The Unequal Toll of Toxic Stress

How the Mental Burdens of Bias, Trauma, and Family Hardship Impact Girls and Women

There is a pervasive lack of sensitivity to the ways in which girls of color signal emotional distress—a widespread failure on the part of adults that results in too many girls falling through the cracks at school.

In this article
A woman looks out to the street from a balcony in San Francisco, February 2005. (AP/Marcio Jose Sanchez)
A woman looks out to the street from a balcony in San Francisco, February 2005. (AP/Marcio Jose Sanchez)

Introduction and summary

In previous work on women’s leadership, the Center for American Progress has explored an array of factors that lead women to fall behind in public life. Rejecting the notion that the women’s leadership gap (as well as the pay gap and empowerment gap generally) can be closed if enough women are enjoined solely to “lean in,” CAP has argued that women’s outcomes are shaped by a combination of social and structural forces that marginalize, and even eject, women at all levels of the work pipeline. Those forces include a lack of work-family policies; an inhospitable work culture; and enduring, often unconscious, racial and gender bias.1

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CAP’s previous work has also, however, shown that any accounting of women’s progress (or lack thereof) in attaining leadership roles in the United States cannot be told as a single story. As inequality in the United States has widened, the gaps among women have grown greater as well. Over the past four decades, the disconnect in the fortunes of college-educated women and their noncollege-educated sisters has grown larger than ever before.2 And white women have fared far better than women of color in attaining leadership roles in the public sector and rising through the ranks of corporate America.

The gap between white women and women of color persists

White women are 31 percent of the U.S. population and 26 percent of elected officials.

Women of color are 20 percent of the U.S. population but just 4 percent of elected officials.3

White women are 26.2 percent of U.S. employees; 26.4 percent of first- or mid-level officials and managers; and 21.8 percent of executive- or senior-level officials and managers in S&P 500 companies.4

Women of color are 18.5 percent of U.S. employees; 10.5 percent of first- or mid-level officials and managers; and 4.7 percent of executive- or senior-level officials and managers in S&P 500 companies.5

The roots of inequality, both between men and women and among women themselves, stem from early life. At the start, some children are provided with the kinds of opportunities, tools, and resources that put them on track for success, while others are pulled off track by life experiences that impede their abilities to learn and flourish. The ways in which the inequities of childhood—in areas such as education, health, neighborhood safety, economic security, and access to high-quality childcare, just for starters—can lead to unequal outcomes in adulthood have been explored by many scholars in recent years.6 However, this report aims to carve out a new and insufficiently discussed aspect of childhood inequity for greater study and attention. Specifically, this report examines how the unacknowledged and untreated toll of toxic stress, often stemming from trauma, saps the potential of far too many girls and women, disrupting their educational trajectories and limiting their abilities to achieve their dreams.

Trauma and toxic stress—that is to say, stress that is powerful, frequent, or unyielding, and largely unmediated by adult support7—are not, of course, problems limited to girls and women. But they often stem from experiences that occur disproportionately in the lives of girls and women—and of girls and women of color in particular.

The American Academy of Pediatrics defines “toxic stress” as “the excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships.”8

Women in the United States are more likely than men to live in poverty. 9 They are far more likely to experience sexual abuse and assault. 10 Moreover, girls and women of color must also deal with racism in all its overt and covert forms. The psychological toll of this lived reality is consequential yet all too often overlooked or misunderstood. Girls and women who internalize their problems pass under the radar, while those who “act out” are stigmatized, and, in the case of girls and women of color in particular, may be criminalized. For this reason, scholars have begun talking in terms of a “sexual abuse to prison pipeline” for girls of color in addition to the “school to prison pipeline” long recognized as a deplorable outcome for too many students of color.11

This report aims to take its place alongside the burgeoning literature on the girl-specific school-to-prison pipeline and create a bridge to work on women’s leadership, arguing that the psychological fallout from toxic stress and trauma must be counted among the structural factors that impede too many girls’ long-term prospects in school and, later, in the workplace.

Considerable public attention has so far focused on the psychological issues, and sometimes dramatic derailment, of high-achieving girls—college-bound, generally white, and generally upper-middle class.12 But the same sort of worry that animates conversations about middle- and upper-middle-class girls pulled under by pathological levels of pressure and stress has not carried over to an equivalent consideration of the psychological fallout of toxic stress caused by poverty, racism, or trauma. A combination of explicit and implicit bias, criminalization, incomprehension, and stigma has tended, in particular, to obscure the distress of girls of color and bury their experiences and their needs.

The adultification13 and criminalization of African American girls who have histories of toxic stress and trauma are perhaps the most dramatic and troubling manifestations of the ways that the psychological needs of women and girls of color are overlooked and misunderstood. But they are not the only ones. There is a pervasive lack of sensitivity to the ways in which girls of color signal emotional distress—a widespread failure on the part of adults that results in too many girls falling through the cracks at school. The price these young women pay in missed educational and, later, work opportunities translates into a major loss in human capital in the United States.

This report will suggest a range of policy areas that should be explored for new solutions. In particular, it will propose:

  • Adopting policies to reduce and prevent toxic stress in vulnerable families, including raising the minimum wage to $15 per hour and providing access to affordable and high-quality childcare, paid family leave, and predictable scheduling
  • Increasing funding for schools to train personnel in trauma-informed practices and hire more culturally competent psychologists, counselors, and social workers capable of screening students for signs of trauma and identifying impediments to learning before they lead to school failure, in addition to:
    • Ending “zero tolerance” school disciplinary policies in favor of measures that foster compassion, problem-solving, and inclusion for girls of color
    • Empowering students with mental health issues that affect their school performance and ability to learn as well as their families to understand how they can assert their right to an Individualized Education Program (IEP) or 504 plan designed to help students thrive in school under the terms of the Individuals with Disabilities Education Act and Section 504 of the Rehabilitation Act
  • Supporting and expanding legislation, such as the Affordable Care Act (ACA), that can make mental health services affordable, accessible, and on par with physical health care, with special attention to boosting the quality; racial and ethnic diversity; language skills; and cultural awareness and sensitivity of care providers
  • Encouraging community-based actions to fight mental health stigma and increase awareness of what toxic stress looks like and how it can be treated and, to the greatest degree possible treated, mitigated and prevented

