Racism-Related Experiences and Traumatic Stress Symptoms in Ethnoracially Minoritized Youth: A Systematic Review and Meta-Analysis

ABSTRACT

Objective

Despite growing evidence demonstrating the association between racial and ethnic discrimination and traumatic stress symptoms in adult populations, the research among youth remains sparse. Drawing upon race-based traumatic stress models, and following the PRISMA-2020 guidelines, this systematic review and meta-analysis aimed to identify the state of the empirical evidence in the association between racism-related experiences and traumatic stress symptoms in ethnoracially minoritized youth.

Method

Scientific databases were searched to identify articles with ethnoracially minoritized youth participants under age 18 years old that examined the association between racial and/or ethnic discrimination and traumatic stress symptoms.

Results

A total of 18 articles comprising 16 studies (N = 4,825 participants) met inclusion criteria. Studies were largely cross-sectional, used nonrandom sampling strategies, focused on Black and Latinx youth, and were conducted in the United States. Furthermore, most studies were theoretically grounded and operationalized racism-related experiences as frequency of direct, personal, everyday discrimination. Few studies examined other dimensions of racism-related experiences. The meta-analysis demonstrated a significant positive association with a medium effect size, r_pooled = .356, 95% confidence interval [CI] = 0.27, 0.44, between racism-related experiences and traumatic stress symptoms. No evidence of moderation by age, sex/gender, race/ethnicity, country, or recruitment setting was detected.

Conclusion

Racism-related experiences may confer risk for traumatic stress symptoms in ethnoracially minoritized youth. Attending to racism-related experiences is critical to improve the cultural responsiveness of trauma-informed services.

Introduction

Racism is a social determinant of health underlying racial and ethnic disparities in health outcomes in connection to, and independent of, poverty (Phelan & Link, 2015). Despite the growing evidence of the harmful effects of racism-related experiences on youth mental health (Benner et al., 2018; Priest et al., 2013), studies on traumatic stress symptoms remain scarce. Racism is a system of power rooted in a hierarchically stratified social structure that perpetuates the oppression of ethnoracially minoritized groups through the inequitable allocation of political, social, and economic resources (Harrell, 2000). Manifestations of racism are wide-ranging and evident across multiple systems (e.g., healthcare, education, housing) and multiple levels (e.g., cultural, institutional, individual, internalized) (Williams & Mohammed, 2013). Thus, racism-related experiences are pervasive, chronic, and insidious and may exert their harm, in part, by causing psychological injuries, and impeding the recovery from these or other injuries.

Ethnoracially minoritized youth are uniquely tasked with developing social identities and navigating group memberships through a devalued social status resulting from the historical and sociopolitical context of a racialized society (García Coll et al., 1996; Spencer et al., 1997). Developmental models centering the lives of ethnoracially minoritized youth emphasize the ways in which racism-related experiences can influence cognitive, emotional, social, and behavioral processes, resulting in far-reaching and enduring effects throughout their lives (García Coll et al., 1996; Spencer et al., 1997). Thus, racial/ethnic discrimination, which constitutes an individual-level, behavioral manifestation of racism that is perceptible and characterized by unjust treatment based on a person’s racial or ethnic group affiliation, is a common experience for ethnoracially minoritized youth (Greene et al., 2006; Pachter et al., 2010; Seaton & Douglass, 2014; Seaton et al., 2008). Moreover, research shows that the occurrence and perceptibility of racial/ethnic discrimination increases from childhood to adolescence (Benner & Graham, 2013; Hughes et al., 2016). This corresponds with increases in psychological distress and decreases in self-esteem later in life (Greene et al., 2006; Hughes et al., 2016).

The negative impact of direct racial/ethnic discrimination results from both overt (e.g., racism-based insults or assaults) and covert (e.g., racism-based prejudices or stereotypes) displays. These common occurrences are also referred to as everyday discrimination or microaggressions (Williams & Mohammed, 2013). Indirect or vicarious exposures to racism (e.g., witnessing someone subjected to racial/ethnic discrimination) have also been identified among youth (Heard-Garris et al., 2018). Institutional-level racism, or racial biases in practices and policies within organizations or institutional settings (i.e., major discriminatory events), assessed as discrimination perpetrated by adults in positions of authority (e.g., teachers, police officers, security guards), is particularly prevalent among Black and Latinx youth in the U.S (Benner & Graham, 2013; Greene et al., 2006). More contemporary manifestations of racism have emerged via online or virtual settings. Similarly, online racial discrimination has been linked to increases in psychological symptoms (i.e., depression, anxiety, externalizing behaviors), particularly among Black and Latinx youth who report spending significant time online (Tynes et al., 2010, 2019).

Prior findings from meta-analytic studies demonstrate the detrimental impact of racial/ethnic discrimination on physical and mental health (Carter et al., 2019; Paradies et al., 2015; Pascoe & Richman, 2009), albeit largely in adults. Recent research suggests that increases in racial/ethnic discrimination are also linked to psychological symptoms including depression and anxiety, social and emotional difficulties, behavioral problems, substance misuse, and suicidal thoughts and behaviors among youth (Benner et al., 2018; Galán et al., 2021; Priest et al., 2013). Further, exposure to racial/ethnic discrimination at a younger age and cumulative exposures over time are associated with greater psychological symptomatology (Cave et al., 2020). Findings from these prior reviews are limited, however, as they did not include meta-analyses (Cave et al., 2020; Priest et al., 2013; Roach et al., 2023); the only one to do so did not include clinical traumatic stress symptoms (Benner et al., 2018). Thus, less is known about the association between racial/ethnic discrimination and youths’ traumatic stress symptoms. To better meet the mental health needs of ethnoracially minoritized youth, it is critical that we understand the role of racism-related experiences in the development of traumatic stress symptoms in this population.

Considering the pervasive, chronic, and distressing nature of racial/ethnic discrimination, scholars propose that, for some individuals, racial/ethnic discrimination may be a potentially traumatic stressor that overwhelms an individual’s capacity to cope. Shaped by one’s appraisal of and subjective response to racism-based incidents, these experiences may result in psychological or emotional injuries (Bryant-Davis & Ocampo, 2005; Carter, 2007; Comas-Díaz et al., 2019) whereby youth may develop adaptations in response to racism that render them vulnerable to mental health problems outside of the context of racist-based events. Supporting this notion, research conducted with adults suggests that racial/ethnic discrimination may overwhelm the stress response system to elicit traumatic stress symptoms (e.g., hyperarousal, avoidance, and dissociation) (Kirkinis et al., 2021). Findings from a systematic review of 28 studies on racial discrimination and trauma symptomatology, largely in adults, reported a significant association that ranged in strength across subgroups (Kirkinis et al., 2021). Moreover, they found that the existing research lacked measures assessing stress resulting specifically from racism-related experiences and most studies did not account for other trauma exposures. Research on racism-based traumatic stress in youth, however, remains scarce.

