RESEARCH AND PRACTICE

Perceived Racial/Ethnic Discrimination Among Fifth-Grade Students and Its Association With Mental Health
Tumaini R. Coker, MD, MBA, Marc N. Elliott, PhD, David E. Kanouse, PhD, Jo Anne Grunbaum, EdD, David C. Schwebel, PhD, M. Janice Gilliland, PhD, Susan R. Tortolero, PhD, Melissa F. Peskin, PhD, and Mark A. Schuster, MD, PhD

Racial/ethnic discrimination has been dened as unfair, differential treatment on the basis of race or ethnicity.1 It disproportionately affects Black, Hispanic, and Asian individuals in the United States, with 90% of Black and 79% of other non-White adults reporting perceived racial/ethnic discrimination, compared with 22% of White adults.2 Some studies have shown that a majority of Black, Asian, and Hispanic adolescents report perceived racial/ethnic discrimination as well.3,4 In a study of 177 Black, Asian, and Hispanic adolescents in 1 urban public school, 57% of 13- to 19-year-olds reported being called a racially insulting name, and 42% reported being excluded from activities by peers because of their race/ethnicity.3 A recent review of the literature on perceived racism and health examined 138 studies (91% of studies focused on adults) and found that the association between perceived racism and health was strongest for negative mental health outcomes (psychological distress, depression, stress, anxiety).5 This association has been found in studies of multiethnic samples of adults and adolescents57 but has not been examined in similar studies of preadolescent children. Studies show that preadolescent children report perceived racial/ethnic discrimination.79 Researchers have proposed that the cumulative distress caused by experiences of perceived racial/ethnic discrimination among Black youths can provoke symptoms of internalizing (e.g., depression) and externalizing (e.g., conduct disorder) disorders.7 Many studies that examined the relationship between perceived racial/ethnic discrimination and mental health in US children focused on adolescents only,1,3,10 used small sample sizes (n < 300),1,3,911 studied children in only 1 school or city,1,3,9,11 studied symptoms of internalizing disorders as the only mental health correlate,1,811 or covered only Black children.4,7,8,11,12 For our study, we examined the prevalence and mental health correlates of perceived racial/ethnic discrimination among Black, Hispanic, White, and other fth-grade

Objectives. We sought to describe the prevalence, characteristics, and mental health problems of children who experience perceived racial/ethnic discrimination. Methods. We analyzed cross-sectional data from a study of 5147 fth-grade students and their parents from public schools in 3 US metropolitan areas. We used multivariate logistic regression (overall and stratied by race/ethnicity) to examine the associations of sociodemographic factors and mental health problems with perceived racial/ethnic discrimination. Results. Fifteen percent of children reported perceived racial/ethnic discrimination, with 80% reporting that discrimination occurred at school. A greater percentage of Black (20%), Hispanic (15%), and other (16%) children reported perceived racial/ethnic discrimination compared with White (7%) children. Children who reported perceived racial/ethnic discrimination were more likely to have symptoms of each of the 4 mental health conditions included in the analysis: depression, attention decit hyperactivity disorder, oppositional deant disorder, and conduct disorder. An association between perceived racial/ ethnic discrimination and depressive symptoms was found for Black, Hispanic, and other children but not for White children. Conclusions. Perceived racial/ethnic discrimination is not an uncommon experience among fth-grade students and may be associated with a variety of mental health disorders. (Am J Public Health. 2009;99:878884. doi:10.2105/ AJPH.2008.144329) students. We also examined the relationship between perceived racial/ethnic discrimination and symptoms of 4 mental health disorders for each race/ethnicity; this analysis was based on a conceptual model for child development that incorporates the effect of racial/ethnic discrimination for children in minority status racial/ ethnic groups.13 fth-grade students were in the study population, representing over 99% of all fth-grade students enrolled in regular classrooms in (1) 10 contiguous public school districts in and around Birmingham, AL; (2) 25 contiguous public school districts in Los Angeles County, CA; and (3) the largest public school district in Houston, TX. We randomly sampled schools with probabilities that were a function of how closely a schools racial/ethnic mix corresponded to the studys racial/ethnic target for each site. This procedure (described elsewhere14) ensured adequate sample sizes of Black, Hispanic, and White children. The 118 sampled schools had 11532 enrolled fth-grade students. Each childs primary caregiver or parent (henceforth referred to as parent) was rst contacted by mail for permission to be contacted by study personnel. A total of 6663 parents who either agreed to be contacted or who indicated they were unsure were invited to participate in the study; 77% of them (n = 5147) completed interviews. We obtained

METHODS
We used data from Healthy Passages, a multisite study of health and its correlates among youths.14 Healthy Passages collected data from parent and child interviews on health behaviors, health outcomes, and related risk and protective factors from a cohort of 5147 fthgrade students.