What toxic stress is and what it does

Most, if not all, children suffer some adversity in their early lives, and most, if not all, experience some stress. But not all are exposed to the kinds of adverse childhood experiences—sexual; physical or emotional abuse or neglect; living in poverty or with household substance abuse or mental illness; having a family member incarcerated; or witnessing domestic violence14—that, particularly in combination, can lead to toxic stress. According to child development experts, toxic stress is stress that is powerful, frequent, or unyielding, and largely unmediated by adult support. 15

Toxic stress hijacks the body’s immune and endocrine systems and is damaging for a child’s developing brain. It can affect attention, memory, planning, future stress responses, 16 and the ability to learn new skills.17 It can leave a child with an impaired ability to deal with powerful or negative emotions, leading to behavioral problems in school, possible self-harm, and substance abuse problems in adolescence. 18 All of this can make a child more likely to drop out of school, adding up to a “chain of adversity,” as termed by the authors of a 2004 study of adults who had witnessed violence as children, which can bring with it a lifetime of negative consequences.19 Those consequences include heart disease, diabetes, frequent mental distress, substance abuse, depression, poor work performance, low academic achievement, financial stress, risk for domestic violence, suicide attempts, unintended pregnancies, early sexual activity, young parenthood, and sexual violence.20

The damage, however, is not inevitable. The degree of harm is proportional to the number and intensity of the stressors a child experiences. 21 For example, having divorced parents in and of itself does not necessarily rise to the level of toxic stress. On the other hand, the chronic experiences of racism, living in an unsafe neighborhood, and experiencing community violence do.22 A considerable body of research literature shows that, with consistent support from caring adults, even children who have experienced severe trauma can prove resilient. 23 But without that support, the brain changes wrought by too heavy a dose of adversity can cause a child to flounder in school and can put her on a track toward future work difficulties and dashed dreams.

There is strong evidence that a wide range of policies—including subsidized childcare, living wage legislation, paid family leave, paid sick leave, and fair scheduling practices—can decrease the odds of toxic stress at home by increasing families’ economic security, enhancing parents’ mental health, and allowing parents to be more physically and psychologically available to meet their children’s needs. 24

These policies, which are discussed in the recommendation section below, should be considered key elements of efforts to prevent the long-term effects of toxic stress.

An unequal dose of adversity means unequal life outcomes

Ever since the mid-1990s, researchers associated with the Centers for Disease Control and Prevention (CDC) and partner institutions have surveyed increasingly diverse samples of people in the United States to gauge their level of exposure to adverse childhood experiences. These researchers have consistently found that girls experience higher rates of adverse childhood experiences than boys, 25 particularly when it comes to sexual abuse26; that children living in poverty have greater exposure to adverse childhood experiences than children in more prosperous families;27 and children of color have more adverse childhood experiences than white children. (The exception being children of color and white children at the very lowest income level, and except when it came to living with a parent with substance abuse or mental illness).28

A troubling caveat
Decades of research has shown that exposure to childhood adversity decreases with higher family income. But a 2016 study that looked specifically at the intersection of race and socioeconomic status found that the positive effects of higher income do not hold up in the same way for children of color. Even at high income levels, children of color continue to experience disproportionately high levels of adversity compared to white children of equivalent socioeconomic status.29

The effects of these unequal doses of adversity are compounded by the fact that girls, children of color, and low-income children are far less likely than boys, white children, and higher-income children, respectively, to receive appropriate help and support if they start showing the kinds of problems at home and in school that are associated with exposure to adverse childhood experiences and toxic stress.30 Some of these problems include depression, learning difficulties, and challenges with self-regulation.

Considerably higher percentages of children from low-income families have mental health problems than do children overall.31 Girls suffer higher rates of depression than boys, starting at puberty.32 There are some indications that girls who experience trauma are more likely than boys to develop PTSD33 and also that girls are more vulnerable than boys to psychological fallout from the stresses of family difficulties and poverty. 34

And yet—perhaps because they tend to internalize rather than externalize their symptoms of pain—girls are half as likely as boys to use mental health services to help them deal with trauma, stress, or other difficulties that impact their functioning.35 Children of all racial and ethnic groups are affected by mental health issues. Yet children of color are far less likely than white children to receive mental health services, and, if they do receive support, are less likely to receive high-quality care.36

Lack of support, racism, stigma, and shame

In part, the dearth of support is a problem of access: School psychologists, counselors with a mental health focus, and social workers are sorely lacking in schools serving communities of color. Mental health resources in communities of color generally are scarce, and seeking mental health care—whether by adults or for children—is often viewed with derision or suspicion. There are historical reasons for this: For example, pervasive racism in the mental health system in the past has led to African Americans being, on the one hand, overpathologized with serious mental disorders and, on the other, underdiagnosed with more common problems such as depression.37 Even today, African American clients continue to report racism and microaggressions from non-African American therapists.38 The mental health workforce is disproportionately white—in 2013, 83.6 percent of the active psychology workforce was white, and African Americans accounted for just 5.3 percent of practitioners39—and often lacks the language skills and cultural sensitivity to work effectively with immigrant communities. A lack of recognition of the role that poverty, violence, racism, and discrimination play in causing toxic stress and mental health issues remains an issue, as does a tendency to downplay the important role that family, friends, and community institutions such as churches play in helping people cope.