In a similar vein, developmental science research shows that ongoing exposure to chronic stress early in life may compromise neurodevelopment in children by overtaxing stress response systems such as neuroendocrine, neurochemical, neurocognitive, and psychophysiological processes (Heim & Nemeroff, 2002; Pechtel & Pizzagalli, 2011; Taylor, 2010). These alterations may disrupt self-regulatory processes, rendering youth more vulnerable to subsequent stressors later in life (McEwen, 2012; Teicher & Samson, 2016). The impact of potentially traumatic events is not only shaped by the frequency and nature of the exposure, but also by the timing of the exposure and subjective response to the trauma (Cloitre et al., 2009). Thus, trauma frameworks that highlight the importance of early and cumulative exposures to psychosocial stressors, particularly those interpersonal in nature, such as complex and developmental trauma (Cloitre et al., 2009; Courtois, 2008; D’Andrea et al., 2012) may advance our understanding of how racial/ethnic discrimination may yield racism-based traumatic stress symptoms in ethnoracially minoritized youth.

The present systematic review and meta-analysis aims to assess the current state of the research on the potential mental health impact of racism-based experiences in ethnoracially minoritized youth. Specifically, this review synthesizes the existing evidence of the association between racism-related experiences and traumatic stress-related symptoms in ethnoracially minoritized children and adolescents.

Methods

The systematic review strategy was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) approach using the PRISMA 2020 checklist (Page et al., 2021). The protocol for this review was published via PROSPERO international prospective register of systematic reviews (PROSPERO 2022 CRD42022310642; Available: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022310642). Ethical approval was not required as human participants were not directly involved in this study.

Eligibility Criteria

Only peer-reviewed articles that described associations between racism-related experiences and traumatic stress symptoms among ethnoracially minoritized children and adolescents were included. The following inclusion criteria were used to identify eligible articles:

1. The majority (at least 50%) of study participants identify as a member of a racially and/or ethnically minoritized group within their respective contexts (e.g., Black/African American, Latinx/Hispanic, Asian/Asian American, Native American/American Indian, Native Hawaiian, Pacific Islander, Middle Eastern/North African) indicating that the study design centered the experiences of ethnoracially minoritized youth; and

2. Participants, on average, are younger than 18 years according to the descriptive statistics reported. If the study was longitudinal, this criterion was applied to the first study time point; and

3. Assessed any form of racism-related experience (e.g., discrimination, prejudice, bias, stereotypes, assaults, insults, harassment), or any type of unfair treatment based on race, ethnicity, ancestry, culture, or skin color, across any level (e.g., cultural, institutional, interpersonal, internalized), across any setting (e.g., direct, indirect, in-person, online); and

4. Assessed clinically significant traumatic stress symptoms as per DSM criteria including alterations in arousal, cognitions and moods, avoidance, reexperiencing, and dissociation regardless of the informant (i.e., parent/caregiver, youth); and

5. Assessed the association between racism-related experiences and traumatic stress symptoms.

Articles were excluded if participants were predominantly non-Hispanic White; participants were not children/adolescents (i.e., 18-years-old or older); the study assessed general experiences of discrimination that could not be isolated from racial/ethnic discrimination (e.g., gender, socioeconomic status, sexual orientation); the manuscript was written in a language other than English or Spanish; the manuscript was not an original research paper (e.g., review or conceptual paper, commentary, letter to the editors); or the manuscript was not published in a peer-reviewed scholarly journal (e.g., dissertation, thesis, book, book chapter, preprint).

Search Strategy and Data Extraction

PsycINFO, EMBASE, and PubMed were initially searched on February 15, 2022. We adapted the search terms and parameters of a past systematic review examining associations between racism-related exposures and traumatic stress in adults (Kirkinis et al., 2021). Specifically, our search included terms related to racism and discrimination AND terms reflecting symptoms of posttraumatic stress AND terms for children and adolescents (see Appendix 1). We did not limit the date of our search. The included studies’ reference lists were also reviewed, as were articles citing the included studies. The search was repeated on September 24, 2023, to capture studies published since the initial search.

Following de-duplication, articles were reviewed via a two-stage process. During the initial phase, two members of the research team conducted an independent, simultaneous review of article titles and abstracts (ES and MI). This process was guided by a decision tree of eligibility criteria. Inclusion and exclusion decisions were tracked in Rayyan QCRI, a web-based software (Ouzzani et al., 2016). A third reviewer (either LPR or CG) was consulted if the two screeners could not reach consensus. Following the initial screening process, four members of the research team conducted the full-text review. One team of two reviewers was assigned to the first half of the articles (ES and MI), while the other team of two reviewers was assigned to the second half of the articles (AML and CE). Five articles were assigned to both teams to calibrate and ensure consistency in decisions.

Data extraction was performed by four independently trained coders (AML, CE, ES, and MI). Interrater reliability was strong with over 90% agreement using a random selection of 10% of the articles. This test was conducted prior to extracting data in the remaining articles. The following data were extracted into a preformatted table: pertinent bibliographic information, sample demographics (e.g., age, sex/gender, race/ethnicity, socioeconomic status), study characteristics (e.g., sample size, recruitment setting, geographic location), theoretical frameworks cited, tools used to measure racism-related experiences, tools used to measure traumatic stress-related symptoms, data analytic strategies, main findings, covariates included in analyses, other relevant findings, and study quality assessment. Discrepancies were identified and resolved in consultation with another member of the study team (either LPR or CG), and if necessary, through group discussion and consensus by the team.

Analysis and Synthesis

Following data extraction, the findings were coded and synthesized to characterize the empirical evidence of the association between racism-related experiences and traumatic stress-related symptoms among ethnoracially minoritized children and adolescents. Methodological approaches across the studies were summarized, including study design (i.e., quantitative vs. qualitative, cross-sectional vs. longitudinal); target population and sampling strategy (e.g., age range, racial/ethnic groups, country, clinical vs. community sample); and the conceptualization and operationalization of racial discrimination and traumatic stress as evidenced by the range and quality of the assessments. Quantitative studies were assessed for the presence and strength of reported associations between racism-related experiences and traumatic stress (e.g., effect sizes). For qualitative studies, overarching themes were identified and incorporated through narrative synthesis.

