In light of recent high profile racially motivated incidents, both globally and specifically in the UK, the impact of racism on health and well-being has become the subject of media attention as well as research, policy and practice. For example, in the UK, a surge of instances of racist abuse posted on social media ensued following the 2016 referendum about the UK's membership of the EU (‘Brexit’)^{Reference Burnett1} and the 2019 death by drowning of 12-year-old Shukri Yahye-Abdi – a young, Black Muslim schoolgirl – sparked protest as many suspected racial motivation behind the bullying in the lead up to her death. The 2020 murder of George Floyd, an unarmed Black man, by a White police officer in the USA sparked global protest.

In this paper, we refer to various types of racism, such as internalised, interpersonal, institutional and structural racism. Definitions are provided in Table 1, taken from USA-based racial justice organisation Race Forward (https://www.raceforward.org/). We also refer to vicarious racism using a recommended definition.^{Reference Heard-Garris, Cale, Camaj, Hamati and Dominguez2}

Table 1 Definitions for racism

All quotes are definitions taken from Race Forward.

Notwithstanding the usefulness of these definitions, the literature suggests the use of the terms ‘racism’ and ‘racial discrimination’ is interchangeable.^{Reference Berger and Sarnyai3} Both are used in reference to unequal and harmful distribution of power in societies on the basis of cultural, ancestral or phenomenological difference among individuals.^{Reference Berger and Sarnyai3} Indeed, when considering racism definitions have related interchangeably to discrimination relating to individuals’ ‘race’, ‘ethnicity’ and ‘ancestry’.^{Reference Ali-Khan, Krakowski, Tahir and Daar4} Whereas race is a sociopolitical construct that groups people based on perceived physical traits, ethnicity captures elements of an individual's identity beyond physical characteristics, such as culture, language and religion.^{Reference Lu, Ahmed, Lamri and Anand5} Ancestry can be further broken down into geographical, genealogical and genetic characterisations.^{Reference Lu, Ahmed, Lamri and Anand5}

Although racism is increasingly recognised as a key contributor to poor mental health,^{Reference Paradies, Ben, Denson, Elias, Priest and Pieterse6} the existing literature primarily focuses on the effects of racism on adults and/or is based in the USA (e.g. Heard-Garris et al^{Reference Heard-Garris, Cale, Camaj, Hamati and Dominguez2} and Paradies et al^{Reference Paradies, Ben, Denson, Elias, Priest and Pieterse6}). A number of meta-analyses found a strong association between poor mental health outcomes and racial discrimination in both adults,^{Reference Williams, Neighbors and Jackson7,Reference Paradies9} and among children and adolescents.^{Reference Lazaridou, Heinz, Schulze and Bhugra10} For example, a significant association between racism and suicidality was found in a systematic review of studies of young people in the USA.^{Reference Rudes and Fantuzzi11} Studies on Indigenous Australians^{Reference Larson, Gillies, Howard and Coffin12} and ethnic minority groups based in the UK^{Reference Chakraborty, McKenzie, Hajat and Stansfeld13} are fewer but have also indicated associations between experiences of racism and poor mental health. For example, Chakraborty et al^{Reference Chakraborty, McKenzie, Hajat and Stansfeld13} found that there was an association between experiences of racial insults and higher scores on a psychosis screening questionnaire among participants aged 16–74 years who were Caribbean, Bangladeshi and Pakistani in England. The experiences that young people have of racism varies. They may experience interpersonal racism, or they may notice the impact on their parents, families and communities through vicarious racism. They may not necessarily connect their experience of exclusion, marginalisation or bullying to race, culture or ethnicity; conversely, they may be too aware, potentially resulting in internalised racism.^{Reference Jacob, Faber, Faber, Bartlett, Ouimet and Williams14} What is clear is that direct and vicarious experiences of racism can result in race-based traumatic stress; that is, the psychological and physiological impact of exposure to racial discrimination, which can be debilitating if prolonged.^{Reference Anderson and Stevenson15} Racial trauma may explain the disproportionate prevalence of exposure to trauma among children and young people of colour compared with White children and young people.^{Reference Saleem, Anderson and Williams16} Moreover, it is suggested that in comparison to general bullying, race-based bullying, a source of racial trauma, has been associated with more negative mental health^{Reference Xu, Macrynikola, Waseem and Miranda17} and general health consequences.^{Reference Xu, Macrynikola, Waseem and Miranda17}

