Racism is a social determinant of health directly associated with negative outcomes in children.1,2 Despite more attention being paid to the concept of racial equity, in which race no longer predicts health outcomes,3 it remains imperative to examine and repair the persistent negative impact of racism on overall child health and well-being. The tripartite model of racism4 illustrates a theoretical framework for understanding racism at 3 levels:
Institutionalized racism exists in covert and insidious ways within larger social institutions (education, housing, and labor markets)5–7 and is closely linked to inequities in safety and prosperity.8
Interpersonal racism occurs directly between individuals, often displayed as intentional or unintentional microaggressions and macroaggressions in casual social situations.
Internalized racism is the internalization of negative stereotypes about the abilities and intrinsic worth of Black or other marginalized individuals. This internal acceptance poses a direct threat to the emotional health, racial self-identity, and self-esteem of Black children.9
Because police brutality and social injustice are persistently inflicted on the Black community,10,11 this manuscript will help health care providers understand how racism is theorized to be internalized, review Segregation-era research on racial identity formation in Black children, and provide a timeline of racial conceptualization and bias formation in children.
How Racism Is Internalized
Persistent economic marginalization and devaluation, combined with societal classifications of superiority and privilege within the White subgroup, can lead to the subconscious normalization of systemic oppression.12–14 Socially observed stereotypes, particularly as represented by news and media outlets, can lead to a negative sense of self-worth or even distancing oneself from one’s own racial group.9 Research shows a positive correlation between racial discrimination and internalized negative beliefs regarding racial inferiority among Black adults in the United States.15,16
Segregation and Self-Racial Identity Formation
In 1954, a landmark research study titled “Racial Identification and Preference in Negro Children”17 became critical evidence in the Supreme Court case Brown v Board of Education. Colloquially called “The Doll Study,” Black children were presented with 1 phenotypically White and 1 phenotypically Black doll. The vast majority showed preference toward White dolls and negative attitudes toward Black dolls. Researchers concluded: “It is clear that the Negro child, by the age of five is aware of the fact that to be colored in contemporary American society is a mark of inferior status. A child accepts as early as six, seven or eight the negative stereotypes about his own group.”15
The Supreme Court voted 9-0 that segregation in schools violated the equal protection clause of the 14th Amendment. The Brown decision cites The Doll Study in its 11th footnote, quoting that, “segregation of White and colored children in public schools has detrimental effect upon the colored children” and this sense of inferiority “affects the motivation of a child to learn.”15
The conclusions of this research study helped end segregation in public schools, based on the children’s overwhelming preference toward the socially privileged White phenotype. This groundbreaking study paved the way for further psychological research into areas of racial self-identity, self-esteem, and self-concept.16
How Children Conceptualize Race and Experience Racism in the Modern Era
Black children are at increasing risk of internalizing negative perceptions as they become old enough to experience and truly understand discrimination. As such, it remains important to recognize how children grow to intellectualize the phenotypic and societal differences between racial groups. Table 1 outlines the development of racial conceptualization and bias formation.
Developmental Framework of Racial Conceptualization and Bias Formation31
| Age . | Research Findings . |
|---|---|
| Birth | Researchers found no statistical difference in how much time newborns spend examining faces of any race, including their own.18 |
| 3 mo | At this age, infants were found to use skin tone and physical features to differentiate between faces of racially discordant groups and demonstrate visual preference for racially concordant faces, assuming they have a racially concordant primary caregiver.18,19 |
| 6 mo | By 6 mo, infants were found to rely on social cues of own-race individuals compared with other-race individuals in times of uncertainty.20 |
| 24 mo | Children at 24 mo of age correctly identified their own race 16% of the time. This improved to 41% of the time at 30 mo and 56% of the time by 36 mo of age.21 |
| 36 mo | At 30 mo of age, the majority of all children studied (near 70%) chose same-race playmates.21 By 36 mo, the majority of Black and White children chose White playmates, showing bias toward the socially privileged group.21 |
| 5 y | Children of all races expect White children to have better possessions (houses, cars, and child’s bedrooms) than Black children, and they predict Black children will have lower status occupations (such as janitor or cashier) when they grew into adults.22–24,26 |
| 6 y | Black children assigned a higher status to jobs that demographically have lower concentrations of Black worker representation (such as doctor, pilot, or scientist). Novel occupations depicted with Black models were judged as lower status than identical occupations depicted with White models.24–26 |
| 11-12 y | Black children from low socioeconomic status backgrounds were statistically less likely to aspire to prestigious occupations than children from higher socioeconomic status backgrounds.24–26 |
| Age . | Research Findings . |
|---|---|
| Birth | Researchers found no statistical difference in how much time newborns spend examining faces of any race, including their own.18 |
| 3 mo | At this age, infants were found to use skin tone and physical features to differentiate between faces of racially discordant groups and demonstrate visual preference for racially concordant faces, assuming they have a racially concordant primary caregiver.18,19 |
| 6 mo | By 6 mo, infants were found to rely on social cues of own-race individuals compared with other-race individuals in times of uncertainty.20 |
| 24 mo | Children at 24 mo of age correctly identified their own race 16% of the time. This improved to 41% of the time at 30 mo and 56% of the time by 36 mo of age.21 |
| 36 mo | At 30 mo of age, the majority of all children studied (near 70%) chose same-race playmates.21 By 36 mo, the majority of Black and White children chose White playmates, showing bias toward the socially privileged group.21 |
| 5 y | Children of all races expect White children to have better possessions (houses, cars, and child’s bedrooms) than Black children, and they predict Black children will have lower status occupations (such as janitor or cashier) when they grew into adults.22–24,26 |
| 6 y | Black children assigned a higher status to jobs that demographically have lower concentrations of Black worker representation (such as doctor, pilot, or scientist). Novel occupations depicted with Black models were judged as lower status than identical occupations depicted with White models.24–26 |
| 11-12 y | Black children from low socioeconomic status backgrounds were statistically less likely to aspire to prestigious occupations than children from higher socioeconomic status backgrounds.24–26 |
Conclusions
The development of a positive racial self-identity has been found to be a protective factor against internalizing racism.27 It is vital to recognize how and when children develop preferences for or against their own race, how they use race as a means to choose playmates, and how Black children perceive their chances of an equitable future. Using the developmental framework of personal racial identity formation and exploration in early childhood, clinicians can remain aware of where a child is in their development of racial understanding and counsel Black parents accordingly.
