The Impact of Racism on Child and Adolescent Health

Telehealth: Opportunities to Improve Access, Quality, and Cost in Pediatric Care

The use of telehealth technology to connect with patients has expanded significantly over the past several years, particularly in response to the global coronavirus disease 2019 pandemic. This technical report describes the present state of telehealth and its current and potential applications. Telehealth has the potential to transform the way care is delivered to pediatric patients, expanding access to pediatric care across geographic distances, leveraging the pediatric workforce for care delivery, and improving disparities in access to care. However, implementation will require significant efforts to address the digital divide to ensure that telehealth does not inadvertently exacerbate inequities in care. The medical home model will continue to evolve to use telehealth to provide high-quality care for children, particularly for children and youth with special health care needs, in accordance with current and evolving quality standards. Research and metric development are critical for the development of evidence-based best practices and policies in these new models of care. Finally, as pediatric care transitions from traditional fee-for-service payment to alternative payment methods, telehealth offers unique opportunities to establish value-based population health models that are financed in a sustainable manner.

Invited Commentary: The Need for Repeated Measures and Other Methodological Considerations When Investigating Discrimination as a Contributor to Health

To determine potential measurement error related to the assessment of lifetime discrimination, Van Dyke et al. (Am J Epidemiol. 2022;191(3):370-378) investigated inconsistencies in reporting of racial, socioeconomic status, and sex discrimination over time among Black and White adults enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. The authors found that "ever" reports of discrimination (as assessed by the Experiences of Discrimination Scale) decreased over time and that populations who most experience discrimination (i.e., Black/African-American people, younger persons, persons of low socioeconomic status, and women) were often also the most likely to inconsistently report discrimination over the course of the study period (from 1992 to 2010). The authors have raised an important issue related to the potential underestimation of lifetime discrimination that may depend on when discrimination is assessed, as well as the social identity of individuals surveyed. With implications for health inequities, these findings highlight study design and methodological issues that should be addressed to accurately estimate the true burden discrimination places on health. In this commentary, we further illuminate potential methodological challenges and opportunities to consider when investigating the impact of discrimination on health.

Structural racism and COVID-19 response: higher risk of exposure drives disparate COVID-19 deaths among Black and Hispanic/Latinx residents of Illinois, USA

Background

Structural racism has driven and continues to drive policies that create the social, economic, and community factors resulting in residential segregation, lack of access to adequate healthcare, and lack of employment opportunities that would allow economic mobility. This results in overall poorer population health for minoritized people. In 2020, Black and Hispanic/Latinx communities throughout the United States, including the state of Illinois, experienced disproportionately high rates of COVID-19 cases and deaths. Public health officials in Illinois implemented targeted programs at state and local levels to increase intervention access and reduce disparities.

Methods

To quantify how disparities in COVID outcomes evolved through the epidemic, data on SARS-CoV-2 diagnostic tests, COVID-19 cases, and COVID-19 deaths were obtained from the Illinois National Electronic Disease Surveillance System for the period from March 1 to December 31, 2020. Relative risks of COVID-19 cases and deaths were calculated for Black and Hispanic/Latinx vs. White residents, stratified by age group and epidemic interval. Deaths attributable to racial/ethnic disparities in incidence and case fatality were estimated with counterfactual simulations.

Results

Disparities in case and death rates became less drastic after May 2020, but did not disappear, and were more pronounced at younger ages. From March to May of 2020, the risk of a COVID-19 case for Black and Hispanic/Latinx populations was more than twice that of Whites across all age groups. The relative risk of COVID-19 death reached above 10 for Black and Hispanic/Latinx individuals under 50 years of age compared to age-matched Whites in the early epidemic. In all Illinois counties, relative risk of a COVID-19 case was the same or significantly increased for minoritized populations compared to the White population. 79.3 and 86.7% of disparities in deaths among Black and Hispanic/Latinx populations, respectively, were attributable to differences in age-adjusted incidence compared to White populations rather than differences in case fatality ratios.

Conclusions

Racial and ethnic disparities in the COVID-19 pandemic are products of society, not biology. Considering age and geography in addition to race/ethnicity can help to identify the structural factors driving poorer outcomes for certain groups. Studies and policies aimed at reducing inequalities in disease exposure may reduce disparities in mortality more than those focused on drivers of case fatality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12698-9.

Sociodemographic and Appointment Factors Affecting Missed Opportunities to Provide Neonatal Ultrasound Imaging

PURPOSE

The aim of this study was to assess disparities in outpatient imaging missed care opportunities (IMCOs) for neonatal ultrasound by sociodemographic and appointment factors at a large urban pediatric hospital.

METHODS

A retrospective review was performed among patients aged 0 to 28 days receiving one or more outpatient appointments for head, hip, renal, or spine ultrasound at the main hospital or satellite sites from 2008 to 2018. An IMCO was defined as a missed ultrasound or cancellation <24 hours in advance. Population-average correlated logistic regression modeling estimated the odds of IMCOs for six sociodemographic (age, sex, race/ethnicity, language, insurance, and region of residence) and seven appointment (type of ultrasound, time, day, season, site, year, and distance to appointment) factors. The primary analysis included unknown values as a separate category, and the secondary analysis used multiple imputation to impute genuine categories from unknown variables.

RESULTS

The data set comprised 5,474 patients totaling 6,803 ultrasound appointments. IMCOs accounted for 4.4% of appointments. IMCOs were more likely for Black (odds ratio [OR], 3.31; P < .001) and other-race neonates (OR, 2.66; P < .001) and for patients with public insurance (OR, 1.78; P = .002). IMCOs were more likely for appointments at the main hospital compared with satellites (P < .001), during work hours (P = .021), and on weekends (P < .001). Statistical significance for primary and secondary analyses was quantitatively similar and qualitatively identical.

CONCLUSIONS

Marginalized racial groups and those with public insurance had a higher rate of IMCOs in neonatal ultrasound. This likely represents structural inequities faced by these communities, and more research is needed to identify interventions to address these inequities in care delivery for vulnerable neonatal populations.

Racial Disparities in Medication Adherence Barriers: Pediatric Epilepsy as an Exemplar

OBJECTIVE

To evaluate how racial disparities in medication adherence barriers relate to key clinical outcomes (i.e., seizure control and adherence) in pediatric epilepsy and to identify the most critical barriers in determining health outcomes in Black youth and White youth.