Sampling Procedure
All fth-grade students enrolled in regular classrooms in 3 US metropolitan area public schools with an enrollment of at least 25

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parents informed consent and childrens assent at the time of the interviews, which were conducted at the parents home, study center, or another preferred location. Interviews were computer assisted and conducted in either English or Spanish.

Measures
Racial/ethnic discrimination. To measure perceived racial/ethnic discrimination, we adapted 2 questions previously used in other studies to measure overt discrimination in youth.1,9 We asked children, Have you ever been treated badly because of your race or ethnicity? Because some children may not have understood the terms race and ethnicity, we also asked them, Have you ever been treated badly because of the color of your skin? We developed a dichotomous variable for perceived racial/ethnic discrimination for positive responses to either question. We asked children who answered yes to either question, Did this happen at school? Mental health measures. We adapted 32 questions from the Diagnostic Interview Schedule for Children Predictive Scales (DPS) to assess the presence of symptoms of depression, attention decit hyperactivity disorder (ADHD), oppositional deant disorder (ODD), and conduct disorder over the previous 12 months. DPS is a widely used screening tool that is based on the Diagnostic Interview Schedule for Children1519; it has been shown to identify children who display symptoms of 11 Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV )20 diagnoses (sensitivities and specicities 89% for ADHD, ODD, conduct disorder, and depression).21 Depressive symptoms were child reported; symptoms of ADHD, ODD, and conduct disorder were parent reported. We created a dichotomous variable for symptoms of each disorder, dened by a score that was above the 90th percentile for the total sample; these cutoff scores were a score of 6 of 8 symptoms for ADHD, 8 of 12 symptoms for ODD, 2 of 8 symptoms for conduct disorder, and 5 of 6 symptoms for depression. This provided a more stringent denition of children with symptoms of each disorder than would cutoff values from previously studied community samples.21 Other measures. We also collected demographic data on each childparent dyad,

including child race/ethnicity (parent reported; categorized as non-Hispanic Black, Hispanic, non-Hispanic White, other race/ethnicity), annual household income as a percentage of federal poverty level (either for 20042005 or 20052006, depending on the enrollment year; 100%, 101%299%, 300%), parents educational attainment (less than high school, high school, general equivalency diploma, some college, or a 4-year college degree or more), and household composition (2-parent household, 1-parent household, other household compositions). Other potentially confounding covariates included child born outside the United States and Spanish-language child interview. Because a majority of children reporting perceived racial/ ethnic discrimination said that it occurred at school, we used the proportion of Black, Hispanic, White, and other students enrolled at each school as a continuous variable.

calculated the odds of having symptoms of 4 different mental health disorders for children who reported perceived racial/ethnic discrimination and for those who did not. In each of these models, we controlled for model 1 covariates. These 4 models were stratied by race/ethnicity to determine differences in the association between each mental health measure and perceived racial/ethnic discrimination by race/ethnicity.

RESULTS
Compared with the sampled schools overall fth-grade enrollment (n =11532), 44% versus 32% of survey respondents were Hispanic, 29% versus 31% were Black, 22% versus 34% were White, and 6% versus 3% were other race/ethnicity (data not shown). A majority (73%) of respondents lived in households with incomes under 300% of the federal poverty level, and 69% had a parent who completed high school or college. Ten percent of the children were born outside the United States, and we conducted 8% of child interviews in Spanish (Table 1).

Statistical Methods
All analyses employed design and nonresponse weights. We used Stata/SE version 10 (StataCorp LP, College Station, TX) to account for the effects of both weights and the clustering of children within sites.2224 We used the c2 test of homogeneity and logistic regression to compare the characteristics of children who did and did not report perceived racial/ethnic discrimination. We then used multivariate logistic regression (model 1) to examine the differences in each of these characteristics while controlling for other potentially confounding covariates (study city, poverty level, parental education level, household composition, and child age, gender, foreign birth, and interview language). We examined perceived racial/ethnic discrimination at school with a similar model (model 2) that included variables to indicate school racial/ ethnic composition. Models 1 and 2 were stratied by child race/ethnicity to examine differences in the associations between perceived racial/ethnic discrimination and sociodemographic factors by race/ethnicity. The stratied version of model 2 included a variable indicating the decreasing proportion of the schools enrollment that was of the childs own race/ethnicity. Next, we used the c2 test and simple logistic regression to compare mental health outcomes for children who reported perceived racial/ethnic discrimination with those who did not. In multivariate logistic regression models 3 through 6, we

