Racism and Child Health: A Review of the Literature and
Lee M. Pachter, DO,* Cynthia García Coll, PhD†
ABSTRACT: Objective: Racism is a mechanism through which racial/ethnic disparities occur in child health. To
assess the present state of research into the effects of racism on child health, a review of the literature was
undertaken. Methods: A MEDLINE review of the literature was conducted between October and November
2007. Studies reporting on empirical research relating to racism or racial discrimination as a predictor or
contributor to a child health outcome were included in this review. The definition of “child health” was broad
and included behavioral, mental, and physical health. Results: Forty articles describing empirical research on
racism and child health were found. Most studies (65%) reported on research performed on behavioral and
mental health outcomes. Other areas studied included birth outcomes, cardiovascular and metabolic dis-
eases, and satisfaction with care. Most research has been conducted on African-American samples (70%), on
adolescents and on older children, and without a uniformly standardized approach to measuring racism.
Furthermore, many studies used measures that were created for adult populations. Conclusions: There are a
limited number of studies evaluating the relationship between racism and child health. Most studies, to date,
show relationships between perceived racism and behavioral and mental health. Future studies need to
include more ethnically diverse minority groups and needs to consider studying the effects of racism in
younger children. Instruments need to be developed that measure perceptions of racism in children and youth
that take into account the unique contexts and developmental levels of children, as well as differences in the
perception of racism in different ethnocultural groups. Furthermore, studies incorporating racism as a specific
psychosocial stressor that can potentially have biophysiologic sequelae need to be conducted to understand
the processes and mechanisms through which racism may contribute to child health disparities.
(J Dev Behav Pediatr 30:255–263, 2009) Index terms: racism, discrimination, stress, health disparities, health status, race, minority, children.
Racial and ethnic health and health care disparities
refer to the differences in illness and disease, health
outcomes, access to and appropriateness of health care
seen between minority and nonminority populations.1,2
With regard to maternal and child health, racial/ethnic
disparities have been noted in infant mortality, rates of
cesarean delivery, use of prenatal technologies, access
to renal transplantation, prescribing patterns, cancer sur-
vival rates, obesity, and asthma, to name a few.1With
regard to child mental health, differential access to men-
tal health services,3as well as diagnosis and treatment for
mental and behavioral health conditions4–7have been
noted among white and minority children.
Various factors may contribute to the racial and eth-
nic health disparities noted above. Differences in envi-
ronmental risk factors, social settings, access to quality
preventive care, and genetic risk can all affect differen-
tial onset and severity of health conditions. Many of
these factors are a result of social stratification, which is
the process that creates a hierarchy of social positions
that are unequal with regard to power, property, status,
and/or psychic gratification.8Social stratification creates
unique situations for minority children and families,
which increases the likelihood of poor developmental
and health outcomes.9,10The effects of social stratifica-
tion are mediated through racism, discrimination, and
oppression, which in turn create segregated environ-
ments that provide less access to the material, social, and
psychological capital described above.9
According to the United Nations, racism is defined
as “any distinction, exclusion, restriction or preference
based on race, color, descent, or national or ethnic
origin which has the purpose or effect of nullifying or
impairing the recognition, enjoyment or exercise, on an
equal footing, of human rights and fundamental free-
doms in the political, economic, social, cultural or any
other field of public life.”11Racism can be more suc-
cinctly defined as the beliefs, attitudes, and actions re-
sulting from categorizing individuals and groups based
on phenotype, heritage, or culture. Racism is based on
From the *Department of Pediatrics and Anthropology, University of Connecticut
School of Medicine, Connecticut Children’s Medical Center, Hartford, CT; †De-
partment of Education, Brown University, Providence, RI.
Received October 2008; accepted December 2008.
Supported by grant K23 HD040348 from the National Institute of Child Health
and Human Development.
Address for reprints: Lee M. Pachter, DO, Connecticut Children’s Medical Center, 282
Washington Street, Hartford, CT 06106; e-mail: email@example.com.