METHODS

This observational study included a sample of youth aged 2-17 years with epilepsy obtained by combining data from four different studies. A total of 226 caregivers and 43 adolescents reported on adherence barriers. An electronic monitor was used to measure adherence to the primary antiepileptic drug. Racial disparities in individual barriers were examined. The relative importance of different types of barriers in determining clinical outcomes was evaluated in both Black and White youth.

RESULTS

Adherence barriers, including running out of medications, access to pharmacies, competing demands, and difficulty swallowing, disproportionally affected Black children with epilepsy compared to White children. System- and community-level barriers emerged as the most important in determining seizure outcomes among Black youth. Both system- and individual-level barriers, on the other hand, were important for adherence outcomes.

CONCLUSIONS

System- and community-level barriers, as opposed to individual-level barriers, are more highly endorsed by Black families compared to White families. These barriers are also the most critical in driving seizure outcomes among Black youth. There is a critical need to shift from a primary focus on individual-level barriers to an approach that deliberately targets larger systemic barriers to reduce the existing adherence and health disparities that affect Black children with pediatric conditions.

Understanding the Psychological Impacts of Teenage Pregnancy through a Socio-ecological Framework and Life Course Approach

The relationship between mental health and teenage pregnancy is complex. Mental health can be both an antecedent and contributing factor to teenage pregnancy and a concurrent factor wherein pregnancy itself can contribute to depression. Expectant and parenting teens (EPT) are faced with the simultaneous challenges of pregnancy and parenting while navigating the developmental tasks of adolescence which increases their risk for mental health problems. In addition, adolescents growing up in stressful community or home situations where their parents experienced depression, further places them and their children at greater risk of repeated patterns over time. However, adverse mental health outcomes are not inevitable. The socio-ecological model combined with a life course perspective provides a framework for understanding the complexity of risk and protective factors at multiple levels that influence knowledge, attitudes, behaviors, and other health outcomes later in life and across generations. This approach has important implications for reducing adolescents' risk of an unintended/mistimed pregnancy and improving mental health and other outcomes for EPT. This paper describes the prevalence of mental health problems in EPT and using a socio-ecological framework and life course perspective explains variations in mental health outcome among EPT. Implications for interventions and innovative approaches are also discussed.

Prospective Associations of Discrimination, Race, and Sexual Orientation with Substance Use in Adolescents

Objective: Adolescents are at high risk for alcohol and cannabis use. Emerging evidence suggests that discrimination exposure is prospectively associated with risk for alcohol use among adolescents of marginalized race, sexual orientation, or gender identity. However, it is unknown whether prospective discrimination-substance use associations among marginalized adolescents are also present for cannabis use. This study examined prospective associations of race, sexual orientation, and discrimination exposure with alcohol and cannabis use over one year. Methods: Data were drawn from a two-wave longitudinal health survey study of 9-11^th graders (n = 350 for the current analyses; Year 1 M_age=15.95 [SD = 1.07, range = 13-19]; 44% male; 44% Black, 22% White, 18% Asian, 16% Multiracial; 16% LGB; 10% Hispanic/Latinx ethnicity) at an urban high school. Two multinomial logistic regressions examined associations of Year 1 race, sexual orientation, and discrimination experiences with Year 2 alcohol and cannabis consumption separately. Results: Year 1 Discrimination exposure was associated with increased risk for Year 2 past-year alcohol use among Asian (OR = 1.34) and past-month alcohol use among Multiracial (OR = 1.30) adolescents, but not Black or LGB adolescents. Discrimination exposure was not associated with any cannabis use pattern in any group. Independent of discrimination, LGB adolescents were at greater risk for monthly alcohol (OR = 3.48) and cannabis use (OR = 4.07) at Year 2. Conclusions: Discrimination exposure is prospectively associated with risk for alcohol use among adolescents of understudied (Asian, Multiracial) racial backgrounds, and should be considered in alcohol prevention and intervention strategies. Risk factors for alcohol and cannabis use among LGB adolescents should continue to be explored.

Examining School Based Health Service Utilization Among Marginalized Youth in Connecticut During COVID

PURPOSE

This study examines how the coronavirus disease 2019 (COVID-19) is affecting utilization of medical and behavioral health services through school based health centers (SBHC s).

METHODS

We leveraged the electronic health records from one of the largest sponsors of SBHCs in the country, and tested differences in SBHC utilization with chi-square tests one year prior to the pandemic (pre-pandemic: March 2019-February 2020) compared to one year into the pandemic period (March 2020-February 2021).

RESULTS

A significant difference in SBHC utilization was found between pre-pandemic and pandemic periods (P <.001). 63.5% of SBHC patients accessed medical services pre-pandemic compared to 51.2% during the pandemic. In contrast, 36.5% of SBHC patients accessed behavioral services pre-pandemic compared to 48.8% during the pandemic, representing a 12.3% increase in SBHC behavioral service utilization since the pandemic.

CONCLUSIONS

SBHCs may serve as an invaluable means of ensuring youth, particularly those from disadvantaged communities, have access to needed behavioral health services during the current public health crisis.

Assessing the Strategies That Children's Hospitals Adopt to Engage the Social Determinants of Health in US Cities

CONTEXT

There is growing evidence that social factors contribute disproportionately to health outcomes in the United States as compared with health care services. As a result, nonprofit hospitals are incorporating strategies to address social needs into their Internal Revenue Service (IRS)-mandated community benefit work. Much of the research base on this subject, however, has focused on the efforts of adult-serving hospitals.

OBJECTIVE

The aim of this study was to determine whether communities surrounding children's hospitals are unique with regard to social needs and categorize how children's hospitals are addressing social needs in their IRS-mandated community benefit work.

METHODS

Using county-level health and economic data, we compared community characteristics of children's hospital counties with the national average. We then coded and analyzed the community benefit reports of all nonprofit children's hospitals in the United States to categorize the different strategies that hospitals adopt to address social needs.

RESULTS

Children's hospitals (N = 168) serve communities with greater social needs than the national average. In terms of community benefit investments, children's hospitals were more likely to identify social needs in their community health needs assessment than adult-serving hospitals, but still less than half identified or addressed 1 or more social needs. Children's hospitals were more likely to adopt interventions that address broader population health rather than strategies that focus on clinical services or children and adolescents in particular.

CONCLUSIONS

Pediatric health care institutions have a profound opportunity to reduce health disparities by altering the social environments in which children develop. Policy makers and scholars should provide support and resources to increase community benefit investments in this area.

Police Exposures and the Health and Well-being of Black Youth in the US: A Systematic Review

IMPORTANCE

Black youth in the US experience disproportionate contact with police even when accounting for criminal or delinquent behavior, which some experts say is fueled by racism and discrimination. While the literature supports the link between racism and adverse health outcomes, less is known about the impact of policing on the well-being of Black youth.