Perceived Racial/Ethnic Discrimination

Fifteen percent of children reported perceived racial/ethnic discrimination; 12% of the total sample reported discrimination at school. More children in Houston (17%; P = .004) and Los Angeles (15%; P = .03) reported perceived racial/ethnic discrimination than did children in Birmingham (12%). More Black (20%; P < .001), Hispanic (15%; P < .001), and other (16%; P < .001) children compared with White (7%) children reported perceived racial/ethnic discrimination. Children living in households with incomes at or above 300% of the federal poverty level (10%; P < .001) were less likely to report perceived racial/ethnic discrimination when compared with children in households with incomes at or below 100% of federal poverty level (15%). Children of parents without a high school education (16%; P < .001) and children of parents with a high school diploma (15%; P = .001) were more likely to report perceived racial/ ethnic discrimination than were children of parents with at least a 4-year college degree (11%). Children living in 1-parent households (16%; P = .03) or in households without any biological parent (foster or adoptive

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TABLE 1Sample Characteristics, Prevalence of Perceived Discrimination, and Unadjusted and Adjusted Odds Ratios (ORs) of Perceived Racial/Ethnic Discrimination Among FifthGrade Students (N = 5147): Birmingham, AL; Houston, TX; and Los Angeles, CA; 20042006
Total, Unweighted Perceived No. Discrimination, (Weighted %) % Total City Birmingham (Ref) Houston Los Angeles Child race/ethnicity Black Hispanic White (Ref) Other Childs age 11 yc Male child Household income as % of federal poverty level 100 (Ref) 101299 300 Parent education Less than high school High school or some college 4-y college degree or more (Ref) Household composition 2 parent (Ref) 1 parent Foster, adoptive, or other Child born outside United States Child interview in Spanish School composition Black Hispanic White (Ref) Other 2850 (58) 2017 (38) 241 (4) 453 (10) 331 (8) ... ... ... ... ... ... ... ... Note. AOR = adjusted odds ratio; CI = condence interval. Unadjusted ORs were not calculated for school racial/ethnic composition variables. a Model 1 examined the differences in the characteristics of children who did and did not report perceived racial/ethnic discrimination while controlling for other potentially confounding covariates (study city, poverty level, parental education level, household composition, and child age, gender, foreign birth, and interview language). Model 1 does not include covariates for school racial/ethnic composition. b Model 2 examined the perceived racial/ethnic discrimination at school and included variables to indicate school racial/ ethnic composition. c The referent category was childs age 10 years or younger. *P < .05; **P < .01; ***P < .001. ... ... ... 0.4 (0.03, 4.8) ... ... ... 1.0 ... ... ... 1.1 (0.6, 2.2) 13 16 24 14 17 ... 1.0 1.3* (1.0, 1.6) 0.9 (0.6, 1.4) 1.2 (0.8, 1.7) ... 1.0 1.0 (0.8, 1.3) 0.9 (0.5, 1.4) 1.5 (1.0, 2.3) ... 1.0 1.0 (0.8, 1.4) 1.5 (0.9, 2.7) 1.0 (0.6, 1.7) 1.3 (0.8, 2.1) 0.8 (0.4, 1.5) 1224 (31) 2352 (45) 1449 (24) 16 15 11 1.6*** (1.3, 2.0) 1.1 (0.8, 1.6) 1.5** (1.2, 1.9) 1.0 (0.7, 1.4) 1.0 1.0 1.1 (0.7, 1.5) 0.9 (0.7, 1.3) 1.0 1596 (37) 1669 (36) 1477 (27) 15 17 10 1.0 1.2 (0.9, 1.4) 1.0 1.3* (1.1, 1.6) 1.0 1.3* (1.0, 1.7) 0.9 (0.6, 1.3) 1594 (31) 1783 (35) 1770 (34) 1738 (29) 1792 (44) 1224 (22) 393 (6) 2808 (57) 2536 (51) 12 17 15 20 15 7 16 15 15 1.0 1.4* (1.0, 1.9) 1.0 1.0 1.5 (1.0, 2.2) 1.5** (1.1, 2.0) 1.4* (1.0, 1.9) 15 Perceived Discrimination Overall, OR (95% CI) Model 1,a AOR (95% CI) Model 2,b AOR (95% CI)

1.6** (1.1, 2.1) 1.8** (1.2, 2.6)

3.2*** (2.3, 4.4) 2.6*** (1.7, 3.8) 2.8*** (1.7, 4.7) 2.3*** (1.7, 3.2) 1.5 (1.0, 2.3) 1.0 1.1 (0.9, 1.3) 1.2 (0.9, 1.4) 1.0 1.1 (0.9, 1.3) 1.2 (0.9, 1.4) 1.4 (0.9, 2.4) 1.0 1.1 (0.9, 1.3) 1.1 (0.9, 1.3)

2.5*** (1.6, 3.8) 2.1** (1.3, 3.3) 2.4*** (1.5, 3.9)

