The Impact of Racism on Children’s Health

This month the American Academy of Pediatrics put out its first policy statement on how racism affects the health and development of children and adolescents.

“Racism is a significant social determinant of health clearly prevalent in our society now,” said Dr. Maria Trent, a professor of pediatrics at Johns Hopkins School of Medicine, who was one of the co-authors of the statement.

Racism has an impact on children and families who are targeted, she said, but also on those who witness it. “We call it a socially transmitted disease: It’s taught, it’s passed down, but the impacts on children and families are significant from a health perspective,” said Dr. Trent, who is the chairwoman of the A.A.P. section on adolescent health. Social transmission makes sense here, because race itself is a social construct, she said: “Genetically, we’re very much the same.”

But the impact of bias on children’s health starts even before they’re born, Dr. Trent said. Persistent racial disparities in birth weight and maternal mortality in the United States today may in part reflect the deprivations of poverty, with less availability of good prenatal care, and poorer medical care in general for minority families, sometimes shaped by unacknowledged biases on the part of medical personnel. High rates of heart disease and hypertension also persist among African-Americans.

There is also increasing attention to the ongoing stress of living with discrimination and racism, and the toll that takes on body and mind throughout life.

That kind of chronic stress can lead to hormonal changes and inflammation, which set people up for chronic disease. Studies show that mothers who report experiencing discrimination are more likely to have infants with low birth weight.

Dr. Nia Heard-Garris, an attending physician at Ann & Robert H. Lurie Children’s Hospital of Chicago, was the lead author of a 2017 review of research studies looking at the impact of racism on children’s health. Too often, she said, studies control for race without considering what experiences are structured into society by race.

The experiences that shape parents also resonate in their children’s lives, Dr. Trent said; parents and caregivers who reported they had been treated unfairly were more likely to have children with behavioral issues such as attention deficit hyperactivity disorder. In another study, African-American boys from 10 to 15 who had experiences with racism were more likely to have behavior problems like aggression. During childhood, she said, stress can create hypervigilance in children who sense that they are living in a threatening world.

And though the A.A.P. has been preparing the statement for almost two years, it comes at a moment when discussions of racism are often in the news, and children may need extra support and care. “While I think society has made tremendous leaps, the reality is we’re seeing a bump in these issues right now,” Dr. Trent said.

The statement directs pediatricians to consider their own practices from this perspective. “It’s not just the academy telling other people what to do, but examining ourselves,” Dr. Trent said. Pediatricians and others involved in children’s health need to be aware of the effects of racism on children’s development, starting in the womb, she said.

Pediatric clinical settings need to make everyone feel explicitly welcome, with images of diverse families up on the wall and with the capacity to provide care in different languages. Those efforts can also include the reception families get at the front desk — and who is staffing that front desk — as well as who is seeing patients in the exam rooms.

“The toys you have in your waiting room should be multicultural,” said Dr. Adiaha I.A. Spinks-Franklin, an associate professor of pediatrics at Baylor College of Medicine. “Bring in multicultural dolls, multicultural figurines, books, videos.”

And the pediatric office needs to be a “safe space” to talk about anything that is worrying the child or the parents, such as whether a child is being bullied, or is bullying.

The statement calls on pediatricians to improve their own practices, but also to get involved in their communities. “Many of us work in education settings and then also justice settings — the goal is really community change,” Dr. Trent said, citing collaborations with emergency medical workers, for example, or advocacy for clean and safe water for the children of Flint, Mich.

“I think there are times where racism is super explicit: Somebody called my kid a name, wrote something on a wall, said something at school,” said Dr. Heard-Garris, who heads an A.A.P. group working on minority health, equity and inclusion. But children may also face more insidious bias in terms of lowered expectations from teachers.

Dr. Spinks-Franklin, a developmental-behavioral pediatrician, said that racial awareness in children follows a set of milestones. By the time children are 3, she said, they begin to recognize normal human variations, including skin color, but without assigning value to them. “A 4-year-old recognizes basic racial stereotypes,” she said. Parents need to be aware of what their children are watching, and provide diverse books and stories with strong positive models.

By age 7, she said, children develop racial permanency, “where you recognize the body you’re born in is the body you have, your skin color isn’t going to change drastically.” Around 9, as part of their identity development, they become more aware of what place their own cultural group holds in society. “When I was 9, I knew exactly what racism looked like and how it felt and how it manifested itself,” said Dr. Spinks-Franklin, who is African-American.

And then in adolescence, as children explore racial and cultural identity, they tend to show strong preferences for their own groups, sorting themselves out by table in the cafeteria.

The goal of racial identity development, Dr. Spinks-Franklin said, is by young adulthood to have a healthy sense of who you are, recognizing your own cultural group without demonizing others. But not everyone gets there.

The most harmful thing is when children internalize racism. “They see so much negativity about people like them they develop negativity about themselves,” Dr. Trent said.

As children are growing and developing, race and racism are tricky topics for parents to navigate, Dr. Heard-Garris said. She wrote an essay in the journal JAMA Pediatrics about her “4-year-old caramel-skinned son” telling her that he was white sometimes, because he had a friend in preschool who played only with white kids. “We may not always get this right — here I am, a person who studies the effect of racism on kids,” she said. “I totally missed the mark.”

[Read the A.A.P.’s guidance on discussing racial bias with children and tipsheets for parents from EmbraceRace.]

These conversations aren’t only for families of color. Dr. Heard-Garris said that one important message parents can convey to their children is, “We’re not perfect, we’re going to mess up when we talk about this, but I think it’s important that we talk about this, and please come back and talk about this when you see things.”

Children, Dr. Trent said, are watching.

“They’re watching our words, our behavior — they’re waiting for us to teach them differently for a healthy future.”