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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.

Describe the demographic and clinical characteristics of children presenting to the emergency department (ED) for agitation and aggression from school versus other sites.We performed a retrospective cross-sectional study of children 5 to 18 years old who were evaluated in an urban tertiary care pediatric ED with a chief complaint of agitation or aggression. We examined demographics, disposition, and payments for children presenting from school versus other sites. We conducted multivariable logistic regression to identify predictors of referral site (school versus all other sites, school versus home) and discharge status (home versus higher level of psychiatric care).Of the 513 included children, 147 (29%) presented from school. Children were more likely to present from school versus other sites if they were Black (adjusted odds ratio [aOR] 2.26, 95% confidence interval [CI] 1.32, 3.88), Latinx (aOR 2.91, 95% CI 1.42, 5.97), or had special educational needs (aOR 2.55, 95% CI 1.64, 3.97). These associations persisted in the analysis of school versus home referrals. Children presenting from school versus all other sites were more likely to be discharged home (aOR 1.60, 95% CI 1.05, 2.44), although this difference did not persist when comparing school versus only home referral. A total of $154,269 (median $367 per encounter) was paid for school referrals to the ED.Children with agitation and aggression referred from school were more likely to be Black, Latinx, or have special educational needs. Future efforts should identify and address root causes of this disparity to decrease ED referrals, reduce healthcare spending, and address inequities.

Children are the poorest age group in our country, with 1 in 6, or 12 million, living in poverty. This sobering statistic became even more appalling in spring 2020 when COVID-19 magnified existing inequities. These inequities are particularly important to pediatricians, because poverty, along with racism and other interrelated social factors, significantly impact overall child health and well-being. It is imperative that pediatric educators redouble their efforts to train learners to recognize and address health inequities related to poverty and all of its counterparts. In this paper, we describe the current state of poverty-related training in pediatric undergraduate, graduate, and continuing medical education as well as opportunities for growth. We highlight gaps in the current curricula, particularly around the intersectionality between poverty and racism, as well as the need for robust evaluation. Using a logic model framework, we outline content, learning strategies, and outcomes for poverty-related education. We include opportunities for the deployment of best practice learning strategies and the incorporation of newer technologies to deliver the content. We assert that collaboration with community partners is critical to shape the depth and breadth of education. Finally, we emphasize the paramount need for high-quality faculty development and accessible career paths to create the cadre of role models and mentors necessary to lead this work. We conclude with a call for collaboration between institutions, accrediting bodies, and policymakers to promote meaningful, outcome-oriented, poverty-related education, and training throughout the medical education continuum.

BACKGROUND: Youth are arrested at high rates in the United States; however, long-term health effects of arrest remain unmeasured. We sought to describe the sociodemographic characteristics and health of adults who were arrested at various ages among a nationally representative sample. METHODS: Using the National Longitudinal Study of Adolescent to Adult Health, we describe sociodemographics and health status in adolescence (Wave I, ages 12−21) and adulthood (Wave V, ages 32−42) for people first arrested at age younger than 14 years, 14 to 17 years, and 18 to 24 years, compared to never arrested adults. Health measures included physical health (general health, mobility/functional limitations, death), mental health (depressive symptoms, suicidal thoughts), and clinical biomarkers (hypertension, diabetes). We estimate associations between age of first arrest and health using covariate adjusted regressions. RESULTS: Among the sample of 10,641 adults, 28.5% had experienced arrest before age 25. Individuals first arrested as children (ie, age

In August 2020, in the midst of a national conversation about racism in the United States, news of a Black eight-year-old boy being arrested for sitting improperly in the school cafeteria spread through the country.1 Body-camera footage showed police attempting to place the boy in handcuffs that slipped from his wrists before they took him to a juvenile detention facility where he was charged with felony battery. The boy's mother and lawyer reported that following arrest, he experienced somatic and trauma symptoms, including headaches, nightmares, and insomnia. His story, and the attention it garnered, illustrate the importance of the growing movement to establish a national minimum age of juvenile justice jurisdiction-an age below which a child cannot be prosecuted in juvenile court. We call upon child and adolescent psychiatrists to join this movement as a critical tool for promoting mental health and racial equity for children.