0.6*** (0.5, 0.7) 0.9 (0.6, 1.3)

households; 24%; P = .002) were more likely to report perceived racial/ethnic discrimination than were children living in 2-parent households (13%; Table 1). In the multivariate analysis, city, child race/ ethnicity, poverty level, and household composition were signicantly associated with perceived racial/ethnic discrimination. Black children had 2.6 times greater odds (95% condence interval [CI] =1.7, 3.8; P < .001) of reporting perceived racial/ethnic discrimination than did White children. Children in households with incomes 101%299% of the federal poverty level were more likely than were those with incomes at or below 100% of the federal poverty level to report perceived racial/ethnic discrimination (odds ratio [OR] =1.3; 95% CI =1.1, 1.6; P = .01). Finally, compared with children in 2-parent households, children in other household compositions (i.e., foster and adoptive households) were more likely to report perceived racial/ethnic discrimination (OR =1.8; 95% CI =1.2, 2.8; P = .01). In the multivariate model for perceived racial/ethnic discrimination at school (with school racial/ethnic composition included as a covariate), city, race, and poverty level were associated with perceived racial/ethnic discrimination (Table 1).

Perceived Racial/Ethnic Discrimination by Child Race/Ethnicity

In the multivariate model for Black children, those in Los Angeles were more likely than were those in Birmingham to report perceived racial/ethnic discrimination (OR =1.9; 95% CI =1.3, 2.7; P = .002). Among Hispanic children, those in households with incomes at 101%299% of the federal poverty level were more likely to report perceived racial/ethnic discrimination (OR =1.5; 95% CI =1.1, 2.0; P = .02) than were children in households with incomes at or below 100% of the federal poverty level. Children who completed Spanish-language interviews were also more likely to report perceived racial/ethnic discrimination (OR =1.7; 95% CI =1.1, 2.8; P = .03) than were those who completed English-language interviews. Finally, among White children, poverty level was the only signicant covariate; those in households with incomes at or below 100% of the federal poverty level were more likely to report perceived racial/ethnic

2.1** (1.3, 3.4) 1.8* (1.2, 2.8)

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discrimination than were those in households with incomes at or above 300% of the federal poverty level (OR = 0.2; 95% CI = 0.1, 0.5; P = .002; Table 2). In the stratied models for perceived racial/ ethnic discrimination at school, city remained a signicant predictor of perceived racial/ethnic discrimination for Black children, but poverty level was no longer a signicant predictor for Hispanic children. Lower poverty levels remained associated with perceived racial/ ethnic discrimination for White children. A decreasing proportion of student enrollment of the childs own race/ethnicity at school was associated with a higher likelihood of perceived racial/ethnic discrimination among Black, White, and other children (Table 2). For all but Hispanic children, this variable had one of the strongest associations in magnitude with perceived racial/ethnic discrimination of any independent variable. For example, a Black student in a school with no other Black students had 3 times the odds of reporting perceived racial/ethnic discrimination compared with a Black student in a school that was nearly 100% Black. This is twice the magnitude of the next largest signicant effect on perceived racial/ethnic discrimination: study city. Similarly, the only White student in a school had 19 times the odds of reporting perceived racial/ethnic discrimination when compared with a White student in an almost entirely White school, a larger difference than the effect of household income or foreign birth.

and other children. Hispanic children who reported perceived racial/ethnic discrimination were more likely than were other Hispanic children to have symptoms of each of the 4 mental health conditions. Black children who reported perceived racial/ethnic discrimination were more likely to have symptoms of depression and conduct disorder only. White children who reported perceived racial/ethnic discrimination were more likely to have symptoms of ODD and conduct disorder. Children of other race/ethnicity were more likely to report symptoms of depression only.

DISCUSSION
Fifteen percent of fth-grade children reported perceived racial/ethnic discrimination; most of these experiences occurred at school. We found positive associations between perceived racial/ethnic discrimination and symptoms of depression, ADHD, ODD, and conduct disorder. The strongest and most consistent association across non-White racial/ethnic groups, however, was between symptoms of depression and perceived racial/ethnic discrimination, with an OR of 2.6 to 3.9 for Black, Hispanic, and other children. This association was not signicant among White children. In a smaller study of Puerto Rican children, researchers found that 49% of children aged 13 and 14 years reported perceived racial/ethnic discrimination, whereas just12% of children aged 7 to 9 years did so.9 Our nding that 15% of children aged 10 to 11 years reported perceived racial/ethnic discrimination also suggests that younger children may less frequently perceive racial/ethnic discrimination than do adolescents. We also found that lower poverty levels were associated with less perceived racial/ethnic discrimination by Hispanics and more perceived discrimination by Whites. One possible reason for this difference could be the racial/ ethnic composition of communities in which the families live. Researchers have hypothesized that among Black youths, higher socioeconomic status may increase their exposure to perceived racial/ethnic discrimination by exposing the child to more individuals of different races/ethnicities.7 Although our data for Black children did not support this hypothesis, the model for Hispanic children did. In addition, because many high-poverty neighborhoods are