Study Quality Assessment

The Newcastle-Ottawa Scale (NOS), adapted for various study designs (e.g., cross-sectional, case control, cohort, longitudinal), was used to ascertain the quality of and risk of publication bias in quantitative studies. The following categories were assessed: sample representativeness, sample size, non-respondents, ascertainment of exposures, ascertainment of outcomes, and quality of descriptive statistics reporting. Depending on cutoff thresholds, articles were rated as “good,” “fair” or “poor” quality. The Critical Appraisal Skills Programme (CASP) was used to ascertain the quality of qualitative studies. Each study was assessed for appropriateness of study design, recruitment strategy, data collection, and analysis. One study was a mixed method design and quality was assessed with both scales.

Meta-Analysis

Where available, quantitative data were extracted that assessed the frequency and/or count of experienced racial or ethnic discrimination as associated with traumatic stress symptoms. All effect sizes were presented or converted to Pearson r. When r-values were delineated by gender (Loyd et al., 2019; Scrimin et al., 2014) or were collected at different time points (Meléndez Guevara et al., 2022) these associations were pooled by converting values to z-scores, averaging the z-scores, then converting them back to r-values (Silver & Dunlap, 1987).¹ Correlations to subscales were not included if a score for the whole inventory was available. Other notes pertaining to specific modifications or accommodations of studies are presented in Table 2.

Table 1. Study and sample characteristics of all articles included in the systematic review.

k=18	k (%) of studies
Year of Publication
2008–2013	4 (22.22)
2014–2019	5 (27.78)
2020–2023	9 (50.00)
Sample Size
n < 100	2 (11.11)
n = 100–500	12 (66.67)
n = 500–1000	2 (11.11)
n > 1,000	2 (11.11)
Geographic region
United States	15 (83.33)
Europe	3 (16.67)
Racial/Ethnic Groups
Multiple race/ethnic groups	8 (44.44)
Black/African American	4 (22.22)
Latino/a/x/e/Hispanic	3 (16.66)
Native American/American Indian	1 (5.56)
Asian/Asian American	1 (5.56)
Middle Eastern (i.e., Druze)	1 (5.56)
Study Design
Quantitative (cross-sectional)	14 (77.78)
Quantitative (longitudinal)	3 (16.67)
Qualitative/Mixed Method	1 (5.56)
Sampling Strategy^
School-based setting	9 (50.00)
Community-based setting	6 (33.33)
Justice-involved setting	3 (16.67)
Clinic-based setting	4 (22.22)
Racism-related Construct Examined^
Everyday discrimination (i.e., interpersonal)	15 (83.33)
Major discriminatory events (i.e., institutional)	9 (50.00)
Indirect/Vicarious	4 (22.22)
More than 1 racism-related construct	6 (33.33)
Assessment of Racism-Related Experiences^
Validated scale	10 (55.56)
Items adapted from validated scale	4 (22.22)
Unvalidated scale in youth	5 (27.78)
Assessment of Traumatic Stress Symptoms
Symptom Severity (continuous)	16 (88.89)
Clinical cutoff (binary)	2 (11.11)

Note. Group discrimination (Loyd et al., 2019) was coded as indirect discrimination. ^totals add up to more than 100% as articles may be coded into more than one category.

Table 2. Characteristics of sample, assessments and main findings reported by all articles included in the review

