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Invited Commentary
March 24, 2021

The Use of Protective Caregiving to Create Positive Racial-Ethnic Socialization and Mitigate Psychological Outcomes of Racial Discrimination

Author Affiliations
  • 1Division of Adolescent Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham
JAMA Netw Open. 2021;4(3):e212544. doi:10.1001/jamanetworkopen.2021.2544

Mitigating the complex longitudinal consequences racism can have on adolescents and their families is challenging. One strategy focuses on racial-ethnic socialization, the process by which society sends messages to individuals about the significance of their race, ethnicity, or cultural values.1 In a secondary analysis comparing 2 unblended randomized clinical trials of rural Georgia–based family-centered prevention programs originally designed to prevent high risk sexual behavior and substance use by enhancing protective caregiving, Brody et al2 investigated the ability of these programs to mitigate the association between Black adolescents’ encounters with discrimination and mental health problems.2 The Strong African American–Teen (SAAF–T) program focused on caregivers of 10th graders aged 14 to 16 years, and the Adults in the Making (AIM) program focused on caregivers of 12th graders ages 17 and 18 years.2 Schools from 12 Georgia counties provided the rosters for recruitment. SAAF–T consisted of a 5-week consecutive program, with 2-hour sessions in which the first hour focused on separate skill-building for adolescents and their caregivers and the second hour focused on interactive application of those skills.2 Caregivers were taught emotional and instrumental support, limit setting, adaptive racial socialization, and communication about sex and alcohol.2 Adolescents learned the importance of abiding by household rules, setting goals and plans for the future, and strategies for resisting substance use.2 AIM was similarly constructed with 6 consecutive weekly 2-hour sessions with adolescents and caregivers developing skills separately.2 No family dyad completed all of the sessions for either program, with many families working a mean of 40 hours or more per week and living below the federal poverty level (64% of families in SAAF-T; 42% of families in AIM).2 Follow up for the studies occurred at 6 months and at 18 months for SAAF-T or 27 months for AIM.2 Both interventions reduced incidence of conduct problems 1.5 to 2 years after completion.2 Furthermore, adolescents in AIM frequently experiencing discrimination at baseline had fewer increases in anxiety and depression symptoms compared with controls.2

The study by Brody et al2 highlights the impact of conscious and unconscious racism, one of the most prevalent and pervasive types of discrimination, and its deleterious effects on Black adolescents’ mental health, although racism negatively impacts everyone in the US. Defined as “negative beliefs, attitudes, actions, or behaviors that are based on phenotypic characteristics or ethnic affiliation,”3 racism is a social construct that exists in many forms. A nationwide survey found that more than 50% of youth of African American and Afro-Caribbean decent ages 13 to 17 experienced discrimination in the past year, while a regional survey conducted in the Northeastern US found that 88% of youth of any race aged 8 to 18 years reported ever experiencing racial discrimination.3,4 Racism exerts profound effects on youth’s identity development, lived experiences, and lifelong health. Youth’s exposure to racism at the personal and structural levels has significant effects on their psychological and biological functioning, including low self-efficacy, low self-esteem, and hopelessness,5 as well as symptoms of depression and anxiety, as mentioned in the study by Brody et al.2 Furthermore, racism not only impacts youth during childhood and adolescence, it also places them at risk for negative health outcomes as adults, including persistent mental health conditions, such as substance use, depression, anxiety, and posttraumatic stress disorder, as well as physical health conditions, such as cardiovascular disease, autoimmune disorders, cancer, emphysema, and diabetes.5 It is unfortunate that the SAAF–T and AIM interventions were originally designed to measure substance use and that the analysis by Brody et al2 did not mention any other related physical or other mental health outcomes.

The study by Brody et al2 has several implications for individuals who work with pediatric populations. First, it provides additional evidence for an association between exposure to racism and mental health. Second, it provides 2 evidenced-based, community-informed, cost-effective programs that can potentially mitigate negative mental health consequences of racism. Third, it uses the fundamental building block of pediatrics, dyadic communication between parents and children, to develop coping skills focused on reenforcing positive racial-ethnic socialization and reducing behavior disorders and mental health symptoms from experiencing racism.