Copyright © 2009 Lippincott Williams & Wilkins
Vol. 30, No. 3, June 2009
www.jdbp.org | 255
racial classification, but most scientists have abandoned
the concept of race as a purely biological variable. As
Jones notes, “race is a social construct, a social classifi-
cation based on phenotype that governs the distribution
of risks and opportunities in our race-conscious soci-
ety.”12Racial discrimination is a mechanism through
which unequal distribution of risks and opportunities
There are models that help to explain how racism
may affect health. According to Williams et al,15racism
creates discrepancies in socioeconomic status which can
then (1) result in differential health outcomes, (2) influ-
ence the quality and quantity of medical care, and (3)
adversely effect psychological and physiological func-
tioning. Adverse health effects may be due to differential
access to material needs, such as adequate nutrition,
housing, environmental toxins, and hazards, as well as to
discrepancies in health care.
Clark et al16identify reasons why racism impacts
health: (1) as a stressor, racism may have negative bio-
psychosocial sequelae that may contribute to health dis-
parities, (2) different exposure to racism may contribute
to variability in health outcomes within minority groups,
and (3) if exposure to racism is a factor related to
negative health outcomes, interventions, and preventive
strategies could be developed to lessen its effects. These
authors and others conceptualize racism as a stressor
that has the potential to affect psychological or physio-
Racism has been studied in adults as a contributor to
racial/ethnic disparities, and has shown to have effects
on a number of physical, mental, and behavioral health
conditions.20–22Little is known about the role of racism
in child health and health care. The relationship be-
tween racism and child health is complex since one
needs to take into account developmental effects that
are unique to children, for example, differences in cog-
nitive and socioemotional development, the effects of
other family member’s experiences of racism, as well as
parental attitudes about raising children of color in a
racially sensitive society.23
If the theoretical models that propose racism as a
stressor are correct, then its effects on children need to
be studied in the same way as other stressors that have
been shown to have negative effects on health and
development (for example, poverty, violence, neglect,
abuse, and social upheaval). To assess the state of re-
search into the effects of racism on child health and
health care, a review of the literature was undertaken.
A systematic search of the literature was conducted
between October and November 2007. The NCBI/Na-
tional Library of Medicine PubMed database was used to
perform the searches. PubMed provides access to biblio-
graphic information from MEDLINE, the National Library
of Medicine’s bibliographic database. MEDLINE includes
references to journal articles in the life sciences with an
emphasis on biomedicine, but also in nursing and other
allied health areas.24,25The database includes articles
from 1950 to the present.
Search strategy used in this review included the follow-
ing string of terms: “Racism or Racial Discrimination” ?
“Child*” ? “x . . ..” The third term (“x . . .”) included the
following: health, health care, preventive services,
screening, behavior, mental health, family, substance
abuse, addiction, drug abuse, smoking, tobacco, stress,
emergency, perinatal, preterm, birth weight, diabetes,
asthma, pulmonary, cardiovascular, hypertension, gas-
trointestinal, sickle cell, genetic, screening, emergency,
transplantation, renal, and obesity. This strategy was
developed to search for all published data that tested the
racism-as-stress models proposed by researchers and the-
orists and discussed above. Since our interest was in
studying racism as a stressor that may have broad psy-
chological and pathophysiological effects, “child health”
was defined broadly. A child health study included those
conducted on children up to college age as defined by
the authors of the articles (although not including stud-
ies exclusively on college samples), as well as studies of
prenatal care and pregnant women. Maternal depression
was included since its effects are commonly presented in
the child health literature as an important and salient
contributor to child health status.
This search resulted in a list of over 4400 articles.