OBJECTIVE

To systematically review the literature describing the association between police exposure and health outcomes for Black youth 26 years and younger.

EVIDENCE REVIEW

A search of PubMed, Embase, Criminal Justice Abstracts, PsycInfo, and Web of Science was conducted. Eligible studies included original peer-reviewed research published from 1980 to December 2020, with a participant population of Black youth, a focus on police exposure, and health as the outcome. Additional articles were identified by hand-searching reference lists of included studies. Data extraction was performed, followed by critical appraisal of all included studies using a convergent segregated approach in which quantitative and qualitative studies were synthesized separately followed by an overarching synthesis across methods.

FINDINGS

A total of 16 quantitative studies including 19 493 participants were included in the review and demonstrated an association between police exposure and adverse mental health, sexual risk behaviors, and substance use. A total of 13 qualitative studies including 461 participants were included in the review, which corroborated and contextualized the quantitative evidence and provided additional health outcomes, such as fear for life or hopelessness.

CONCLUSIONS AND RELEVANCE

Evidence shows that police exposures are associated with adverse health outcomes for Black youth. Clinicians, scientists, public health practitioners, and policy makers can partner with local governments to enact reforms that mitigate the health impact of policing on youth.

Association Between Language Use and ICU Transfer and Serious Adverse Events in Hospitalized Pediatric Patients Who Experience Rapid Response Activation

BACKGROUND

Hospitalized patients and caregivers who use a language other than English have worse health outcomes, including longer length of stay, more frequent readmissions, and increased rates of in-hospital adverse events. Children who experience clinical deterioration (as measured by a Rapid Response Team event) during a hospitalization are at increased risk for adverse events and mortality.

METHODS

We describe the results of a retrospective cohort study using hospital records at a free-standing, quaternary children's hospital, to examine the association of language of care with outcomes (transfer to intensive care, adverse event, mortality prior to discharge) following Rapid Response Team event, and whether increased interpreter use among patients who use a language other than English is associated with improved outcomes following Rapid Response Team event.

RESULTS

In adjusted models, Rapid Response Team events for patients who use a language other than English were associated with higher transfer rates to intensive care (RR 1.1, 95% CI 1.01, 1.21), but not with adverse event or mortality. Among patients who use a language other than English, use of 1-2 interpreted sessions per day was associated with lower transfer rates to intensive care compared to use of less than one interpreted session per day (RR 0.79, 95% 0.66, 0.95).

CONCLUSION

Rapid Response Team events for hospitalized children of families who use a language other than English are more often followed by transfer to intensive care, compared with Rapid Response Team events for children of families who use English. Improved communication with increased interpreter use for hospitalized children who use a language other than English may lead to improvements in Rapid Response Team outcomes.

Antiracism in the Field of Neonatology: A Foundation and Concrete Approaches

Neonatal patients and families from historically marginalized and discriminated communities have long been documented to have differential access to health care, disparate health care, and as a result, inequitable health outcomes. Fundamental to these processes is an understanding of what race and ethnicity represent for patients and how different levels of racism act as social determinants of health. The NICU presents a unique opportunity to intervene with regard to the detrimental ways in which structural, institutional, interpersonal, and internalized racism affect the health of newborn infants. The aim of this article is to provide neonatal clinicians with a foundational understanding of race, racism, and antiracism within medicine, as well as concrete ways in which health care professionals in the field of neonatology can contribute to antiracism and health equity in their professional careers.

Future Directions for Vaccinating Children against the American Endemic: Treating Racism as a Virus

For Black American youth and their families, the racial terror that claimed the life of George Floyd in May 2020 is nothing new, as stories of people who look just like them have been part and parcel of their lived experience in the United States. Beyond state-sanctioned murder, Black youth were also witnessing the disproportionate transmission, treatment, and travesty plaguing their community with COVID-19 - all predictable outcomes given the inequitable systems supporting the American pipeline from cradle to grave. Why, then, were so many White Americans just coming into awareness of this deadly disease of individual and systemic racism that has ravaged Black American communities for centuries? In this work, we seek to explain in what ways racism is tantamount to a social virus and how its permeation is endemic to the American body, rather than an emerging threat, like a pandemic. We will also address how better conceptualizing racism as a virus allows for more accurate, precise, and feasible treatments for transmitters and targets of racism with respect to prevention (e.g., inoculation) and intervention (e.g., healing and vaccination). Finally, we will describe clinical therapeutic trials that will help to decipher whether our treatment of this social disease is effective, including family-level interventions and systemic shifts in prevention through clinical training.

Longitudinal Effects of Racial Discrimination on Depressive Symptoms Among Black Youth: Between- and Within-Person Effects

OBJECTIVE

Black youth experience racial discrimination at high rates. This study sought to further understand the longitudinal effects of racial discrimination on the mental health of Black youth by examining cross-lagged associations between perceived racial discrimination and depressive symptoms at the between-person (interindividual) level and the within-person (intraindividual) level.

METHOD

A group of 346 Black youths (mean age 10.9 years) from the rural southern United States reported racial discrimination and depressive symptoms 4 times over 24.5 months. A cross-lagged panel model was used to examine between-person concurrent and lagged effects, and a random intercept cross-lagged panel model was used to examine within-person concurrent and lagged effects.

RESULTS

There were significant concurrent associations at all waves in both models. Additionally, there were significant lagged effects from perceived racial discrimination to depressive symptoms, but not from depressive symptoms to perceived racial discrimination, in both models.

CONCLUSION

Youth experiencing higher levels of racial discrimination subsequently develop more depressive symptoms than youth experiencing less discrimination (between-person effects), and youth experiencing higher levels of discrimination relative to their own average subsequently report increases in depressive symptoms (within-person effects). These findings provide a rigorous test of conceptual models outlining the harmful effects of racial discrimination on mental health, add to a growing body of work documenting these effects on Black youth, and underscore the need for systemic changes to reduce the amount of discrimination Black youth experience and for interventions to promote resilience among Black youth in the face of cultural marginalization.

Association between pediatric TBI mortality and median family income in the United States: A retrospective cohort study

BACKGROUND

There are regional disparities in pediatric traumatic brain injury (TBI) mortality across the United States, but the factors underlying these differences are unclear.

METHODS

We performed a retrospective cross-sectional analysis of the Pediatric Health Information System database including inpatient hospital encounters for children less than 18 years old with a primary diagnosis of TBI between 2010-2019.