While pediatric offices may not be the ideal place to adapt and incorporate these 2 programs, pediatric clinicians can think about how the study by Brody et al2 supports the importance of practicing with a trauma-informed lens and helping youth develop healthy relationships and coping skills to effectively navigate life. This is particularly true as pediatric organizations, like the American Academy of Pediatrics and the Society for Adolescent Health and Medicine, come out and formally acknowledge racism as an adverse childhood experience (ACE) and a form of trauma that continues to impact young people in the US.1,6 Ensuring that pediatric offices have organizational cultures in which everyone acknowledges the pervasiveness of trauma like racism, is trained in trauma awareness, knowledge, and skills, and responds appropriately to trauma is crucial if the goals of care are to maximize safety, facilitate recovery, and support the child’s ability to thrive, as stated by the National Child Traumatic Stress Network.7

Although it sheds light on racial discrimination and mitigation strategies, this study by Brody et al2 should be viewed in the context of some important limitations. First, it did not account for the continuum of exposure to the violence of racial discrimination on adolescents and their caregivers nor the transgenerational transmission of stress. While caregivers, mostly mothers, were expected to be the main interventionist in this study, they, too, through their own experiences with personal and vicarious racism, may have been experiencing mental and physical health conditions attributable to experiences of racism that limited their capacity to moderate their children’s experiences. Additionally, the omission of fathers and siblings from the discussion magnifies an often excluded group in family-based interventions, as racial attacks on Black men and boys in particular impact the entire family. Second, this study is not generalizable, nor may its impacts be extrapolated to Black adolescents or other adolescents of color living in nonrural areas. This limitation is further amplified by the use of caregivers, as opposed to the adolescents themselves, reporting discrimination experienced by adolescents in the AIM trial. Third, Brody et al2 did not incorporate the social determinants of health, the conditions in which people are born, live, work, and age that are shaped by racism and the distribution of money, power, and resources at global, national, and local levels, into their measurement tools.5 Social determinants of health account for an estimated 60% or more of physical and psychological outcomes and are largely responsible for health inequities. The adolescents and their families in the study by Brody et al2 were largely working poor and living below the federal poverty level despite working a mean of 40 or more hours a week. The limited economic mobility and racial discrimination experienced by adolescents and their families must both be viewed as separate yet compounding ACEs that also have associations with physical and psychological health. Thus, the expanded definition of ACEs to include racism is crucial to the abilities of health care practitioners to care for all children, as the definition now supports the concept that racism is a form of toxic stress that has the potential to lead to epigenetic changes and, in some cases, permanent structural changes in the developing brain.8 Additionally, it should be noted that adolescents were recruited from school rosters, thus those who may be at greatest risk of poor mental health outcomes secondary to racism were not eligible for inclusion.

While interventions like those examined by Brody et al2 are important, it may be ambitious to expect short-term programs to be able to fully ameliorate the psychosocial and physical health outcomes of continuous exposure to racism. Because “racism is a socially transmitted disease,” as explained by Bell,9 future interventions must be intentionally designed, long-term, continuous, and aimed at primary prevention and dismantling of racism, the root cause of mental health inequities under investigation by Brody et al.2 Most importantly, that intentionality must extend to all expressions of racism, including less recognized variations, such as prejudices, stereotypes, microaggressions, tokenism, and colorblindness.1

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Article Information

Published: March 24, 2021. doi:10.1001/jamanetworkopen.2021.2544

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Hill SV et al. JAMA Network Open.

Corresponding Author: Tamera Coyne-Beasley, MD, MPH, Division of Adolescent Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, 310 Children’s Park Pl I, 1600 Seventh Ave S, Birmingham, AL 35233-1711 (coybea@peds.uab.edu).

Conflict of Interest Disclosures: None reported.

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