The Impact of Racism on Child and Adolescent Health - MNAAP

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POLICY STATEMENT               Organizational Principles to Guide and Define the Child Health
                                                          Care System and/or Improve the Health of all Children

                           The Impact of Racism on Child and
                           Adolescent Health
                           Maria Trent, MD, MPH, FAAP, FSAHM,a Danielle G. Dooley, MD, MPhil, FAAP,b Jacqueline Dougé, MD, MPH, FAAP,c SECTION ON

The American Academy of Pediatrics is committed to addressing the                          abstract
factors that affect child and adolescent health with a focus on issues that may
leave some children more vulnerable than others. Racism is a social
determinant of health that has a profound impact on the health status of                    Division of Adolescent and Young Adult Medicine, Department of
                                                                                           Pediatrics, School of Medicine, Johns Hopkins University, Baltimore,
children, adolescents, emerging adults, and their families. Although progress              Maryland; bDivision of General Pediatrics and Community Health and
has been made toward racial equality and equity, the evidence to support                   Child Health Advocacy Institute, Children’s National Health System,
                                                                                           Washington, District of Columbia; and cMedical Director, Howard
the continued negative impact of racism on health and well-being through                   County Health Department, Columbia, Maryland
implicit and explicit biases, institutional structures, and interpersonal
                                                                                           Drs Trent, Dooley, and Dougé worked together as a writing team to
relationships is clear. The objective of this policy statement is to provide an            develop the manuscript outline, conduct the literature search, develop
evidence-based document focused on the role of racism in child and                         the stated policies, incorporate perspectives and feedback from
                                                                                           American Academy of Pediatrics leadership, and draft the final version
adolescent development and health outcomes. By acknowledging the role of                   of the manuscript; and all authors approved the final manuscript as
racism in child and adolescent health, pediatricians and other pediatric health
professionals will be able to proactively engage in strategies to optimize                 This document is copyrighted and is property of the American
                                                                                           Academy of Pediatrics and its Board of Directors. All authors have filed
clinical care, workforce development, professional education, systems                      conflict of interest statements with the American Academy of
                                                                                           Pediatrics. Any conflicts have been resolved through a process
engagement, and research in a manner designed to reduce the health effects                 approved by the Board of Directors. The American Academy of
of structural, personally mediated, and internalized racism and improve the                Pediatrics has neither solicited nor accepted any commercial
                                                                                           involvement in the development of the content of this publication.
health and well-being of all children, adolescents, emerging adults, and their
                                                                                           Policy statements from the American Academy of Pediatrics benefit
families.                                                                                  from expertise and resources of liaisons and internal (AAP) and
                                                                                           external reviewers. However, policy statements from the American
                                                                                           Academy of Pediatrics may not reflect the views of the liaisons or the
                                                                                           organizations or government agencies that they represent.

                                                                                           The guidance in this statement does not indicate an exclusive course
STATEMENT OF THE PROBLEM                                                                   of treatment or serve as a standard of medical care. Variations, taking
Racism is a “system of structuring opportunity and assigning value based                   into account individual circumstances, may be appropriate.

on the social interpretation of how one looks (which is what we call ‘race’)               All policy statements from the American Academy of Pediatrics
                                                                                           automatically expire 5 years after publication unless reaffirmed,
that unfairly disadvantages some individuals and communities, unfairly                     revised, or retired at or before that time.
advantages other individuals and communities, and saps the strength of
the whole society through the waste of human resources.”1 Racism is
a social determinant of health2 that has a profound impact on the health                   Address correspondence to Maria Trent, MD. E-mail:

status of children, adolescents, emerging adults, and their families.3–8
Although progress has been made toward racial equality and equity,9 the                        To cite: Trent M, Dooley DG, Dougé J, AAP SECTION ON
evidence to support the continued negative impact of racism on health and                      ADOLESCENT HEALTH, AAP COUNCIL ON COMMUNITY PEDIATRICS,
                                                                                               AAP COMMITTEE ON ADOLESCENCE. The Impact of Racism on
well-being through implicit and explicit biases, institutional structures,
                                                                                               Child and Adolescent Health. Pediatrics. 2019;144(2):e20191765
and interpersonal relationships is clear.10 Failure to address racism will

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PEDIATRICS Volume 144, number 2, August 2019:e20191765                                   FROM THE AMERICAN                ACADEMY OF PEDIATRICS
continue to undermine health equity          The objective of this policy statement          of low birth weight have been
for all children, adolescents, emerging      is to provide an evidence-based                 associated with perceived
adults, and their families.                  document focused on the role of                 racial discrimination and maternal
                                             racism in child and adolescent                  stress.25,33,34
The social environment in which              development and health outcomes.