FINDINGS

Lower median family income was associated with pediatric TBI mortality. Encounters from zip-codes with a median family income of <$20,000 had a 3.1% (29/950) mortality, as opposed to 1.3% (29/2,267) mortality for zip-codes with a median family income of >$80,000 (p = 0.00096). In multivariable logistic regression, every $10,000 of income was associated with an odds ratio of mortality of 0.94 (95% confidence interval 0.90 - 0.98). 82.5% (397/481) of ballistic TBI injuries were caused by a firearm. Lower income was associated with a higher proportion of ballistic TBI injuries (2.5% [24/950] for <$20,000 versus 0.3% [7/2,267] for >$80,000, p < 0.0001). In multivariable logistic regression, ballistic TBI injuries were associated with an odds ratio of mortality of 5.19 (95% confidence interval 4.00 - 6.73). United States regional variation in pediatric TBI mortality was linearly associated with the percentage of ballistic TBI (adjusted r-squared 0.59, p = 0.0097).

INTERPRETATION

Children from lower income zip-codes are more likely to sustain a ballistic TBI, and more likely to die. Further work is necessary to determine causal factors underlying these associations and to design interventions that prevent these injuries and/or improve outcomes.

Creating a health equity and inclusion office in an academic pediatric medical center: priorities addressed and lessons learned

BACKGROUND

Over the last two decades, medical schools and academic health centers have acknowledged the persistence of health disparities in their patients and the lack of diversity in their faculty, leaders and extended workforce. We established an Office of Health Equity and Inclusion (OHEI) at our pediatric academic medical center after a thorough evaluation of prior diversity initiatives and review of faculty development data.

OBJECTIVE

To describe the lessons learned at a pediatric academic medical center in prioritizing and implementing health equity, diversity and inclusion (EDI) initiatives in creating the OHEI.

MATERIALS AND METHODS

We reviewed internal administrative data and faculty development data, including data related to faculty who are underrepresented in medicine, to understand the role of our EDI initiatives in the strategic priorities addressed and lessons learned in the creation of the OHEI.

RESULTS

The intentional steps taken in our medical center's strategic approach in the creation of this office led to four important lessons to improve pediatric health equity: (1) board, senior executive and institutional prioritization of EDI initiatives; (2) multi-specialty and interprofessional collaboration; (3) academic approach to EDI programmatic development; and (4) intentionality with accountability in all EDI initiatives.

CONCLUSION

The key lessons learned during the creation of an Office of Health Equity and Inclusion can provide guidance to other academic health centers committed to implementing institutional priorities that focus their EDI initiatives on the improvement of pediatric health equity.

An Initiative to Increase Residency Program Diversity

A physician workforce that reflects the patient population is associated with improved patient outcomes and promotes health equity. Notwithstanding, racial and ethnic disparities persist within US medical schools, making some individuals underrepresented in medicine (URM). We sought to increase the percentage of URM residents who matched into our pediatric residency programs from a baseline of 5% to 35% to achieve demographic parity with our patients. We developed a multifaceted approach using multiple iterative tests of change, with the primary strategy being increased visibility of URM trainees and faculty to residency applicants. Strategies included applicant interviews with URM faculty, interview dinners with URM residents, visibility at academic conferences for URM trainees, development of targeted marketing materials, and a visiting student program supported by networking with URM residents. The primary outcome measure was the percentage of matched residents in the categorical pediatrics, child neurology, and medical genetics training programs who identified as URM. The percentage of URM residents increased to 16% (6 of 37) in 2018, 26% (11 of 43) in 2019, 19% (8 of 43) in 2020, and 21% (9 of 43) in 2021 (a four-year average of 22% URM residents; P = .0002). This progress toward a more representative residency program was met by challenges, such as pipeline concerns, the minority tax, and recruitment during a pandemic. We were able to implement small, low-resource strategies that had a large cumulative impact and could be implemented in other residency programs. Specific tactics and challenges encountered are discussed in this special article.

Pediatric Discharge From the Emergency Department Against Medical Advice

In this Ethics Rounds we present a conflict regarding discharge planning for a febrile infant in the emergency department. The physician believes discharge would be unsafe and would constitute a discharge against medical advice. The child's mother believes her son has been through an already extensive and painful evaluation and would prefer to monitor her well-appearing son closely at home with a safety plan and a next-day outpatient visit. Commentators assess this case from the perspective of best interest, harm-benefit, conflict management, and nondiscriminatory care principles and prioritize a high-quality informed consent process. They characterize the formalization of discharge against medical advice as problematic. Pediatricians, a pediatric resident, ethicists, an attorney, and mediator provide a range of perspectives to inform ethically justifiable options and conflict resolution practices.

Predictors of Depressive Symptoms in Caregivers of Children With Poorly Controlled Asthma: Is the Neighborhood Context Important?

Children residing in low-income neighborhoods are disproportionately affected by asthma morbidity and mortality. Neighborhood violence has been explored in relationship to child morbidity and health and developmental outcomes, but less is known about the relationship of violence to caregiver mental health. The purpose of this study was to examine the relationship of neighborhood violent crime victimization (objective and subjective measures), perceptions of community well-being and support, and depressive symptoms among a sample of primarily single female caregivers of children with uncontrolled asthma. This is a secondary analysis of baseline data obtained from a randomized controlled trial of a home-based environmental control intervention for children aged 3 to 12 years, who were primarily African American, and diagnosed with persistent, uncontrolled asthma. Results showed that both objective and subjective measures of crime, particularly in those with relatively low life stress (P < .001), limited education of the caregiver (P < .001), and fewer children (P < .01) in the household had direct associations with depressive symptoms in caregivers of children with uncontrolled asthma. Neighborhood perceptions of satisfaction and a sense of community, as well as perceptions of social support, were not associated with depressive symptoms. Our findings emphasize the need to screen for depressive symptoms, life stress, as well as both objective and subjective perceptions of neighborhood violence among caregivers of children with poorly controlled asthma. Furthermore, when providing holistic care to these caregivers, stress reduction and the provision of mental health resources are paramount.

