The cover story of the New York Times Magazine on April 11 garnered more attention for a problem that is increasingly becoming news but is not new: Black women and babies die at alarmingly high rates during pregnancy and childbirth. But the article advanced the conversation in two important ways: first, by acknowledging that racism is to blame for these disparities, and second, by elevating the role of doulas as a potential intervention for Black mothers and babies.
The author, Linda Villarosa, explained: “Recently there has been growing acceptance of what has largely been, for the medical establishment, a shocking idea: For black women in America, an inescapable atmosphere of societal and systemic racism can create a kind of toxic physiological stress, resulting in conditions—including hypertension and pre-eclampsia—that lead directly to higher rates of infant and maternal death.”
But the reality is that it’s not just pregnant women who see the health impacts of racism—these types of disparities cross gender, age, ethnic and racial lines. People of color, especially African-Americans, experience the highest rates of diabetes, hypertension, heart disease, and much more. Therefore, to truly get at the root causes of these health problems, we’d need to eliminate racism. We’d need to dismantle or dramatically reform institutions that uphold racist paradigms.
In the meantime, interventions like doulas, as the Times piece suggests, could protect pregnant people and buffer the impacts of racism on maternal health. This raises the question: What other interventions should be considered for the wide range of conditions affecting people exposed to systemic injustices while the work to change the larger structures continues? Over the course of the next few months, we’ll be looking at a number of those potential interventions to shine a light on the approaches that could ameliorate or prevent the health impacts of racism.
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For our first piece, we’ll look at self-regulation, an umbrella term used primarily by psychologists to describe a set of skills that allow people to deal appropriately with stress, potentially preventing it from having toxic impacts. One thing that we know about the physiological stress described in the New York Times Magazine piece is that whether it is toxic or not depends on our ability to cope with the stress. The inability to cope with stress is part of what results in the health problems we see into adulthood. Because of its potential, and the fact that these skills can be taught and strengthened throughout a lifetime, self-regulation is a promising intervention for the health impacts of racism.
Toxic Stress and Adverse Childhood Experiences
As has been well documented, discrimination has a detrimental impact on health, and the relationship between the experiences of discrimination and poor health likely has to do with the impact of toxic stress. Nadine Burke Harris, a pediatrician in San Francisco and the author of a book about childhood adversity, describes it this way: “Our biological stress response is designed to save our lives from something threatening, and that’s healthy. The problem is that when the stress response is activated repeatedly it can become overactive and affect our brain development, our immune systems and even how our DNA is read and transcribed,” Burke Harris told the New York Times. “High doses of stress hormones can inhibit the brain’s executive functioning and make it harder for kids or adults to exercise impulse control.”
To gain control and “stop yourself when you’re feeling upset, you have to have three basic skills—working memory, cognitive flexibility, and inhibitory control,” Monica Tsethlikai, a psychologist at Arizona State University who researches cognitive development in American Indian children, explained in a recent phone interview with Rewire.News. Cognitive flexibility, she explained, lets you know there is another choice you can make. Working memory lets you know that there are consequences for your behaviors. And inhibitory control is what stops you from making a choice with negative consequences. These skills are what allow us to choose not to lash out in anger, for example, or to avoid coping with stress through behaviors like substance abuse or excessive drinking, both of which can have negative impacts on health.
The causes of that toxic stress can vary, but adverse childhood experiences (ACEs) are a big focus of the research. “A toxic stress response can occur when children experience strong, frequent, and/or prolonged adversity that overwhelms their skills or support,” explained a report written by researchers at Duke University. These experiences include “physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship (i.e., poverty)—whereby their stress response system stays activated for extended periods of time.”
While definitions can differ slightly, ACEs are experiences that can be traumatic, and are associated with health problems into adulthood. “Adverse childhood experiences, such as violence, family psychopathology, or parent death, can have negative effects on lifelong physical and mental health,” explained a 2016 article in the American Journal of Preventive Medicine. The authors outlined the specific problems tied to ACEs: “learning/behavior problems and obesity in children and heart disease, autoimmune diseases, smoking, alcoholism, and depression in adults.”
There is a lot of research looking into the association between ACEs and these problems later in life, but not all of it teases apart the relationship to race and ethnicity. Dr. David Williams, a sociologist at Harvard University and a major figure in documenting the connection between racism and poor health, explained in a phone interview with Rewire.News that while ACEs exist at all levels of income, “adverse childhood experiences are not randomly distributed in the population. There are certain subgroups that have higher levels of ACEs.” The two groups he outlined specifically were based on income level and race/ethnicity. “Poor kids, irrespective of race, had higher levels of ACEs. Disadvantaged racial/ethnic groups also have higher levels of early childhood adversity.” A February 2018 Child Trends report also found that Black and Latino kids have higher levels of ACEs than white children: “Nationally, 61 percent of black non-Hispanic children and 51 percent of Hispanic children have experienced at least one ACE, compared with 40 percent of white non-Hispanic children and only 23 percent of Asian non-Hispanic children.” A 2016 study found that American Indian/Alaska Native children also had significantly higher levels of ACEs than non-Hispanic white children.