Due to the medical subject heading algorithm use by
MEDLINE, many of the search results did not actually
relate to racism (for example, medical subject heading
includes the general term “prejudice” when searching
for “racism,” and the general term “discrimination”
when searching for “racial discrimination”). Our criteria
for inclusion in this review were that the article had to
report on an empirical (i.e., data driven) study of a child
health or health care condition that included a direct
measure of self-reported racism as a main exposure (in-
dependent) variable, and be in the English language. An
article title, abstract, and text were reviewed for inclu-
sion, with exclusion of articles occurring at each stage of
the review. In addition, the PubMed “related links” cita-
tions for each reviewed article were also reviewed for
potential inclusion. For each identified article, additional
retrospective and prospective citation searches were
conducted as follows: (1) reference list of each reviewed
article was examined to find older articles that fit the
review criteria, and (2) an ISI Web of Knowledge Cita-
tion Index search was conducted on each article to find
any subsequent publications that may have cited the
Forty articles presenting empirical studies were iden-
tified. Twenty-six articles reported on the association of
racism with behavior/mental health issues; 8 reported
on racism vis-a `-vis birth outcomes, 4 on cardiovascular
health; 1 on satisfaction with care; and 2 on metabolic
disease (1 included satisfaction with care as well). The
Racism and Child Health
Journal of Developmental & Behavioral Pediatrics
Table and following discussion summarize the findings
Most studies on the effects of racism on child health
pertain to behavioral, emotional, and mental health:
Depression, Anxiety, Self-Esteem
Self-reported discrimination as well as expectations
of discrimination were associated with depressive symp-
toms, low self-esteem/self-worth, and anxiety in adoles-
cents and in preadolescents.26–40Only one of these stud-
ies showed no effect of racial discrimination on these
For example, a 5-year longitudinal study of 714 Afri-
can-American adolescents from Iowa and Georgia who
were 10 to 12 years of age at enrollment showed effects
of perceived racism on depression and conduct prob-
lems.26The longitudinal nature of this study allowed the
researchers to conclude that perceived racism led to
increased depression and conduct disorder, not the re-
verse. Results also showed that youth from higher socio-
economic status families were more likely to have per-
ceived racism. Furthermore, the effects of racism were
lessened by nurturant parenting and having prosocial
In one of the few articles reporting on racism in
Latino children, mainland Puerto Rican youth in Grades
1 to 3 who perceived discrimination reported higher
levels of depressive symptoms, school stress, and behav-
ioral adjustment.33Forty-nine percent of Puerto Rican
adolescents sampled perceived racial discrimination, and
those who perceived or worried about discrimination
had lower global self-worth scores. Another study in a
mostly Mexican-American sample of Latino adolescents
found that self-esteem partially mediated the effects of
perceived discrimination on depressive symptoms.38
A study of African-American adolescents noted that
parental racial discrimination was associated with child
distress (general anxiety and depression) independent of
the child’s own experiences with racial discrimination.39
Perceptions of racism was shown to be associated
with internalizing and externalizing behaviors, anger,
conduct problems, and delinquent behaviors in adoles-
One study reported on African-American mother’s de-
nial of experiences of racism and its effects on inter-
nalizing and externalizing problem behaviors in their
3 to 4 year olds.47
A study of 84 African-American boys aged 10 to 15
years found that personal experiences with racism were
correlated with higher levels of parent-reported exter-
nalizing problems, self-reported internalizing and exter-
nalizing problems, higher levels of hopelessness, and
Table 1. Studies of Perceptions of Racism and Child Health
References Summary of Findings
Depression 26, 28–33, 35, 37–40Eleven of 12 studies showed association between perceptions
of racism and depression
Association between perceptions of racism and anxiety in 3
Significant negative association between perceptions of racism
and components of self-esteem in all studies except one,
which had sample of young children (Grades 1–3)
In all studies, an association between perceptions of racism
and internalizing and externalizing problem behaviors,
conduct problems, anger, and delinquent behaviors
Maternal perceptions of racism associated with poor parenting
styles, low parenting satisfaction, and depressive symptoms
Perceived racism was associated with alcohol use in African-
American and Native American youth
Perceived racism was associated with tobacco use in African-
Perceived racism was associated with drug use in African-
American and Native American youth
Six of 7 studies (in 8 articles) demonstrated a positive
relationship between perceptions of racism and either
premature delivery of low birth weight
No significant relationships found between racism and blood
pressure in adolescents
Perceptions of racism associated with low satisfaction with care
Perceptions of racism associated with poor metabolic control,
poor dietary adherence, insulin resistance
Anxiety31, 33, 39
Self-esteem, self-concept27, 28, 30, 33–36, 38
26, 29, 33, 35, 36, 41–47
Parenting, maternal depression48, 49
Alcohol use 46, 50
Tobacco use 39, 51
Drug use39, 42, 46
Low birth weight, prematurity52–59
Cardiovascular disease (blood
pressure, arterial elasticity)
Satisfaction with care
Vol. 30, No. 3, June 2009
© 2009 Lippincott Williams & Wilkins
poorer self-esteem.36Some of these associations were
mediated through hostile attribution bias (i.e., attribut-
ing hostile intent to situations) and trait anger. Another
study with 195 Native American children in fifth through
eighth grade found that perceived discrimination was
associated with increased internalizing behaviors (with-
drawn, somatic complaints, anxiety, and depression sub-
scales on the Achenbach youth self-report instrument),
after controlling for age, gender, and family income.46
Daily racial hassles were associated with internalizing
and externalizing behavioral problems in a group of 350
pre- and early adolescent youth (Grades 5–8).41These
effects were mediated through general stress and low-
ered global self-esteem.