Increased behavioral health needs and continued psychosocial stress among children with medical complexity and their families during the COVID-19 pandemic

Objective

Children with medical complexity (CMC) and their caregivers are at increased risk for multiple psychosocial stressors that can impact child and family well‐being and health outcomes. During the COVID‐19 pandemic, when access to supports diminished, psychosocial screening and integrated behavioral health (IBH) services in the primary care setting were crucial in identifying and addressing the unique needs of this population

Methods

Universal screening to identify psychosocial needs was implemented in a primary care clinic for CMC that includes IBH services. Data on the prevalence of psychosocial screening and IBH services for young children and their caregivers before and during the COVID‐19 pandemic were evaluated

Results

Psychosocial screening levels remained stable during the pandemic. Psychosocial needs were identified for 36% of screeners prior to the COVID‐19 pandemic and 33% during the COVID‐19 pandemic. The need for IBH services increased during the COVID‐19 time period resulting in a significant increase in IBH services

Conclusions

For CMC and their caregivers, psychosocial needs identified through psychosocial screening remained high during the pandemic, demonstrating the importance of screening for this population. The need for IBH services during the COVID‐19 pandemic increased, underscoring the value and demand for these services particularly during an unprecedented time.

Perceived Racial/Ethnic Discrimination, Physical and Mental Health Conditions in Childhood, and the Relative Role of Other Adverse Experiences

Adverse childhood experiences (ACEs) are associated with poor health. Childhood experiences of racial/ethnic discrimination and other forms of racism may underlie or exacerbate other ACEs. We explored health-related associations with perceived racial/ethnic discrimination relative to other ACEs, using data from 2016-2019 National Survey of Children's Health, an annual cross-sectional, nationally representative survey. Parent responses for 88,183 children ages 6-17 years with complete data for ACEs (including racial/ethnic discrimination) were analyzed for associations between racial/ethnic discrimination, other ACEs, demographics, and physical and mental health conditions with weighted prevalence estimates and Wald chi-square tests. To assess associations between racial/ethnic discrimination and health conditions relative to other ACEs, we used weighted Poisson regressions, adjusted for exposure to other ACEs, age, and sex. We assessed effect modification by race/ethnicity. Prevalence of other ACEs was highest among children with racial/ethnic discrimination, and both racial/ethnic discrimination and other ACEs were associated with having one or more health conditions. Adjusted associations between racial/ethnic discrimination and health conditions differed by race/ethnicity (interaction P-values < 0.001) and were strongest for mental health conditions among Hispanic/Latino (adjusted prevalence ratio (aPR)=1.62, 95% confidence interval (CI): 1.24-2.10) and non-Hispanic/Latino Asian American (aPR=2.25, 95% CI: 1.37-3.71) children. Results suggest racial/ethnic discrimination and other ACEs are associated with child health conditions, with differences in relative associations by race/ethnicity. Public health efforts to prevent childhood adversity, including racial/ethnic discrimination and other forms of racism could be associated with improvements in child health.

What is diversity?

This article introduces the topic of diversity in this minisymposium by defining the terminology as well as providing descriptions of the positive impact of diversity. We aimed not only to examine the proven effects of diversity, but also to understand the barriers present so we can effectively mitigate these at the individual, institutional and systemic levels.

Social and Relational Health Risks and Common Mental Health Problems Among US Children: The Mitigating Role of Family Resilience and Connection to Promote Positive Socioemotional and School-Related Outcomes

Nearly 70% (67.6%) of US children with mental, emotional, and behavioral problems (MEB) experienced significant social health risks (SHR) and/or relational health risks (RHR). Shifts are needed in child mental health promotion, prevention, diagnosis, and treatment to address both RHR and SHR. Public health approaches are needed that engage families, youth, and the range of child-serving professionals in collaborative efforts to prevent and mitigate RHR and SHR and promote positive mental health at a community level. Building strong family resilience and connection may improve SR and, in turn, academic and social outcomes among all US children with or without MEB.

“Why Don’t They Just Move Closer?”: Adolescent Critical Consciousness Development in YPAR About Food Security

The aim of this paper is to explore high school students’ critical consciousness development in the context of youth participatory action research (YPAR) focused on food security at an alternative school in Alabama. The YPAR project took place in an elective agriscience class with 10 students (Seven Black, two white, one Latino) who were in the 10th to 12th grades. Utilizing data from researcher notes, classroom observations, and archival classroom documents, we present students’ YPAR project outcomes to share their research-driven solutions to food insecurity in their community. Vignettes of classroom dialogue are also constructed to illustrate moments of reflection in the YPAR context about food security. We present three “critical moments,” or instances of social analysis, to illustrate how students’ individual-level attributions occurred alongside teacher dialogue and student-led investigation of structural inequities in the community. Findings illustrate how students’ nonlinear critical consciousness development consisted of reliance on individual-level attributions in classroom dialogue co-occurring with systems-thinking activities and other YPAR project outcomes. This paper has implications for research on the imperfect and wavering nature of adolescent critical consciousness development in YPAR.

Addressing Racism in Preventive Services: Methods Report to Support the US Preventive Services Task Force

IMPORTANCE

In January 2021, the US Preventive Services Task Force (USPSTF) issued a values statement that acknowledged systemic racism and included a commitment to address racism and health equity in recommendations for clinical preventive services.

OBJECTIVES

To articulate the definitional and conceptual issues around racism and health inequity and to describe how racism and health inequities are currently addressed in preventive health.

METHODS

An audit was conducted assessing (1) published literature on frameworks or policy and position statements addressing racism, (2) a subset of cancer and cardiovascular topics in USPSTF reports, (3) recent systematic reviews on interventions to reduce health inequities in preventive health or to prevent racism in health care, and (4) health care-relevant professional societies, guideline-making organizations, agencies, and funding bodies to gather information about how they are addressing racism and health equity.

FINDINGS

Race as a social category does not have biological underpinnings but has biological consequences through racism. Racism is complex and pervasive, operates at multiple interrelated levels, and exerts negative effects on other social determinants and health and well-being through multiple pathways. In its reports, the USPSTF has addressed racial and ethnic disparities, but not racism explicitly. The systematic reviews to support the USPSTF include interventions that may mitigate health disparities through cultural tailoring of behavioral interventions, but reviews have not explicitly addressed other commonly studied interventions to increase the uptake of preventive services or foster the implementation of preventive services. Many organizations have issued recent statements and commitments around racism in health care, but few have provided substantive guidance on operational steps to address the effects of racism. Where guidance is unavailable regarding the proposed actions, it is principally because work to achieve them is in very early stages. The most directly relevant and immediately useful guidance identified is that from the GRADE working group.

CONCLUSIONS AND RELEVANCE

This methods report provides a summary of issues around racism and health inequity, including the status of how these are being addressed in preventive health.

Assessing Racial and Ethnic Discrimination in Children: A Scoping Review of Available Measures for Child Health Disparities Research

Objectives: To characterize the availability, content, and psychometric properties of self-reported measures that assess race/ethnicity-related discrimination or psychosocial stress and have potential relevance to studies of health disparities in children and adolescents.

