Race & Ethnicity

Structural and interpersonal racism have adverse health effects on children, families, and communities of color.  These health effects occur bodily through stress and inflammation, and secondarily through inequities in nutrition, clean air and water, economic opportunity, education, home ownership, banking, and access to safe spaces to play, exercise, and grow (e.g., Loftus et al 2020; Madzia et al 2019). Adverse effects of structural and interpersonal racism impact physical and mental health.

Structural and interpersonal racism are also built into the systems of health care that should provide treatment and relief from physical and mental illness.  Pediatric clinicians can learn about ways in which racism has shaped medicine, about the impact of racism on their patients and the families of their patients, and to become anti-racist in their practice.

Racism and Mental Health

Experiencing racism is associated with poor pediatric mental health outcomes, including increased depressed mood, anxiety, negative self-esteem, aggression, conduct problems, alcohol and drug use, and smoking (Priest et al 2019). 

These associations may occur through the experience of racism by the index child but also through parentally experienced traumatic stress affecting child mental health (Galan et al 2022). 

Suicide rates have been high among Native American adolescents for years (cdc.gov).  Recent analysis showed an increase in suicide rates for Black children aged 5-12 years to be twice that as rates for White children of the same age group from 2001-2015 (Bridge et al 2022). 

Racism and Health Care

Race- and ethnicity-based diparities have been identified in access to health care, diagnostic and assessment patterns, treatments offered, and health outcomes. 

Physician implicit bias toward black children has been found equal to bias toward black adults in emergency departments (Johnson et al 2017). 

Black children are less likely to have imaging done for abdominal pain than are white children, and black and Latinx children are more likely to have perforated appendicitis than are white children (Fanta et al, 2021). 

Black children are more likely to be diagnosed with externalizing disorders such as ADHD and conduct disorder than are white children, and less likely to be diagnosed with depression or anxiety. 

Steps toward Anti-Racist Pediatric Practice

These steps and strategies are based on Table 1, Fanta et al 2021. 

Individual Level

  • Cultivate cultural humility and awareness of the impact of power and priviledge
  • Promote professional development and training mitigating the impact of racism, discrimination and bias on health inequities

Institutional level

  • Commit to recruitment, retention and advancement of a diverse workforce
  • Identify and eliminate processes and practices that propogate inequities and race-based medicine
  • Pursue data-informed quality improvement efforts that decrease inequities
  • Elevate voices of patients, families, and community organizations

Structural Level

  • Advocate for policy reform to eliminate inequities in the social conditions of marginalized pediatric patient population

References

Beers, L. S., Szilagyi, M., Seigel, W. M., Davis, W. S., Fukuda, Y., Joseph, M., Wright, J. L., & Goza, S. H. (2021). Immunizing Against Hate: Overcoming Asian American and Pacific Islander Racism. Pediatrics, 148(1), e2021051836. https://doi.org/10.1542/peds.2021-051836

Bridge, J. A., Horowitz, L. M., Fontanella, C. A., Sheftall, A. H., Greenhouse, J., Kelleher, K. J., & Campo, J. V. (2018). Age-Related Racial Disparity in Suicide Rates Among US Youths From 2001 Through 2015. JAMA Pediatrics, 172(7), 697–699. https://doi.org/10.1001/jamapediatrics.2018.0399

Coker, T. R., Elliott, M. N., Toomey, S. L., Schwebel, D. C., Cuccaro, P., Tortolero Emery, S., Davies, S. L., Visser, S. N., & Schuster, M. A. (2016). Racial and Ethnic Disparities in ADHD Diagnosis and Treatment. In Pediatrics (Vol. 138, Issue 3). https://doi.org/10.1542/peds.2016-0407

Douglas, R. D., Alvis, L. M., Rooney, E. E., Busby, D. R., & Kaplow, J. B. (2021). Racial, ethnic, and neighborhood income disparities in childhood posttraumatic stress and grief: Exploring indirect effects through trauma exposure and bereavement. Journal of Traumatic Stress, 34(5), 929–942. https://doi.org/10.1002/jts.22732

Fanta, M., Ladzekpo, D. & Unaka, N. Racism and pediatric health outcomes.  2021 Curr Probl Pediatr Adolesc Health Care 51:101087

Galán, C. A., Meza, J. I., Ridenour, T. A., & Shaw, D. S. (2022). Racial Discrimination Experienced by Black Parents: Enduring Mental Health Consequences for Adolescent Youth. Journal of the American Academy of Child & Adolescent Psychiatry, S0890856722002453. https://doi.org/10.1016/j.jaac.2022.04.015

Goodkind, J. R., Ross-Toledo, K., John, S., Hall, J. L., Ross, L., Freeland, L., Coletta, E., Becenti-Fundark, T., Poola, C., Begay-Roanhorse, R., & Lee, C. (2010). PROMOTING HEALING AND RESTORING TRUST:POLICY RECOMMENDATIONS FOR IMPROVING BEHAVIORAL HEALTH CARE FOR AMERICAN INDIAN/ALASKA NATIVE ADOLESCENTS. American Journal of Community Psychology, 46(3–4), 386–394. https://doi.org/10.1007/s10464-010-9347-4

Heard-Garris, N. J., Cale, M., Camaj, L., Hamati, M. C., & Dominguez, T. P. (2018). Transmitting Trauma: A systematic review of vicarious racism and child health. Social Science & Medicine, 199, 230–240. https://doi.org/10.1016/j.socscimed.2017.04.018

Johnson, T. J., Winger, D. G., Hickey, R. W., Switzer, G. E., Miller, E., Nguyen, M. B., Saladino, R. A., & Hausmann, L. R. M. (2017). A comparison of physician implicit racial bias towards adults versus children. Academic Pediatrics, 17(2), 120–126. https://doi.org/10.1016/j.acap.2016.08.010

Loftus, C. T., Ni, Y., Szpiro, A. A., Hazlehurst, M. F., Tylavsky, F. A., Bush, N. R., Sathyanarayana, S., Carroll, K. N., Young, M., Karr, C. J., & LeWinn, K. Z. (2020). Exposure to ambient air pollution and early childhood behavior: A longitudinal cohort study. Environmental Research, 183, 109075. https://doi.org/10.1016/j.envres.2019.109075

Madzia, J., Ryan, P., Yolton, K., Percy, Z., Newman, N., LeMasters, G., & Brokamp, C. (2019). Residential Greenspace Association with Childhood Behavioral Outcomes. The Journal of Pediatrics, 207, 233–240. https://doi.org/10.1016/j.jpeds.2018.10.061

Nguyen-Truong, C. K. Y., Rakha, S., Eti, D. U., & Angelesco, L. (n.d.). Deconstructing Racialized Experiences in Healthcare: What a Missed Opportunity for Healing Looks Like and Healthcare Resources for Children and Their Families. Asian/Pacific Island Nursing Journal, 5(4), 227–235. https://doi.org/10.31372/20200504.1109

Pachter, L. M., Caldwell, C. H., Jackson, J. S., & Bernstein, B. A. (2018). Discrimination and Mental Health in a Representative Sample of African American and Afro Caribbean Youth. Journal of Racial and Ethnic Health Disparities, 5(4), 831–837. https://doi.org/10.1007/s40615-017-0428-z