Mental Health
Table 3 shows the percentage of children with perceived racial/ethnic discrimination with symptoms of depression, ADHD, ODD, and conduct disorder. After controlling for covariates, children who reported perceived racial/ethnic discrimination were more likely to have symptoms of depression (OR = 2.7; 95% CI = 2.0, 3.5; P < .001), ADHD (OR =1.6; 95% CI =1.2, 2.1; P = .002), ODD (OR =1.8; 95% CI =1.4, 2.4; P < .001), and conduct disorder (OR = 2.1; 95% CI =1.5, 2.8; P < .001) than were children who did not report discrimination. In stratied analyses (Table 4), there were differences in this association between mental health measures and perceived racial/ethnic discrimination among Black, Hispanic, White,

disproportionately Black and Hispanic,25 White children with lower incomes may be more likely to be exposed to non-White children and experience discrimination. In the stratied models for perceived racial/ethnic discrimination at school, we found that the proportion of students at school of the childs own race/ethnicity was the strongest predictor of perceived racial/ ethnic discrimination for all non-Hispanic racial/ ethnic groups. Thus, exposure to children of different races/ethnicities was more important than any socioeconomic factor, including poverty level, in predicting perceived racial/ethnic discrimination at school. Children reporting perceived racial/ethnic discrimination were more likely to have symptoms of all 4 mental health conditions compared with children not reporting discrimination. Although the association was strongest for depressive symptoms, there were also signicant associations with ADHD, conduct disorder, and ODD symptoms. Other studies have found a strong link between perceived racial/ethnic discrimination and internalizing3,8,9,12,26 and externalizing symptoms.8,9,27 A study of 714 Black children found that increases in perceived racial/ethnic discrimination over a 5-year period were associated with depressive symptoms and conduct problems.7 Another study of 136 adolescents documented an association between perceived racial/ethnic discrimination and depressive symptoms among Black, Asian, and Hispanic children.1 In the study of Puerto Rican children, those who reported perceived racial/ethnic discrimination had signicantly more depressive symptoms. Parents of children with perceived racial/ethnic discrimination reported more behavioral problems than did those who did not report perceived racial/ethnic discrimination.9 Finally, in a study of 84 Black male children, researchers found that perceived racial/ ethnic discrimination was associated with externalizing and internalizing symptoms, low self-concept, and hopelessness.11 There were important differences in the association of mental health measures and perceived racial/ethnic discrimination for each racial/ethnic group. Among Hispanic children, perceived racial/ethnic discrimination was positively associated with symptoms of all 4 mental health disorders. The ORs for each mental health measure were,