First Author (year)	Sampling/Country/Mean Age/Gender/Race composition	Racism-related experience/Measure	Traumatic Stress Symptom/Measure	Main Findings	Risk of Bias
Cross-sectional
Ellis (2008)	School sample (N=306) U.S. Mage: 15.4; SD = 2.2 Sex: 62% M Race: 100% Black (Somali)	Personal everyday discrimination (Everyday Discrimination; Williams et al., 1997)	UCLA PTSD Reaction Index (Rodriguez et al., 1999)	Increases in frequency of personal everyday discrimination was positively associated with PTSD symptom severity.	Low
Gray (2012)	School sample (N=168) U.S. Mage: 16.95; SD = 0.99^a Sex: 100% F Race: 67.8% White Hispanic; 32.14% Black	Personal major discrimination (Major Discrimination Scale; Williams et al., 1997)	Trauma Symptom Checklist (Elliot & Briere, 1992)	Increases in the count of personal major discriminatory events endorsed was positively associated with traumatic stress symptoms, even after controlling for grade, school, and ethnicity.	Low
Kang (2014)	Justice involved sample (N=189) U.S. Mage: 17.03, SD = 1.29 Sex: 100% M Race: 100% Black	Personal everyday, major and vicarious discrimination (Spencer Discrimination Scale; unpublished)*	Trauma Symptom Checklist (Elliot & Briere, 1992)	Increases in degree of perception of personal everyday, major, and vicarious discrimination was positively associated with PTSD symptom severity.	Medium
Scrimin (2014)	School sample (N=159) Israel Mage: 15.8, SD = 2.7 Sex: 64.4% F Race: 100% Druze	Personal everyday discrimination (Perceived Discrimination; Whitbeck, et al., 2001)	UCLA PTSD Reaction Index for DSM-IV: Adolescent Version (Rodriguez et al., 1999; Steinberg et al., 2004)	Increases in count of personal everyday discrimination was positively associated with PTSD symptom severity, even after controlling for gender.	Low
Brockie (2015)	Community sample (age subgroup 15-19 y.o., N=132) U.S. (specific location NR) Mage: age subgroup 15-19 y.o. NR Sex: 51% F Race: 100% Native American	Personal everyday discrimination (modified Perceived Discrimination Scale; Whitbeck et al., 2002)	Short Screen for PTSD (Breslau et al. 1999)	Youth reporting increases in personal everyday discrimination had higher odds of meeting criteria for PTSD, even after controlling for age, gender, tribe, and school attendance.^b	Low
Loyd (2019)	Justice involved sample (N=173) U.S. Mage: 16.1, SD = 1.1 Sex: 55% M Race: 86% Black; 9% Latinx; 5% Biracial/Multiracial	Personal everyday and major discrimination (Adolescent Discrimination Distress Index; Fisher et al., 2000) Group discrimination (Perceived Discrimination subscale of Scale of Ethnic Experience; Malcarne et al., 2006)*	UCLA PTSD Reaction Index for DSM-IV: Adolescent Version (Rodriguez et al, 1999; Steinberg et al., 2004)	Increases in frequency of personal everyday and major discrimination was positively associated with PTSD symptoms, even after accounting for age and group (intervention or control) assignment. Increases in perceptions of group discrimination was associated with PTSD symptoms in girls, but not boys.^c	Low
Tynes (2019)	Community sample (N=302) U.S. Mage: 14.89, SD = 2.64 Sex: 54.6% M Race: 66.23% Black; 33.77% Latinx/Hispanic	Vicarious discrimination; 3-items developed for the study i.e., frequency of (1) seeing images or videos of others from their ethnic group being beaten, (2) arrested or detained, or (3) viral video of a black person being shot by police.	New York PTSD Risk Score (Boscarino et al., 2010) - 4th item about avoidant behavior was omitted	Increases in frequency of vicarious discrimination was positively associated with PTSD symptoms, even after accounting for age, sex, ethnicity, and household income.	Medium
Spaas (2022)	School sample (N=1366) Belgium, Denmark, Finland, Norway, Sweden Mage: 15.41, SD = NR Sex: 54.1% M Race: 27.3% Syrian; 20.7% Somali; 16.9% Afghan; 10.6% Bulgarian; 7.2% Thai; 5.6% Polish; 5.4% Ghanaian; 4.8% Romanian; 4.3% Spanish	Personal everyday and major discrimination (Brief Perceived Ethnic Discrimination Questionnaire; Brondolo et al., 2005)*	Children’s Revised Impact of Events Scale-8 (Perrin et al., 2005)	Increases in frequency of personal everyday and major discrimination was positively associated with PTSD symptoms in both refugee and non-refugee migrants, even after accounting for age, gender, time since resettlement, and country of residence.^d	Low
Brabeck (2022)	School sample (N=306) U.S. Mage: 16.63, SD = 1.75 Sex: 58% F Race: 100% Latinx	Personal everyday and major discrimination; (Adolescent Discrimination Distress Index; Fisher et al., 2000)	Child PTSD Symptoms Scale (Foa et al., 2001)	Increases in frequency of personal major and everyday discrimination was positively associated with PTSD symptom severity, even after controlling for age, nativity, trauma exposure, and family resilience. Association was stronger in females than males.	Low
Ermis-Demirtas (2022)	Community/School sample (N=116)U.S. (specific location NR) Mage: 16.50, SD = 1.75 Sex: 51.7% M Race: 52% Chinese American, 24.1% Japanese American, 9.5% Korean American, 6.9% Vietnamese American, 3.4% Thai American	1-item lifetime racial/ethnic discrimination (binary response) COVID-related discrimination (adapted from Online Victimization Scale; Tynes et al., 2010, Perceived Discrimination by Adults/Peers Scale; Rosenbloom & Way, 2004	UCLA PTSD Reaction Index-5 (Rolon-Arroyo et al., 2020)	Endorsing lifetime racial discrimination was positively associated with PTSD symptom severity. Increases in COVID-related online and offline racial discrimination were positively associated with PTSD symptom severity, even after accounting from DSM-5 traumatic events and lifetime discrimination.	Low
Mendez (2022)	Justice involved sample (N=266) U.S. Mage: 15.93, SD = 1.38 Sex: 79% M Race: 40% White/Caucasian; 38.5% Latinx/Hispanic; 8.7% Biracial/Multiracial; 5.8% Black/African American; 2.5% Native American	3-items adapted from Bias Attack Scale from the Juvenile Victimization Questionnaire i.e., non-acceptance, verbal insult, physical assault (JVQ; Finkelhor et al., 2005)	UCLA PTSD Reaction Index for DSM-IV: Adolescent Version (Rodriguez et al., 1999; Steinberg, et al., 2004)	Increases in the count of personal everyday discrimination was positively associated with PTSD symptom severity, even after controlling for age, gender, ethnicity, and trauma history.	Low
Polanco-Roman (2022)	Clinical sample (N=46)U.S. Mage: 15.40, SD = 1.83 Sex: 80.4% F Race: 65.2% Hispanic/Latino, 10.9% Non-Hispanic Black, 10.9% Black Caribbean, 4.3% Non-Hispanic White, 2.2% Asian	Personal everyday, major and vicarious discrimination (Perceptions of Racism in Children and Youth; Pachter et al., 2010)	Childhood PTSD Symptom Scale (Foa et al. 2001)	Increases in frequency and count of personal everyday, major and vicarious discrimination was positively associated with PTSD symptom severity.^e	Low
Verelst (2022)	School sample (N=2,320) ​​UK, Finland, Sweden Mage: 13.92, SD = 1.20 Sex: 51.4% M Race: 18.95% Somali; 11.87% Syrian; 9.61% Iraqi; 3.65% Eritrean; 2.74% Afghan	Personal everyday and major discrimination (Brief Perceived Ethnic Discrimination Questionnaire; Brondolo et al., 2005) *	Children’s Revised Impact of Events Scale-8 (Perrin et al., 2005)	Increases in frequency of personal everyday and major discrimination was positively associated with PTSD symptom severity, even after controlling for sex, country, and nationality.^g	Low
McFarland (2023)	Clinic-based (N=785) U.S. Mage: 15 Sex: 70% M Race: 65% African American; 24% Latinx, 8% multiracial, 3% other	1-item (“Did the officer use racial slurs?”) binary response: yes/no	9-item PTS index (unvalidated scale)	Youth responding ‘yes’ to whether a police officer used a racial slur during a stop reported a higher PTS index, even after accounting for other intrusive behaviors by the police officers.	Low
Longitudinal
Flores (2010)	Community (N=110) U.S. Mage: 18.80, SD = 1.02 Sex: 54% M Race: 100% Mexican American	Personal everyday discrimination (Discrimination Stress Scale; Flores et al., 2008)*	PTSD Symptoms Scale - Self-Report (Boney-McCoy & Finkelhor, 1996)	Increases in frequency of personal everyday discrimination was positively associated with PTSD symptom severity 6 months later, even after controlling for SES, acculturation, and social support.	Medium
Meléndez Guevara (2022)	School sample (N=547) U.S. Mage: 12.80, SD = 1.03 Sex: 55.4% F Race: 100% Latinx	Personal major discrimination (Adolescent Discrimination Distress Index; Fisher et al., 2000), adapted to assess only school-related items	Posttraumatic Stress Problems Subscale of the Youth Self Report from the Child Behavioral Checklist (Achenbach, 2007)	Increases in frequency of major discrimination was positively associated with PTSD symptoms 6 months later in girls, but not boys, even after accounting for baseline levels of traumatic stress symptoms, age, and nativity.^f	Medium
Wilson (2023)	Community/Clinic-based (N=25) U.S. Mage: 16.40 (SD = 1.63) Sex: 60% F Race: 100% African American	Personal everyday and major discrimination; (Adolescent Discrimination Distress Index; Fisher et al., 2000); 3-items developed for daily assessment	Childhood PTSD Symptom Scale (Foa et al. 2001)	Increases in baseline racial discrimination distress was associated with increases in baseline PTSD symptoms, though not in two-week daily assessments	Medium
Mixed Methods
Ellis (2010)	School sample (Quant: N=135; Qual: N =14) U.S. Mage: Quant = 15.4 SD =2.2, Qual = 17, SD = NR Sex: Quant = 62.2% M; Qual = 50% M; Focus Group = 81% Race: 100% Black (Somali)	Personal everyday discrimination (Everyday Discrimination; Williams, et al., 1997)	Quant: UCLA PTSD Reaction Index (Rodriguez et al., 1999) Qual: semi-structured interview	Increases in frequency of personal everyday discrimination was positively associated with PTSD symptom severity, even after controlling for trauma history, Somali acculturation, and American acculturation.^g	Low