Pediatric health care providers must be prepared to discuss the effects of exposure to racism, including the category of internalized racism.28 Bright Futures resources are available for discussing racism, bias, and discrimination with patients and families.29 Intentional efforts and anticipatory guidance are needed to prevent Black children from internalizing negative messages. These negative messages limit Black children’s sense of potential and may result in the need to “codeswitch” or adjust aspects of their appearance, behaviors, and speech to optimize the comfort of the dominant social subgroup in exchange for fair treatment.30
More literature is needed to analyze the importance of critical allyship, study outcomes of age-based anticipatory guidance, and identify ways to prevent White children from internalizing the idea that race equity solely benefits the Black community. Future efforts should be made to provide specific attention to these vital concepts.
Table 2 provides a six-point approach to address internalized racism in the Black community. It is imperative to examine one’s own intrinsic biases, recognize the developmental stages of racial awareness and identity formation, and engage with and advocate alongside community partnerships to help address biases and inequities in the health, justice, and educational systems. These strategies will optimize developmental outcomes in Black children and improve their identity formation and perceived self-value.
Overcoming Internalized Racial Oppression29
| 1. Analyze the historical and cultural context of internalized racial oppression |
| 2. Recognize negative messages and work to unteach them |
| 3. Understand how internalized racial superiority spreads among the racially dominant |
| 4. Organize with members of other racially oppressed groups |
| 5. Celebrate the Black community and Black culture |
| 6. Support community organizations and leadership |
| 1. Analyze the historical and cultural context of internalized racial oppression |
| 2. Recognize negative messages and work to unteach them |
| 3. Understand how internalized racial superiority spreads among the racially dominant |
| 4. Organize with members of other racially oppressed groups |
| 5. Celebrate the Black community and Black culture |
| 6. Support community organizations and leadership |
Dr Chavis conceptualized the original topic, drafted the initial manuscript, and critically reviewed and revised the manuscript; Dr Johnson conceptualized the original topic and critically reviewed and revised the manuscript; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.
Comments
Letter to the editor--Updated Race Terminology
Correct medical terminology with the word “race,” currently defines it as a grouping of people with no biologic basis (2,3,4). Unfortunately, past medical literature has employed race to discuss societal ideas of population differences, with sometimes implied inferiority, based on arbitrary appearance variation such as skin pigment, hair texture, and palpebral eye shape. Updated medical race terminology (2,3) currently advocated by the AMA, emphasizes the fact that the idea of a scientific existence of distinct human races is a genetically false and wrong conceptualization. The correct AMA terminology allows for the word race to be only used as a social construct, and it requires capital letters in such groupings or designations. This exception permits meaningful discussions on current inequities, mistreatments, and even murder that take place in our society.
However, social constructs are abstract adult ideas that are poorly understood by young children. Children require straight forward words that are factually accurate. Specifically, children need to understand that there is no White race nor Black race, nor Asian or Oriental race. There is no Native American race, Hispanic race, or Pacific Islander race either. We all are the same human beings and simply have different backgrounds and appearances. We human beings look different depending on where our ancestors came from. Period.
Children do easily comprehend these diversities in appearances, backgrounds, as well as countries of origins. As they get older, they understand ethnicities and cultures, too. Thus, there is Black culture, Hispanic background, Asian ethnicity and Brazilian national origin, as correct examples.
The more accurate narrative then is that people are categorized and mistreated based on their background or ancestry or country of origin. Racism remains, however, an essential term to teach children, as articulated by Dr Chavis and Dr Johnson, because the notion of inferior grouping and treatment of people most definitely persists.
Racism today and through history has caused horrendous atrocities that have resulted in inter-generational inequities. This is essential information that all children need to know, but communication requires change for medical accuracy and because racism may be enhanced with this belief in race (5).
Thus, prevention of children internalizing this false narrative begins with elimination of the race medical myth. Embracing diversity while discouraging discrimination are concepts helpful to children and their self-esteem. Our discussions with children may advance in the future, with the framing of race and racism as an old way of thinking. The words we use are important for children. Clearly, their healthy self-identity and self-esteem depend on it.
James R Baugh MD
International Adoption Specialist and General Pediatrician
1.Chavis A, Johnson D, Internalized Racism and Black Self-Identity Formation. Pediatrics 2023 Aug; 152 (2): 3-5
2. Flanagin A., Frey T., Christianson, MA., et al, Updated guidance on the reporting of race and ethnicity in medical and science journals. JAMA 2021 Aug; 326 (7):621-627
3. AAP Board of Directors and Executive Committee, AAP Perspective: Race-Based Medicine. Pediatrics 2021 Oct; 148(4)
4. Long J., Human genetic diversity and the nonexistence of biological races. Human Biology 2003 Aug;75(4):449-471
5. Fields, K et al, Racecraft: The Soul of Inequality in American Life, New York, New York;Verso Books; 2014