A study of 71 black youth aged 14 to 18 years dem-
onstrated that increased distress over racist experiences
resulted in greater internalizing and externalizing coping
strategies, whereas greater perceived control over racist
experiences was associated with greater use of social
support and problem-solving coping strategies after con-
trolling for gender, grade, socioeconomic status, and
Parenting, Maternal Depression
Since child health, behavior, and development are
embedded in larger spheres of relationships, the effects
of racism on other family members may have ripple
effects on children. A study of African-American families
with 10- to 11-year old children showed that mothers’
perceptions of racial discrimination were related to poor
parental psychological function, which then adversely
affected parenting satisfaction and parenting style.48An-
other study of African-American mothers found that low
education, food insecurity, poor housing, lack of money
in a crisis, and lack of child care were all significantly
associated with maternal depression, but when everyday
racial discrimination was entered into the model none of
those other risk factors remained significant.49
Alcohol, Tobacco, Drug Use
Anger due to racial discrimination was predictive of
average number of drinks per week in black adolescents
(controlling for age and gender), but not of alcohol depen-
dency.50A study of African-American girls aged 11 to 19
years old reported a strong correlation between percep-
tions of everyday racial discrimination and tobacco smok-
ing status, which seems to be mediated through stress.51
Perceived discrimination was shown to influence al-
cohol and drug use in Native American youth aged 9 to
16 years living on tribal reservations.46A longitudinal
study of African-American adolescents reported that ra-
cial discrimination was associated with alcohol, tobacco,
and drug use.39Furthermore, parental experiences of
discrimination were also associated with children’s sub-
stance use (mediated through both parental and child
anxiety and depression). A follow-up study showed that
early perceived discrimination at ages 10 to 12 contin-
ued to be associated with drug use at 5-year follow-up.42
Pregnancy, Low Birth Weight, and Preterm Birth
Seven studies (in 8 articles) assessed the role of per-
ceived racism in the occurrence of adverse pregnancy
outcomes.52–59Six of the 7 studies showed a positive
relationship between racism and adverse outcomes; 1
study found no effects.57Self-reported racism was asso-
ciated with delivering a very low birth weight child
(?1500 g)52,53,56,58as well as preterm birth.54,55,58,59
Studies compared black women with white women, as
well as black women who experienced racism com-
pared with black women who did not. In one study,
effects were strongest for black women with higher
education levels (more than 12 years) and those be-
tween the ages of 20 and 29.52,56These studies also
noted that discrimination in all aspects of life, not just in
health care settings, had effects on birth outcome.
For example, Collins et al53studied a small sample of
low-income African-American mothers and found an as-
sociation between self-reported episodes of racism and
very low birth weight. The same group conducted a
larger case-controlled study of 104 African-American
women who delivered very low birth weight (VLBL)
(?1500 g) preterm (?37 weeks) infants, compared with
African-American women who delivered non-LBW term
domains: at work, getting a job, at school, getting medical
care, and getting service at a store or restaurant. The odds
discrimination was 1.9 (95% CI: 1.2–3.1), with the greatest
effects seen for discrimination at work or finding a job.