Design: Using PRISMA extension guidelines for scoping reviews, we searched Ovid Medline, CINAHL, PsychInfo, and Scopus databases from 1946 to April 20, 2020, using the search terms “stress,” “child,” “adolescents,” “discrimination,” and “psychometrics.” We limited the search to articles in English, with children and adolescents, in the United States. For each measure, we extracted information about the content, reliability, and construct validity.

Results: The 12 measures that met inclusion criteria assessed discrimination or stress from racial discrimination in African American children and adolescents (n=8), acculturative stress in Hispanic/Latino children (n=1), or bicultural stress in Mexican American adolescents (n=2), and one measure assessed both discrimination-related and acculturative stress in Hispanic/Latino children. The majority (n=7) articles were published between 2001 and 2010. All discrimination measures evaluated individual experiences of discrimination and one also evaluated stressfulness of discrimination and coping. The acculturative stress measures assessed general stress and immigration-related discrimination, and the bicultural stress measures evaluated many different aspects of biculturalism.

Conclusions: Despite the recent increased interest in the racial discrimination and stress as a contributor to racial or ethnic health disparities affecting U.S. children and adolescents, the small number of eligible measures identified and incomplete coverage of various types of racial and ethnic discrimination within and across population groups indicates a currently inadequate capacity to conduct child health disparity studies on this issue.

Evaluation of a city-wide school-located influenza vaccination program in Oakland, California with respect to race and ethnicity: A matched cohort study

Background:

Increasing influenza vaccination coverage in school-aged children may substantially reduce community transmission. School-located influenza vaccinations (SLIV) aim to promote vaccinations by increasing accessibility, which may be especially beneficial to race/ethnicity groups that face high barriers to preventative care. Here, we evaluate the effectiveness of a city-wide SLIV program by race/ethnicity from 2014 to 2018.

Methods:

We used multivariate matching to pair schools in the intervention district in Oakland, CA with schools in a comparison district in West Contra Costa County, CA. We distributed cross-sectional surveys to measure caregiver-reported student vaccination status and estimated differences in vaccination coverage levels and reasons for non-vaccination between districts stratifying by race/ethnicity. We estimated difference-in-differences (DID) of laboratory confirmed influenza hospitalization incidence between districts stratified by race/ethnicity using surveillance data.

Results:

Differences in influenza vaccination coverage in the intervention vs. comparison district were larger among White (2017–18: 21.0% difference [95% CI: 9.7%, 32.3%]) and Hispanic/Latino (13.4% [8.8%, 18.0%]) students than Asian/Pacific Islander (API) (8.9% [1.3%, 16.5%]), Black (5.9% [−2.2%, 14.0%]), and multiracial (6.3% [−1.8%, 14.3%)) students. Concerns about vaccine effectiveness or safety were more common among Black and multiracial caregivers. Logistical barriers were less common in the intervention vs. comparison district, with the largest difference among White students. In both districts, hospitalizations in 2017–18 were higher in Blacks (Intervention: 111.5 hospitalizations per 100,00; Comparison: 134.1 per 100,000) vs. other races/ethnicities. All-age influenza hospitalization incidence was lower in the intervention site vs. comparison site among White/API individuals in 2016–17 (DID −25.14 per 100,000 [95% CI: −40.14, −10.14]) and 2017–18 (−36.6 per 100,000 [−52.7, −20.5]) and Black older adults in 2017–18 (−282.2 per 100,000 (−508.4, −56.1]), but not in other groups.

Conclusions:

SLIV was associated with higher vaccination coverage and lower influenza hospitalization, but associations varied by race/ethnicity. SLIV alone may be insufficient to ensure equitable influenza outcomes.

Outcomes From a Novel Graduate Medical Education Leadership Program in Advancing Diversity, Equity, and Inclusion

BACKGROUND

Academic medicine needs more diverse leadership from racial/ethnic minorities, women, people with disabilities, and LGBTQIA+ physicians. Longitudinal structural support programs that bring together underrepresented in medicine (UiM) and non-UiM trainees are one approach to build leadership and scholarship capacity in diversity, equity, and inclusion (DEI).

OBJECTIVE

To describe the creation, satisfaction with, and feasibility of a Leadership Education in Advancing Diversity (LEAD) Program and evaluate scholars' changes in self-efficacy, intended and actual behavior change, and outputs in leadership and DEI scholarship.

METHODS

In 2017, we created the LEAD Program, a 10-month longitudinal, single institution program that provides residents and fellows ("scholars") across graduate medical education (GME) with leadership training and mentorship in creating DEI-focused scholarship. In the first 3 cohorts (2017-2020), we assessed scholars' self-efficacy, actual and planned behavior change, and program satisfaction using IRB-approved, de-identified retrospective pre-/post-surveys. We measured scholarship as the number of workshops presented and publications developed by the LEAD scholars. We used descriptive statistics and paired 2-tailed t tests to analyze the data.

RESULTS

Seventy-five trainees completed LEAD; 99% (74 of 75) completed the retrospective pre-/post-surveys. There was statistically significant improvement in scholars' self-efficacy for all learning objectives. All trainees thought LEAD should continue. LEAD scholars have created workshops and presented at local, regional, and national conferences, as well published their findings. Scholars identified the greatest benefits as mentorship, developing friendships with UiM and ally peers outside of their subspecialty, and confidence in public speaking.

CONCLUSIONS

LEAD is an innovative, feasible GME-wide model to improve resident and fellow self-efficacy and behaviors in DEI scholarship and leadership.

The Role of Parents in Reducing Academic, Health, and Behavioral Problems for Native American, African American, and Latinx Adolescents

OBJECTIVE

The aim of the study was to determine how parental modeling of thoughtful behavior and the home physical environment may reduce the number of developmental problems exhibited by Native American, African American, and Latinx adolescents.

METHOD

Demographic and home environmental data were collected from 54 Native American, 131 African American, and 159 Latinx families living in 4 states as part of a home visit. Parents and adolescents were administered surveys that captured adolescent health, social skills, problem behavior, self-efficacy beliefs, vocabulary attainment, and school grades. Scores from the surveys were combined to construct both an adolescent problems index and a household risk index. For each of the 3 racial/ethnic groups examined, the adolescent problems index was regressed on parental modeling and encouragement of mature behavior, the home physical environment, and the household risk index.