Stigma and shame, particularly in communities of color, are also major barriers standing in the way of acknowledging, treating, and preventing the effects of toxic stress in vulnerable girls and women. 40 Yet the shame and silence, especially surrounding sexual assault and abuse, can worsen the effects of trauma and make it more difficult for survivors to access help. As Kimberlé Williams Crenshaw, a professor at UCLA School of Law and Columbia School of Law, put it during a 2016 YWCA policy briefing on trauma and violence in the lives of girls of color: “It’s a parallel system of denial — part of the everyday practice of marginalization.”41

Racism also plays a powerful and pernicious role in the underrecognition and undertreatment of the mental health needs of girls of color. When trauma is overlooked or undiagnosed, it can lead to other behaviors—including disruptive behavior in the classroom—that are a common reaction to both trauma and injustice that some experts see as help-seeking and adaptive.42 African American girls are often met with uncomprehending and hostile responses from teachers and other school personnel who tend to be disproportionately white.43 Instead of counseling, these students receive punishment and—all too often—suspensions, expulsions, and referrals to law enforcement.44 Indeed, according to the authors of a 2015 report from the National Crittenton Foundation and National Women’s Law Center, “For girls with mental health needs, the juvenile justice system becomes a proxy for the mental health system in too many cases.” 45 Overall, African American children are almost three times less likely than white children to receive mental health care when they show signs of distress and nearly four times as likely to be suspended for minor classroom misconduct.46 According to one 2017 report, black girls are four times more likely to be arrested and seven times more likely to be suspended than their white counterparts.47

In her 2016 book, Pushout: The Criminalization of Black Girls in Schools, Monique W. Morris explores how looking at black children through such a biased lens, combined with the use of zero tolerance school disciplinary policies, has created a situation where black girls as young as 6 or 7 years old have been arrested at school for throwing tantrums or being disruptive. Morris notes that, black girls are commonly labeled “irate,” “insubordinate,” “disrespectful,” or “uncontrollable” by their teachers, and while making up just 16 percent of the female student population in the United States, they are nearly one-third of all girls referred to law enforcement and more than one-third of all girls arrested in school.48

Once pushed out, these girls do not easily get back on track. Nearly 48 percent of black girls who are expelled from school in the United States do not then have access to educational services, Morris writes.49 Harsh disciplinary policies are known to be a risk factor for dropping out of high school—an event that leads to future low-wage work and, often, unemployment and even incarceration.50

While Asian American girls, by and large, are not criminalized, they, too, can suffer the effects of a brain drain caused by unacknowledged depression and stress—a so-called “web of pain,” described by Boston University professor of social work Hyeouk Chris Hahm. This pain, she writes, stems from internalizing the “model minority” stereotype, racial discrimination, and a “fractured identity”—a term she uses to describe having to navigate the very different cultural worlds and expectations of their often foreign-raised parents and their American-raised peers. The multitude of different cultures and countries of national origin make collective studies of Asian American families problematic—and there is still a dearth of research. However, recent studies by the Asian American Federation have shown that, in 2014, Asian American adolescent girls had the highest rate of depression among all racial and ethnic groups in the United States, while Asian American women between the ages of 15 and 24 had some of the highest rates of suicide across all racial groups. Although Asian American immigrant families experience an outsized dose of stress—stemming from poverty; acculturation; the pressure on adults to work long hours and support an extended family; and on children to succeed at a very high level in school; coupled with significant rates of domestic violence—the federation notes Asian Americans are also among the least likely of all racial and ethnic groups to seek out mental health care due to a lack of awareness, cultural stigma, and language barriers. 51

Luis H. Zayas, dean of the School of Social Work at the University of Texas at Austin and author of the 2011 book Latinas Attempting Suicide: When Cultures, Families and Daughters Collide,52 has suggested that complex cultural pressures account for significantly elevated rates of emotional distress among young Latinas as well. In 2015, according to the CDC’s “High School Youth Risk Behavior Survey,” 46.7 percent of Hispanic or Latino girls in ninth through 12th grades reported having felt sad or hopeless almost every day for two weeks in a row, so much so that they stopped doing some of their usual activities in the 12 months before the survey. That number was a considerably higher percentage than for African American, Asian, or white girls. Hispanic or Latino girls were also the most likely of these groups to have attempted or made a plan to attempt suicide in the past year.53 Suicide attempts by Latina teenagers, Zayas has written, may be a “cultural idiom of distress”—a way of expressing the painful contradictions they face between parental expectations of behavior and American culture, particularly around autonomy and individuation. “Among Latina teen suicide attempters,” Zayas writes, “the experience of marginalization and alienation is central: young women may be caught between two or more life-ways that are not congruous and [find] little help from those around [them] in negotiating the resultant tensions.”54

Lack of support and treatment feed the persistence of mental health problems and their consequences

The link between mental distress and school performance is clear: Mental health problems such as depression or PTSD are linked to higher rates of missing school, lower educational achievement, and dropping out of school, as well as to higher rates of suspension and expulsion. 55 Depression can also lead to an increased chance of parenthood at a young age—known to be one of the key drivers of low-income women dropping out of school due to a lack of structural supports both during pregnancy and after. 56

In their 2014 report, “Unlocking Opportunity for African American Girls,” the NAACP Legal Defense and Education Fund and National Women’s Law Center make a strong case that the level of toxic stress—compounded by the number and types of stressors and volume of reoccurrence—experienced by an undue number of African American girls has had a significant impact on their ability to thrive in school. The compound pressures lead to their underachieving and falling behind other groups of girls in high school completion and college attendance. “Trauma — from sexual harassment and assault, community violence, and the daily stressors of racism and sexism — can have a negative effect on academic performance for any child,” the authors write. “For African American girls, the build-up of overlapping forms of trauma may have an even more negative effect.”57

The stresses of poverty, racism, abuse, and other trauma do not end with childhood, and their effects on performance do not end in high school.