children are raised shapes child and                                                         Investments in policies to address
                                             This policy statement will allow
adolescent development, and                                                                  social determinants of health, such as
                                             pediatricians to implement
                                                                                             poverty, have yielded improvements
pediatricians are poised to prevent          recommendations in practice that will
                                                                                             in the health of children. The Food
and respond to environmental                 better address the factors that make
                                                                                             Stamp Program, a War on Poverty
circumstances that undermine child           some children more vulnerable than
                                                                                             initiative first developed in the 1930s
health. Pediatrics as a field has yet to      others.13 The statement also builds
                                                                                             during the Great Depression and later
systematically address the influence          on existing AAP policy
                                                                                             revived in the 1960s, is linked to
of racism on child health outcomes           recommendations associated with
                                                                                             improvements in birth outcomes.35
and to prepare pediatricians to              other social determinants of health,
                                                                                             Efforts in education, housing, and
identify, manage, mitigate, or prevent       such as poverty, housing insecurity,
                                                                                             child health insurance have also led to
risks and harms. Recognizing that            child health equity, immigration
                                                                                             improved health outcomes for issues
racism has significant adverse effects        status, and early childhood
                                                                                             such as lead poisoning, injuries,
on the individual who receives,              adversity.9,17–19
                                                                                             asthma, cancer, neurotoxicity,
commits, and observes racism,11,12
                                                                                             cardiovascular disease, and mental
substantial investments in                   RACISM AS A CORE DETERMINANT OF                 health problems.20,36,37 Expansion of
dismantling structural racism are            CHILD HEALTH                                    child health insurance has improved
required to facilitate the societal
                                             Racism is a core social determinant of          health care access for children, with
shifts necessary for optimal
                                             health that is a driver of health               significant gains for African American
development of children in the United
                                             inequities.20–22 The World Health               and Hispanic children in terms of
States. The American Academy of
                                             Organization defines social                      access to well-child, doctor, and
Pediatrics (AAP) is committed to
                                             determinants of health as “the                  dental visits.38 Despite these
reducing the ongoing costs and                                                               improvements, it is important to
                                             conditions in which people are born,
burden of racism to children, the                                                            recognize that children raised in
                                             grow, live, work, and age.” These
health care system, and society.13,14                                                        African American, Hispanic, and
                                             determinants are influenced by
                                             economic, political, and social factors         American Indian populations
Today’s children, adolescents, and
                                             linked to health inequities (avoidable          continue to face higher risks of
emerging adults are increasingly
                                             inequalities in health between groups           parental unemployment and to reside
diverse. Strategies to address health
                                             of people within populations and                in families with significantly lower
and developmental issues across the
                                             between countries). These health                household net wealth relative to
pediatric life span that incorporate
                                             inequities are not the result of                white children in the United States,
ethnicity, culture, and circumstance
                                             individual behavior choices or genetic          posing barriers to equal opportunities
are critical to achieving a reduction in
                                             predisposition but are caused by                and services that optimize health and
health disparities. Accordingly,
                                             economic, political, and social                 vocational outcomes.39–45
pediatrics should be at the forefront
of addressing racism as a core social        conditions, including racism.23                 Juvenile justice involvement is also
determinant. The inclusion of racism         The impact of racism has been linked            a critical social determinant of health.