National surveys are important for providing data on the mental health of minoritised ethnic groups, which may give some indication of the effects of experiences of racism. Data with adult populations in England suggest that common mental health disorders, post-traumatic stress and psychoses are more prevalent in adults from minoritised groups than in ‘White’ adults, with particularly high rates among ‘Black’ adults.^{Reference McManus, Bebbington, Jenkins and Brugha18} (We note that both ‘White’ and ‘Black’ have been put in quotations to express the imprecisions of racial categories.) It is well established that many of these disorders commonly first have their onset in childhood or adolescence (e.g. Solmi et al^{Reference Solmi, Radua, Olivola, Croce, Soardo and Salazar de Pablo19}). However, in contrast, recent NHS data suggest ‘White’ children and young people are more likely to have a mental health condition than ‘Black, Asian Minority Ethnic’ children and young people.^{Reference Newlove-Delgado, Marcheselli, Williams, Mandalia, McManus and Savic20} Although, notably, there is a marked lack of quality and completeness of data for many ethnic groups coupled often with small sample sizes within groups, often resulting in aggregation of ethnic groups sometimes into one all-encompassing group, and so the estimates should be considered with caution.^{Reference Newlove-Delgado, Marcheselli, Williams, Mandalia, McManus and Savic20} Together these findings raise the possibility that the mental health needs of minoritised groups of children and young people are overlooked and the particular contribution of experiences of racism remains unclear, particularly given wider potential issues with access to services, recognition of poor mental health among ethnic minorities as well as the recording of these conditions.

Research with adults highlights the contribution of experiences of racism to poor mental health. A review of literature from various countries found experiences of interpersonal racism, specifically discrimination, were associated with poor mental health among adults.^{Reference Williams, Lawrence, Davis and Vu21} Furthermore, an England-based study found both interpersonal racism and perceived experiences of racism were associated with an increased risk of common mental health disorders and symptoms of psychosis among adults aged 16–74 years.^{Reference Karlsen, Nazroo, Mckenzie, Bhui and Weich22}

Given these findings, it seems highly likely that experiences of racism will also have significant impacts on the mental health of children and young people as they are in a particularly important life stage with respect to their development of self and identity^{Reference Knowles, Gayer-Anderson, Beards, Blakey, Davis and Lowis23} and vulnerability to the development of mental health problems.^{Reference Heard-Garris, Cale, Camaj, Hamati and Dominguez2} Additionally, children's lives are heavily linked to experiences with and of those around them (including peers, family members and trusted others). This cross-generational link has been found between maternal experiences of interpersonal racism, specifically discrimination, and infant cortisol level; more frequent maternal reports of discrimination predicted higher cortisol levels among Black infants.^{Reference Dismukes, Shirtcliff, Jones, Zeanah, Theall and Drury24}

Where systematic reviews have been conducted that have demonstrated significant associations between racism and poor mental health among children and young people^{Reference Heard-Garris, Cale, Camaj, Hamati and Dominguez2,Reference Priest, Paradies, Trenerry, Truong, Karlsen and Kelly25} they have predominantly included studies conducted in the USA. One review, for example, identified a consistent and strong relationship between racial discrimination and negative mental health conditions such as anxiety. They also found a negative relationship between racial discrimination and positive mental health indicators, such as self-worth.^{Reference Priest, Paradies, Trenerry, Truong, Karlsen and Kelly25} However, the kinds of racism faced and its impact on mental health is likely to vary depending on the country. For example, differences in the association between racism and mental health have been found between Australia and the UK and between ethnic groups within these countries.^{Reference Terhaag, Fitzsimons, Daraganova and Patalay26} Specifically, this study found that ethnic minority children in Australia experienced more victimisation compared with those in the UK. Furthermore, among ethnic groups in Australia, indigenous children had poorer mental health, while in the UK, Pakistani and Bangladeshi children had poorer mental health.^{Reference Terhaag, Fitzsimons, Daraganova and Patalay26} With a lack of research focusing on the associations between racism and mental health in children and young people, and particularly the specific experiences in the UK, we set out to identify the broad existing literature on the association between experiences of racism and mental health in children and young people in the UK.

Results

Description of included studies

As shown in Fig. 1, in total eight studies were included in this review, with five providing quantitative data and three providing qualitative data. Details related to the study characteristics are provided in Table 2.

Fig. 1 Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram showing process for identifying eligible papers.

Table 2 Details of included studies

ns, not significant; PM_2.5 refers to minuscule particles in the air that can be harmful; SDQ, Strengths and Difficulties Questionnaire; TDS, total difficulties score; HADS, Hospital Anxiety and Depression Scale; NI, Northern Ireland.