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TABLE 2Adjusted Odds Ratios (AORs) of Fifth-Grade Students Perceived Racial/Ethnic Discrimination, Overall and at School, by Race/Ethnicity: Birmingham, AL; Houston, TX; and Los Angeles, CA; 20042006
Black, AOR (95% CI) Overall City Birmingham (Ref) Houston Los Angeles Childs age 11 y Male child Household income as % of federal poverty level 100 (Ref) 101299 300 Parent education Less than high school High school or some college 4-y college degree or more (Ref) Household composition 2 parent (Ref) 1 parent Foster, adoptive, or other Child born outside United States Child interview in Spanish City Birmingham (Ref) Houston Los Angeles Childs age 11 y Male child Household income as % of federal poverty level 100 (Ref) 101299 300 Parent education Less than high school High school or some college 4-y college degree or more (Ref) Household composition 2 parent (Ref) 1 parent Foster, adoptive, or other Child born outside United States Child interviewed in Spanish Decreasing proportion of student enrollment of childs own race/ethnicity by school Note. CI = condence interval. *P < .05; **P < .01; ***P < .001. 1.0 1.0 (0.7, 1.3) 1.2 (0.5, 3.2) 0.5 (0.1, 1.7) ... 3.1*** (1.8, 5.1) 1.0 1.1 (0.8, 1.6) 2.8* (1.2, 6.5) 1.0 (0.5, 1.9) 1.6 (0.9, 2.7) 1.6 (0.8, 3.4) 1.0 0.5 (0.2, 1.1) 0.2 (0.03, 2.0) 4.0** (1.5, 11.1) ... 19.1** (3.6, 101.4) 1.0 2.3 (0.8, 6.2) 3.7* (1.1, 12.6) 0.5 (0.2, 1.6) ... 103* (1.7, > 103) 1.0 (0.5, 2.2) 1.0 (0.7, 1.5) 1.0 1.4 (0.7, 2.6) 1.2 (0.6, 2.4) 1.0 1.5 (0.6, 3.7) 0.6 (0.3, 1.1) 1.0 0.5 (0.1, 3.1) 0.6 (0.3, 1.2) 1.0 1.0 1.2 (0.9, 1.7) 1.1 (0.7, 1.8) 1.0 1.5 (1.0, 2.2) 1.0 (0.5, 2.1) 1.0 0.4** (0.2, 0.8) 0.2** (0.1, 0.5) 1.0 0.9 (0.4, 1.8) 0.4 (0.2, 1.1) 1.0 1.1 (0.7, 1.6) 1.5* (1.0, 2.1) 1.1 (0.8, 1.4) 1.0 (0.7, 1.4) 1.0 1.2 (0.3, 5.0) 1.6 (0.4, 6.7) 1.1 (0.8, 1.6) 1.1 (0.8, 1.6) 1.0 0.5 (0.2, 1.3) 0.5 (0.2, 1.3) 0.8 (0.4, 1.6) 0.9 (0.5, 1.6) 1.0 1.9 (0.7, 5.5) 1.9 (0.6, 5.9) 1.0 (0.5, 2.0) 1.5 (0.7, 3.2) 1.0 0.9 (0.7, 1.2) 1.4 (0.8, 2.8) 0.4 (0.1, 1.5) ... 1.0 1.1 (0.8, 1.6) 2.2 (0.9, 5.1) 0.9 (0.5, 1.6) 1.7* (1.1, 2.8) At school 1.0 0.6 (0.3, 1.4) 1.5 (0.3, 7.7) 2.8 (1.0, 7.9) ... 1.0 2.3 (0.9, 6.0) 4.2* (1.2, 15.1) 0.5 (0.2, 1.4) ... 1.0 1.3 (0.9, 1.7) 1.4 (0.9, 2.2) 1.0 (0.5, 1.9) 1.0 (0.7, 1.5) 1.0 1.0 1.5* (1.1, 2.0) 0.9 (0.5, 1.9) 1.1 (0.6, 2.0) 0.9 (0.5, 1.8) 1.0 1.0 0.5 (0.2, 1.0) 0.2** (0.1, 0.5) 1.4 (0.6, 3.5) 1.0 (0.6, 1.7) 1.0 1.0 1.0 (0.5, 2.0) 0.5 (0.2, 1.2) 0.8 (0.1, 5.1) 0.9 (0.4, 1.7) 1.0 1.0 1.3 (0.9, 2.0) 1.9** (1.3, 2.7) 1.0 (0.7, 1.3) 1.2 (0.9, 1.6) 1.0 1.1 (0.8, 4.3) 1.4 (0.3, 5.5) 1.2 (0.9, 1.6) 1.2 (0.8, 1.6) 1.0 1.8 (1.0, 3.2) 1.1 (0.6, 2.1) 0.9 (0.5, 1.8) 1.0 (0.6, 1.7) 1.0 2.1 (0.8, 6.0) 1.2 (0.4, 3.3) 1.0 (0.5, 2.0) 1.4 (0.8, 2.6) Hispanic, AOR (95% CI) White, AOR (95% CI) Other, AOR (95% CI)

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TABLE 3Prevalence of Mental Health Condition Symptoms and Unadjusted and Adjusted Odds Ratios (ORs) of Having Symptoms of a Mental Health Condition Among Fifth-Grade Students, by Perceived Racial/Ethnic Discrimination: Birmingham, AL; Houston, TX; and Los Angeles, CA; 20042006
Overall Prevalence, No. (%) Depression ADHD ODD Conduct disorder 366 (7) 515 (10) 407 (8) 431 (8) Prevalence Among Those Who Perceived Discrimination, % 31 21 23 25

OR (95% CI) 2.9*** (2.3, 3.8) 1.6*** (1.3, 2.1) 1.8*** (1.4, 2.4) 2.1*** (1.6, 2.8)

AORa (95% CI) 2.7*** (2.0, 3.5) 1.6** (1.2, 2.1) 1.8*** (1.4, 2.4) 2.1*** (1.5, 2.8)

Note. ADHD = attention decit hyperactivity disorder; ODD = oppositional deant disorder; AOR = adjusted odds ratio; CI = condence interval. a ORs were adjusted for race/ethnicity, parent education, poverty level, child age and gender, city, household composition, child interview language, and child foreign birth. **P < .01; ***P < .001.

that was foreign born). The majority, however, came from families with US-born parents and spoke English as the only language at home. No previous studies have examined this association for nonimmigrant White preadolescent children in the United States. However, a study of a multiethnic sample of 177 adolescents found that White adolescents reported less distress from experiences of institutional and educational-related racial/ethnic discrimination than did Black or Hispanic adolescents.3 Further research is needed to investigate possible mechanisms or models to explain the association between symptoms of ADHD and perceived racial/ethnic discrimination that we found among Hispanic children only.