is in alignment with the health equity       to birth disparities and mental health          Because racial inequity continues to
pillar of the AAP strategic plan.15 In       problems in children and                        shape the juvenile justice system, this
a series of workshops in 2016 during         adolescents.6,24–30 The biological              area is a modern example of race
national meetings of pediatricians, 3        mechanism that emerges from                     being an important determinant of
strategic actions were identified: (1)        chronic stress leads to increased and           short- and long-term outcomes. The
development of a task force within           prolonged levels of exposure to stress          AAP published a statement in 201146
the AAP to address racism and other          hormones and oxidative stress at the            focusing on key health issues of
forms of discrimination that impact          cellular level. Prolonged exposure to           justice-involved youth, which was
the health status and outcomes of            stress hormones, such as cortisol,              recently revised to include an in-
minority youth, (2) development of           leads to inflammatory reactions that             depth discussion on racial and ethnic
a policy statement on racism, and (3)        predispose individuals to chronic               inequalities for this population.47
integration of evidence-based                disease.31 As an example, racial                Although the overall rates of youth
anticipatory guidance about racism           disparities in the infant mortality             incarceration have decreased, African
into Bright Futures.16                       rate remain,32 and the complications            American, Hispanic, and American

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2                                                                                                 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Indian youth continue to be                      discovery, innovation, and medical-              Through these underpinnings, racism
disproportionately represented.48                pharmaceutical collaborations.56                 became a socially transmitted disease
While incarcerated, youth experience             Rather than focusing on preventing               passed down through generations,
additional adverse experiences, such             the social conditions that have led to           leading to the inequities observed in
as solitary confinement and abuse,                racial disparities, science and society          our population today. Although the
that have the potential to undermine             continue to focus on the disparate               endemic nature of racism has
socioemotional development and                   outcomes that have resulted from                 powerful impacts on perceived and
general developmental outcomes.49–51             them, often reinforcing the posited              actual health outcomes, it is also
Differential treatment of youth                  biological underpinnings of flawed                important to note that other forms of
offenders on the basis of race shapes            racial categories.57 Although race               discrimination (eg, sex, religion,
an individual’s participation and                used in these ways has been                      sexual orientation, immigrant status,
ultimate function in society. This type          institutionalized, linked to health              and disability status) are actively at
of modern racism must be recognized              status, and impeded our ability to               play and have created a syndemic
and addressed if the United States               improve health and eliminate health              with the potential to undermine child
seeks to attain health equity.52                 disparities,58,59 it remains a powerful          and family health further. It is
                                                 measure that must be better                      important to address racism’s impact
                                                 measured, carefully used, and                    on the health and well-being of
THE DEVELOPMENT OF RACE AS                       potentially replaced to mark progress            children, adolescents, and emerging
A CONSTRUCT                                      in pediatric health disparities                  adults to avoid perpetuating a health
Race as a social construct is rooted in          research.60,61                                   system that does not meet the needs
history and remains a mechanism                                                                   of all patients.52 Pediatricians are
through which social class has been              As such, it is important to examine              uniquely positioned to both prevent
controlled over time. Flawed science             the historical underpinnings of race             and mitigate the consequences of
was used to solidify the permanence              used as a tool for subjugation.                  racism as a key and trusted source of
of race, reinforce the notions of                American racism was transported                  support for pediatric patients and
racial superiority, and justify                  through European colonization. It                their families.
differential treatment on the basis of           began with the subjugation,
phenotypic differences as people                 displacement, and genocide of
from different parts of the world                American Indian populations and was              CHILDHOOD EXPERIENCES OF RACISM
came in contact with each other.53               subsequently bolstered by the                    Children can distinguish the
Race emerged as a social                         importation of African slaves to frame           phenotypic differences associated
classification used to assign                     the economy of the United States.                with race during infancy73–75;
dominance of some social classes                 Although institutions such as slavery            therefore, effective management of
over others.53 Scientific,                        were abolished more than a century               difference as normative is important