Notes: M = male, F = female; NR = Not reported*No psychometric evidence available for the scale’s performance in youth;^aSample age mean and standard deviation provided by study authors, not reported in original manuscript;

^br-value converted from odds-ratio as presented in the manuscript that also controlled for gender, tribal affiliation, and school attendance;^cr-value pooled from separate boys’ and girls’ coefficients;^dr-value provided by study authors, not reported in original manuscript;^eIncluded associations with frequency only;

^fr-value pooled from discrimination at time one to trauma symptoms at time one and to time two;

^gExcluded from meta-analysis.

A total of 18 studies were flagged as eligible or potentially eligible for inclusion in the meta-analysis. Ellis et al. (2010) was omitted as this sample and all measures were identical to Ellis et al. (2008), the latter of which was retained. Verelst et al. (2022) was also omitted as this sample and all measures were drawn from the same study reported by Spaas et al. (2022). Thus, the final list included 16 studies (Table 2). The methods by Tynes et al. (2019) differed slightly from the others, but was retained in the final analyses, as it was the only study to report on online exposures to racism-related experiences. Namely, the authors did not ask about personally experienced discrimination. Rather, they asked about witnessing or viewing videos of racism-based violence and discrimination. Given the similarity of effect sizes and difficulty identifying eligible articles on this topic, we retained this article in the model. Omission of this study did not change significance or magnitude of effect size in the analyses.

Given some notable heterogeneity across samples, we used a random effects maximum likelihood meta-analysis. We also conducted moderation analyses on country of origin (i.e., United States vs. elsewhere), setting (i.e., justice-involved vs. elsewhere), age,² gender proportion (i.e., whether the sample was < 40% or over 60% female, k = 5; all studies presented binary gender identities only), and predominant race (i.e., Black/African ancestry, k = 6, Latinx/Hispanic, k = 6, and others k = 4). These moderators were not significant (ps ≥ .10). Therefore, we did not proceed to subgroup analyses or further meta-regression. Data were analyzed with Stata 18.0 (StataCorp, Inc., 2023, College Station, TX).

Results

The search yielded 326 results, and an additional four were identified by searching reference lists and citing literature. Of these, 122 were removed as duplicates (Figure 1). Of the remaining 208 articles, an additional 156 were excluded following title/abstract review. In the full-text review, 18 articles were identified as meeting all criteria. These articles described the findings of 16 unique studies.

Figure 1. PRISMA-2020 screening process flowchart.

Sample Characteristics

Details on the sample and study characteristics across all 18 articles included in the review are provided in Table 1. Most were published within the last 3 years. Most articles had modestly sized samples ranging from 100 to 500 participants, with a mean sample size of 301.56 and an overall total of 4,825 participants across all studies. Five articles did not report sample age ranges and instead reported grade ranges. Where available, participant ages ranged from 9 to 20 years old, with a mean age of 16.114 years (SD = 1.53). The samples were largely recruited from the United States. Other studies were conducted in Israel, UK, Belgium, Denmark, Norway, and Sweden. Only one article included a nationally representative US sample. A plurality of articles included a racially and ethnically diverse sample. The remaining articles focused exclusively on specific groups of racially and/or ethnically minoritized youth including Black/African American (k = 4; 22.22%), Latinx/Hispanic (k = 3;16.67%), Native American/American Indian (k = 1; 5.56%), Asian American (k = 1; 5.56%), and Middle Eastern/North African (k = 1; 5.56%). The average distribution of sex/gender, reported as a binary in all articles, did not differ from 50%, t(15) = 0.13, p = .90. One article (5.56%) focused exclusively on girls, and one (5.56%) focused exclusively on boys.

Study Design and Analytic Strategy

Almost all articles were cross-sectional, three were longitudinal, and one was a mixed method design. Researchers in nine (50%) of the articles used nonrandom sampling (i.e., purposive or snowball sampling) or convenience sampling (k = 1; 5.56%), with the remaining using random sampling with targeted populations (k = 8; 44.44%). The majority of participants were recruited from school-based settings, followed by community-based settings, justice-involved settings (e.g., juvenile detention center, probation offices), and clinical settings. Four articles recruited from multiple settings.

Most articles (k = 14; 77.78%) reported a theoretical framework that guided their research inquiry and informed their conceptualization of the constructs examined. The most widely cited framework was Carter’s (2007) race-based traumatic stress framework. However, most articles cited more than one framework (k = 9; 50.00%).

Assessment of Racism-Related Experiences

Details on the main findings reported in each article included in the review are in Table 2. About half of the articles used a scale psychometrically validated to assess racism-related experiences in youth, with nearly half of these originally developed for use with youth. Scales utilized included the Adolescent Discrimination Distress Index (k = 4; 22.22%) (Brabeck et al., 2022; Loyd et al., 2019; Meléndez Guevara et al., 2022; Wilson et al., 2023), the modified version of the Perceived Discrimination Scale (k = 2; 11.11%) (Brockie et al., 2015; Scrimin et al., 2014), Perceptions of Racism in Children and Youth (k = 1; 5.56%) (Polanco-Roman et al., 2022), and the youth adapted versions of the Everyday Discrimination Scale (k = 2; 11.11%) (Ellis et al., 2008, 2010) and Major Discrimination Scale (k = 1; 5.56%) (Gray & Montgomery, 2012). Five articles (27.78%) included scales lacking psychometric validation in youth (Flores et al., 2010; Kang & Burton, 2014; Loyd et al., 2019; Spaas et al., 2022; Verelst et al., 2022). One article included select items from larger inventories (Mendez et al., 2022), one article included items developed for their study (Tynes et al., 2019), and two articles used a single-item to assess racial discrimination (Ermis-Demirtas et al., 2022; McFarland et al., 2023). Racism-related experiences were largely operationalized as personal experiences of racial/ethnic discrimination in the form of individual-level, everyday discrimination (k = 15; 83.33%).

