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. Author manuscript; available in PMC: 2022 Jan 1.
Published in final edited form as: Nurs Res. 2021 Jan;70(5):S43–S52. doi: 10.1097/NNR.0000000000000529

Maternal Experiences of Racial Discrimination, Child Indicators of Toxic Stress, and the Minding the Baby® Early Home Visiting Intervention

Eileen M Condon 1, Amalia Londono Tobon 2, Brianna Jackson 3, Margaret L Holland 4, Arietta Slade 5, Linda Mayes 6, Lois S Sadler 7
PMCID: PMC8405547  NIHMSID: NIHMS1716114  PMID: 34173377

Abstract

Background:

Racism is a significant source of toxic stress and a root cause of health inequities. Emerging evidence suggests that exposure to vicarious racism (i.e., racism experienced by a caregiver) is associated with poor child health and development, but associations with biological indicators of toxic stress have not been well studied. It is also unknown whether two-generation interventions, such as early home visiting programs, may help to mitigate the harmful effects of vicarious racism.

Objective:

The purpose of this study is to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress, and to test whether relationships are moderated by prior participation in Minding the Baby® (MTB), an attachment-based early home visiting intervention.

Methods:

Ninety-seven maternal-child dyads (n=43 intervention dyads, n=54 control dyads) enrolled in the MTB Early School-Age follow up study. Mothers reported on racial discrimination using the Experiences of Discrimination Scale. Child indicators of toxic stress included salivary biomarkers of inflammation (e.g., c-reactive protein, panel of pro-inflammatory cytokines), body mass index, and maternally reported child behavioral problems. We used linear regression to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress, and included an interaction term between experiences of discrimination and MTB group assignment (intervention vs. control) to test moderating effects of the MTB intervention.

Results:

Mothers identified as Black/African American (33%) and Hispanic/Latina (64%). In adjusted models, maternal experiences of racial discrimination were associated with elevated salivary IL-6 and TNF-α levels in children, but not child BMI or behavior. Prior participation in the MTB intervention moderated the relationship between maternal experiences of discrimination and child IL-6 levels.

Discussion:

Results of this study suggest that racism may contribute to the biological embedding of early adversity through influences on inflammation, but additional research with serum markers is needed to better understand this relationship. Improved understanding of the relationships among vicarious racism, protective factors, and childhood toxic stress is necessary to inform family and systemic level intervention.

Keywords: Racism, stress, physiological, inflammation, mother-child relations, psychosocial intervention

Toxic stress is a concept used to describe the physiologic, health, and behavioral consequences of exposure to severe or unrelenting stressors in childhood that overwhelm available support systems (Shonkoff et al., 2012). In a toxic stress response, chronic activation of the autonomic nervous system and hypothalamic-pituitary-adrenal axis leads to a persistent release of catecholamines, glucocorticoids, and inflammatory cytokines that cause “wear and tear” on the body, including the cardiovascular, immune, and metabolic systems (McEwen, 2003; Shonkoff et al., 2012). Over time, these physiological disruptions contribute to poor lifelong health and development, including increased risk for obesity, asthma, and behavioral difficulties, and as such, childhood toxic stress is considered a root cause of health inequities (Shonkoff et al., 2012). Commonly studied sources of toxic stress include maltreatment, poverty, and household disruption (Johnson et al., 2013; McEwen & McEwen, 2017; Shonkoff et al., 2012), and numerous interventions have been developed to help strengthen family protective factors and prevent or mitigate these sources of stress and adversity (Britto et al., 2017; Garner, 2013). However, despite the pervasiveness of racism as a stressor among Black, Indigenous, and People of Color (BIPoC) (Goosby et al., 2018; Harrell, 2000), associations between racism and biological indicators of toxic stress have not been well studied, and it is unclear whether existing early childhood interventions help to mitigate the harmful effects of racism-related stress (Shonkoff et al., 2021). In order to more effectively prevent toxic stress and promote health equity among racially marginalized families, it is critical to better understand the relationship between racism, toxic stress, and early childhood intervention among racially and ethnically diverse children and families.