Studies varied widely in terms of who provided the data (parents, youth workers, young people), sample size (from 14 youth workers to 6645 young people), demographic profiles, study region and the focus of the study. Only four of the studies had a specific focus on how racism affects youth mental health.^{Reference Cassidy, O'Connor, Howe and Warden28,Reference Astell-Burt, Maynard, Lenguerrand and Harding31,Reference Bécares, Nazroo and Kelly32,Reference Karamanos, Mudway, Kelly, Beevers, Dajnak and Elia35} The majority of studies (n = 7/8) focused on children and young people aged 10 years or over. Only one study focused on young children under the age of 10 years,^{Reference Bécares, Nazroo and Kelly32} and this specifically explored how racism affected the children's mothers. As shown in Table 2, seven out of eight studies focused on experiences within school settings, with five of these studies also asking about racism both within and outside of school. Four studies used youth self-report for mental health and racism, while one study used parental report and three studies used interviews (parents, youth workers and young people).

Studies providing quantitative data varied in measures of racism, with two ^{Reference Astell-Burt, Maynard, Lenguerrand and Harding31,Reference Bécares, Nazroo and Kelly32} asking just one question each regarding racism (‘How common are insults or attacks to do with someone's race or colour?’; ‘Has anyone made you feel bad or hassled you because of your race, skin colour or where you were born?) and one study^{Reference Karamanos, Mudway, Kelly, Beevers, Dajnak and Elia35} asking both (‘Has anyone made you feel bad or hassled you because of your race, skin colour, or where you were born?’ and ‘Has anyone made you feel bad or hassled you because of your religion?’). One study used both the Hospital Anxiety and Depression Scale (HADS) and perceived discrimination scale.^{Reference Cassidy, O'Connor, Howe and Warden28} The latter scale was a combination of two measures, one used by^{Reference Verkuyten36} and the other developed by.^{Reference Phinney, Madden and Santos37} Youth mental health outcome measures also varied; the Strengths and Difficulties Questionnaire (SDQ) was used in three studies^{Reference Astell-Burt, Maynard, Lenguerrand and Harding31,Reference Bécares, Nazroo and Kelly32,Reference Karamanos, Mudway, Kelly, Beevers, Dajnak and Elia35} and one study used an anonymous self-report open-response questionnaire, in which a reference to bullying was made.^{Reference Fortune, Sinclair and Hawton30}

For two of the qualitative studies, relevant data were secondary to the main aims of the studies.^{Reference Derrington29,Reference McMullen, Jones, Campbell, McLaughlin, McDade and O'Lynn33} They were included due to one quote in the studies that referred to the effect of racism and racism on young people's mental health. One study explored perceived causes of emotional distress among their participants and was also included due to one quote referring to the effects of racism.^{Reference O'Neill, Stapley, Stock, Merrick and Humphrey34}

Study findings

Four studies directly focused on the effects of racism on the mental health of children and young people^{Reference Cassidy, O'Connor, Howe and Warden28,Reference Astell-Burt, Maynard, Lenguerrand and Harding31,Reference Bécares, Nazroo and Kelly32,Reference Karamanos, Mudway, Kelly, Beevers, Dajnak and Elia35} and one study focused on the prevention of self-harm among adolescents.^{Reference Fortune, Sinclair and Hawton30} The four studies that examined youth self-reported mental health symptoms found evidence for a significant direct association between perceived discrimination, reported racism and youth mental health symptoms (anxiety among young women and depression and anxiety among young men,^{Reference Cassidy, O'Connor, Howe and Warden28} total difficulties in the SDQ,^{Reference Astell-Burt, Maynard, Lenguerrand and Harding31} and increased conduct problems.^{Reference Karamanos, Mudway, Kelly, Beevers, Dajnak and Elia35}

Bécares et al^{Reference Bécares, Nazroo and Kelly32} specifically focused on maternal experiences of racism and families’ experiences of unfair treatment, and reported a significant indirect association between maternal experiences and parent reported SDQ scores, which was mediated by self-reported ‘harsh parenting’. Fortune et al^{Reference Fortune, Sinclair and Hawton30} focused on self-harm prevention and found that 6% of the respondents referred to discrimination and racism, and although Asian pupils, compared with the overall sample, were less likely to mention bullying, they tended to highlight racism as a specific form of bullying. The remaining three studies provided qualitative data, although there was just one relevant quote from each that related to how racism affected the mental health of children and young people. Two of these quotes were given by a parent and youth worker, and only one was from a young person.