Background Consensus about behaviors that define effective supervision by residents of more junior trainees on pediatric inpatient rounds is lacking. Objective Use modified Delphi method to develop a checklist of essential supervisory behaviors pediatric residents demonstrate while leading inpatient, non-ICU, nonspecialty teaching rounds and pilot the checklist. Design/Methods One hundred and forty-one initial candidate behaviors were identified through literature review and narrowed by local stakeholders. Forty-one behaviors were submitted to national experts identified through purposive sampling to be refined using the modified Delphi method. Participants indicated agreement with behaviors’ inclusion in the checklist and whether any were nonobservable. Measures of central tendency and dispersion were used to identify consensus with a behavior's inclusion in the next cycle. A criterion was eliminated if >25% of experts felt it was not observable. Cycles continued until consensus was reached on ≤20 behaviors. The resulting checklist was piloted at 2 hospitals. Results After 2 modified Delphi cycles, consensus was obtained on 18 behaviors for inclusion in the final checklist. These were spread across 3 subcategories: teaching, leadership, and patient safety. In the pilot, the checklist of behaviors discriminated between residents with differing levels of competency in supervising trainees on inpatient rounds. For residents who had the checklist completed by 2 faculties, there was 75% agreement in behaviors observed. Conclusion(s) Based on literature review, local stakeholder input, and consensus of national experts through the modified Delphi method, we created and piloted a checklist of observable behaviors characteristic of effective clinical supervision by pediatric residents leading trainee teams on inpatient, non-ICU, nonspecialty rounds.

ImportanceThe US has high rates of adverse birth outcomes, with substantial racial disparities augmented by stress and neighborhood disadvantage. Black people are more likely to live in neighborhoods with high rates of incarceration, which is a source of both stress and neighborhood disadvantage and, thus, may contribute to adverse birth outcomes.ObjectiveTo determine whether neighborhoods with high incarceration rates also have higher rates of adverse birth outcomes compared with neighborhoods with lower rates.Design, Setting, and ParticipantsThis cross-sectional study used publicly available data from the New York City Department of Health (2010-2014). Censored Poisson regression, with the US Census tract as the unit of analysis, was used to examine the association of neighborhood incarceration rate and birth outcomes. Multivariable models included percentage of births aggregated to the Census tract by maternal factors (age, parity, singleton vs multiple birth, insurance, and race) and neighborhood factors (poverty, education, and violent crime). Analyses were performed between May 2021 and October 2022.ExposureNeighborhood incarceration rate, categorized into quintiles.Main Outcomes and MeasuresThe primary outcome was the incidence rate ratio (IRR) of preterm birth and low birth weight. Secondary outcomes were IRRs of very preterm birth, extremely preterm birth, and very low birth weight. Hypotheses were formulated before data collection.ResultsAmong 2061 Census tracts with 562 339 births, incarceration rates varied from 0 to 4545 people incarcerated per 100 000, and high-incarceration neighborhoods had more residents of Black race (54.00% vs 1.90%), living in poverty (32.30% vs 10.00%), and without a general educational development equivalent (28.00% vs 12.00%) compared with low-incarceration neighborhoods. In fully adjusted models, high-incarceration neighborhoods had a 13% higher IRR of preterm birth (IRR, 1.13; 95% CI, 1.08-1.18), 45% higher IRR of very preterm birth (IRR, 1.45; 95% CI, 1.24-1.71), 125% higher IRR of extremely preterm birth (IRR, 2.25; 95% CI, 1.59-3.18), 10% higher IRR of low birth weight (IRR, 1.10; 95% CI, 1.05-1.16), and 52% higher IRR of very low birth weight compared with low-incarceration neighborhoods (IRR, 1.52; 95% CI, 1.28-1.81).Conclusions and RelevanceNeighborhood incarceration rate was positively associated with adverse birth outcomes, particularly those associated with infant mortality. Black people were significantly more likely to live in high-incarceration neighborhoods, suggesting that mass incarceration may contribute to racial disparities in birth outcomes.