Vicarious Racism and Childhood Toxic Stress

Racism is a multidimensional construct that includes structural racism, which is characterized by oppressive historical and institutional forces that perpetuate discriminatory legislation and policies, cultural racism, which describes a societal ideology of white supremacy, and interpersonal racism, or the harmful individual biases, assumptions, or beliefs that reinforce bigotry, intolerance, and hostility (Bailey et al., 2017; Nazroo et al., 2020; Shonkoff et al., 2021). Emerging evidence suggests that children may also be especially vulnerable to vicarious racism, a type of interpersonal racism that describes indirect exposure to discrimination experienced by others, such as a caregiver (Heard-Garris et al., 2018). Recent studies demonstrate that vicarious racism is associated with poor mental and socioemotional health in children, including depressive symptoms, anxiety, and behavioral problems (Heard-Garris et al., 2018). However, very few studies have examined associations between vicarious racism and biological and health indicators of a toxic stress response (Condon et al., 2019; Heard-Garris et al., 2018; Shonkoff et al., 2021). Improved understanding of vicarious racism as a stressor in early childhood is critical for understanding how racism “gets under the skin” and to identify novel targets for intervention to prevent toxic stress.

Buffering Vicarious Racism through Early Childhood Intervention

While unyielding and intersecting forms of racism may all contribute to a toxic stress response in childhood (Shonkoff et al., 2021), two-generation early childhood interventions may specifically be well suited to address toxic stress related to vicarious racism. This is because the mechanisms underlying vicarious racism transmission are also frequent targets of intervention for families experiencing stress and adversity. In a systematic review of vicarious racism and child health, Heard-Garris et al. (2018) identified caregiver depression, harsh parenting practices, and caregiver negative affect balance as mediating pathways connecting caregiver experiences of racial discrimination with poor child health and behavioral outcomes. Other recent studies support these findings; in a study of African American mothers with adolescents, maternal experiences of racial discrimination were associated with adolescents’ internalizing and externalizing behavior problems, and this relationship was mediated by maternal depressive symptoms and involved-vigilant parenting (Holloway & Varner, 2021). In a study of African American mothers with preschool-aged children, mothers’ perceived racial discrimination was associated with increased parenting stress, and this relationship was mediated by depressive symptoms and stress overload (Condon, In Press).

Two-generation early childhood interventions, such as maternal-child home visiting programs, often target the same mechanisms that underlie vicarious racism transmission (Garner, 2013). While the focus and approach of each home visiting model varies, these programs often seek to promote supportive caregiving, reduce caregiver stress, address maternal depression, and prevent child maltreatment (Dalziel & Segal, 2012; Duffee et al., 2017; Sama-Miller, 2018).Early home-visiting programs utilize proactive and participatory approaches to offer holistic and tailored support, while also considering the contextual nuances and unique stressors facing individuals, families, and communities. Therefore, while not specifically designed to address issues related to racism, it is possible that by reducing caregiver stress, promoting caregiver mental health, and improving the quality of caregiver-child relationships, home visiting interventions may help to buffer intergenerational transmission of racism-related stress among children and families with racialized identities.

The Minding the Baby® Intervention

In this study, we examine the federally-recognized home visiting model Minding the Baby® (MTB), an intensive, evidence-based, and interdisciplinary two-generation intervention for first-time mothers (Sadler et al., 2013). The MTB model includes regular home visits from both a nurse and a social worker, beginning during pregnancy and continuing until the child turns 2 years of age. The goal of MTB is to promote physical and mental health in the mother and child, develop secure parent-child attachment relationships, and support the parent’s emerging capacities to reflect upon her own and the child’s experience. Results of the MTB randomized controlled trials (RCT) and follow up studies demonstrate that participation in MTB enhances maternal reflective functioning and infant attachment, thereby building parental capacities and supporting positive health and behavioral outcomes (Londono Tobon et al., 2020; Ordway et al., 2018; Sadler et al., 2013; Slade et al., 2019).

The MTB intervention was not specifically designed to help mothers cope with racism-related stress. However, the respectful and trusting clinician-parent relationship is geared toward helping caregivers develop ways of regulating stress and strong emotions, and MTB home visitors work actively to reduce environmental stressors and promote positive parenting in the context of stress and trauma. The frequency and focus of home visits are flexible, allowing MTB home visitors to focus on what the family needs most at that time. Therefore, we hypothesize that by helping caregivers develop the capacity to process and regulate cumulative and painful stressors, and by providing caregivers with a corrective emotional experience, MTB may provide caregivers with the tools necessary to protect their children from experiencing vicarious racism and prevent the intergenerational transmission of racism-related stress.