Anxiety and depression are approximately twice as likely to afflict women than men58—a consistent finding that researchers attribute, at least in part, to women’s greater exposure to stressors such as exposure to violence and abuse. 59 Living with day-to-day gender bias is a factor too. Women’s common experience of role overload—to clarify, all the duties that attend the “second shift” of unpaid work at home that begins when the paid work day is over—has also been identified as a driver of stress-induced anxiety and depression. 60 Even pay discrimination has been shown to play a role in women’s increased rates of anxiety and depression. 61

Women of color are disproportionately subjected to an accumulation of forces that negatively impact mental well-being, what Diane R. Brown and Verna M. Keith, editors of In and Out of Our Right Minds: The Mental Health of African American Women, call the “triangulation of race, gender, and socioeconomic status.”62 Exposure to racism is a stressor that increases vulnerability to depression and anxiety (particularly if the bias is internalized).63 Being on the receiving end of frequent microaggressions—words or actions that subtly, sometimes unconsciously, convey prejudice toward a member of a marginalized group—also has been linked to depression and anxiety.64

In 2012, researchers showed that workplace discrimination was a chronic stressor playing out in poorer health, higher rates of emotional distress, and a lower sense of general well-being in a sample of African American professional women. 65 Some researchers have theorized that transgenerational societal trauma—the cumulative stresses of poverty, racism, victim blaming, and lack of support—may make low-income African American women particularly vulnerable to depression and PTSD. 66 Yet women of color are less likely than white women to seek and receive support and counseling for mental distress.67

The biased lens through which many teachers view African American girls leads them to label their signs of mental distress as bad behavior requiring harsh discipline. The same bias on the part of police officers can lead to death. The legal scholar Kimberlé Williams Crenshaw, and Andrea J. Ritchie, an attorney and author, have written that in a number of cases where black women have died in encounters with police officers, the women were having mental health crises. Yet police officers viewed them as threatening and dangerous rather than in distress and requiring compassion and care. Due to the lack of access to mental health services in most African American communities, police—with no special training or capabilities—often serve as the “first and only responders to mental health crises experienced by Black women,” write Crenshaw and Ritchie.68

The price of dealing with all these stressors is not merely psychological: Depression can lead to lower earnings, greater unemployment, and more work disability and missed work days as well as considerable lost productivity due to what is termed “presenteeism”—when workers show up for their jobs but get little done.69 Anxiety causes, on average, 4.6 lost workdays per month.70 Likewise, experiencing sexual assault is also known to result in reduced employment and income.71

Recommendations: Preventing the loss of potential by addressing toxic stress

Toxic stress—from childhood adversity, sexual violence, gender discrimination, and racism—saps the educational and vocational potential of too many girls and women. This is a loss that our society simply cannot afford. Fortunately, many of the underlying causes of toxic stress can be identified and addressed and the physical and mental fallout can be prevented. The key is to recognize symptoms and then make sure they are productively treated. Moreover, there are proven ways that public policy can make a difference.

Nurturing relationships with parents and other key adults are known to be a protective factor that can keep at-risk children from developing the most negative outcomes of toxic stress.72 Public policy can help make and keep those relationships healthy and strong. Policies that boost families’ economic security, reduce parental stress, and help parents feel empowered and more physically and emotionally available for their children will contribute to reducing the toll of toxic stress.

Adopt family and child-friendly policies that help to reduce toxic stress

Studies on child abuse and neglect have shown that policies that help secure parental employment, housing, as well as access to health care, social services, and child care all help protect children by supporting their parents’ abilities to make ends meet, reducing parental stress and depression.73 Paid sick days have also been shown to reduce depression and stress, while irregular scheduling is associated with greater levels of parental depression and stress.74 For this reason, the CDC has called for policies such as subsidized child care, a living wage, paid family leave, paid sick leave, and fair and consistent scheduling as child protective measures.75

Increase funding and resources for schools to expand, support, and improve mental health services that can aid and empower students and families

Schools are the most common entry point for children and teenagers to receive services for mental health needs.76 Yet, according to a 2016 CAP analysis of public school staffing data, only 63 percent of public schools employ a full-time school counselor; 22 percent have a full-time psychologist; and 18 percent have an in-house social worker. Schools in communities of color are particularly underserved. According to CAP’s analysis, Alabama suspended almost 20 percent of its black students in the 2011-12 school year, yet less than 1 percent of the state’s schools reported employing a full-time psychologist. And only 47 percent of Rhode Island’s schools employed a full-time counselor in the 2011-12 school year, while 13 percent of the state’s Hispanic students received an out-of-school suspension.77

Federal, state, and local policymakers should increase funding for diverse and linguistically and culturally competent school psychologists, counselors, and social workers who can recognize signs of distress in at-risk students and can provide both support and outside referrals to evidence-based treatment.

State laws should require the presence of culturally and linguistically competent counselors in elementary and middle as well as high schools and mandate lower student-to-counselor ratios. As CAP has previously recommended, policymakers should also increase funding sources for reform models that establish school-based mental health centers, such as full-service community schools. 78

The Mental Health in Schools Act, introduced in June 2017 by Rep. Grace Napolitano (D-CA) and Sen. Al Franken (D-MN), proposed increased funding for an expansion of comprehensive school-based mental health services and supports, with training for school employees, parents, and other family members, as well as members of the community who spend extensive time with children.79

School personnel should be trained to identify students with hidden disabilities, such as emotional and learning difficulties that impair functioning. Trained school personnel should be available to refer family members to a local Parent Training and Information Center—which should receive increased congressional funding in order to build competence on trauma-informed work—so families can learn how to secure school-based services for students with disabilities under the terms of the Individuals with Disabilities Education Act and section 504 of the Rehabilitation Act.

End harmful disciplinary policies that force girls of color out of school

Schools must also change disciplinary policies that respond to minor behavioral infractions with suspensions and expulsions and instead implement race-conscious policies that are responsive to students’ needs and offer support and remediation rather than punishment. School personnel, from teachers up to community officers, as well as other key adults in regular contact with children, such as doctors and faith leaders, must be trained in trauma-informed practices and methods to combat bias against students of color and build competence in offering support.