Limitations
There are limitations to this study. First, we conducted this study in 3 metropolitan areas in the United States, but the results may not generalize to the overall US population of similarly aged children. Second, nonresponse bias may be present because we did not have permission to contact all parents for inclusion in the study. However, the sampling weights account for differential nonresponse by gender, race/ethnicity, and school, ensuring the representativeness of the weighted sample with respect to these characteristics and reducing potential nonresponse bias. Third, this study focused on 2 questions to determine perceived racial/ethnic discrimination. There are other measures of perceived racial/ethnic discrimination that provide more detailed information on the nature of these discriminatory experiences (e.g., discrimination by peers or teachers).5,29 Fourth, other types of discrimination (e.g., gender discrimination) may also be related to childrens mental health. Lastly, from our data, we do not know if episodes of discrimination caused, or even preceded, the mental health problems.

TABLE 4Adjusted Odds Ratios (AORs) of Having Symptoms of a Mental Health Condition, by Perceived Racial/Ethnic Discrimination, Among Fifth-Grade Students: Birmingham, AL; Houston, TX; and Los Angeles, CA; 20042006
Blacks Perceiving Discrimination, AOR (95% CI) Depression ADHD ODD Conduct disorder 2.6*** (1.6, 4.2) 1.4 (0.9, 2.0) 1.6 (1.0, 2.5) 1.9** (1.3, 2.8) Hispanics Perceiving Discrimination, AOR (95% CI) 3.3*** (2.1, 5.2) 2.0** (1.2, 3.2) 2.4*** (1.5, 3.9) 2.3* (1.2, 4.2) Whites Perceiving Discrimination, AOR (95% CI) 1.2 (0.5, 3.0) 2.0 (0.9, 4.4) 2.4* (1.1, 5.3) 3.7** (1.7, 7.9) Other Races/Ethnicities Perceiving Discrimination, OR (95% CI) 3.9* (1.2, 12.7) 0.5 (0.1, 1.7) 0.9 (0.1, 7.1) 0.4 (0.1, 1.4)

Note. ADHD = attention decit hyperactivity disorder; ODD = oppositional deant disorder CI = condence interval. ORs were adjusted for race/ethnicity, parent education, poverty level, child age and gender, city, household composition, and child foreign birth. ORs for Hispanic children were additionally adjusted for childs interview language. *P < .05; **P < .01; ***P < .001.

in general, greater for Hispanic than for Black children, and there were fewer mental health correlates of perceived racial/ethnic discrimination among Black children; we do not have data to explain these ndings. Parents of US-born Black children are more likely to be US-born themselves and to have experienced racial discrimination as youths. These parents may use their own experiences to help their child anticipate and deal with discrimination. Seventy-eight percent of the Hispanic children who reported perceived racial/ ethnic discrimination had foreign-born parents, who likely did not encounter US racial/ ethnic discrimination during their own

childhood; however, racism is a broad, international problem that also affects many Latin American countries.28 White children were the only racial/ethnic group that did not have an association between perceived racial/ethnic discrimination and depressive symptoms; perceived racial/ethnic discrimination was only associated with symptoms of externalizing disorders. In addition, we found a negative association between income and perceived racial/ethnic discrimination for White children but not for other racial/ethnic groups. Of the White children who reported perceived racial/ethnic discrimination, some were children of immigrants (16% had a parent

Conclusions
Our ndings suggest that perceived racial/ ethnic discrimination is not an uncommon experience for fth-grade students and may have deleterious effects on their mental health. Although other studies have examined this association with smaller samples and more limited mental health measures, to our knowledge, ours is the rst to examine both the

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RESEARCH AND PRACTICE

prevalence and variety of mental health correlates of perceived racial/ethnic discrimination in a large, multisite sample of Black, Hispanic, White, and other preadolescent children. We found that the association between perceived racial/ethnic discrimination and mental health measures differs by race/ethnicity, suggesting that this association may have different mechanisms by child race/ethnicity and mental health condition. Conceptual models that help us understand the association between symptoms of depression or conduct disorder may therefore not fully explain the association for ADHD. Our ndings also have implications for childrens mental health care. Public health professionals and pediatric health care providers may be able to help families address and cope with racial/ethnic discrimination experienced by children and may need to give particular attention to discrimination as they evaluate children for mental health disorders. Because the majority of children who experienced perceived racial/ethnic discrimination experienced it at school, these discussions may t well into the discussions of school environment that many families already have with their health care providers. j

authors contributed to the study design and review of drafts of the article.

Acknowledgments
The Healthy Passages Study is funded by the Centers for Disease Control and Prevention, Prevention Research Centers (cooperative agreements U48DP000046, U48DP000057, and U48DP000056). Note. The ndings and conclusions in this report are those of the authors and do not necessarily represent the ofcial position of the Centers for Disease Control and Prevention.