Analysis of the prevalence of ACEs across racial and ethnic groups does vary though, with different data sets reaching divergent conclusions. Centers for Disease Control and Prevention data about ACE prevalence among adults, for example, does not find a significant variance across racial groups. One of the main differences between the data is who is reporting—the Child Trends data relies on the National Survey of Children’s Health, which asks parents to answer survey questions about their children, whereas the CDC data asks adults to self-report their own adverse experiences from childhood.
What remains consistent, however, is that the health outcomes for people of color are significantly worse than non-Hispanic whites. So while not all of the self-regulation research makes the explicit link to racism and discrimination, the research on what improves outcomes for those who’ve experienced ACEs still offers a potential pathway for intervention and prevention of the health impacts of racism.
Self-Regulation as a Potential Intervention
One intervention that shows promise in regards to combating the negative consequences of ACEs and toxic stress is self-regulation. As Dr. Desiree Murray, a clinical psychologist and lead researcher on a Duke University project focused on the issue, put it, “self-regulation is about managing thoughts and feelings in a way that helps you achieve your goals, solve problems, or inhibit impulses. We think of self-regulation as the foundation for adaptation and flexibility in response to stress.”
Self-regulation has the potential to correct, re-adjust, or even prevent the ways in which adversity and discrimination manipulate our nervous system responses and our health. As Burke Harris explained in her viral 2014 TED talk: “Well, imagine you’re walking in the forest and you see a bear. Immediately, your hypothalamus sends a signal to your pituitary, which sends a signal to your adrenal gland that says, ‘Release stress hormones! Adrenaline! Cortisol!’ And so your heart starts to pound, your pupils dilate, your airways open up, and you are ready to either fight that bear or run from the bear. And that is wonderful if you’re in a forest and there’s a bear. But the problem is what happens when the bear comes home every night, and this system is activated over and over and over again, and it goes from being adaptive, or life-saving, to maladaptive, or health-damaging.” That increased activation is what self-regulation skills, for children and adults, could potentially address, providing a major buffer to the impacts of racism on health.
Here’s an example of how self-regulation works in practice: When a child gets upset over, say, a toy being taken away by another child during playtime, a caregiver guides them to self-soothe. The caregiver might suggest the child take a few breaths or take a break, engage in physical activity, find a stuffed animal to hug, or draw. The process of coming down from a difficult emotion through non-harmful techniques (as opposed to hitting the other child in anger, for example) is how self-regulation can play out. The tools for self-regulating vary widely, from one-on-one mentoring programs that teach these skills to elementary school kids with behavioral problems, to toolkits on social and emotional skills development for parents and educators to use with children between the ages of 3 and 9.
Between 2015 and 2016, Murray and her team put out a four-part report, funded by the U.S. Department of Health and Human Services, examining the research on self-regulation, its impact on toxic stress, and the interventions reviewed in scientific literature. One of the reasons self-regulation has received this level of investigation and attention is that the skills can be improved and strengthened throughout one’s lifetime, making it a promising intervention.
Another important element of the self-regulation model is that, while the term implies it’s a set of behaviors done independently, Murray’s research shows that it’s actually very dependent on supportive caregivers; kids learn those skills through modeling from their caregivers. Explained the first report in the series, “Through warm and responsive interactions … support, coaching, and modeling are provided to facilitate a child’s ability to understand, express, and modulate their thoughts, feelings, and behavior.” This means that kids suffer when their caregivers themselves don’t have the self-regulation skills necessary to manage their own emotional well-being.
Burke Harris has found this as well at her Center for Youth Wellness in San Francisco. “One of the key ingredients for keeping the body’s stress response out of the toxic stress zone is the presence of a healthy buffering caregiver,” she told the New York Times. “So we need to educate parents and caregivers about the impact a child’s environment and exposures may be having on their health. We also know that if a caregiver is able to self-regulate, their kids have much better outcomes.”
This aspect of how self-regulation works is important, especially in the context of addressing the deeply rooted impact of racism and discrimination. “Children are affected not only by the experience that they directly have,” explained Williams, “But they also can be affected by the experiences of their parents. High levels of discrimination for the parent also has negative experiences on the health of the child.” So any interventions focused on self-regulation would need to strengthen the self-regulation skills of both caregiver and child in order to improve outcomes. “This is why a lot of groups and think tanks are talking about dual-generation intervention approaches,” said Murray. “Some of it has made its way into the thinking about teachers as well, who are critical caregivers.” These dual-generation interventions can look like providing education for parents alongside children about the importance of self-regulation and the skills involved. While this means that for children whose parents are also facing adversity, there is a double challenge, it also means that supportive adults (who can also be extended family, teachers, or other caregivers) can be instrumental in helping the child learn to cope.