anthropologic, and historical inquiry            ago, discriminatory policies, such as            in a diverse society. To identify,
further solidified race as a social               Jim Crow laws, were developed to                 address, and manage the impacts of
construct.54 Modern science,                     legalize subjugation. As the United              racism on child health, it is critical
however, has demonstrated that there             States expanded west in North                    that pediatricians understand 3 key
is only 1 biological race and that the           America and into Alaska and the                  levels through which racism operates:
clines (phenotypic differences in skin           Pacific Islands, the diversity of                 (1) institutional, (2) personally
and eye color, hair texture, and bone            populations encompassing the United              mediated, and (3) internalized. The
structure) at the core of early                  States also expanded. Native                     experience of race is also impacted by
anthropologic research were                      Hawaiian and Pacific Islander,                    other identities that people have
insufficient to establish different               Alaskan native, Asian American, and              related to ethnicity, sex, religious
races among human beings. Dr                     Latino American populations have                 affiliation, immigrant status, family
Francis Collins, former director of the          experienced oppression and similar               composition, sexuality, disability, and
National Human Genome Project and                exclusions from society.62–65                    others that must be navigated
presently the director of the National           Although some racial and/or ethnic               alongside race. Much of the
Institutes of Health, has affirmed that           groups have received reparations66               discussion to date related to the
humans are 99.9% the same at the                 and fared better than others over                historical underpinnings of race deals
level of their genome.55 Despite this,           time, remnants of these policies                 with institutionalized (or structural)
efforts to collect, organize, and                remain in place today and continue               racism, expressed through patterns of
categorize individuals on the basis of           to oppress the advancement of                    social institutions (eg, governmental
the plausibility of the 0.01% human              people from historically aggrieved               organizations, schools, banks, and
variation remain a force of scientific            groups.67–72                                     courts of law) that implicitly or

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PEDIATRICS Volume 144, number 2, August 2019                                                                                            3
explicitly discriminate against              is repetitive, causing stress levels to         sleep and time spent at home,
individuals from historically                increase because of anticipation of             children spend a significant portion of
marginalized groups.22,52,76,77              future events.11 Internalized negative          their time in educational settings.95–97
Children experience the outputs of           stereotypes related to race can                 Educational achievement is an
structural racism through place              unconsciously erode self-perception             important predictor of long-term
(where they live), education (where          and capacity and may later play out in          health and economic outcomes for
they learn), economic means (what            the form of stereotype threat or the            children. Adults with a college degree
they have), and legal means (how             fear of confirming a negative                    live longer and have lower rates of
their rights are executed). Research         stereotype of one’s race.91 Stereotype          chronic disease than those who did
has identified the role of implicit and       threats can undermine academic and              not graduate from college.98 It is
explicit personally mediated racism          vocational attainment, key                      critical for pediatricians to recognize
(racism characterized by assumptions         developmental milestones for the                the institutional, personally mediated,
about the abilities, motives, or intents     victim. Underachievement then                   and internalized levels of racism that
of others on the basis of race)78 as         reinforces the stereotype held by both          occur in the educational setting
a factor affecting health care delivery      the perpetrator and victim, further             because education is a critical social
and general health outcomes.79–86            enhancing the vulnerability of the              determinant of health for children.99
The impacts of structural and                victim and the bystander to repeated
personally mediated racism may               acts of overt or covert victimization.          Disparities in educational access and
result in internalized racism                These observations suggest that                 attainment, along with racism
(internalizing racial stereotypes            universal interventions to eliminate            experienced in the educational
about one’s racial group). A positive        racism (experienced as a victim or              setting, affect the trajectory of
racial identity mediates experiences         bystander) from the lives of children           academic achievement for children
of discrimination and generates              and to engage in active societal                and adolescents and ultimately
optimal youth development                    antiracism bystander behavioral                 impact health. Chronic absenteeism,
outcomes.12,87,88 The importance of          intervention may optimize well-being            defined as missing $10% of school
a prosocial identity is critical during      for all children and the adults who             days in an academic year, is a strong
adolescence, when young people               care for them. For individual                   predictor of educational achievement.
