Diminished Returns of Socioeconomic Resources, and Black Middle-Income Children’s Health Paradox-Reply

In Reply

We appreciate the comments made by Assari and Caldwell in response to our Research Letter.¹ We agree that the phenomenon of Marginalization-Related Diminished Returns (MDRs) provides a useful framework for contextualizing our findings. For instance, the Figure shows the odds of perceived racism among Black children compared with White children by household income.¹ Black children with a household income of $75 000 or more had higher odds of perceived racism than those with a household income of less than $75,000 (adjusted odds ratio, 8.23; 95% CI, 5.18–13.08 vs 2.43; 95% CI, 1.62–3.67) – an observation that may be explained by MDRs, as higher-income Black children tend to live in more discrimination-prone environments than their lower-income counterparts.

Assari and colleagues have brought much attention to the critical issue of MDRs. In one of their articles, parental socio-economic status and education were reported to have weaker protective effects against attention-deficit/hyperactivity disorder, impulsivity, and substance use among Black children compared with White children.² Discrimination associated with MDRs also occurs within the school setting. According to our results, almost 5 times as many Black children reported teacher discrimination compared with their White peers.¹ This observation is especially concerning given Assari and Caldwell’s previous findings that higher teacher discrimination was associated with lower school performance among Black youth.³

Intervention strategies must be undertaken to address racism and discrimination within clinical practice settings. Pediatricians must first assess their own implicit and explicit biases. Potential debiasing procedures include counter-stereotypic training, increasing intergroup contact, and fostering an inclusive and diverse workforce.⁴ Health care professionals should create a culturally safe environment in which they acknowledge and are cognizant of the racism experienced by children and families.⁵ Pediatricians should recognize that high household income may amplify rather than mitigate exposure to perceived discrimination among youth in racial or ethnic minority groups. These strategies can be extended to school personnel and the entire education system, which are tasked with creating a safe, effective, and supportive environment for the development and education of all children.

Professional organizations and institutions can also take a broader advocacy role against racism, for instance by providing ongoing professional education to pediatricians on implicit biases, advocating for increased access to culturally sensitive mental health services in schools and engaging community leaders to create healthy food markets and safe playgrounds in neighborhoods with predominantly racial or ethnic minority populations.⁵ Health care professionals are uniquely situated to advocate for equity in our increasingly diverse society. Addressing racism during childhood is needed to disrupt the cycle of racial inequity, and pediatricians can make a profound impact by doing so.⁶

MDRs are generally discussed within the context of race and ethnicity and socioeconomic status. However, future research could examine MDRs at the intersection of several sociodemographic characteristics, including socioeconomic status, race and ethnicity, sex, and sexual orientation.

Figure 1.

Odds of Perceived Racism among Black Children by Household Income

The figure reports adjusted odds ratios of perceived racism by 3 household income among Black children compared with White children, adjusted for sex and parent education.