Study Purpose

Utilizing data from the MTB Early School-Age follow-up study cohort (Londono Tobon et al., 2020), the purpose of this study was to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress (inflammatory biomarkers, body mass index, behavioral problems), and to test whether these relationships are moderated by previous participation in the MTB intervention. In a prior exploratory study using a subsample of this dataset (n = 54, control group families only), we found that maternal experiences of racial discrimination were associated with increased salivary interleukin-6, a pro-inflammatory cytokine, in children (Condon et al., 2019). Utilizing the complete follow up study dataset (N = 97 dyads), we now build on this preliminary work by: (1) examining whether our prior finding is sustained in an expanded sample; (2) testing associations with other biobehavioral indicators of toxic stress; and, (3) exploring the moderating effects of the MTB intervention.

Methods

We conducted a secondary analysis of cross-sectional data from the MTB-Early School Age follow-up study (Londono Tobon et al., 2020). Participants were eligible for the follow-up study if: the child was early school age (4–10 years) at the time of data collection; the child’s mother had custody or regular contact with the child; and the dyad was residing within state. Data were collected during a single visit at a private location (e.g., participant’s home, community library), and participants were compensated $50 for their time. Additional details regarding the MTB-Early School Age follow-up study design and methods have previously been reported elsewhere (Londono Tobon et al., 2020).

Sample

Sixty-four percent of eligible families (N = 97 dyads) enrolled in the follow up study, including 43 dyads from the MTB intervention group and 54 dyads from the control group (Table 1). The average time since completion of the MTB RCT was 4.6 years. Women were on average 27 years of age (SD = 3.1) and average child age was 6.6 years (SD = 1.7). Women identified as Hispanic/Latina (64%), non-Hispanic Black/African American (33%), and other/multiple races (3%). Hispanic/Latina women were primarily of Puerto Rican, Dominican, and Mexican descent. Ninety-one percent of women reported receiving at least one form of public assistance (e.g., Medicaid, Supplemental Nutrition Assistance Program, Temporary Assistance for Needy Families). Intervention and control group dyads did not differ by demographic characteristics except maternal race/ethnicity, with Hispanic/Latina women from the control group less likely to enroll than Hispanic/Latina women from the intervention group.

Table 1.

Sample Demographics for the Minding the Baby® Early School Age Follow-up Study

Variable Total Sample Intervention Group (n = 54 dyads) Control Group (n = 43 dyads) p-value
Maternal age in years, M (SD)a 27 (3.1) 27 (2.9) 26 (3.3) .60
Child age in years, M (SD) 6.6 (1.9) 6.6 (1.7) 6.7 (2.1) .82
Time since intervention completion in years, M (SD) 4.6 (1.9) 4.6 (1.7) 4.7 (2.1) .82
Maternal education in years, M (SD) 13 (1.7) 13 (1.7) 13 (1.7) .61
Maternal race/ethnicity, n (%)
 Non-Hispanic Black 32 (33) 7 (16) 25 (46) <.01
 Hispanic 60 (62) 33 (77) 27 (50)
 Other 5 (5.1) 3 (7.0) 2 (3.7)
Child race/ethnicity, n (%)
 Non-Hispanic Black 33 (34) 8 (19) 25 (46) .02
 Hispanic 61 (63) 33 (77) 28 (52)
 Other 3 (3.1) 2 (4.7) 1 (1.9)
Child female sex, n (%) 46 (47) 22 (51) 25 (46) .63
 Receiving public assistance, n (%)b 88 (91) 39 (91) 49 (91) .99
Martial Status, n (%)
  Single/Separated/Divorced 65 (67) 28 (65) 37 (68) .72
  Married/Living Together 32 (33) 15 (35) 17 (32)
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Note: Demographics originally reported in Londono Tobon et al., 2020; = Mean; SD = Standard Deviation

a

Independent samples t-test used; Mann-Whitney U used for all other continuous demographic variables

b

Fisher’s exact test used; Pearson’s Chi-square test used for all other categorical demographic variables

Variables and Measures

Maternal Experiences of Racial Discrimination

Mothers completed the Experiences of Discrimination (EOD) scale, an instrument designed to evaluate lifetime experiences of unfair treatment due to race/ethnicity in both major and minor situations. Mothers reported on a Likert scale how frequently (never, once, 2–3 times, 4 or more times) they had ever experienced discrimination or unfair treatment in each of the following nine situations: at school, getting a job, at work, getting housing, getting medical care, getting service in a store/restaurant, getting credit, bank loans or a mortgage, on the street or in a public setting, or from the police or in the courts (Krieger et al., 2005). For each situation, responses were coded as 0 (“never”), 1 (“once”), 2.5 (“2–3 times”), and 5 (“4 or more times”). Items were summed to create a total frequency score ranging from zero to forty-five (Krieger et al., 2005).