RESULTS

Modeling and encouragement of mature behavior was a significant bivariate predictor of overall problems in all 3 groups of adolescents-albeit the overall regression model was nonsignificant for Native Americans. By contrast, the other 2 predictors were nonsignificant in regression models for all 3 groups.

CONCLUSION

Native American, African American, and Latinx adolescents often face a multitude of risks, including poverty and discrimination. As a consequence, adolescents from these 3 racial/ethnic groups frequently display problems pertaining to health, competence, and adaptive behavior. The results from this study suggest that adolescents from such demographic groups are less likely to manifest developmental problems if their parents model mature behavior and encourage the adolescent to act in thoughtful ways.

The Substance and Circumstances of Race and Immigration Talk in High School Gender and Sexuality Alliances

Gender & Sexuality Alliances (GSAs) are school-based clubs that support youth of diverse sexual orientations and gender identities. As identity-centered spaces, GSAs could also foster discussions related to race and immigration (i.e., race and immigration talk). We conducted semi-structured interviews from 2016 to 2018 with 38 GSA members (ages 13-20 years old) of diverse racial/ethnic, immigrant-origin (first and second generations in the United States born of immigrant parents), sexual orientation, and gender identities. Race and immigration talk often occurred when discussing current events (e.g., the 2016 US Presidential Election). Students reported that race and immigration talk depended on representation (i.e., GSA demographics), if it was deemed personally relevant to members, and whether students perceived issues of race and immigration as part of the agenda of the GSA. Some students indicated motivation to discuss racism and nativism yet refrained from doing so due to discomfort or fear of misspeaking. Overall, youth primarily viewed the GSA as a space for LGBTQIA+-oriented discussions and support yet expressed potential for fostering productive race and immigration talk in GSAs given the ongoing US sociopolitical climate. Discussions facilitated by advisors focusing on inter-connected oppression (e.g., intersections of racism and heterosexism) and that leverage brave space discussion dynamics may help students develop competencies to engage in race and immigration talk.

Association of Neighborhood Gun Violence With Mental Health-Related Pediatric Emergency Department Utilization

IMPORTANCE

Many children and adolescents in the United States are exposed to neighborhood gun violence. Associations between violence exposure and children's short-term mental health are not well understood.

OBJECTIVE

To examine the association between neighborhood gun violence and subsequent mental health-related pediatric emergency department (ED) utilization.

DESIGN, SETTING, AND PARTICIPANTS

This location-based cross-sectional study included 128 683 ED encounters for children aged 0 to 19 years living in 12 zip codes in Philadelphia, Pennsylvania, who presented to an urban academic pediatric ED from January 1, 2014, to December 31, 2018. Children were included if they (1) had 1 or more ED visits in the 60 days before or after a neighborhood shooting and (2) lived within a quarter-mile radius of the location where this shooting occurred. Analysis began August 2020 and ended May 2021.

EXPOSURE

Neighborhood violence exposure, as measured by whether a patient resided near 1 or more episodes of police-reported gun violence.

MAIN OUTCOMES AND MEASURES

ED encounters for a mental health-related chief complaint or primary diagnosis.

RESULTS

A total of 2629 people were shot in the study area between 2014 and 2018, and 54 341 children living nearby had 1 or more ED visits within 60 days of a shooting. The majority of these children were Black (45 946 [84.5%]) and were insured by Medicaid (42 480 [78.1%]). After adjusting for age, sex, race and ethnicity, median household income by zip code, and insurance, children residing within one-eighth of a mile (2-3 blocks) of a shooting had greater odds of mental health-related ED presentations in the subsequent 14 days (adjusted odds ratio, 1.86 [95% CI, 1.20-2.88]), 30 days (adjusted odds ratio, 1.49 [95% CI, 1.11-2.03]), and 60 days (adjusted odds ratio, 1.35 [95% CI, 1.06-1.72]).

CONCLUSIONS AND RELEVANCE

Exposure to neighborhood gun violence is associated with an increase in children's acute mental health symptoms. City health departments and pediatric health care systems should work together to provide community-based support for children and families exposed to violence and trauma-informed care for the subset of these children who subsequently present to the ED. Policies aimed at reducing children's exposure to neighborhood gun violence and mitigating the mental symptoms associated with gun violence exposure must be a public health priority.

The Role of Resilience in Ethnic Minority Adolescent Navigation of Ecological Adversity

Adverse childhood experiences and health disparities profoundly affect the health of ethnic minority adolescents and influence their overall well-being. In light of current health disparities and civil unrest, this secondary analysis sought to better understand resilience among ethnic minority adolescents living in rural eastern North Carolina (NC). Using Ungar's (2013) Theory of Resilience and Seven Tensions, the two tensions that depicted the most adversity for these adolescents were social justice and power and control. Racism and discrimination were identified as prevalent risk factors. Four tensions in the model, cultural adherence, identity, cohesion, and access to material resources, were linked to protective factors and represented ethnocultural pride. Findings suggest that rural-dwelling African American and Latinx adolescents share concerns related to racial adversity but navigate their ecological experiences in unique ways.

The Roles of Settings in Supporting Immigrants' Resistance to Injustice and Oppression: A Policy Position Statement by the Society for Community Research and Action: A Policy Statement by the Society for Community Research and Action: Division 27 of the American Psychological Association

In 2018, in response to increasingly oppressive and widespread federal immigration enforcement actions in the United States (U.S.) and around the globe - including family separation, immigration raids, detention, deportation of people who have lived in the country for much of their lives - the Society for Community Research & Action produced a statement on the effects of deportation and forced separation on immigrants, their families, and communities (SCRA, 2018). The statement focused exclusively on the impacts of deportation and forced family separation, documenting the damage done by oppressive U.S. policies and practices. We felt it was imperative to document this harm, and yet were uncomfortable producing a narrow paper that focused solely on harm. There are multiple ways immigrants and their allies resist deportation and other forms of oppression. This resistance is done individually, collectively, and in settings that vary in size and scope, including community-based, faith-based, direct care, and educational settings, as well as entire municipalities and transnational organizing settings. Settings facilitate resistance in many ways, focusing on those who are oppressed, their oppressors, and systems of oppression. In this statement, we describe the unique and overlapping ways in which settings facilitate resistance. We situate this review of the scientific and practice literature in the frameworks of change through social settings, empowering settings, healing justice, and decolonization. We also document recommendations for continued resistance.