There was also a dose-response effect; the odds ratio for
very low birth weight and racism in one or more domain
was 1.9 whereas the odds ratio with 3 or more domains
was 3.2 (95% CI: 1.5–6.6). These effects were strongest in
women aged 20 to 29 years, as well as among women with
more than 12 years of formal education.52,56
Another large study of 352 births showed the risk of
preterm delivery for blacks was 2.54 (95% CI: 1.33–4.85)
compared with whites, but when adjusting for self-re-
ported racial discrimination the odds ratio decreased to
1.71 (95% CI: 0.84–3.48), demonstrating that for this
sample, self-reported racism largely explained the black–
white differential in preterm birth. Likewise, the risk of
low-birth weight deliveries was reduced from 4.24
(1.31–13.67) to 2.11 (0.75–5.93) when adjusted for self-
reported experiences of racial discrimination.58
There is a literature on the effects of perceived racism
on blood pressure (BP) in adults20–22,60,61; many of these
studies show perceived racism as having a deleterious
effect on BP. Interestingly, the small literature in chil-
dren and adolescents does not show similar effects. In
teens, perceptions of unfair treatment due to race was
not associated with elevated BP readings.62,63One study
looked at the interaction between racism and coping
styles and found that neither was predictive of BP, but
Racism and Child Health
Journal of Developmental & Behavioral Pediatrics
BP was lower in those who perceived racism and who
had an “accepting” coping style.64
Racism-related vigilance (the tendency to attend to
anticipated racist events) was marginally associated
with decreased large artery elasticity in black male youth
in elementary and middle schools (mean age 11.4, SD
1.5), but not in females.65Compromised large artery
elasticity is thought to be a preclinical predictor of car-
Chen and Matthews66studied cardiovascular reactiv-
ity in low socioeconomic status children to ascertain the
role of coping strategies during stressful situations. They
found that African-American children were more likely
to appraise ambiguous social scenarios as containing
hostile intent, and this in turn was related to increased
cardiovascular reactivity. Although this study did not
address racism per se, one could infer that perceptions
of racism could be considered one such stressful “hostile
intent appraisal,” and thus contribute to cardiovascular
Satisfaction With Care
None of the studies were found that investigated chil-
dren’s perceptions of racism and their satisfaction with
A study of families of children with insulin-dependent dia-
betes mellitus found that perception of racism was the
strongest predictor of mother’s satisfaction with care, com-
pared with other variables such as neighborhood stressors,
family stress and resources, maternal education, employ-
ment status, marital status, and family income; and satisfac-
tion with care predicted dietary adherence, child health
status, and metabolic control.67
In addition to the study described above, another
study conducted in Barbados looked at the relationship
between internalized racism (the degree to which an
individual agrees with racial stereotypes regarding his or
her race), body mass index, waist circumference, fasting
glucose, and insulin.68Girls (but not boys) aged 14 to 16
years with high-internalized racism had 3.3 higher odds
of insulin resistance than those with low internalized
racism, after adjusting for birth weight, income, physical
activity, food preference, and other variables.
This review reports on the research conducted on
racism as a factor in child health and health care out-
comes. Through an extensive search only 40 articles
reporting empirical research on racism and children’s
health or health care were identified. As a comparison, a
general review of empirical studies of the effects of
racism on health published in 2006 found 138 articles,
with over 90% of the studies conducted on adults.20
Most of the studies reviewed related to the associa-
tions between racism and children’s health, not health
care. Of the 40, 26 (65%) concerned behavioral and
mental health, and 8 (20%) addressed pregnancy out-
comes. Other areas of health and health care were found
to be understudied, so one can not yet make inferences
regarding the associations between racism and these
The study of racism and child health is a new and
emerging area of investigation. All reviewed studies
were all published between the years 1994 to 2007.
Twenty-eight (70%) were published since 2003.
Even within this small group of studies, certain char-
acteristics and trends became evident:
Limited Population Groups
The literature is heavily weighted toward the study of
racism in only one particular minority group: African-
Americans. Twenty-eight of the 40 studies (70%) were
conducted in African-American (5 in comparison to
white samples). Only 3 studies were conducted exclu-
sively with Latinos,33,37,38one with Native Americans,46
and one with Korean American youth.44Only 3 studies
compared multiple ethnic minority groups (African-
East Asian/South Asian/white27; and Latin American/
Asian American/West Indian30).
The paucity of studies with Latinos is surprising given
that this is the fastest growing minority group in the
United States.69It is also interesting that given the post-
9/11 social landscape, none of the studies on the effects
of racism have yet been conducted with groups from the
Middle East or South Asian subcontinent.
Although all minority groups share common experi-
ences resulting from social stratification processes inher-
ent in modern Western society, it can also be argued that
the experiences of racism may differ in diverse groups.
Such discrimination may be based on skin color, cultural
practices, area of origin, language, or accent, and these
factors are differentially distributed among members of
different groups. As the population of the United States
becomes more diverse, a more inclusive approach to the
study of disparities and the causes of such disparities is
needed. Researchers who study racism should consider
including diverse ethnic/racial groups into their study
Limited Age Groups
The literature reviewed is skewed toward older chil-
dren. Only 9 studies included children in elementary or
middle school33,36,40–42,45,46,48,65(only 1 study included
children in first to third grade33). All other studies were
conducted on high-school aged or older adolescents.