The EOD was designed for use with racially and ethnically diverse samples (Thrasher et al., 2012) and is frequently used in studies of Black and Hispanic/Latinx adults and children (Paradies et al., 2015; Priest et al., 2013). The EOD scale has demonstrated high internal consistency and test-retest reliability in past studies (Bastos et al., 2010; Cunningham et al., 2011; Krieger et al., 2005), and reliability of the EOD scale was adequate (α=.75) in the current study. In psychometric testing, the EOD had the strongest correlation with an underlying discrimination construct (r = .79) compared to other self-report discrimination measures (Krieger et al., 2005). In subsequent studies, the EOD scale has been associated with numerous constructs in multiethnic samples that support the validity of this instrument, including depression, anxiety, psychological distress, hypertension, and neighborhood racial composition (Benjamins, 2013; Hunt et al., 2007; Krieger et al., 2011; Sims et al., 2012).

Child Inflammatory Biomarkers

We collected saliva from children to evaluate c-reactive protein (CRP) and a panel of pro-inflammatory cytokines: interleukin (IL)-1β, IL-6, IL-8, and tumor necrosis factor (TNF)-α. CRP is a nonspecific marker of inflammation and has been associated with stressors in childhood, including interpersonal conflict and neighborhood vulnerability (Condon, 2018). Pro-inflammatory cytokines are protein messengers of the immune system produced locally by immune cells and are activated in response to stressors (Condon, 2018). Saliva was primarily collected via a passive drool. A small number of very young children (n = 11) were developmentally unable to provide passive drool samples, and instead cotton swabs were used. Saliva samples analyzed at Salimetrics® laboratories using enzyme immunoassay (CRP) and a 4-plex electrochemiluminescence immunoassay (cytokine panel). Samples were analyzed in duplicate, and we used the mean value of the two repetitions in our analyses. Prior to saliva collection, the researchers conducted an oral exam and recorded any evidence of unfilled dental caries, loose or missing teeth, or other signs of oral inflammation.

Child Body Mass Index

We measured children’s height and weight with a calibrated stadiometer and scale. Body mass index (BMI; kg/m2) and BMI z-scores were calculated based on Centers for Disease Control and Prevention growth charts by age and gender (Grummer-Strawn et al., 2010). Elevated BMI is a validated measure of obesity, and is associated with cardiovascular and metabolic risk factors in children (Achenbach & Ruffle, 2000; Grummer-Strawn et al., 2010).

Child Behavioral Problems

Mothers completed age-appropriate versions of the Child Behavior Checklist (CBCL 1½−5 and CBCL 6–18), widely used measures of child behavioral problems that have been validated in samples of Black/African American and Hispanic/Latino parents (Achenbach & Ruffle, 2000; Gross et al., 2006). Standardized t-scores based on child age and gender were calculated using instrument software, allowing for comparability across the two CBCL versions. Scores include the CBCL total score and externalizing (e.g., aggressive, hyperactive) and internalizing (e.g., anxious, withdrawn) behavior subscales, with higher scores indicating more behavioral problems. Reliability of the total score and subscales was high for both the CBCL 1½−5 (α = .76 – .91) and CBCL 6–18 (α = .84 – 97).

Data Analysis

Salivary Biomarker Data

We transformed the salivary biomarkers (CRP, IL-1B, IL-6, IL-8, TNF-α) to improve normality of the distributions. Salivary biomarker data were missing for seven children; reasons for missing data included mother refusal (n = 1), child refusal (n = 1), sample quantity not sufficient or out of assay range (n = 4), and palatal petechiae noted on oral exam (n = 1) (Condon et al., 2020). We calculated intra-assay coefficients of variability (CV) to evaluate the reliability of sample duplicates, and average intra-assay CVs ranged from 2.4% (IL-1B) to 6.3% (TNF-α). High CVs (>15%) were noted for TNF-α (n = 8) and IL-8 (n = 1) values; upon examination, we found that the absolute differences between replicates for these cases were small (<1pg/mL), and thus we did not exclude them from the dataset (Riis, Ahmadi, Hamilton, Bryce, et al., 2021). We also standardized saliva values and identified extreme outliers (>4 SD from the mean) in the models including CRP (n = 1) and IL-6 (n = 2). As these values were biologically plausible and we did not find evidence of laboratory or saliva collection error, we included these values in the models and used robust standard errors to address evidence of heteroskedasticity (Ahmadi et al., 2021; Granger & Taylor, 2020). To evaluate the effects of potential oral confounders (mouth sores, unfilled caries, missing teeth, loose teeth, recent dental examination), we tested correlations between salivary biomarker levels and these oral characteristics (Riis et al., 2020). CRP levels were correlated with the presence of loose teeth noted on oral exam (r = .23, p = .03), but no other significant correlations were detected.