must navigate the impacts of social          intervention to occur, however,                 Chronic absenteeism
status and awareness of personally           bystanders must identify critical               disproportionately affects children of
mediated discrimination based on             situations, view them as an                     color, children living in poverty,
race.89–91                                   emergency, develop a sense of                   children with disabilities, and
                                             personal responsibility, have self-             children with chronic diseases.100 In
Although children and adolescents            efficacy to succeed with the                     high school, 21.2% of Hispanic, 23.4%
who are the targets of racism                intervention, perceive the costs of             of African American, and 27.5% of
experience the most significant               nonintervention as high, and                    American Indian children were
impact, bystanders are also adversely        consciously decide to help.11,92                chronically absent in 2013–2014
affected by racism. As an example,           Research has demonstrated that                  compared with 17.3% of white
young adults who were bystanders to          racism has an effect on health across           children.101 Immigration enforcement
racism and other forms of                    racial groups in communities                    and the fear of apprehension by
victimization as youth experience            reporting high levels of racism93 but           authorities can negatively affect
profound physiologic and                     that racially diverse environments,             school attendance for Hispanic and
psychological effects when asked to          such as schools, can benefit all youth           black immigrants, thereby
recall the memory of a past anchoring        by improving cognitive skills such as           perpetuating inequalities in
event as a victim or bystander that          critical thinking and problem-                  attendance.102 According to the
are comparable to those experienced          solving.94                                      National Center for Education
by first responders after a major                                                             Statistics, the graduation rate for
disaster. Three core features that                                                           white students nationally in
characterized the abusive event(s)           RACISM AT THE INTERSECTION OF                   2015–2016 was 88% compared with
were as follows: (1) an individual gets      EDUCATION AND CHILD AND                         76% for African American students,
hurt psychologically or physically, (2)      ADOLESCENT HEALTH                               72% for American Indian students,
a power differential exists (eg, age,        Educational and vocational                      and 79% for Hispanic students.103
size and/or stature, or status) versus       attainment are key developmental                Disparities in chronic absenteeism
the target individual resulting in           outcomes that pediatricians monitor             and high school graduation rates
domination and erosion of the                to assess for successful growth and             prevent children from realizing the
target’s self-esteem, and (3) the abuse      development. After accounting for               full benefits of educational attainment

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4                                                                                                 FROM THE AMERICAN ACADEMY OF PEDIATRICS
and can increase the development of              teachers’ expectations of their                  suspended 3 times more and expelled
chronic disease and reduce overall               students, with data demonstrating                1.9 times more than white
life expectancy.104                              that white and other non–African                 students.120 To mediate the effects of
                                                 American teachers are more likely                institutional and personally mediated
Although the landmark US Supreme
                                                 than African American teachers to                racism in the educational setting and
Court case Brown v Board of
                                                 predict that African American                    prevent internalized racism, studies
Education banned government-
                                                 students would not finish high                    show that a positive, strong racial or
sponsored segregation and laid
                                                 school.113 Similarly, data indicate that         ethnic identity and parental
a foundation for equal access to
                                                 teachers may underestimate the                   engagement in families is protective
a quality public education, the US
                                                 ability of African American and Latino           against the negative effects of racial
Department of Education continues to
                                                 students, which can lead to lower                discrimination on academic
report institutional or structural
                                                 grade point averages and fewer years             outcomes.121–123
inequality in educational access and
                                                 of schooling.114 African American
outcomes,105 even in the most diverse
                                                 students who have 1 African
and well-resourced communities in                                                                 HOW PEDIATRICIANS CAN ADDRESS
                                                 American teacher in elementary
the United States. Students from                                                                  AND AMELIORATE THE EFFECTS OF
                                                 school are more likely to graduate
historically aggrieved groups have                                                                RACISM ON CHILDREN AND
                                                 from high school and enroll in college           ADOLESCENTS
less access to experienced teachers,
                                                 than their peers who do not have an
advanced coursework, and resources                                                                Pediatricians and other child health
                                                 African American teacher; the
and are also more harshly punished                                                                professionals must be prepared to
                                                 proposed mechanism for this
for minor behavioral infractions                                                                  discuss and counsel families of all
                                                 improved long-term educational
occurring in the school setting.105                                                               races on the effects of exposure to
                                                 outcome is the exposure to a role
They are less likely to be identified                                                              racism as victims, bystanders, and
                                                 model early in the educational
for and receive special education                                                                 perpetrators.124–126 Pediatricians can
                                                 experience.115 These findings indicate
services,106 and in some states, school                                                           implement systems in their practices
                                                 the importance of ensuring a diverse
districts with more nonwhite children                                                             that ensure that all patients and
                                                 teacher workforce, particularly as the
receive lower funding at any given                                                                families know that they are welcome,
                                                 population of students in US schools
poverty level than districts with more                                                            that they will be treated with mutual
