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Nia is a first-grade student with a history of trauma who was brought in by ambulance to the pediatric emergency department for “out of control behavior” at school. This is the first of multiple presentations to the emergency department for psychiatric evaluation, stabilization, and management throughout her elementary and middle school years. Several of the visits resulted in admission to the inpatient pediatric service, where she “boarded” while awaiting transfer to an inpatient psychiatric facility. At times, clinical teams used involuntary emergency medications and physical restraints, as well as hospital security presence at the bedside, to control Nia’s behavior. Nia is Black and her story is a case study of how structural racism manifests for an individual child. Her story highlights the impact of adultification bias and the propensity to mislabel Black youth with diagnoses characterized by fixed patterns of negative behaviors, as opposed to recognizing normative reactions to trauma or other adverse childhood experiences—in Nia’s case, poverty, domestic violence, and Child Protective Services involvement. In telling Nia’s story, we (1) define racism and discuss the interplay of structural, institutional, and interpersonal racism in the health care, education, and judicial systems; (2) highlight the impact of adultification bias on Black youth; (3) delineate racial disparities in behavioral health diagnosis and management, school discipline and exclusion, and health care’s contributions to the school-to-prison pipeline; and finally (4) propose action steps to mitigate the impact of racism on pediatric mental health and health care.

“Do you think she’ll be ready to go home tomorrow?” The team turns toward the father’s 6-year-old daughter. This is her tenth admission for status asthmaticus, and she is now on day 2 of continuous albuterol. “I know the roaches make her asthma worse, but our landlord is useless,” he explains. “I pick up her medications as often as I can, but the inhaler costs $200 since I lost my job and insurance.” The team explains the necessary steps before discharge. Outside the room, after a period of silence, the attending says, “Let’s space her albuterol and get her out of bed today.” Walking to the next room, the attending adds, “We should reach out to social work too.” As pediatric hospitalists, we encounter patients and families like this every day. Although we are confident in our ability to treat a patient’s acute illness and teach trainees evidence-based medical management, too often, we miss opportunities to both model and teach the role of the pediatrician-advocate in the hospital. Pediatrics was the first medical specialty to include “advocacy” in the Accreditation Council of Graduate Medical Education (ACGME) program requirements for residency training. However, the “advocacy” requirement is formally designated as an “ambulatory experience,” significantly limiting its scope and impact.1 Advocacy and advocacy training can, does, and should occur across all pediatric clinical settings and specialties. The inpatient setting, where pediatric residents spend the majority of their time, is particularly well-suited to advocacy training. Intentional advocacy training in the inpatient setting would improve the skills of future pediatrician-advocates while also elevating the quality of inpatient medical care. We propose, therefore, that the ACGME change the language of the advocacy training requirement to either explicitly include “inpatient advocacy” (advocacy on behalf of patients admitted to the hospital and/or in an effort to …