Bivariate and Multivariate Models

We used bivariate analyses to compare demographic characteristics and experiences of racial discrimination between the control and intervention group participants. We used Pearson correlations to examine bivariate relationships between maternal experiences of racial discrimination and child indicators of toxic stress. We then used linear regression to examine associations between maternal experiences of racial discrimination, controlling for MTB group assignment (intervention vs. control), maternal race/ethnicity (due to differences in MTB enrollment), and child age (which is also a proxy for time since intervention completion). We also included an interaction term between experiences of discrimination and MTB group assignment, in order to examine and control for the effects of MTB as a moderator of the relationship between maternal experiences of discrimination and child outcomes. In the model with CRP as the outcome, we controlled for the presence of loose teeth due to detected correlations, as described above. For the model with TNF-α as the outcome, we controlled for use of cotton swabs for collection (n = 11), as TNF-α is known to be sensitive to swab filtration (Riis, Ahmadi, Hamilton, Hand, et al., 2021). We tested child gender as a covariate but ultimately did not include it because it did not improve model fit. Data were analyzed using SAS® 9.4.

Results

Maternal Experiences of Racial Discrimination

Frequency of maternal experiences of racial discrimination ranged from 0 to 27, with an average of 3.7 (SD = 5.2) reported (Table 2). There was no difference in EOD frequency scores between the MTB intervention and control group women (p = .34). Reported EOD scores were higher among Black/African American women (M = 4.4, SD = 5.1) than Hispanic/Latina women (M = 3.3, SD = 5.7), but this difference was not statistically significant (p = .33).

Table 2.

Descriptive Statistics for Study Variables
Mean Standard Deviation
Maternal Experiences of Racial Discrimination 3.69 5.52
Child Indicators of Toxic Stress
 C-Reactive Protein (pg/mL) 12204 27357
 Interleukin-1β (pg/mL) 82.9 92.9
 Interleukin-6 (pg/mL) 9.84 19.9
 Interleukin-8 (pg/mL) 792 833
 Tumor Necrosis Factor-a (pg/mL) 4.75 4.93
 Body Mass Index (z-score) 0.73 1.29
 Total Behavior Problems (t-score) 50.6 10.6
 Externalizing Behaviors (t-score) 49.3 10.5
 Internalizing Behaviors (t-score) 50.4 10.1
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Experiences of Racial Discrimination and Child Outcomes

In bivariate analyses, maternal experiences of racial discrimination were not correlated with child indicators of toxic stress (Table 3). However, in adjusted regression models, maternal experiences of racial discrimination were associated with higher salivary IL-6 (p = .01) and TNF-α (p = .02) levels in children (Table 4). Maternal experiences of racial discrimination were not associated with children’s BMI or behavioral problems in adjusted models. Participation in the MTB intervention moderated the association between maternal experiences of racial discrimination and child IL-6 levels (p = .049), such that this relationship was only present among control group families (Table 4). Participation in the MTB intervention also moderated the association between maternal experiences of racial discrimination and child externalizing behavior problems (p = .02), such that the direction of effects differed by group (Table 4). Maternal experiences of racial discrimination were positively associated with externalizing behaviors among intervention group participants, but negatively associated with externalizing behaviors among control group participants. However, the main effect of racial discrimination was not statistically significant in this model.

Table 3.

Correlations between Maternal Experiences of Racial Discrimination and Child Indicators of Toxic Stress
r p-value
C-Reactive Protein (pg/mL)a 0.03 .80
Interleukin-1β (pg/mL)b −0.10 .36
Interleukin-6 (pg/mL)b 0.08 .44
Interleukin-8 (pg/mL)b −0.13 .23
Tumor Necrosis Factor-a (pg/mL)b 0.12 .25
Body Mass Index z-score −0.06 .57
Total Behavior Problems (t-score) 0.10 .35
Externalizing Behaviors (t-score) 0.06 .55
Internalizing Behaviors (t-score) 0.13 .22
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Note.

a

Indicates inverse square-root transformation applied to variable

b

Indicates natural log-transformation applied to variable

Table 4.