                                                 continues to diversify.116 School racial
white children.107                                                                                respect, and that high-quality care
                                                 climate, which refers to norms,
Children may also experience                     curricula, and interactions around               will be delivered regardless of
personally mediated racism early in              race and diversity within the school             background using the tenets of
their schooling, which may be                    setting, also impacts educational                family- and patient-centered care.127
internalized and ultimately affect               outcomes for students.117 Students               To do this, it is critical for
their interactions with others.108               who had a positive perception of                 pediatricians to examine their own
Early teacher-child interactions are             school racial climate had higher                 biases.128 Pediatricians can advocate
important for long-term academic                 academic achievement and fewer                   for community initiatives and
outcomes. The relationship of teacher            disciplinary issues.118 Racial                   collaborate with government and
to student across ages and grade                 inequities in school discipline begin            community-based organizations to
levels influences school adjustment,              early, and school discipline has long-           help redress biases and inequities in
literacy, math skills, grade point               term consequences for children.                  the health, justice, and educational
average, and scholastic aptitude test            Although federal civil rights laws               systems. These strategies may
scores.109–111 Given the critical                prohibit discrimination in the                   optimize developmental outcomes
nature of the student-teacher                    administration of discipline in public           and reduce exposure to adverse
relationship, it is important to explore         schools, the US Government                       events that dramatically alter the
how racism and implicit bias affect              Accountability Office found that                  lived experiences, health, and
this dynamic. Student-teacher racial             African American and American                    perceived self-value of youth.48,129,130
mismatch can impact academic                     Indian students are overrepresented
performance, with studies showing                among students experiencing                      Optimizing Clinical Practice
that African American children are               suspension.119 Data from the US                  In practice, pediatricians and other
more likely to receive a worse                   Department of Education confirm                   child health care providers encounter
assessment of their behavior when                that a disproportionate number of                children every day who have
they have a non-Hispanic white                   African American children receive                experienced racism. There are
teacher than when they have an                   more than 1 out-of-school suspension             interventions available for use in the
African American teacher.112 This                in preschool and overall in                      medical home that can identify and
finding may result from racial bias in            kindergarten through grade 12 are                potentially ameliorate inequities.

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PEDIATRICS Volume 144, number 2, August 2019                                                                                             5
• Create a culturally safe medical             youth and families for protective             • Encourage policies to foster
  home131 where the providers                  factors,9 such as a supportive                  interactive learning communities
  acknowledge and are sensitive to             extended family network, that can               that promote cultural humility (eg,
  the racism that children and                 help mitigate exposure to racist                self-awareness, lifelong
  families experience by integrating           behaviors.138                                   commitment to self-evaluation, and
  patient- and family-centered               • Infuse cultural diversity into AAP-             commitment to managing power
  communication strategies and                 recommended early                               imbalances)150,151 and provide
  evidence-based screening tools that          literacy–promotion programs147 to               simulation opportunities to ensure
  incorporate valid measures of                ensure that there is                            new pediatricians are competent to
  perceived and experienced racism             a representation of authors, images,            deliver culturally appropriate and
  into clinical practice.132–136               and stories that reflect the cultural
                                                                                               patient- and family-centered
• Use strategies such as the Raising           diversity of children served in
  Resisters approach during                    pediatric practice.                           • Integrate active learning strategies,
  anticipatory guidance to provide                                                             such as simulation156 and language
                                             • Encourage pediatric practices and
  support for youth and families to                                                            immersion,157 to adequately
                                               local chapters to embrace the
  (1) recognize racism in all forms,                                                           prepare pediatric residents to serve
                                               challenge of testing best practices
  from subversive to blatant displays                                                          the most diverse pediatric
                                               using Community Access to Child
  of racism; (2) differentiate racism                                                          population to date to exist in the
                                               Health grants and participation in
  from other forms of unfair                                                                   United States158 and lead diverse
                                               national quality-improvement
  treatment and/or routine                                                                     and interdisciplinary pediatric care
                                               projects to examine the                         teams.159
  developmental stressors; (3) safely          effectiveness of office-based
  oppose the negative messages and/                                                          • Advocate for policies and programs
                                               interventions designed to address
  or behaviors of others; and (4)                                                              that diversify the pediatric
                                               the impact of racism on patient
  counter or replace those messages                                                            workforce and provide ongoing
  and experiences with something                                                               professional education for
                                             • Encourage practices and chapters                pediatricians in practice as
                                               to develop resources for families               a strategy to reduce implicit
• Train clinical and office staff in            with civil rights concerns, including
  culturally competent care                                                                    biases and improve safety and
                                               medicolegal partnerships and                    quality in the health care delivery
  according to national standards for
                                               referrals to agencies responsible               system.160–162
  culturally and linguistically
                                               for enforcing civil rights laws.
