Opinion | The Intersection of Black Youth Mental Health and Racism

On October 19, several leading pediatric organizations declared a national state of emergency for child and adolescent mental health, in part due to the immense toll of the COVID-19 pandemic. Youth mental health is an emergency, no doubt: the overcrowded emergency departments where youth may wait for days, sometimes weeks, to be admitted to an inpatient hospital due to bed shortages; the conversations about suicidality and family turmoil that psychiatrists must have with children in busy hospital hallways rather than in quiet individual rooms; the child and adolescent inpatient units stuffed to capacity, pressured to receive an overwhelming number of patients.

Yet, now that a mental health emergency has been declared, I worry even more that Black children and adolescents will fall further through the cracks.

When several of my Black child and adolescent patients were repeatedly called the n-word by white patients while an all-white staff watched without intervening, this unacceptable behavior was blamed on the pandemic. The staff did not intervene because they were “stressed and short-staffed.” No staff meeting was called to address the lack of protection for my Black patients because “communication difficulties have been exacerbated by the pandemic.” The pandemic has become a scapegoat — a convenient excuse — for tolerating racist behavior that has been targeted at Black children and adolescents in hospitals for decades.

This Mental Health Crisis Isn’t New

The mental health of Black American youth was in crisis long before COVID-19 devastated the world, but no national public health crisis was called. In 2019, the Congressional Black Caucus (CBC) Emergency Taskforce on Black Youth Suicide and Mental Health released a report documenting the alarming increases in Black youth suicide rates. The suicide death rates among Black youth have been increasing faster than those of any other racial/ethnic group in America, and Black youth under 13 years old are twice as likely to die by suicide compared to their white peers. According to preliminary federal data published today, the suicide rate for Black girls and women ages 10 to 24 increased more than 30% in 2020, and by 23% among Black boys and men in the same age group. Yet, many suicide predictor models continue to list “white race” as a factor that increases risk of suicide, and the myth that Black youth do not commit suicide persists.

So, what’s contributing to these trends? In 2019, the American Academy of Pediatrics released a policy statement naming racism as a driver of health inequities in Black children and adolescents, including but not limited to, mental health. Many studies also document the deleterious effects of racism — distinct from socioeconomic status — on the mental health of Black children and adolescents, such as depression and low self-esteem. Black teenagers may experience racism, often in the form of race-related bullying, more than five times per day, with a greater number of experiences tied to greater intensity of depressive symptoms. Beyond just peers, racism is alive in the minds of teachers. Teachers rate Black students as having lower math skills than their white peers with comparable test scores. Even as young as pre-K, teachers expecting bad behavior watch Black children, especially boys, more than their white peers — and they do more than just watch. Black children and adolescents are more likely to be suspended for the same behaviors as white peers, perpetuating the school-to-prison-pipeline. Anecdotally, many Black children and adolescents have a story — or ten — of racist statements made by teachers, which undoubtedly affect their mental well-being.

Despite the unique challenges experienced by Black youth, research focusing on their mental health is scarce, especially when it comes to the racism they experience. A recent study showed that in psychological research, race is rarely mentioned, and when it is, the study is authored and edited by almost all white scholars. There is a dire need for research that examines the mental health of Black youth to develop tailored, targeted interventions. Unfortunately, Black researchers, who might be more likely to study the mental health of Black children, are less likely to be funded by NIH than white researchers. Outside of research, mental health providers should be leading the charge in addressing the mental health of Black youth, yet psychiatry remains a largely white-dominated and white-centered field. We can do better.

The Role of the Medical System and Medical Education

Despite rampant racism, psychiatrists are not routinely trained in how to navigate these issues on an individual or systemic level. They should be. Instead, racial disparities in child and adolescent mental health are often taught with the same inaccurate narrative: Black children have worse mental health outcomes than white children because they are poorer, resulting in less resources and access to care. For instance, the higher rates of cerebral palsy in Black children is attributed to maternal education and socioeconomics, rather than the toxic stress of racism experienced by Black mothers, which results in adverse birth outcomes. Medical education teaches that Black children have less attention deficit-hyperactivity disorder (ADHD) diagnoses than white children, but fails to teach that Black children are underdiagnosed for ADHD due to clinician racism.

To be sure, socioeconomic status does play a role in Black youth mental health outcomes, but it is by no means the sole factor. After all, money does not protect Black children and adolescents from racism. And even when discussing socioeconomic status, it is inaccurate to discuss poverty in the Black community without acknowledging the intentional economic oppression of Black Americans due to white supremacy.

However, it is not surprising that mental health providers are largely unequipped to target Black child and adolescent mental health. The medical system, psychiatry included, has a long history of racism towards Black patients — and children and adolescents are not immune. Black children are more likely to be physically restrained in emergency departments, and more likely to be diagnosed with disruptive disorders, like oppositional defiant disorder, than their white peers with comparable behaviors. This makes sense, given that Black children are more likely to be misperceived as angry. How can psychiatrists and other healthcare providers possibly address Black child and adolescent mental health when they themselves are engaging in medical racism? How can healthcare providers help Black youth navigate the impacts of racism on their mental health, COVID-19 or not, when they have little to no training in racism-related stress? They can’t — at least, not adequately.

Pushing for Change

To truly address Black youth mental health, significant change is needed. Teachers must check their own racist behavior and must be trained in how to identify and protect Black youth from the impacts of racism, from individual bullying to the intentional economic oppression of Black Americans. Physicians and other pediatric mental healthcare providers, from child psychiatrists to social workers, should ask Black children about their experiences of racism in schools and serve as advocates. Pediatric healthcare providers are in dire need of training as well. Medical education must start teaching and training healthcare providers in how to identify racism and mitigate its effects on Black youth in the medical system, even if that means calling out their own behavior or that of a colleague. Reporting systems should be put in place so healthcare providers who see racist events in the hospital experienced by children are able to safely report them without fear of retaliation. Racism by clinicians and staff results in poorer care and should be reported as one would report giving the wrong medication to a patient. Finally, adverse mental health outcomes in Black children and adolescents should not be attributed solely to poverty, lack of education, or less access to care. Instead, we must start citing racism and the intentional economic oppression of Black American families, which trickles down to the resources and mental healthcare access that Black children are privy to. After all, we are in the midst of a double pandemic: COVID-19 and racism.

Amanda Calhoun, MD, MPH, is an adult/child psychiatry resident at Yale Child Study Center/Yale School of Medicine. Calhoun is also a Public Voices fellow of the OpEd Project at Yale University.