Adjusted Associations between Maternal Experiences of Discrimination and Child Indicators of Toxic Stress with Moderation by the MTB Intervention

Child Indicators of Toxic Stress (dependent variables) Experiences of Racial Discrimination
 MTB Intervention vs Control (ref)
 Experiences of Discrimination*MTB
n β (SE) p-value β (SE) p-value β (SE) p-value
C-Reactive Proteina,c 89 −.02 (0.01) .89 0.40 (0.01) .001 0.03 (0.01) .87
Interleukin-1β b 89 −0.03 (0.03) .86 0.14 (0.23) .21 −0.08 (0.04) .68
Interleukin -6b,c 89 0.35 (0.03) .01 −0.01 (0.26) .99 −0.38 (0.03) .01
Interleukin -8b 89 −0.08 (0.03) .67 −0.16 (0.23) .22 0.03 (0.04) .89
Tumor Necrosis Factor-ab 89 0.44 (0.03) .02 −0.06 (0.23) .66 −0.39 (0.04) .06
BMI z-score 96 −0.11 (0.04) .57 −0.10 (0.33) .43 0.11 (0.05) .59
Total Behavior Problems 97 −0.07 (0.33) .69 −0.34 (2.55) .005 0.30 (0.63) .12
Externalizing Behaviors 97 −0.23 (0.33) .18 −0.41 (2.52) .001 0.46 (0.40) .02
Internalizing Behaviors 97 0.05 (0.32) .77 −0.28 (2.48) .03 0.17 (0.39) .38
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Note: Linear regression models adjusted for maternal race/ethnicity, and child age. C-reactive protein model also adjusted for presence of loose teeth, and TNF-a model adjusted for saliva collection by cotton swab. MTB, Minding the Baby®.

a

Indicates inverse square-root transformation applied to variable

b

Indicates natural log transformation applied to variable

c

Indicates heteroskedasticity consistent standard errors used

Discussion

Results of this study contribute to a growing body of literature demonstrating that vicarious racism may contribute to the biological embedding of early adversity through pathways linked with physiologic stress. We found that maternal experiences of racial discrimination were associated with increased child salivary IL-6 and TNF-α levels, biomarkers of oral inflammation that may be reflective of chronic physiologic stress (Condon, 2018). However, we did not find associations between maternal experiences of racial discrimination and child BMI or behavioral problems. We also did not find consistent evidence to support our hypothesis that participation in the Minding the Baby® early home visiting intervention buffers the effects of vicarious racism on child indicators of toxic stress. Additional research on the biobehavioral mechanisms that both contribute to and protect against intergenerational transmission of racism-related stress is necessary to inform both family and systemic level interventions.

Participation in the MTB intervention moderated the association between maternal experiences of racial discrimination and child salivary IL-6 levels, such that this association was only present among control group families. While this may reflect a protective effect of the MTB intervention, we did not find consistent moderating effects across study outcomes, and thus we are unable to draw a conclusion about the role of MTB in preventing vicarious racism. For example, as the sample size of the intervention group was small, it is possible that we simply had inadequate statistical power to detect a relationship between maternal experiences of racism discrimination and child salivary IL-6 levels in the intervention group. Use of salivary biomarkers in children remains exploratory, and thus it is also possible that our findings in the control group were spurious, or that the presence of unmeasured confounders influenced our results (Condon, 2018). However, paired with our novel finding of a relationship between maternal experiences of racial discrimination and increased child salivary TNF-a levels, these findings suggest that additional research on the physiological effects of experiencing vicarious racism in childhood is warranted.

Our salivary biomarker findings should also be interpreted with caution because salivary cytokines reflect local oral inflammation, and not systemic inflammation (Condon, 2018). Recent evidence also suggests that moderately elevated levels of IL-6 can exist even in the absence of a local inflammatory state, due to IL-6’s involvement in somatic maintenance (i.e., immunity and tissue repair) (Del Giudice & Gangestad, 2018). However, past studies have identified relationships between these salivary cytokines and indicators of child stress and health, including behavioral problems, sleep disruption, maternal psychological distress, and preterm birth (El‐Sheikh et al., 2007; Keller et al., 2010; Riis et al., 2016; Sesso et al., 2014). This suggests that although salivary cytokines reflect local inflammation and somatic maintenance, these noninvasive biomarkers may be a feasible proxy for immune processes linked with chronic stress and provide important insight into physiological functioning, especially in pediatrics studies.