  appropriate services.139,140                                                               Optimizing Systems Through
                                             • Encourage pediatric-serving
• Assess patients for stressors (eg,           organizations within local                    Community Engagement, Advocacy,
  bullying and/or cyberbullying on                                                           and Public Policy
                                               communities, including pediatric
  the basis of race)141 and social                                                           • Acknowledge that health equity is
                                               practices, hospitals, and health
  determinants of health often                                                                 unachievable unless racism is
                                               maintenance organizations, to
  associated with racism (eg,                                                                  addressed through
                                               conduct internal quality-assurance
  neighborhood safety, poverty,                                                                interdisciplinary partnerships with
                                               assessments that include analyses
  housing inequity, and academic                                                               other organizations that have
                                               of quality of care and patient
  access) to connect families to                                                               developed campaigns against
                                               satisfaction by race and to initiate
  resources.9,142,143                                                                          racism.163,164
                                               improvement protocols as needed
• Assess patients who report                   to improve health outcomes and                • Engage community leaders to
  experiencing racism for mental               community trust.                                create safe playgrounds and
  health conditions, including signs of                                                        healthy food markets to reduce
  posttraumatic stress, anxiety, grief,                                                        disparities in obesity and
  and depressive symptoms, using             Optimizing Workforce Development                  undernutrition in neighborhoods
  validated screening tools and              and Professional Education                        affected by poverty.
  a trauma-informed approach to              • Advocate for pediatric training               • Advocate for improvements in the
  make referrals to mental health              programs that are girded by                     quality of education in segregated
  services as needed.144                       competencies and subcompetencies                urban, suburban, and rural
• Integrate positive youth                     related to effective patient and                communities designed to better
  development approaches,145                   family communication across                     optimize vocational attainment and
  including racial socialization,123,146       differences in pediatric                        educational milestones for all
  to identify strengths and assess             populations.148,149                             students.

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6                                                                                                 FROM THE AMERICAN ACADEMY OF PEDIATRICS
• Support local educational systems              • Collaborate with first responders               important to begin untangling the
  by connecting with and supporting                and community police to enhance                thread of racism sewn through the
  school staff. The AAP Council on                 positive youth engagement by                   fabric of society and affecting the
  School Health provides resources to              sharing expertise on child and                 health of pediatric populations.
  help physicians engage and interact              adolescent development and                     Pediatricians must examine and
  with their school system and                     mental health, considering                     acknowledge their own biases and
  provides guidelines around the role              potential differences in culture, sex,         embrace and advocate for innovative
  of school physicians and school                  and background.178                             policies and cross-sector partnerships
  health personnel.165,166                       • Advocate for fair housing practices,           designed to improve medical,
• Advocate for federal and local                   including access to housing loans              economic, environmental, housing,
  policies that support implicit-bias              and rentals that prohibit the                  judicial, and educational equity for
  training in schools and robust                   persistence of historic                        optimal child, adolescent, and
  training of educators in culturally              “redlining.”179                                emerging adult developmental
  competent classroom management                                                                  outcomes.