The Supportive School Climate Act of 2015—introduced in the Senate by Sens. Cory Booker (D-NJ) and Chris Murphy (D-CT) and in the House by Rep. Danny Davis (D-IL)—was one attempt to bring about such changes through policy. More recently, Sen. Heidi Heitkamp (D-ND)’s Trauma-Informed Care for Children and Families Act of 2017, aimed to create Medicaid demonstration projects to test trauma-informed approaches to screening, diagnosis, and treatment while calling on states to collect and report data on adverse childhood experiences.

Protect and expand the ACA to make mental health services affordable and accessible

One of the most notable gains brought by the ACA was the requirement that both public and private insurance plans offer mental health and substance abuse treatment as part of their essential health benefit packages.80 These policies have proven critical in shrinking the racial/ethnic health care coverage gap and increasing access to mental health and substance abuse treatment for people of color.81 Both the House and Senate health care bills introduced this year in an effort to repeal and replace the ACA contained provisions to allow states to waive this essential health benefit requirement.82 Should Congress take such action in the future, Americans could also lose their guarantee that no person can be denied coverage for pre-existing conditions as well—a blow that would hit particularly hard for all people with mental health issues, which tend to be chronic conditions. Such a change in health care policy would have a disproportionate impact on communities of color.

The ACA must be maintained and strengthened with robust enforcement mechanisms implemented to ensure that mental health parity is a reality. 83 To increase the availability of mental health care providers who participate in health insurance, all incentives should be found to require health insurers to reimburse for behavioral health services at rates equivalent to practitioners in other specialties.

Fight stigma at the community level to address the societal attitudes that make the symptoms of toxic stress more shameful than those of heart disease or diabetes

Policymakers should seek ways to provide the public with more and better education on the long-term effects of adverse childhood experiences. In addition, these policies should embrace incentives that encourage parents to seek professional help. 84 In May 2017, Rep. Judy Chu (D-CA) introduced the Stop Mental Health Stigma in Our Communities Act. The bill proposes to amend the Public Health Service Act to provide outreach and education on symptoms of mental illness as well as information about evidence-based, culturally informed, and linguistically appropriate behavioral and mental health treatments, with a particular emphasis on reducing the stigma associated with mental health in Asian American, Native Hawaiian, and Pacific Islander communities.85


Substantive discussions of issues such as trauma and toxic stress that affect brain health and development—along with their resultant long-term consequences for learning, emotional well-being, education, work, and earnings—have been conspicuously absent from the talk and literature about women’s leadership. Yet no conversation about the structural factors that hold women back—and contribute to inequality among different groups of women—can be complete without their mention.

Women’s progress is still too frequently viewed through the lens of individual achievement with a focus on personal strengths, weaknesses, and choices. However, as Marilyn Metzler and a team of researchers writing on adverse childhood experiences for the CDC recently put it, “[T]he choices a person makes are shaped by the choices a person has, which are themselves shaped by structural policies and processes.” 86

Conditions, such as depression, that arise from toxic stress and affect all aspects of well-being are still heavily stigmatized. Yet acknowledging these problems—and getting high-quality support—can make a world of difference in helping girls flourish in school and stay on track in adulthood. Girls with unrecognized needs that sap their self-confidence and sense of self-efficacy may find it extremely difficult, if not impossible, to acquire the skills that can lead to a future of opportunity. Women with unequal burdens of pain are not equally free to succeed.

About the author

Judith Warner is a senior fellow at the Center for American Progress and the author of We’ve Got Issues: Children and Parents in the Age of Medication.


This paper would not have seen the light of day without the generous support and encouragement of my colleagues at the Center for American Progress. I would particularly like to thank Will Beaudouin and Carl Chancellor on CAP’s editorial team for their gracious and graceful editing under extreme time pressure; Kaitlin Holmes for her crucial help with research; and Shilpa Phadke for having the vision to bring this project into being. I would also like to thank Melisa Boteach, Catherine Brown, Rebecca Cokley, Rejane Frederick, Jocelyn Frye, Katherine Gallagher Robbins, Danyelle Solomon, Jamila Taylor, and Rebecca Vallas for their very careful reading and thoughtful comments.