Maternal experiences of racial discrimination were not associated with child BMI or behavioral problems in our adjusted models. Prior studies demonstrate that maternal experiences of racial discrimination are associated with BMI among 3-year olds (Dixon et al., 2012) and poor socioemotional health among preschool and school-age children (Caughy et al., 2004; Harris-McKoy et al., 2014). Obesity and behavioral problems are also common and deleterious effects of experiencing toxic stress (Garner, 2013; Shonkoff et al., 2012). However, these outcomes are also affected by complex and intersecting environmental, behavioral, and genetic influences (Kumar & Kelly, 2017; Shonkoff et al., 2012). Therefore, it is possible that our sample size was too small to detect the effects of maternal experiences of discrimination among a myriad of other influences on BMI and behavior. It is also possible that due to increasing independence, school-age children are less vulnerable to vicarious racism experienced by their mothers, and more likely to be harmed by racism perpetrated by peers, teachers, or the media (Heard-Garris et al., 2018). Additional research is necessary to understand the mechanisms through which racism contributes to toxic stress across the course of child development.

We hypothesized that participating in MTB, an attachment-based maternal-child home visiting intervention from pregnancy to child age 2, would help mitigate the effects of vicarious racism among BIPoC families when children reach early school age. Like other early home visiting interventions, MTB aims to reduce maternal stress by addressing past trauma and connecting families with resources, so that navigating a challenging and likely racist care system may seem more possible. In addition, a critical component of MTB is the opportunity for the parent to develop a trusting relationship with a clinician who is curious about them and about their experience, and whose practice is diversity- and trauma-informed. While these efforts to buffer stress and maintain an anti-racist stance do not necessarily guarantee the absence of implicit bias on the part of the clinician, a reflective environment means that these issues can be recognized and addressed. MTB is also unique in its focus on enhancing parental reflective functioning; that is, a parent’s ability to understand and interpret the child’s thoughts, feelings, and intentions (Slade et al., 2019). This skill not only promotes sensitive, responsive maternal-child interactions, but may also be particularly useful for engaging in racial socialization strategies, such as explaining experiences of racial discrimination in developmentally sensitive ways (Slade et al., 2019; Wang et al., 2020). However, MTB was not specifically designed to address the harmful effects of experiencing racism and racial discrimination, and despite the intensive and comprehensive approach of the intervention, we found inconsistent evidence to support our hypothesis that MTB protects against vicarious racism in our follow up study sample.

Early home visiting interventions like MTB may benefit from incorporating specific strategies to address stress related to interpersonal racism and promote protective strategies that may reduce racism-related stress. This includes strategies to promote racial socialization, a process through which caregivers convey information about race and prepare children to live in a racialized society, which has been proposed as a strategy for healing past and current family race-based trauma (Anderson & Stevenson, 2019; Wang et al., 2020). Early home visiting interventions may also benefit from partnering with BIPoC communities and families to develop strategies to improve families’ wellbeing and address racism-related stress at both the structural and interpersonal level. Negative racial/ethnic biases are common among healthcare providers (FitzGerald & Hurst, 2017), and evidence suggests that racial/ethnic concordance between a home visitor and family may improve home visiting enrollment and engagement (Daro et al., 2003). Thus, in order to more effectively reduce the harmful effects of racism through early home visiting intervention, efforts must be made to recruit, retain, and fairly compensate BIPoC home visitors, match home visitors and participants based on race/ethnicity, and train all home visitors to reflect on and address their own implicit biases.

While the incorporation of more targeted strategies in family-level interventions may help to buffer the harmful effects of racism among BIPoC families, the onus of preventing intergenerational transmission of racism-related stress cannot, and should not, be placed on the individual family or practitioner alone. Rather, in order to mitigate the harmful effects of racism and achieve health equity, addressing systemic racism and dismantling racist policies and institutions must be the ultimate goal of innovative interventions, programs, and policies. These efforts should include educating all health care and social service providers regarding antiracist practices, so that interactions with these providers do not increase experiences with discrimination. Systemic level policies to reduce maternal stress and improve equity, such as a living wage, paid family leave, and universal healthcare and childcare, must also be prioritized (Doran et al., 2020).