  to improve disparities in academic             Optimizing Research
  outcomes and disproportionate                  • Advocate for funding and                       SECTION ON ADOLESCENT HEALTH
  rates of suspension and expulsion                dissemination of rigorous research             EXECUTIVE COMMITTEE, 2018–2019
  among students of color, reflecting               that examine the following:                    Maria E. Trent, MD, MPH, FAAP, Chairperson
  a systemic bias in the educational                                                              Robert M. Cavanaugh Jr, MD, FAAP
                                                   1. the impact of perceived and
  system.167                                                                                      Amy E. Lacroix, MD, FAAP
                                                      observed experiences of                     Jonathon Fanburg, MD, MPH, FAAP
• Advocate for increased access                       discrimination on child and                 Maria H. Rahmandar, MD, FAAP
  to support for mental health                        family health outcomes180;                  Laurie L. Hornberger, MD, MPH, FAAP
  services in schools designed                                                                    Marcie B. Schneider, MD, FAAP
                                                   2. the role of self-identification              Sophia Yen, MD, MPH, FAAP
  to help teachers better manage
                                                      versus perceived race on child
  students with disruptive
                                                      health access, status, and
  classroom behaviors and to                                                                      STAFF
  reduce racial disparities in school                                                             Karen S. Smith
  expulsion.144,168,169                            3. the impact of workforce
                                                      development activities on
• Advocate for curricula that are
                                                      patient satisfaction, trust, care           COUNCIL ON COMMUNITY PEDIATRICS
  multicultural, multilingual, and
                                                      use, and pediatric health                   EXECUTIVE COMMITTEE, 2018–2019
  reflective of the communities in
                                                      outcomes161;                                Lance Alix Chilton, MD, FAAP, Chairperson
  which children in their practices
                                                                                                  Andrea E. Green, MD, FAAP
  attend school.170                                4. the impact of policy changes and
                                                                                                  Kimberley Jo Dilley, MD, MPH, FAAP
                                                      community-level interventions
• Advocate for policies and programs                                                              Juan Raul Gutierrez, MD, FAAP
                                                      on reducing the health effects of           James H. Duffee, MD, MPH, FAAP
  that diversify the teacher
                                                      racism and other forms of                   Virginia A. Keane, MD, FAAP
  workforce to mitigate the effects of                                                            Scott Daniel Krugman, MD, MS, FAAP
                                                      discrimination on youth
  the current demographic mismatch                                                                Carla Dawn McKelvey, MD, MPH, FAAP
                                                      development; and
  of teachers and students that                                                                   Julie Michelle Linton, MD, FAAP
  affects academic attitudes and                   5. integration of the human                    Jacqueline Lee Nelson, MD, FAAP
                                                      genome as a way to identify                 Gerri Mattson, MD, FAAP
  attainment for all students.115,171
                                                      critical biomarkers that can be
• Advocate for evidence-based
                                                      used to improve human health                LIAISON
  programs that combat racism in the
                                                      rather than continue to classify
  education setting at a population                                                               Donene Feist
                                                      people on the basis of their
                                                      minor genetic differences and
• Encourage community-level                           countries of origin.55                      STAFF
  advocacy with members of those                                                                  Dana Bennett-Tejes, MA, MNM
  communities disproportionately
  affected by racism to develop                  CONCLUSIONS
  policies that advance social                                                                    COMMITTEE ON ADOLESCENCE, 2018–2019
                                                 Achieving decisive public policies,
  justice.19,175                                 optimized clinical service delivery,             Cora C. Breuner, MD, MPH, FAAP,
• Advocate for alternative strategies            and community change with an                     Elizabeth M. Alderman, MD, FSAHM, FAAP
  to incarceration for management of             activated, engaged, and diverse                  Laura K. Grubb, MD, MPH, FAAP
  nonviolent youth behavior.50,176,177           pediatric workforce is critically                Janet Lee, MD, FAAP

                                    Downloaded from by guest on August 1, 2019
PEDIATRICS Volume 144, number 2, August 2019                                                                                                  7
Makia E. Powers, MD, MPH, FAAP                         Lauren B. Zapata, PhD, MSPH – Centers for            Klein, Janie Ward, Michael Lindsey,
Maria H. Rahmandar, MD, FAAP                           Disease Control and Prevention                       Lance Chilton, James Duffee, Andrea
Krishna K. Upadhya, MD, FAAP
                                                                                                            Green, Julie Linton, Virginia Keane,
Stephenie B. Wallace, MD, FAAP
                                                       STAFF                                                Jackie Nelson, Raul Gutierrez, Lase
                                                                                                            Ajayi, Lee Beers, Nathaniel Beers, Heidi
LIAISONS                                               Karen S. Smith
                                                                                                            Schumacher, and Tonya Vidal Kinlow.
Liwei L. Hua, MD, PhD – American Academy
of Child and Adolescent Psychiatry                     ACKNOWLEDGMENTS
Geri D. Hewitt, MD – American College of               We are grateful for internal review
Obstetricians and Gynecologists                        and critical feedback by Drs Benard                    ABBREVIATION
Seema Menon, MD – North American Society
of Pediatric and Adolescent Gynecology                 Dreyer, Olanrewaju Falusi, Renee                       AAP: American Academy of
Ellie E. Vyver, MD, FRCPC, FAAP – Canadian             Jenkins, Judith Palfrey, Krishna                            Pediatrics
Pediatric Society                                      Upadhya, Joseph Wright, Jonathan

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2019 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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