  1. Judith Warner, “Opening the Gates: Clearing the Way for More Women to Hold Political Office” (Washington: Center for American Progress, 2017) available at; Judith Warner and Danielle Corley, “The Women’s Leadership Gap” (Washington: Center for American Progress, 2017) available at; Judith Warner, “For Women to Lead, They Have to Stay in the Game” (Washington: Center for American Progress, 2014), available at; Jocelyn Frye, “Defining Power and Why It Matters: Securing Women’s Equality and Women’s Futures” (Washington: Center for American Progress,2017), available at
  2. Ruth Milkman, “Class Inequalities Among Women,” The Sociologist, January 4, 2017, available at
  3. Reflective Democracy Campaign, “Reflective Democracy Research Findings Summary Report” (2017), available at
  4. Catalyst, “Women in S&P 500 Companies by Race/Ethnicity” available at
  5. Ibid.
  6. See, for example, see Jorge Luis García and others “The Life-cycle Benefits of an Influential Early Childhood Program” (Chicago: Human Capital and Economic Opportunity Global Working Group, 2016), available at; Flemming Lander and others, “Social inequalities in childhood are predictors of unemployment in early adulthood,” Danish Medical Journal (3) (2012), available at
  7. National Scientific Council on the Developing Child, “INBRIEF: The Impact of Early Adversity on Children’s Development (InBrief)” (2007), available at
  8.  A.S. Garner and J.P. Shonkoff; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics, “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health,” Pediatrics 129 (1)  (2012), available at
  9. Kaiser Family Foundation, “Nonelderly Adult Poverty Rate by Gender,” available at,%22sort%22:%22asc%22%7D (last accessed October 2017).
  10. 17.2 vs 6.7 percent. See, Centers for Disease Control and Prevention, “Morbidity and Mortality Weekly Report: Adverse Childhood Experiences Reported by Adults – Five States, 2009,” available at (last accessed October 2017).
  11. Malika Saada Saar and others “The Sexual Abuse to Prison Pipeline: The Girls’ Story” (Washington: Human Rights Project for Girls, Georgetown Law Center on Poverty and Inequality, and Ms. Foundation for Women, 2015), available at
  12. See, for example, Stephen Hinshaw and Rachel Kranz, The Triple Bind: Saving Our Teenage Girls from Today’s Pressures and Conflicting Expectations (New York City: Ballantine Books, 2009, available at
  13. Rebecca Epstein, Jamilia J. Blake, and Thalia Gonzalez, “Girlhood Interrupted: The Erasure of Black Girls’ Childhood” (Washington: Center on Poverty and Inequality, Georgetown Law, 2017), available at
  14. Centers for Disease Control and Prevention, “About the CDC-Kaiser ACE Study,” available at (last accessed November 2017).
  15. National Scientific Council on the Developing Child, “INBRIEF: The Impact of Early Adversity on Children’s Development (InBrief).”
  16. Ibid.
  17. Marilyn Metzler and others, “Adverse childhood experiences and life opportunities: Shifting the narrative,” Children and Youth Services Review 72 (2017): 141–149.
  18. Substance Abuse and Mental Health Services Administration, “Adverse Childhood Experiences,” available at (last accessed November 2017).
  19. Ross Macmillan and John Hagan, “Violence in the Transition to Adulthood: Adolescent Victimization, Education, and Socioeconomic Attainment in Later Life” Journal of Research on Adolescence 14 (2): 127–158, available at;
  20. andy A. Sansone, Justin S. Leung, and Michael W. Wiederman, “Five forms of childhood trauma: Relationships with employment in adulthood,” Child Abuse & Neglect 36 (9): 676–679; Yong Liu and others “Relationship between adverse childhood experiences and unemployment among adults from five U.S. states,”  Social Psychiatry and Psychiatric Epidemiology 48 (2013): 357–369, available at Robert F. Anda and others, “Childhood Abuse, Household Dysfunction, and Indicators of Impaired Adult Worker Performance,” Permanente Journal 8 (1) (2004): 30–38; Metzler and others, “Adverse childhood experiences and life opportunities: Shifting the narrative.”
  21. Centers for Disease Control and Prevention, “About the CDC-Kaiser ACE Study,” available at (last accessed October 2017).
  22. The CDC’s first wave of research on ACEs, conducted in the mid-1990s, was based on results from more than 17,000 members of a Health Maintenance Organization in Southern California who were overwhelmingly white and more educated than the national average. In 2012 and 2013, researchers surveyed nearly 2,000 people in predominantly African American and Latino neighborhoods in Philadelphia using an expanded ACE list that included items such as experiencing racism, witnessing violence in the community, living in an unsafe neighborhood, experiencing bullying, or having experienced foster care. They found that 73 percent had at least one ACE as conventionally defined by the earlier research; 63 percent had at least one ACE of the type in the newly expanded definition; and 49 percent had experienced both. Fourteen percent of respondents experienced only the expanded ACEs and would have gone unnoticed under the old measure. Peter F. Cronholm and others “Adverse Childhood Experiences: Expanding the Concept of Adversity,” American Journal of Preventive Medicine 49 (3) (2015): 354–361.
  23. Centers for Disease Control and Prevention, “About the CDC-Kaiser ACE Study.”
  24. National Center for Injury Prevention and Control, “Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities” (Atlanta: Division of Violence Prevention, Centers for Disease Control and Prevention, 2016), available at
  25. YWCA, “Girls of Color and Trauma,” available at (last accessed November 2017); Saar and others, “The Sexual Abuse to Prison Pipeline”; Francine T. Sherman and Annie Balck, “Gender Injustice: System-Level Juvenile Justice Reforms for Girls” (Portland, OR; Washington: National Crittenton Foundation; National Women’s Law Center, 2015), available at
  26. 17.2 vs 6.7 percent. Centers for Disease Control and Prevention, “Morbidity and Mortality Weekly Report.”
  27. Natalie Slopen and others, “Racial Disparities in Child Adversity in the U.S.,” American Journal of Preventive Medicine 50 (1) (2016):47–56 .
  28. Ibid.
  29. Ibid.
  30. Hodgkinson, S. and others, “Improving Mental Health Access for Low-Income Children and Families in the Primary Care Setting,” Pediatrics 139 (1) (2017), available at
  31. Ibid.
  32. Centers for Disease Control and Prevention, “Mental Health Surveillance Among Children – United States, 2005-2011,” Morbidity and Mortality Weekly Report, May 13, 2013, available at; Ramin Mojtabai, Mark Olfson, and Beth Han “National Trends in the Prevalence and Treatment of Depression in Adolescents and Young Adults,” Pediatrics 138 (6) (2016); Also, see Paul R. Albert, “Why is depression more prevalent in women?,” Journal of Psychiatry & Neuroscience 40 (4) (2015): 219–221, available at