13. Garcia Coll C, Lamberty G, Jenkins R, et al. An integrative model for the study of developmental competencies in minority children. Child Dev. 1996;67: 18911914. 14. Windle M, Grunbaum JA, Elliott M, et al. Healthy passages. A multilevel, multimethod longitudinal study of adolescent health. Am J Prev Med. 2004;27:164172. 15. Leung PW, Lucas CP, Hung SF, et al. The test-retest reliability and screening efciency of DISC Predictive Scales-version 4.32 (DPS-4.32) with Chinese children/ youths. Eur Child Adolesc Psychiatry. 2005;14:461465. 16. Hoven CW, Duarte CS, Lucas CP, et al. Psychopathology among New York city public school children 6 months after September 11. Arch Gen Psychiatry. 2005; 62:545552. 17. Chen KW, Killeya-Jones LA, Vega WA. Prevalence and co-occurrence of psychiatric symptom clusters in the U.S. adolescent population using DISC predictive scales. Clin Pract Epidemol Ment Health. 2005;1:22. 18. Shaffer D, Fisher P, Lucas CP, et al. NIMH Diagnostic Interview Schedule for Children version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. J Am Acad Child Adolesc Psychiatry. 2000;39:2838. 19. Grupp-Phelan J, Wade TJ, Pickup T, et al. Mental health problems in children and caregivers in the emergency department setting. J Dev Behav Pediatr. 2007;28: 1621. 20. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC: American Psychiatric Association; 1994. 21. Lucas CP, Zhang H, Fisher PW, et al. The DISC Predictive Scales (DPS): efciently screening for diagnoses. J Am Acad Child Adolesc Psychiatry. 2001;40:443449. 22. Williams RL. A note on robust variance estimation for cluster-correlated data. Biometrics. 2000;56:645 646. 23. Skinner CJ. Domain means, regression and multivariate analyses. In: Skinner CJ, Holt D, Smith TMF, eds. Analysis of Complex Surveys. Chichester, England: Wiley; 1989:5988. 24. Wooldridge J. Econometric Analysis of Cross Section and Panel Data. Cambridge, MA: MIT Press; 2002. 25. diversitydata.org and Harvard School of Public Health. Metropolitan quality of life data. Share of population living in high poverty areas, 2000 Available at http:// www.diversitydata.org. Accessed January 6, 2008. 26. Gibbons FX, Gerrard M, Cleveland MJ, et al. Perceived discrimination and substance use in African American parents and their children: a panel study. J Pers Soc Psychol. 2004;86:517529. 27. DuBois DL, Burk-Braxton C, Swenson LR, et al. Race and gender inuences on adjustment in early adolescence: investigation of an integrative model. Child Dev. 2002;73:15731592. 28. Coalition of Latin American and Caribbean Cities Against Racism, Discrimination and Xenophobia. First Annual General Conference of the Coalition of Latin American and Caribbean Cities Against Racism, Discrimination and Xenophobia; September 2526, 2007; Montevideo, Uruguay. 29. Landrine H, Klonoff EA. The schedule of racist events: a measure of racial discrimination and a study of its negative physical and mental health consequences. J Black Psychol. 1996;22:144168.

Human Participant Protection

Institutional review boards at each study site and the Centers for Disease Control and Prevention approved this study.

References
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About the Authors

Tumaini R. Coker is with the Department of Pediatrics, Mattel Childrens Hospital, David Geffen School of Medicine, University of California, Los Angeles, and the RAND Corporation, Santa Monica, CA. Marc N. Elliott and David E. Kanouse are with the RAND Corporation, Santa Monica, CA. Jo Anne Grunbaum is with the Division of Adult and Community Health, Centers for Disease Control and Prevention Research, Atlanta, GA. David C. Schwebel is with the Department of Psychology, University of Alabama, Birmingham. M. Janice Gilliland is with the Department of Maternal and Child Health, University of Alabama, Birmingham. Susan R. Tortolero and Melissa F. Peskin are with the Center for Health Promotion and Prevention Research, University of Texas Health Science Center-Houston, Houston. Mark A. Schuster is with the Department of Medicine, Childrens Hospital Boston, Harvard Medical School, Boston, MA, and the RAND Corporation, Santa Monica. Requests for reprints should be sent to Tumaini R. Coker at UCLA/RAND Center for Adolescent Health Promotion, 1072 Gayley Ave, Los Angeles, CA 90024 (e-mail: tcoker@mednet.ucla.edu). This article was accepted September 2, 2008.

Contributors
T. R. Coker was responsible for study origination, data analysis, interpretation of ndings, and writing the article. M. N. Elliott and D. E. Kanouse contributed to data analysis and interpretation of ndings. M. A. Schuster contributed to data analysis, interpretation of ndings, critical review of the article, and overall supervision. All

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American Journal of Public Health | May 2009, Vol 99, No. 5