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.

Trauma responses are normal reactions to abnormal or violent events, yet many health care providers treat the challenging behavioral manifestations of trauma with judgment or misunderstanding. As providers who care for vulnerable children, it is our obligation to understand and interrogate our roles within systems that perpetuate the overcriminalization of developmentally appropriate responses to trauma and abuse, which create the trauma-to-prison pipeline. By understanding this pipeline and its impact, we as health care providers can better support our trauma-exposed patients and advocate for systemic change to dismantle and disrupt it. Exposure to trauma and abuse can impact the reactivity of the prefrontal cortex’s “fear circuitry,” perpetuating a prolonged or sudden stress response even if a tangible danger is not present.1 Fear responses can be difficult to manage, particularly in youth, and can lead to substance use, emotional outbursts, self-harm, truancy, or other challenging behaviors to cope with underlying activation.2 Unfortunately, many institutions, including health care, augment the negative impacts of trauma by pathologizing these behaviors rather than recognizing and treating them for what they are: manifestations of trauma. Here we discuss 2 well-described pathways that health care providers should recognize, in which existing systems increase the likelihood for traumatized children to be incarcerated and … Address correspondence to Yuan He, MD, MPH, School of Medicine, University of Pennsylvania, 423 Guardian Dr, Blockley Hall, Philadelphia, PA 19147. E-mail: yuan.he{at}pennmedicine.upenn.edu

The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on the health of people globally. Yet, not all people are being affected by this crisis equally. In the United States, this pandemic has exacerbated long-standing inequities and entrenched structural racism. At the onset of the crisis, few data were available detailing the demographic characteristics of individuals with COVID-19. However, as data emerged, it became apparent that communities of color were disproportionately affected. To illustrate these inequities, we analyzed publicly available race and ethnicity data on COVID-19 cases and deaths and were one of the first groups to compile these findings. We launched a social media campaign to highlight these racial and ethnic inequities and raise awareness among public and elected officials. Given the tremendous amount of missing data, we demanded transparency in state reporting of race and ethnicity data. Using both messaging and mapping tools, we publicized state and city efforts to address these inequities, focusing on the creation of task forces tackling the racial inequities of COVID-19. As racial and ethnic data on COVID-19 cases and mortality became more widely reported, statistics emerged about the downstream effects of these inequities. Despite initial false reassurance that COVID-19 largely spared children, the pandemic has exacerbated many social needs, leading to significant negative impacts on children. For example, as pediatricians, we saw how worsening food insecurity was affecting children. Using social media and infographics, we launched an additional stage of the campaign to illustrate these inequities and highlight advocacy opportunities.

Introduction The medical community recognizes the importance of confronting structural racism and implicit bias to address health inequities. Several curricula aimed at teaching trainees about these issues are described in the literature. However, few curricula exist that engage faculty members as learners rather than teachers of these topics or target interdisciplinary audiences. Methods We developed a longitudinal case conference curriculum called Health Equity Rounds (HER) to discuss and address the impact of structural racism and implicit bias on patient care. The curriculum engaged participants across training levels and disciplines on these topics utilizing case-based discussion, evidence-based exercises, and two relevant conceptual frameworks. It was delivered quarterly as part of a departmental case conference series. We evaluated HER's feasibility and acceptability by tracking conference attendance and administering postconference surveys. We analyzed quantitative survey data using descriptive statistics and qualitatively reviewed free-text comments. Results We delivered seven 1-hour HER conferences at our institution from June 2016 to June 2018. A mean of 66 participants attended each HER. Most survey respondents (88% or more) indicated that HER promoted personal reflection on implicit bias, and 75% or more indicated that HER would impact their clinical practice. Discussion HER provided a unique forum for practitioners across training levels to address structural racism and implicit bias. Our aim in dissemination is to provide meaningful tools for others to adapt at their own institutions, recognizing that HER should serve as a component of larger, multifaceted efforts to decrease structural racism and implicit bias in health care.