  33. Sherman and Balck, “Gender Injustice.”
  34. Ibid.
  35. Girls age 8 to 15 are 50 percent less likely than boys their age to use mental health services. National Institute of Mental Health, “Statistics,” available at (last accessed October 2017).
  36. Margarita Alegria, Melissa Vallas and Andres Pumariega, “Racial and Ethnic Disparities in Pediatric Mental Health,” Child and Adolescent Psychiatric Clinics (19) (4) (2010): 759–774, available at; Margarita Alegria and others, “Disparities in Child and Adolescent Mental Health and Mental Health Services in the U.S.” (New York: William T. Grant Foundation, 2015), available at
  37. David R. Williams and Ruth Williams-Morris, “Racism and Mental Health: The African American experience,” Ethnicity & Health 5 (3-4) (2000): 243–268.
  38. Mental Health America, “Black & African American Communities and Mental Health,” available at (last accessed October 2017).
  39. American Psychological Association Center for Workforce Studies, “2005-13: Demographic of the U.S. Psychology Workforce” (2015), available at
  40. Fear of stigma—both for having mental health issues and for seeking treatment—emerges consistently in studies of both college students of color and older adults of color as a major deterrent to getting help. See, Hsiu-Lan Cheng and others, “Racial and Ethnic Minority College Students’ Stigma Associated with Seeking Psychological Help: Examining Psychocultural Correlates,” Journal of Counseling Psychology, 60 (1) (2013): 98–111. See also, Earlise Ward and others, “African American men and women’s attitude toward mental illness, perceptions of stigma, and preferred coping behaviors,” Nursing Research 62 (3) (2013):185–194, available at
  41. Kimberlé Crenshaw, “YWCA National Day of Action Policy Briefing: Stand Against Racism: On A Mission for Girls of Color,” YouTube, April 28, 2016, available at
  42. Sherman and Balck, “Gender Injustice: System-Level Juvenile Justice Reforms for Girls.”
  43. See Tom Rudd, “Racial disproportionality in School Discipline: Implicit Bias is Heavily Implicated,” (Columbus, OH: Kirwan Institute for the Study of Race and Ethnicity, 2014), available at; Seth Gershenson, “The alarming effect of racial mismatch on teacher expectations,” (Washington: Brookings Institution, 2015), available at; Lisette Partelow, Angie Spong, Catherine Brown, and Stephenie Johnson, “America Needs More Teachers of Color and a More Selective Teaching Profession,” (Washington: Center for American Progress, 2017), available at
  44. Kimberlé Williams Crenshaw with Priscilla Ocen and Jyoti Nanda, “Black Girls Matter: Pushed Out, Overpoliced and Underprotected” (New York: Center for Intersectionality and Social Policy Studies, African American Policy Forum, 2015), available at
  45. Sherman and Balck, “Gender Injustice.”
  46. Shannon Stagman and Janice L. Cooper, “Children’s Mental Health: What Every Policymaker Should know (New York: National Center for Children’s Poverty, Mailman School of Public Health, Columbia University, 2010) available at;  Cited in Perpetual Baffour, “Counsel or Criminalize? Why Students of Color Need Supports, Not Suspensions,” (Washington: Center for American Progress, 2016), available at
  47. Misha N. Inniss-Thompson, “Summary of discipline data for girls in U.S. public schools: an analysis from the 2013-14 U.S. department of education office for civil rights data collection” (Berkeley, CA: National Black Women’s Justice Institute, 2017), available at
  48. Monique W. Morris, Pushout: The Criminalization of Black Girls in Schools (New York: The New Press, 2016), p. 4 and 11.
  49. Ibid, p. 3.
  50. Crenshaw with Ocen and Nanda, “Black Girls Matter.”
  51. Asian American Federation, “Overcoming Challenges to Mental Health Services for Asian New Yorkers” (2017), available at Also see, Asian American Federation, “The State of Asian American Children” (2014), available at
  52. Luis H. Zayas, Latinas Attempting Suicide: When Cultures, Families, and Daughters Collide (New York: Oxford University Press, 2011), p. xiii.
  53. Centers for Disease Control and Prevention, “Youth Risk Behavior Surveillance System: High School Youth Risk Behavior Survey, 2015,” available at (last accessed October 2017).
  54. Luis H. Zayas and Lauren E. Gulbas, “Are suicide attempts by young Latinas a cultural idiom of distress?” Transcultural Psychiatry 49 (5) (2012): 718–734, available at
  55. Jose Blackorby and Renee Cameto, “Changes in School Engagement and Academic Performance of Students with Disabilities” (Menlo Park, CA: SRI International, 2004), available at; Jose Blackorby and others, “The Academic Performance of Secondary School Students with Disabilities” (Menlo Park, CA: SRI International, 2003), available at; Mary Wagner, “Youth with Disabilities Leaving Secondary School” (Menlo Park, CA: SRI International, 2005), available at; All cited in Stagman and Cooper, “Children’s Mental Health”; Also see, American Psychiatric Association Foundation, “Quantifying the Cost of Depression,” available at (last accessed  November 2017).
  56. Ronald C. Kessler and others, “Social consequences of psychiatric disorders, II: Teenage parenthood,” The American Journal of Psychiatry 154 (1997): 1405–1411, available at ; See also American Psychiatric Association Foundation, “Quantifying the Cost of Depression.”
  57. NAACP Legal Defense and Education Fund and National Women’s Law Center, “Unlocking Opportunity for African American Girls” (2014), available at
  58. Jonathan Platt and others, “Unequal depression for equal work? How the wage gap explains gendered disparities in mood disorders,” Social Science & Medicine 149 (2016), available at
  59. Ibid.
  60. Ibid.
  61. A 2016 Columbia University study looked at survey data for more than 22,000 working adults in the United States and found that the past-year odds of experiencing depression were almost twice as great for women as for men except when women were earning incomes equal or greater to that of men matched to them in age, education level, industry, and marital status; in that situation, the gender gap in depression disappeared. Overall, women in the sample were 2.5 times as likely as men to have experienced anxiety in the past year. Those earning less than their male peers were more than four times as likely to suffer anxiety than men. But, once again, those earning as much or more than their male peers, were less likely than the men to experience anxiety. This pattern held true for women at all levels of the income scale. See, Ibid.