Strengths & Limitations

Examination of this unique cohort – a follow up of an intensive home visiting intervention RCT – allowed us to examine both the effect of maternal experiences of racial discrimination and the possible moderating effects of a two-generation intervention. To our knowledge, this was the first study to explore the role of home visiting in preventing vicarious racism and intergenerational transmission of racism-related stress. This study also contributes to a small but growing body of literature on salivary biomarker values in young children (Riis et al., 2016). This study was also strengthened by a multiethnic sample that included both non-Hispanic Black/African American and Hispanic/Latino mother-child dyads. We did not have adequate statistical power to examine whether the relationship between maternal experiences of racial discrimination and child indicators of toxic stress varied by racial/ethnic group. However, our results support past research demonstrating that vicarious racism may have harmful effects on both Black/African American and Hispanic/Latinx families (Heard-Garris et al., 2018). It is also important to note the heterogeneity among Hispanic/Latina families in our sample and among the Hispanic/Latinx community as a whole, which includes diverse cultural and ancestral backgrounds, including Afro-Latinx. Future research is necessary to examine racial and ethnic differences in the intergenerational transmission of racism and racial discrimination, as both exposures and coping strategies may vary among ethnic and cultural groups.

Among women in our sample, experiences of discrimination scores were similar or slightly lower than rates reported in past studies (Krieger et al., 2005), which may reflect a social desirability bias. The EOD also captures overt experiences of racial discrimination, such as unfair treatment in school or by the police, but may miss other important sources of racism such as racial microaggressions. Future research may be improved by including both implicit and explicit measures of racism in order to better capture the complex and insidious nature of racism and the harmful effects of racism-related stress (Krieger et al., 2010; Lewis et al., 2015). Because our sample included socioeconomically marginalized families, participants also likely experienced multiple other stressors in the years since intervention completion in addition to racism-related stress. While psychometric testing supports the validity of the Experiences of Discrimination scale (Krieger et al., 2005), it is possible that the presence of other stressors influenced our findings. We also were unable to examine the effects of protective factors or coping mechanisms, which may also influence intergenerational transmission of stress. Future mixed methods or qualitative research studies may provide important insight into the mechanisms that perpetuate vicarious racism and the potential for early childhood interventions to protect against racism-related stress.

We measured salivary biomarkers in children because they are noninvasive, and we conducted oral exams and sensitivity analyses to address potential issues around sample reliability. However, future studies with serum biomarkers may be warranted to better understand the effects of vicarious racism on child inflammation. Finally, our sample size was too small to examine mediating pathways between maternal experiences of racial discrimination, protective factors, and child indicators of toxic stress. Examining the role of maternal physiologic stress, mental health, or parenting may provide valuable insight into the mechanisms underlying intergenerational transmission of racism and inform future approaches to family and systemic level intervention.

Conclusion

Results of this study support a growing body of literature demonstrating the harmful effects of vicarious racism on child health, and the potential role of inflammation in the intergenerational transmission of racism-related stress. Additional research is needed to understand the effects of maternal experiences of racial discrimination on child indicators of toxic stress across the course of development, and this has important implications for developing targeted interventions. Simultaneous efforts to reduce race-related stress through intervention on the family level, and to dismantle structural racism on the systemic level, are necessary to promote equity and prevent toxic stress among BIPoC families.

Acknowledgement:

Research reported in this publication was supported by the National Institute of Nursing Research of the National Institutes of Health under Awards Number F31NR016385, T32NR008346, and K99NR018876; and the National Institute of Mental Health under Award Number T32MH018268. This research was also supported by the NAPNAP Foundation, the Connecticut Nurses Foundation, the Jonas Nurse Leaders Scholars Program, the Alpha Nu chapter of Sigma Theta Tau International, and the American Academy of Child and Adolescent Pilot Research Award. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

The authors thank Minding the Baby® research assistants Andrea Miller, BA (Yale Child Study Center) and Priscilla Qinglan Ding, PhD (Purdue University, formerly Yale School of Nursing) for their assistance with recruitment and data collection. We also gratefully acknowledge the families who participated in this study for contributing their time and expertise.

Footnotes

The authors have no conflicts of interest to report.

Ethical Conduct of Research: This research study was approved by the Yale University Institutional Review Board (HIC # 1607018027).

Contributor Information

Eileen M. Condon, Yale School of Nursing, Orange, CT.

Amalia Londono Tobon, Warren Alpert Medical School, Brown University, Providence, RI.

Brianna Jackson, Yale School of Nursing, Orange, CT.

Margaret L. Holland, Yale Child Study Center, New Haven, CT.

Arietta Slade, Yale Child Study Center, New Haven, CT.

Linda Mayes, Yale Child Study Center, New Haven, CT.

Lois S. Sadler, Yale School of Nursing, Orange, CT.

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