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Racism: Developmental Perspective Can Inform Tough Conversations

Updated: May 4, 2021

Can we help our pediatric patients with the complicated problems of racism, especially if we are

privileged (and even white) professionals? We may not have experienced discrimination, but we can still advise and address it. Racist discrimination, fear, trauma, or distress may produce or exacerbate conditions we are treating. I have found it often revealing to ask: “Have you, your child, or your family had an experience with racism that may be contributing to today’s concern?”

Three levels of racism impact children’s health and health care:

  1. “Structural or institutional” policies that influence social determinants of health

  2. “Personally mediated” differential treatment based on assumptions about one’s abilities, motives, or intents

  3. “Internalization” of stereotypes into one’s identity, undermining confidence, self-esteem, and mental health

We can help advocate about structural racism and ensure equity within our offices, but how best to counsel the families and children themselves?

Racism includes actions of “assigning value based on the social interpretation of how a person looks” (Ethn Dis. 2008;18[4]:496-504). “Social interpretations” develop from an early age.


Newborns detect differences in appearance and may startle or cry seeing a parent’s drastic haircut or new hat. Parents generally know to use soothing words and tone, bring the difference into view gradually, smile and comfort the child, and explain the change; these are good skills for later, too.


Infants notice skin color, which, unlike clothes, is a stable feature by which to recognize parents. Social interpretation of these differences is cued from the parents’ feelings and reactions. Adults naturally transmit biases from their own past unless they work to dampen them. If the parent was taught to regard “other” as negative or is generally fearful, the child mirrors this. Working to reduce racism thus requires parents (and professionals) to examine their prejudices to be able to convey positive or neutral reactions to people who are different. Parents need to show curiosity, positive affect, and comfort about people who are different, and do well to seek contact and friendships with people from other groups and include their children in these relationships. We can encourage this outreach plus ensure diversity and respectful interactions in our offices.

Three Years and Older

Children from age 3 years value fairness and are upset seeing others treated unfairly – easily understanding “not fair” or “mean.” If the person being hurt is like them in race, ethnicity, religion, gender, or sexual preference, they also fear for themselves, family, and friends.

How to Discuss Racism

Balance is needed in discussing racism to avoid increasing fear or overpromising as risks are real and solutions difficult. Children look to adults for understanding and evidence of action to feel safer, rather than helpless.

We should communicate directly to children (whether you believe it completely or not) that:

  • Leaders are working on “making the rules more fair”

  • People “won’t be allowed do it again”

  • Everyone deserves respect

Even better:

  • Parents and older children can generate ideas about possible child actions, giving them some power as an antidote to anxiety.

  • Age-related possibilities might include:

  • Drawing a picture of people getting along

  • Talking about equity at show-and-tell

  • Writing a note to officials

  • Making a protest sign

  • Posting thoughts on Facebook

  • Protesting

Buffer Against Outside Influences

With age, the culture increasingly influences a child’s attitudes. Children see lots of teasing and bullying based on differences from being overweight or wearing glasses, to skin color. We can recommend:

  • Helping interpret for children that bullies are insecure, or sometimes have been hurt, and they put other people down to feel better than someone else.

  • Thinking about racist acts in this way may reduce the desire for revenge and a cycle of aggression.

  • Coaching on effective anti-bullying strategies that help children recognize bullying, see it as an emergency that requires their action, tell adults, and take action. This action could be:

  • Surrounding the bully

  • Standing tall

  • Making eye contact

  • Having a dismissive retort

  • Asking questions that require the bully to think, such as “What do you want to happen by doing this?”

  • Coaching our patients and their parents on these principles as well as advising schools.

Point Out Strengths

Children need to be told that those being put down or held down – especially those like them – have strengths; have made discoveries; have produced writings, art, and music; have shown military bravery, moral leadership, and resistance to discrimination, but it is not the time to show strength when confronted by a gun or police. We can and can recommend that parents:

  • Collect and share examples to discuss strengths and accomplishments of people like them to help buffer the child from internalization of racist stereotypes.

  • Since children need positive role models who look like them, seek out diverse professionals in children’s lives.

  • Dentists

  • Doctors

  • Teachers

  • Clergy

  • Mentors

  • Coaches

  • Ensure that diverse dolls and books are available, and that the children’s shows, movies, and video games are watched together and include diverse people doing good or brave things. These exposures also are key to all children becoming anti-racist.

Help Parents Teach

Parents can be advised to initiate discussion of racism because children, detecting adult discomfort, may avoid the topic.

  • Encourage families to give their point of view; otherwise children simply absorb those of peers or the press.

  • Parents should tell their children:

  • “I want you to be able to talk about it if someone is mean or treats you unfairly because of [the color of your skin, your religion, your sex, your disability, etc.].

  • You might feel helpless, or angry, which is natural. We need to talk about this so you can feel strong.

  • Then we can plan on what we are going to do.

  • ”The “sandwich” method of “ask-give information-ask what they think” can encourage discussion and correct misperceptions.

Racist policies have succeeded partly by adult “bullies” dehumanizing the “other.” Most children can consider someone else’s point of view by 4½ years old, shaped with adult help.

  • Parents can begin by telling babies

  • “That hurts, doesn’t it?”

  • Toddlers and older

  • “How would you feel if ... [someone called you a name just because of having red hair]?”

  • “How do you think she feels when ... [someone pushes her out of line because she wears certain clothes]?” in cases of grabbing, not sharing, hitting, bullying, etc.

  • Older children and teens can analyze more abstract situations.

  • “What if you were the one who ... [got expelled for mumbling about the teacher]?”

  • “What if that were your sister?”

  • “How would the world be if everyone ... [got a chance to go to college]?”

We can encourage parents to propose these mental exercises to build the child’s perspective-taking while conveying their opinions.

Experiences, including through media, may increase or decrease fear; the child needs to have a supportive person moderating the exposure, providing a positive interpretation, and protecting the child from overwhelm, if needed.

Experiences are insufficient for developing anti-racist attitudes, though; listening and talking are needed.

  • Ask children about what they notice, think, and feel about situations reflecting racism, especially as they lack words for these complicated observations.

  • Discuss television, Internet, and newspaper examples of both racism and anti-racism.

  • Recommend watching or reading together, and asking questions such as,

  • “Why do you think they are shouting [protesting]?”

  • “How do you think the [victim, police] felt?”

  • “What do you think should be done about this?”

  • Acknowledge the child’s confusion, fear, anxiety, sadness, or anger as normal and appropriate, not dismissing, too quickly reassuring, or changing the subject, even though it’s uncomfortable.

We Can Make a Difference!

Physicians and nurse practitioners can make a difference by being aware of our privilege and biases, being open, modeling discussion, screening for impact, offering strategies, advocating with schools, and providing resources such as therapy or legal counsel, as for other social determinants of health.

Excerpts by Dr. Barbara Howard from Pediatric News. Dr. Howard is also the co-founder of CHADIS.

CHADIS is a unique screening, decision support and patient engagement system designed to streamline and optimize healthcare by providing clinicians with evidence-based data that improves diagnosis and management of health, emotional, developmental and behavioral concerns.

CHADIS offers over 600 tools to help doctors, educators, and parents screen for and monitor a variety of developmental, behavioral health, and general health issues for children and adults. Tools Link

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