all the time.

DOCTOR: No. Fruit or juice?

JANE (low voice, little or no eye contact, looks at the doctor’s scribbles on the paper he is filling out): Ummh humn.

Lareau goes on to describe examples of assertion, in addition to reserve, on the part of both Harold and his mother. She then concludes:

Nevertheless, there was an important difference in the character of the interaction between the McAllisters and their doctor and the Williamses and their doctor. Neither Harold nor his mother seems as comfortable as Alexander, who was used to extensive verbal conversation at home. Unlike either McAllister, Alexander is equally at ease initiating questions as answering them. Harold, who was used to responding to directives at home, answered questions from the doctor but posed none of his own. Unlike Ms. Williams, Ms. McAllister did not train her son to be assertive with authority figures, nor did she prepare him for his encounter with the doctor. Finally, the two families approached the visit with their doctor with different levels of trust. This unequal level of trust, as well as differences in the amount and quality of information divulged, can yield unequal profits to the individuals involved during a historical moment when professionals define appropriate parenting as involving assertiveness and reject passivity as inappropriate.

A lifetime of living the lessons learned

In analyzing her observations, Lareau points out that there are advantages to natural growth parenting and disadvantages to the concerted cultivation style. Natural parenting encourages greater autonomy in children and requires them to be more resourceful, independent and imaginative. The disadvantages of concerted cultivation appear to be children who are argumentative, frequently bored, demanding of attention, and who have weaker ties to siblings and other relatives.

Ultimately, however, these different parenting styles lead to the perpetuation of social inequality. The advantage of concerted cultivation is the creation of a sense of entitlement, confidence, articulateness, and organizational skills. We live in a society that values these qualities, especially in educational, professional, and employment settings. When children from poor and working class families become adults, they are at a competitive disadvantage.

This, of course, is denied by those of a conservative, neoliberal, or small-government persuasion.

Many people in the United States hold the view that the society is, in fundamental ways, open. They believe that individuals carve out their life paths by drawing on their personal stores of hard work, effort, and talent. All children are seen as having approximately equal life chances. Or, if children’s life chances appear to differ, this is seen as due to differences in raw talent, initiative, aspirations, and effort. This perspective directly rebuffs the thesis that the social structural location of the family systematically shapes children’s life experiences and life outcomes. Rather, the outcomes individuals achieve over the course of their lifetime are seen as their own responsibility.

The truth, however, is much more complex and deserves our attention.

The social position of one’s family of origin has profound implications for life experiences and life outcomes. But the inequality our system creates and sustains is invisible and thus unrecognized. We would be better off as a country if we could enlarge our truncated vocabulary about the importance of social class. For only then might we begin to acknowledge more systematically the class divisions among us.

Rick Santorum, please take note.

Image source: The Fiscal Times

Resources:

Dorothy Wickenden, Joe and Debbie, The New Yorker, February 27, 2012

Annette Lareau, Unequal Childhoods: Class, Race, and Family Life