Effects of Perceptions of Racism on Healthcare
Only one study addressed how perceptions of racism
affected a person’s interaction with the child health care
system.67One would expect that experiences with per-
ceived racism—by parents or children—in ambulatory
offices and clinics, hospitals, and emergency depart-
Vol. 30, No. 3, June 2009
© 2009 Lippincott Williams & Wilkins
ments might affect a person’s satisfaction with care, trust
in providers, and as a result, utilization patterns. Al-
though there are studies showing relationships between
patient/provider language and racial concordance and
child health care outcomes,70,71perceived racism has
not yet been adequately studied as a contributory factor
in the determination of child health care choices, per-
ceptions, or quality.
Measures of Racism
There is no standardized approach to the measure-
ment of racism. In the 40 studies reviewed in this article,
there were 31 different questionnaires used to measure
perceptions of racism. The most commonly used instru-
ment—the Schedule of Racist Events72—was used in
only 5 studies.26,39,40,42,45Even when common instru-
ments were used, different versions were used for dif-
ferent studies. For example, 4 different versions of the
Racism and Life Experiences Scale were used (with a
range of 4–36 items included). Seven studies created
scales specifically for the study, and 5 studies used single
or multiple questions specifically created for the study.
More concerning than the lack of standardization of
instruments is that only 10 of the 28 studies that included
data from children used instruments that were created
and/or tested on children of like age.27–29,35,36,38,41,46,63,64
Most studies used instruments that were modified versions
of adult questionnaires, with questionable or unstudied
validity in children. Unless researchers choose instruments
that have been tested for validity and reliability in the
specific study population (i.e., children), one cannot be
certain whether the study taps into the latent construct
(racism) in the most optimal fashion.
Future studies need to use appropriately standardized
instruments. The authors of the IOM report Children’s
Health, the Nation’s Wealth73recommend that instru-
ments be developed to measure discrimination and rac-
ism in different age groups and different ethnicities.
They also recommend that large-scale national surveys
such as National Health and Nutrition Examination Sur-
vey (NHANES), National Health Interview Survey (NHIS),
and the National Longitudinal Survey of Youth incorpo-
rate measures of racism and discrimination (p 149).
Evaluation of the Theoretical Models
The literature cited here supports the racism-as-stres-
sor models described by Williams et al, Clark et al, and
others.15,16,17,19,22,61,74,75The studies in this review show
that that racism is associated with differential health
outcomes and can adversely affect psychological and
physiological functioning. Furthermore, they provide
data to show that racism is associated with negative
biopsychosocial sequelae that may contribute to health
disparities, and different exposure to it contributes to
variability in health outcomes within groups. This is
most evident in the literature demonstrating its associa-
tion with poor birth outcomes. With regard to behavior
and mental health, it can be hypothesized that racism’s
effects are mediated through stress, but few articles
specifically address this relationship. As discussed be-
low, future studies need to assess specific physiological
stress mechanisms as a potential mediators of the effects
of racism and poor health outcomes.
All the studies reviewed operationalized racism as
subjective perceptions of individuals. Although there is
some debate on the relative benefits of the subjective
versus objective approach,19most researchers and the-
oreticians view racism as a phenomenological (i.e., sub-
jective) experience.15–17,21,76This places the study of
racism within the model of stress that gives importance
not only to the objective event itself but also on an individ-
ual’s appraisal of the event and coping responses.77
FUTURE DIRECTIONS FOR THE STUDY OF
RACISM IN CHILD HEALTH AND HEALTH CARE
To date, the study of the relationship between racism
and child health and health care is limited in that most of
the research has been conducted in the areas of mental
or behavioral health and pregnancy outcomes. Racism
needs to be studied vis-a `-vis other physical health condi-
tions where racial/ethnic disparities are seen, such as
asthma and obesity for example. Furthermore, percep-
tions of racism may be an important contributor to poor
satisfaction with care, low trust in health care providers,
and lower use of services. As stated above, racial and
ethnic disparities in access, diagnosis, and treatment of
mental health conditions have been noted. The connec-
tions between such disparities and perceptions of racism
have not yet been studied.