Half of the articles examined personal experiences of racism in the form of institutional-level or major discriminatory events, and a quarter examined vicarious or indirect experiences via witnessing it happen to others. Nearly a third of the articles assessed more than one form of racism-related experiences. The majority of the articles measured racism-related experiences via frequency (k = 12; 66.67%), count of unique discriminatory experiences (k = 3; 16.67%), ever experienced (k = 1; 5.56%), subjective distress (k = 1; 5.56%), or degree of perception (k = 1; 5.56%). Most articles did not report a timeframe for occurrences of the racism-related experiences (k = 12; 66.67), though four reported on lifetime experiences (22.22%), one reported on past year experiences (5.56%), and one reported on past 3 months experiences (5.56%).

Assessment of Traumatic Stress Symptoms

All but one article used a validated scale consistent with diagnostic criteria as outlined by the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) to assess traumatic stress symptoms. The majority of the articles (k = 16; 88.89%) examined traumatic stress symptoms as a continuous variable using symptom severity, and the remaining operationalized traumatic stress symptoms as a binary variable using a clinical cutoff. Nearly all articles specifically assessed for PTSD symptoms (k = 16; 88.89%), whereas two articles used a scale for PTSD and dissociative symptoms via the Traumatic Symptom Checklist (Briere & Runtz, 1989). This scale, however, was originally developed for use with adults and not youth. The UCLA PTSD (Pynoos et al., 1998) scale was the most widely used measure of traumatic stress symptoms (k = 6; 33.33%), followed by the Childhood PTSD Symptom Scale (k = 4;22.22%) (Foa et al., 2001).

Main and Other Relevant Findings

All articles demonstrated a positive, statistically significant association between racism-related experiences and traumatic stress symptoms. This pattern of results emerged regardless of sample demographics (e.g., age, sex/gender, socioeconomic status, immigration status), acculturation levels, social support, other traumatic exposures like war, adverse childhood experiences, daily stressors, and negative life events, and regardless of study design, measurement type, or whether racial/ethnic discrimination was operationalized as institutional, personally experienced, or vicariously experienced. Furthermore, the association was detected when racial/ethnic discrimination was assessed as frequency or count of events. Findings from the NOS indicate that the majority of studies demonstrated low risk for bias (k = 13; 72.22%). The remaining five articles met criteria for medium risk for bias (27.78%). In three articles, the association between racial/ethnic discrimination and traumatic stress symptoms was stronger for girls than boys, even after accounting for other relevant factors like demographics and other potentially traumatic exposures (Brabeck et al., 2022; Loyd et al., 2019; Meléndez Guevara et al., 2022).

Results of Meta-Analysis

A total of 16 studies were included in the analysis, each with one included effect size. All estimates showed a positive correlation between racial/ethnic discrimination measures and trauma symptoms. Three correlation coefficients could be considered small-to-negligible (approximately .10–.20) (Kang & Burton, 2014, McFarland et al., 2023; Spaas et al., 2022), (Figure 2a). The rest of the effects varied from small to large (r = .25 to .63). Most effect sizes (57%) were between .40 and .63, indicating moderate to high associations. No effect sizes were negative and all significantly differed from zero. The pooled effect size was moderate: r_pooled = .356, 95% CI_r [0.274, 0.438]. Unsurprisingly, the average outcome differed from zero, z = 8.51, p < .001. According to the Q-test, the true outcomes were heterogeneous, Q(15) = 123.41, p < .001, τ² = 0.02, I² = 86.47%. Hence, even though there is evidence of significant heterogeneity (indicated by I² >75%), the true outcomes of the studies are likely meaningful, and generally in the same direction as the estimated average outcome. Further, as discussed above, key moderators did not better explain this variance. Given the small pool of studies, the four small effect sizes likely contributed to the observed heterogeneity.³ There was no indication of outliers in this model: all effect sizes were ± 3 SDs of the mean, and Cook’s distances were within acceptable parameters. Inspection of the funnel plot (Figure 2b) and results of Egger’s regression do not suggest publication bias or variance in sample sizes could account for the observed results, |z| = 1.04, p = .30.

Figure 2. Forest plot of the effect sizes (above) and funnel plot of all observations (below) for individual studies included in the meta-analysis.

Discussion

This is the first systematic review and meta-analysis to examine the association between racism-related experiences and traumatic stress symptoms in ethnoracially minoritized youth. The search yielded a total of 18 articles comprising 16 unique studies (N = 4,825 participants). The relatively limited number of studies indicate that this topic remains understudied; however, this area has garnered more attention in recent years. Adolescents from Black and Latinx backgrounds were most frequently represented in the samples, largely recruited from school-based settings in the United States. Studies were largely cross-sectional, used nonrandom sampling strategies, and were theoretically grounded. There was variability in the assessment of racism-related experiences. Whereas most studies operationalized racism-related experiences as direct and personal/everyday discrimination, some studies also examined institutional/major discriminatory and vicarious exposures. Additionally, most studies assessed racism-related experiences via frequency but did not report on the time frame of these exposures. All but one article used a validated clinical screen for traumatic stress symptoms. No study assessed traumatic stress symptoms in direct response to racism-related experiences, consistent with an earlier review examining these associations in adults (Kirkinis et al., 2021). In the meta-analysis, we identified a significant positive association with a medium effect size between racism-related experiences and traumatic stress symptoms in ethnoracially minoritized youth.

Our observed findings are consistent with results from prior meta-analyses examining racism-related experiences and health outcomes (Carter et al., 2019; Paradies et al., 2015; Pascoe & Richman, 2009) and with results from a systematic review examining racism-related experiences and traumatic stress symptoms, largely in adults (Kirkinis et al., 2021). The present findings suggest that, as observed with adults, ethnoracially minoritized youth may be at increased risk of developing traumatic stress symptoms following racism-related experiences. In comparison to the Kirkinis et al. (2021) review, our review suggests that the impact of racism-related experiences is not a unique feature of adulthood but also adversely impacts children and adolescents. This extends findings from a prior systematic review demonstrating a significant association between racism-related experiences and difficulties with emotion regulation (Roach et al., 2023), a common response among trauma-exposed youth (Cloitre et al., 2009; Courtois, 2008; D’Andrea et al., 2012). Thus, our findings provide additional empirical support to the conceptual models extending racism-based traumatic stress frameworks to ethnoracially minoritized youth (Bernard et al., 2020; Jernigan & Daniel, 2011; Saleem et al., 2020).