Murray’s research reviewed the existing literature on successful interventions that improved self-regulation skills in children across different age groups. The findings are promising in that many do show improvement in self-regulation skills via these interventions. “Broad, substantive changes in self-regulation can be obtained with comprehensive interventions during the preschool years, with positive impacts seen on cognitive and emotional regulation along with behavior and stress,” the third report in the series said. “A variety of intervention approaches appear effective, including those that focus on direct skills instruction with children and those that focus on caregiver co-regulation.” Even in studies with young adults between the ages of 18 and 25, the researchers found that “using almost exclusively direct skills instruction, with many computer-administered interventions, substantive positive effects on self-regulation are seen across a number of areas.”
Challenges for Self-Regulation Research
In order to fully make the link between the impact of racism and self-regulation as an intervention for toxic stress, social scientists would need to address a number of gaps in their research. For one, racism and discrimination are not adequately captured in the measurements of adverse childhood experiences. Williams believes racism and discrimination should themselves be considered an adverse childhood experience. He thinks it may be even more important to capture this aspect today than ever. “Within our current political environment, there are likely to be ACEs linked not only to race but also linked to immigration status that would also have negative effects on children. It’s striking to me that the Southern Poverty Law Center has documented that during the presidential campaign, the number one site of hostility in the United States was K-12 schools. We have to think very broadly in the current environment of all the sources of stress in the lives of children.”
Another important gap is the way research on self-regulation examines the impacts of these interventions for different groups based on race and ethnicity. In the report referenced above, socioeconomic status was used to examine impacts on low-income children, but race or ethnicity were not examined independently. Those demographic statistics were reported in the research overviews, but the specific impacts on communities of color would require further investigation specifically. When asked about self-regulation as a potential intervention for the impacts of racism, Williams responded: “I am not aware of any specific study that has looked at the role of self-regulation in terms of addressing the stress of racism directly, but I am aware that there is a larger literature that self-regulation is certainly a positive resource that individuals have and can lead to good developmental outcomes.”
Tsethlikai is developing a body of research about how tribal communities can improve their self-regulation skills. A study she conducted in 2011 with children of the Tohono O’odham Nation demonstrated that children who were engaged in culturally based activities, including indigenous language learning, showed better development of the cognitive skills involved in self-regulation. But one of the barriers she’s found is a resistance to the idea of self-regulation as a concept. “The tribes were saying: ‘no we don’t like the research on self-regulation,’” explained Tsethlikai. “We couldn’t even get them to buy into the word.”
This goes back to the way the word itself may misrepresent the concept. It’s not actually a set of skills that are developed or employed solely on the individual level, but instead in community and partnership with adults and peers. In a brief for the Office of Planning, Research and Evaluation, titled Reflections on the Relevance of “Self-Regulation” in Native Communities, and released in May, Tsethlikai explored this challenge and suggested that a reframe might be necessary to fully capture a culturally relevant concept that encompasses self-regulation skills. “Within tribal communities that choose to consider this construct, self-regulation may be better represented by a more global term that is more holistic than the construct used in Euro-American research.”
Another challenge, of course, is funding and resources for these interventions, particularly in public schools and other social service agencies that reach low-income folks. “Schools can be really good resources,” said Murray of self-regulation support. “The question is, are they? Right now in our country, I don’t know that they necessarily are.” Divestment in public education and decreased funding for social services are clearly part of our national landscape, and are problems in many states, including North Carolina, where Murray is based. “One of the problems is that some of the kids who are most in need of [intervention] are less likely to have access to those resources,” explained Murray.
Understanding the cognitive and emotional skills that allow individuals to cope with stress is an important piece of the puzzle of undoing or preventing the harm caused by racism on health. With stronger research to support it, interventions could be designed specifically for groups at risk of health problems due to racism. Those interventions could focus on strengthening their self-regulation skills as young people, for example, similar to early interventions for children with literacy challenges. While funding is always a challenge, these interventions could be folded into existing structures and programs supporting young people at risk.
But self-regulation isn’t the only arena that shows promise as an intervention into the health impacts of racism. Other interventions—such as strong racial socialization, cultural practices, and social support—have shown promise for buffering the impacts of toxic stress, adverse childhood experiences, and potentially racism and discrimination. In the coming months we’ll explore in depth what the research offers about these interventions as avenues for improving the health of communities of color, as the broader work to dismantle racism continues.