Below are some recommendations for future study:
Mechanisms Not Description
Many studies presented here are descriptive or corre-
lational, showing associations between racism and
health outcomes. Future investigations should attempt
to go beyond the descriptive to study the processes and
mechanisms through which racism affects child health
outcomes. Fortunately, many of the articles cited in this
review that study racism and mental and behavioral
health actually do address processes. Most of these stud-
ies are published in social science journals, using ana-
lytic techniques that explore mediator and moderator
effects (such as structural equation modeling). These
techniques are not yet commonly used in the health and
Since racial discrimination is part of a complex nexus
of psychosocial factors that may influence behavioral,
mental, and physical health and development in chil-
dren, researchers needs to consider including appropri-
ate macro- and micro-level covariates into study designs
so that we can learn more about the independent and
interrelated effects of racism vis-a `-vis factors such as age,
gender, social class, socioeconomic status, neighbor-
hood setting, family setting and composition, racial and
ethnic socialization styles, racial and ethnic pride, accul-
turation, self-esteem, self-efficacy, and temperament, for
Racism and Child Health
Journal of Developmental & Behavioral Pediatrics
example. Which covariates one should include depends
on the research question and theoretical model underly-
ing the study.
Another important area for future investigation con-
cerns the role of individual differences in response to
racism. If we view racism as a stressor that may affect
individuals with similar exposures differently, then un-
derstanding the factors that contribute to these differ-
ences need to be investigated. This is especially impor-
tant if we want to develop interventions aimed at
limiting the effect of this stressor on child health.
Also, as noted above, racism occurs at the child,
family, community, neighborhood, and societal levels.
Studies that look at these contexts and which investigate
“nested effects”—children in families, families in neigh-
borhoods, neighborhoods in regions, regions in larger
society, with each level having interrelated and indepen-
dent effects—would be helpful in determining multi-
level processes and mechanisms.
The Socio-Psycho-Physiological Interface
According to the National Scientific Council on the
Developing Child, toxic stress refers to “. . . strong, fre-
quent or prolonged activation of the body’s stress man-
agement system. Stressful events that are chronic, un-
controllable, and/or experienced without the child
having access to support from caring adults tend to
provoke these types of toxic stress responses.”79Racism
should be conceptualized as a toxic stressor. Such stress
results in allostatic load, or the “wear and tear” in the
body’s homeostatic systems (e.g., neuroendocrine, car-
diovascular, metabolic, autonomic nervous, and immune
systems).80,81Allostatic load contributes to the occur-
rence of chronic diseases and conditions.
Studies investigating the physiological effects of rac-
ism on the sympathetic-adrenal-medullary, hypothalamic
pituitary adrenal, and the immune systems, as well as
brain structure and function (i.e., neural plasticity) in the
developing child may provide insight into the potential
mechanisms behind the relationships between per-
ceived racism and child health.18,82Recent literature on
racial/ethnic differences in these systems provides inter-
esting data. For example, DeSantis et al found that mi-
nority adolescents had flatter diurnal cortisol slopes, a
pattern which may be associated with poor health. Both
genetic and environmental factors were likely contribu-
tors to these findings, and the authors speculate that
racism may be one such environmental factor.83Another
study of sleep patterns in adults noted that an African-
American study sample had less deep sleep and more
fatigue than the white sample, and perceived discrimi-
nation mediated these differences.84If sleep architec-
ture, fatigue, and altered cortisol levels contribute to the
wear and tear that defines allostatic load, these studies
demonstrate specific physiologic mechanisms through
which racism may affect health. Future research that
combines the psychosocial study of racism and the neu-
robiophysiological study of stress will provide insights
into how social phenomena such as racism affect child
health and illness and contribute to racial/ethnic dispar-
ities. This integrative “neurons to neighborhoods” ap-
proach85is well suited to the study of racism and child
Racism is a mechanism through which racial and
ethnic disparities in child health and health care may
occur. This review suggests that it is an under-re-
searched area to date. The literature has predominantly
focused on behavioral and mental health conditions,
older children and adolescents, and African-Americans,
with few studies of the effects of racism in other minor-
ity groups. Most instruments used to measure racism in
these studies were developed for adults; a more devel-
opmentally appropriate approach to measuring racism in
children is needed. The future holds promise as investi-
gators look to study racism as an agent of stress, and seek
to find the biophysiological mechanisms through which
this source of stress may have effects on health and
illness throughout the lifespan.
The authors thank Bruce A. Bernstein for his input during the
preparation of this manuscript.
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