Findings from our meta-analysis further suggest that the association between racism-related experiences and traumatic stress symptoms was statistically similar across settings, countries, sex/gender, or racial/ethnic group. However, we cannot conclude invariance as a function of these variables unequivocally given the relatively small pool of studies with limited variety of settings and populations. In fact, two studies reported that after accounting for demographics and other trauma exposures, the association was stronger in girls than boys, but it was both beyond the scope of the present study to pursue these analyses meta-analytically as there was insufficient data to do so. Further research is warranted to investigate whether the impact of racism-related experiences may differentially impact risk for traumatic stress symptoms across genders. Since most studies were cross-sectional and did not assess the time of racism-related experiences, more longitudinal studies are warranted to examine the temporal sequence and long-term effects of racism-related experiences on traumatic stress symptoms. This distinction is important as a previous meta-analysis, albeit in adults, reported a stronger association between racial discrimination and health outcomes in exposures occurring in the past year compared to lifetime (Carter et al., 2019). It is also possible that youth at risk of developing traumatic stress symptoms may be more vulnerable to the harmful effects of racism-related exposures.

Given notable variability in the established validity of tools used in the included studies, there is a need to improve assessment of racism-related experiences and youth outcomes. For instance, included studies used scales developed for adults and adapted for use with youth. This method raises concerns as experiences most relevant to youth may be overlooked such as online exposures to racism, which is a growing problem in ethnoracially minoritized youth (Tynes et al., 2020). Thus, it is critical to use scales that demonstrate reliability and validity in ethnoracially minoritized youth. The cumulative impact of racism-related experiences may also be underestimated as studies largely focused on a single dimension of racism (i.e., perceptible forms of racism that manifested as racial/ethnic discrimination via direct, individual-level personal or everyday discriminatory experiences). Studies rarely accounted for nativity and immigration influences, or intersectionality (i.e., the intersection of multiple social identities) (Krieger, 2012). Future studies should examine important components of intersectional experiences of discrimination (i.e., gender identity, acculturation, geographic region, sexual orientation, or socioeconomic status), which could help elucidate the different ways in which racial discrimination manifests for different subgroups of ethnoracially minoritized youth. Future research should also attend to structural racism, or the totality of the effects of racial biases in policies and practices that manifest across various institutions (Williams & Mohammed, 2013), another understudied form of racism that has also been linked to adverse youth health outcomes such as suicidality (English et al., 2020). Lastly, no study examined internalized racism, or endorsement of negative attitudes about one’s self as a member of an ethnoracially minoritized group (Williams & Mohammed, 2013). Indeed, research with adults suggests that increases in internalized racism may confer risk for adverse mental health outcomes (David et al., 2019; Gale et al., 2020).

Prior research has identified potential protective factors that may attenuate the harmful effects of racism-related experiences such as racial/ethnic socialization (i.e., messages exchanged between caregivers and youth about racialized experiences), critical reflections of racial issues, activism, and racial/ethnic identity (i.e., a strong sense of cultural pride or belonging as a group member from a minoritized group) (Anderson & Stevenson, 2019; Bañales et al., 2021; Heard-Garris et al., 2021; Neblett et al., 2012). No studies included in this review, however, examined potential protective factors in the association between racial discrimination and traumatic stress symptoms. Thus, there is a need for research on ways to potentially attenuate the harmful effects of racism-related experiences to protect against traumatic stress symptoms among ethnoracially minoritized youth.

To improve cultural responsiveness and sensitivity of existing mental health services, particularly among ethnoracially minoritized youth, it is critical that we better understand the mechanisms through which racism-related experiences may confer risk for traumatic stress symptoms. This research would be facilitated by studies expanding conceptualizations of racism beyond single dimensions to more accurately capture the cumulative impact of racism across various dimensions, levels, and systems, and how these exposures may change across developmental stages and across contexts. Future research should also draw upon more contemporary frameworks of racism that capture experiences that are particularly relevant to ethnoracially minoritized youth living in a digital age i.e., online racism.

The present findings offer important clinical implications that could inform existing mental health services to address the unique mental health needs of ethnoracially minoritized youth. Specifically, clinicians are encouraged to account for racism-related experiences when working with ethnoracially minoritized youth endorsing traumatic stress symptoms, and to draw upon racism-based traumatic stress frameworks to inform assessment and intervention. Indeed, a new intervention aims to target racism-based traumatic stress in African American youth by adapting a trauma-focused Cognitive Behavioral Therapy through promoting racial socialization (Metzger et al., 2021).

Limitations

The findings from this systematic review and meta-analysis should be interpreted in the context of the following limitations. First, we excluded unpublished manuscripts, theses, and dissertations. Exclusion of these data may underestimate existing literature on this topic and may also inflate the true significance of the association, as published articles may be more likely to report significant associations. Notably, however, the NOS findings suggest low-to-medium risk for bias and findings from our meta-analysis did not suggest publication bias. Second, we recognize that ethnoracially minoritized youth are a heterogeneous group, and that by subsuming all racially and ethnically minoritized groups together, we were unable to capture between-group differences. Similarly, the findings may not generalize to all ethnoracially minoritized youth, as Black and Latinx adolescents in the United States were most represented in the studies included in the review. Third, the studies included in this review examined traumatic stress symptoms that may or may not be directly connected to racism-related experiences, and since the majority of the studies used cross-sectional designs, we are limited in our ability to infer causal relations. Unfortunately, this research continues to be hampered by the dearth of tools assessing racism-based traumatic stress in youth, though some tools in adults have recently emerged with preliminary psychometric evidence (Pieterse et al., 2022; Williams et al., 2018). Fourth, since we only included English and Spanish language articles, we may be underestimating the existing literature in other languages including from other global settings. Lastly, we did not include effect sizes accounting for other trauma exposures in the meta-analyses, which were not provided for all included studies, potentially obscuring the magnitude of association between racism-related experiences and traumatic stress symptoms. Nevertheless, the significant association between racism-related experiences and traumatic stress symptoms remained even when accounting for other trauma and stress exposures.

