Racism Should Be Treated as an Adverse Childhood Experience

Michael Vlessides

April 30, 2019

Racism can have deleterious effects and should be treated by pediatricians as an adverse childhood experience with significant physical and behavioral ramifications, according to Adiaha Spinks-Franklin, MD, from Texas Children's Hospital in Houston.

"By far, the number one stressor for black Americans is racism," Spinks-Franklin told Medscape Medical News. "And that stress has an effect on the entire physiologic system, including the nervous system, the immune system, the endocrine system, and the end organs."

Racial stress has been directly linked to preterm labor and birth, infant mortality, and maternal mortality, she reported during a symposium at the Pediatric Academic Societies 2019 Meeting in Baltimore.

But the effects of racism on the health of black Americans is far more widespread — and insidious — than that, she added. Black Americans have higher baseline levels of cortisol than their peers from other cultural groups in the United States, she explained. This can lead to a host of potential downstream physical effects, including elevated risks for diabetes, high blood pressure, cancer, and stroke. In children, it has been associated with increased rates of asthma and obesity.

But the negative effects of racism on child health do not end there. "It can also lead to poor academic outcomes," said Spinks-Franklin. "When the brain is under constant threat of a racially motivated experience, it is constantly looking for, assessing, and predicting when the threat may come. That's going to interfere with how well a child performs in school."

And in American schools, black children experience more severe punishment than children of other ethnicities for similar transgressions, she added. "All of this puts a lot of stress on young children."

Helping Patients Cope

It is incumbent upon pediatricians and other pediatric providers to educate themselves about the effects of racism and learn to help their patients cope, said Spinks-Franklin.

"We typically ask patients during our clinical encounters about stressors they may have experienced," she said. "However, a stressor that we don't routinely ask about is racism."

Much of the pediatrician's work begins before the patient walks through the clinic door, said Nia Heard-Garris, MD, from the Feinberg School of Medicine at Northwestern University in Chicago. The way she sees it, pediatricians can help potential victims of racism by creating safe, welcoming environments.

"We need to do the hard work of being reflective and understanding our own biases," she told Medscape Medical News. "For example, I've visited offices that were only decorated with pictures of white children. What kind of message is that sending?"

Empathy is another critical trait; patients often desperately need someone in a position of trust and power to validate their experiences, even if immediate solutions are not forthcoming. "In situations like this, it's okay to say something like, 'I don't have the answers, but I can understand that's upsetting and that has hurt you. So, let's work together to figure out how to help you work through this'," said Heard-Garris.

Such safe and open discussions, she added, might be the most important thing she and her colleagues can offer patients.

It's not something theoretical or something that disappeared with Jim Crow laws. This is an ongoing threat that people of color deal with every single day.

"It's very important that pediatric providers be aware that this is a real and present threat for black American children," Spinks-Franklin said. "It's not something theoretical or something that disappeared with Jim Crow laws. This is an ongoing threat that people of color deal with every single day. And it directly affects our physical and mental health."

Various professional organizations have developed tools that pediatric providers can use to help patients deal with racism. For example, a 2014 document from the American Academy of Pediatrics (AAP) — part of its trauma toolbox for primary care — provides suggestions to help pediatricians address adverse childhood experiences in patients.

The academy acknowledges in the document that lack of time, the complexity of topics, limited referral resources, and discomfort with the subject matter can all affect how a pediatrician deals with a child's potential exposure to traumatic events.

Given that, the document provides a four-step process that can be used to "begin identifying children who have experienced trauma or who are affected by the traumatic events experienced by their parents and caregivers, with the goal of being prepared to respond should an issue be identified."

The AAP has also developed The Resilience Project, which is dedicated to helping and protecting children and youth exposed to adverse childhood experiences of all stripes. The website provides, for example, lists of useful organizations, agencies, and state-based resources for families, caregivers, and providers.

Although such resources are a good start, racism-specific research and resources are lacking, Heard-Garris pointed out. She did, however, suggest that providers can coordinate patient appointments with agencies or social workers, support patient involvement in various social-justice organizations, and encourage patients to journal as a way to make sense of their experiences.

Victims can also combat the effects of racism by becoming active in their communities. Some research has shown the positive effect of this type of involvement in youth who experience racism, especially because "not doing anything can make them feel sad and hopeless," she explained.

But first, pediatricians must recognize that racism is a significant adverse childhood experience for black Americans. And "providers need to educate themselves regarding the effects of racism on health," said Spinks-Franklin. "It's important to start reading articles and books that address this issue."

The way she sees it, there is no reason for pediatricians to turn a blind eye to the serious health effects of racism on black Americans.

"It's okay to feel ill-equipped," she added. "But as physicians, we are resourceful people. Whenever there is a topic we are not very familiar with, we know how to study and equip ourselves. And we should use the same approach for dealing with racism."

Franklin-Spinks and Heard-Garris have disclosed no relevant financial relationships.

Pediatric Academic Societies (PAS) 2019 Meeting. Presented April 27, 2019.

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