A new era: improving use of sociodemographic constructs in the analysis of pediatric cohort study data

Given the diversity of sex, gender identity, race, ethnicity, and socioeconomic position (SEP) in children across the United States, it is incumbent upon pediatric and epidemiologic researchers to conduct their work in ways that promote inclusivity, understanding and reduction in inequities. Current child health research often utilizes an approach of "convenience" in how data related to these constructs are collected, categorized, and included in models; the field needs to be more systematic and thoughtful in its approach to understand how sociodemographics affect child health. We offer suggestions for improving the discourse around sex, gender identity, race, ethnicity, and SEP in child health research. We explain how analytic models should be driven by a conceptual framework grounding the choices of variables that are included in analyses, without the automatic "adjusting for" all sociodemographic constructs. We propose to leverage newly available data from large multi-cohort consortia as unique opportunities to improve the current standards for analyzing and reporting core sociodemographic constructs. Improving the characterization and interpretation of child health studies with regards to core sociodemographic constructs is critical for optimizing child health and reducing inequities in the health and well-being of all children across the United States. IMPACT: Current child health research often utilizes an approach of "convenience" in how data related to sex, race/ethnicity, and SEP are collected, categorized, and included in models. We offer suggestions for how scholars can improve the discourse around sex, gender identity, race, ethnicity, and SEP in child health research. We explain how analytic models should be driven by a conceptual framework grounding the choices of variables that are included in analyses. We propose to leverage newly available large cohort consortia of child health studies as opportunities to improve the current standards for analyzing and reporting core sociodemographic constructs.

Racial and Ethnic Disparities in Physical Restraint Use for Pediatric Patients in the Emergency Department

This cross-sectional study explores the use of physical restraint on youth at risk of harming themselves or others in the emergency department, stratified by race and ethnicity.

Microaggressions: Privileged Observers' Duty to Act and What They Can Do

Racism and sexism that manifest as microaggressions are commonly experienced by members of minoritized groups. These actions and comments erode their subjects' vitality and sense of belonging. Individuals from minoritized groups are often left in a quandary, weighing the potential benefits and risks of addressing the comments. Placing the burden to interrupt bias on our marginalized colleagues is unjust. In part, it is inappropriate to expect them to dismantle a system that they did not create. It is essential for individuals with privilege who observe microaggressions to address the speaker and support their colleagues. In this Ethics Rounds, we present 2 cases in which individuals from minoritized groups experience racism and sexism that manifest as microaggressions. The first case involves a Black female physician making recommendations in a business meeting being characterized by a male colleague as emotional. The commentators analyze how both gender and race constrain the range of acceptable emotions one may exhibit and the harm that this causes. The second case involves a Black intern being identified by a parent as a custodian. Commentators describe how such microaggressions can harm trainees' performance and sense of belonging. In both cases, observers did nothing or only spoke to the subject in private. Commentators provide specific guidance regarding actions that bystanders can take to become upstanders and how they can decenter themselves and their discomfort and leverage their privilege to interrupt microaggressions. By becoming upstanders, individuals can remove the disproportionate responsibility for addressing microaggressions from marginalized colleagues.

Feasibility of implementing systematic social needs assessment for children with medical complexity

BACKGROUND

Children with medical complexity (CMC) have inter-related health and social needs; however, interventions to identify and respond to social needs have not been adapted for CMC. The objective of this study was to evaluate the feasibility of implementing social needs screening and assessment within pediatric complex care programs.

METHODS

We implemented systematic social needs assessment for CMC (SSNAC) at two tertiary care centers in three phases: (1) pre-implementation, (2) implementation, and (3) implementation monitoring. We utilized a multifaceted implementation package consisting of discrete implementation strategies within each phase. In phase 1, we adapted questions from evidence-informed screening tools into a 21-item SSNAC questionnaire, and we used published frameworks to inform implementation readiness and process. In phases 2-3, clinical staff deployed the SSNAC questionnaire to parents of CMC in-person or by phone as part of usual care and adapted to local clinical workflows. Staff used shared decision-making with parents and addressed identified needs by providing information about available resources, offering direct assistance, and making referrals to community agencies. Implementation outcomes included fidelity, feasibility, acceptability, and appropriateness.

RESULTS

Observations from clinical staff characterized fidelity to use of the SSNAC questionnaire, assessment template, and shared decision-making for follow-up on unmet social needs. Levels of agreement (5-point Likert scale; 1 = completely disagree; 5 = completely agree) rated by staff for key implementation outcomes were moderate to high for acceptability (mean = 4.7; range = 3-5), feasibility (mean = 4.2; range = 3-5), and appropriateness (mean = 4.6; range = 4-5). 49 SSNAC questionnaires were completed with a 91% response rate. Among participating parents, 37 (76%) reported ≥ 1 social need, including food/nutrition benefits (41%), housing (18%), and caregiver needs (29%). Staff responses included information provision (41%), direct assistance (30%), and agency referral (30%).

CONCLUSIONS

It was feasible for tertiary care center-based pediatric complex care programs to implement a standardized social needs assessment for CMC to identify and address parent-reported unmet social needs.

Adverse childhood experiences and behavior problems among poor Black children: Nonresident father involvement and single mothers' parenting stress

BACKGROUND

Adverse childhood experiences (ACEs) in early childhood and developmental outcomes during the middle childhood and adolescent years have been understudied among low-income Black families.

OBJECTIVE

To test a model linking economic hardship, single mothers' parenting stress, ACEs, and nonresident fathers' involvement in early childhood to behavior problems in middle childhood and adolescence.

PARTICIPANTS AND SETTING

We used six waves of longitudinal data from a subsample of 800 unmarried Black mothers, nonresident fathers, and their children (at child birth and ages 1, 3, 5, 9, and 15) from the Fragile Families and Child Wellbeing Study, a nationally representative data set.

METHOD

Structural equation models with latent variables that incorporate path analysis and confirmatory factor analysis were tested.

RESULTS

Mothers' economic hardship was associated directly with parenting stress (beta = 0.27, p < .001) and related both directly (beta = 0.22, p < .001) and indirectly (through parenting stress) to the children's increased likelihood of exposure to ACEs (indirect effect = 0.05, p < .001). Nonresident fathers' involvement early on (child's age 1 to 5) was associated directly with reductions in the mothers' economic hardship (beta = -0.18, p < .001), children's reduced exposure to ACEs (beta = -0.15, p < .001), and fewer behavior problems in middle childhood and adolescence (beta = -0.10, p < .001).

CONCLUSION

Nonresident Black fathers' involvement in single-mother families may buffer the adverse consequences over time for economically and socially disadvantaged Black children of exposure to ACEs in early childhood. Interventions that encourage sustained involvement by nonresident Black fathers with young children and their single mothers are recommended.