Conclusion

The present study provides the first systematic review and meta-analysis of the association between racism-related experiences and traumatic stress symptoms in ethnoracially minoritized youth. Findings demonstrate consistent positive associations with a medium effect size, suggesting that ethnoracially minoritized youth who experience racial and ethnic discrimination may be at elevated risk for developing traumatic stress symptoms. The present findings have important clinical implications, as they may help improve the cultural responsiveness of mental health services available to ethnoracially minoritized youth.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

LPR is supported by the Health Equity Scholars for Action Fellowship from the Robert Wood Johnson Foundation. CTE is supported by a training grant from the National Institute on Drug Abuse [5R25DA035161-07, Multiple PIs: Ruglass and Hien].

Notes

¹ This process likely introduces some bias in the values, but we believe it is unlikely this bias changed the overall results of this study given how close the r-values were that were pooled. For example, the correlation associated with boys in Scrimin et al. (2014) was .50 whereas for girls it was .57; for Loyd et al. (2019), the coefficient for boys was .42 and for girls it was .48. For Meléndez Guevara et al. (2022), the correlation between racial/ethnic discrimination at Time 1 to Trauma symptoms at Time 1 was .42, and to Trauma at Time 2 was .36. Authors of these studies were contacted to obtain these values without pooling, but were not provided at the time of manuscript publication.

² McFarland et al. (2023) did not report the mean age of their sample and was omitted from this analysis.

³ Omitting these four studies resulted in acceptable heterogeneity (I² = 65.93%) without changing the magnitude of the effect size, r_pooled = 0.434, 95% CI_r [.365, .503].

Appendix

Appendix 1. Search terms used and the total number of articles that resulted in each database

Database	Version	Search Terms	Search Results
PsycINFO	Title / Abstract	ti(“racial discrimination” OR racism OR “perceived racism” OR “perceived discrimination” OR “racial oppression” OR “ethnic discrimination” OR “ethnic oppression” OR “racial prejudic*” OR “racial inequities” OR “racial harass*” OR “unfair treat*” OR “hate crime”) AND ti(“race based trauma” OR “race-based trauma” OR “race based stress” OR “race-based stress” OR “racial stress” OR “racial trauma” OR PTSD OR “post-traumatic stress” OR “posttraumatic stress” OR “post-trauma*” OR “post trauma*” OR posttrauma* OR “stress disorder*” OR DESNOS OR “disorders of extreme stress” OR “disorder of extreme stress” OR “complex trauma” OR flashback* OR nightmare* OR hypervigilan* OR dissociation OR derealization OR depersonalization) AND ti(child* OR adolesc* OR youth OR kid* OR “young people” OR pediatric OR student*) OR ab(“racial discrimination” OR racism OR “perceived racism” OR “perceived discrimination” OR “racial oppression” OR “ethnic discrimination” OR “ethnic oppression” OR “racial prejudic*” OR “racial inequities” OR “racial harass*” OR “unfair treat*” OR “hate crime”) AND ab(“race based trauma” OR “race-based trauma” OR “race based stress” OR “race-based stress” OR “racial stress” OR “racial trauma” OR PTSD OR “post-traumatic stress” OR “posttraumatic stress” OR “post-trauma*” OR “post trauma*” OR posttrauma* OR “stress disorder*” OR DESNOS OR “disorders of extreme stress” OR “disorder of extreme stress” OR “complex trauma” OR flashback* OR nightmare* OR hypervigilan* OR dissociation OR derealization OR depersonalization) AND ab(child* OR adolesc* OR youth OR kid* OR “young people” OR pediatric OR student*)	139
PubMed	Title / Abstract	(“racial discrimination”[Title/Abstract] OR “racism”[Title/Abstract] OR “perceived racism”[Title/Abstract] OR “perceived discrimination”[Title/Abstract] OR “racial oppression”[Title/Abstract] OR “ethnic discrimination”[Title/Abstract] OR “racial prejudic*”[Title/Abstract] OR “racial inequities”[Title/Abstract] OR “racial harass*”[Title/Abstract] OR “unfair treat*”[Title/Abstract] OR “hate crime”[Title/Abstract]) AND (“race-based stress”[Title/Abstract] OR “racial stress”[Title/Abstract] OR “racial trauma”[Title/Abstract] OR “PTSD”[Title/Abstract] OR “post-traumatic stress”[Title/Abstract] OR “posttraumatic stress”[Title/Abstract] OR “post trauma*”[Title/Abstract] OR “posttrauma*”[Title/Abstract] OR “stress disorder*”[Title/Abstract] OR “DESNOS”[Title/Abstract] OR “disorders of extreme stress”[Title/Abstract] OR “complex trauma”[Title/Abstract] OR “flashback*”[Title/Abstract] OR “nightmare*”[Title/Abstract] OR “hypervigilan*”[Title/Abstract] OR “dissociation”[Title/Abstract] OR “derealization”[Title/Abstract] OR “depersonalization”[Title/Abstract]) AND (“child*”[Title/Abstract] OR “adolesc*”[Title/Abstract] OR “youth”[Title/Abstract] OR “kid”[Title/Abstract] OR “kids”[Title/Abstract] OR “young people”[Title/Abstract] OR “pediatric”[Title/Abstract] OR “student*”[Title/Abstract])	90
Embase	Title / Abstract	(‘racial discrimination’:ab,ti OR ‘racism’:ab,ti OR ‘perceived racism’:ab,ti OR ‘perceived discrimination’:ab,ti OR ‘racial oppression’:ab,ti OR ‘ethnic discrimination’:ab,ti OR ‘racial prejudic*’:ab,ti OR ‘racial inequities’:ab,ti OR ‘racial harass*’:ab,ti OR ‘unfair treat*’:ab,ti OR ‘hate crime’:ab,ti) AND (‘race-based stress’:ab,ti OR ‘racial stress’:ab,ti OR ‘racial trauma’:ab,ti OR ‘ptsd’:ab,ti OR ‘post-traumatic stress’:ab,ti OR ‘posttraumatic stress’:ab,ti OR ‘post trauma*’:ab,ti OR ‘posttrauma*’:ab,ti OR ‘stress disorder*’:ab,ti OR ‘desnos’:ab,ti OR ‘disorders of extreme stress’:ab,ti OR ‘complex trauma’:ab,ti OR ‘flashback*’:ab,ti OR ‘nightmare*’:ab,ti OR ‘hypervigilan*’:ab,ti OR ‘dissociation’:ab,ti OR ‘derealization’:ab,ti OR ‘depersonalization’:ab,ti) AND (‘child*’:ab,ti OR ‘adolesc*’:ab,ti OR ‘youth’:ab,ti OR ‘kid’:ab,ti OR ‘kids’:ab,ti OR ‘young people’:ab,ti OR ‘pediatric’:ab,ti OR ‘student*’:ab,ti)	97