  62. Diane R. Brown and Verna M. Keith, eds “In and Out of Our Right Minds: The Mental Health of African American Women” (New York: Columbia University Press, 2003), available at
  63. Veronica Womack, “A Movement Against Racism Should Be a Movement for Mental Health,” Time, March 27, 2015, available at See also, Mental Health America, “Black & African American Communities and Mental Health,” available at (last accessed November 2017); David R. Williams and Ruth Williams-Morris, “Racism and Mental Health: The African American experience,” Ethnicity & Health 5 (3-4) (2000): 243­–268, available at
  64. Kevin L. Nadal and others, “The impact of Racial Microaggressions on Mental Health: Counseling Implications for Clients of Color,” Journal of Counseling & Development 92 (2014): 57­–66.
  65. J. Camille Hall, Joyce E. Everett, and Johnnie Hamilton-Mason, professors of social work at the University of Tennessee, Knoxville, Smith College, and Simmons College, respectively, conducted qualitative interviews with 41 African American professional women in three states, more than three-quarters of whom had bachelors degrees (and nearly half of whom had master’s degrees or higher). They found rampant workplace discrimination, expressed through stereotypes; unfair demands; an absence of mentoring; exclusion from work cliques; being ignored and/or harassed; and assumed to be incompetent, plus lower pay as well as a greater likelihood of working in less-secure, low-level positions with few opportunities for advancement. The women spoke of being seen as “hostile,” the authors noted in a 2012 article in the Journal of Black Studies; they talked of learning that education and training did not guarantee them career progression, told of having to shift speech patterns and behaviors to avoid being seen in stereotypical ways, and of feeling scrutinized, isolated, and without control. Said one participant who’d lost a job to a less well-educated white colleague: “Even if you work and follow the rules, racism will keep you down.” Camille Hall, Joyce E. Everett, and Johnnie Hamilton-Mason, “Black Women Talk About Workplace Stress and How They Cope,” Journal of Black Studies 43 (2) (2012): 207–226.
  66. Thema Bryant-Davis and others, “Struggling to Survive: Sexual Assault, Poverty, and Mental Health Outcomes of African American Women,” American Journal of Orthopsychiatry 80 (1) (2010): 61­–70, available at
  67. Stagman and Cooper, “Children’s Mental Health”; Office of Minority Health, “Mental Health and Hispanics,” available at (last accessed October 2017);Centers for Disease Control and Prevention, “Tables of CDC 2016, Summary Health Statistics: National Health Interview Survey: 2014,” available at (last accessed October 2017); Cited in Office of “Minority Health, “Mental Health and African Americans,” available at (last accessed October 2017); Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, the U.S. Department of Health and Human Services, and RTI International, Office of Minority Health, “Results from the 2014 National Survey on Drug Use and Health: Mental Health Detailed Tables” (2015), Table 1.22B, available at; U.S. Department of Health and Human Services, “Minority Health and African Americans,” available at (last accessed October 2017); U.S. Department of Health and Human Services, “Mental Health and Asian Americans,” available at (last accessed  October 2017); Mental Health America, “Asian American Pacific Islander Communities and Mental Health,” available at (last accessed October 2017).
  68. Kimberlé Williams Crenshaw and others “Say Her Name: Resisting Policy Brutality Against Black Women” (New York: Center for Intersectionality and Social Policy Studies, July 2015 Update), available at
  69. Ronald C. Kessler, “The costs of depression,” Psychiatric Clinics of North America, 35 (2012): 1–14; Paul E. Greenberg and others, “The economic burden of adults with major depressive disorder in the United States (2005 and 2010),” Journal of Clinical Psychiatry 76 (2015): 155–162; both cited in American Psychiatric Association Foundation Center for Workplace Mental Health, “Quantifying the Cost of Depression,” available at (last accessed October 2017). Also see, University of Michigan Depression Center, “Depression and Lost Productivity,” available at (last accessed October 2017).
  70. American Psychiatric Association Foundation, “Anxiety Disorders,” available at (last accessed October 2017).
  71. Thema Bryant-Davis and others, “Struggling to Survive: Sexual Assault, Poverty, and Mental Health Outcomes of African American Women,” American Journal of Orthopsychiatry 80 (1) (2010): 61–70, available at
  72. Margarita Alegria and others, “Disparities in Child and Adolescent Mental Health and Mental Health Services in the U.S.,” (New York: William T. Grant Foundation, 2015), available at
  73. National Center for Injury Prevention and Control, “Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities” (Atlanta: Division of Violence Prevention, Centers for Disease Control and Prevention, 2016), available at
  74. For a roundup of studies, see National Center for Injury Prevention and Control, “Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities” (Atlanta: Division of Violence Prevention, Centers for Disease Control and Prevention, 2016), available at
  75. Ibid.
  76. National Association of School Psychologists, “Position Statements,” available at (last accessed October 2017).
  77. Baffour, “Counsel or Criminalize.”
  78. Ibid.
  79. MaryKatherine Brueck, “Promoting Access to School-Based Services for Children’s Mental Health,” AMA Journal of Ethics 18 (12) (2016): 1218–1224.
  80. Mental Health America, “Position Statement 71: Health Care Reform,” available at (last accessed October 2017).
  81. Artiga, Petry Ubri, and Julia Foutz, “What is at Stake for Health and Health Care Disparities under ACA Repeal?,” Kaiser Family Foundation, March 17, 2017, available at
  82. Matthew Fiedler, “Like the AHCA, the Senate’s health care bill could weaken ACA protections against catastrophic costs,” Brookings Institution, June 23 2017, available at
  83. Center for the Application of Prevention Technologies, “Adverse Childhood Experiences,”, available at (last accessed October 2017).
  84. Ibid.
  85. Stop Mental Health Stigma In Our Communities Act, H.R. 2677, 115 Cong., 1st sess., available at
  86. Metzler and others, “Adverse childhood experiences and life opportunities.”; SAMHSA, “Adverse Childhood Experiences,” available at (last accessed November 2017).

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