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. Author manuscript; available in PMC: 2024 May 1.
Published in final edited form as: Hosp Pediatr. 2023 May 1;13(5):461–470. doi: 10.1542/hpeds.2023-007133

Structural Racism in Behavioral Health Presentation and Management

Tyler Rainer a,*, Jamie K Lim b,*, Yuan He c, Joanna Perdomo d, Katherine A Nash e, Caroline J Kistin f, Destiny G Tolliver g, Elizabeth McIntyre g, Heather E Hsu h
PMCID: PMC10714315  NIHMSID: NIHMS1930206  PMID: 37066672

Abstract

Nia is a first-grade student with a history of trauma who was brought in by ambulance to the pediatric emergency department for “out of control behavior” at school. This is the first of multiple presentations to the emergency department for psychiatric evaluation, stabilization, and management throughout her elementary and middle school years. Several of the visits resulted in admission to the inpatient pediatric service, where she “boarded” while awaiting transfer to an inpatient psychiatric facility. At times, clinical teams used involuntary emergency medications and physical restraints, as well as hospital security presence at the bedside, to control Nia’s behavior. Nia is Black and her story is a case study of how structural racism manifests for an individual child. Her story highlights the impact of adultification bias and the propensity to mislabel Black youth with diagnoses characterized by fixed patterns of negative behaviors, as opposed to recognizing normative reactions to trauma or other adverse childhood experiences—in Nia’s case, poverty, domestic violence, and Child Protective Services involvement. In telling Nia’s story, we (1) define racism and discuss the interplay of structural, institutional, and interpersonal racism in the healthcare, education, and judicial systems, (2) highlight the impact of adultification bias on Black youth, (3) delineate racial disparities in behavioral health diagnosis and management, school discipline and exclusion, and healthcare’s contributions to the school-to-prison pipeline, and finally (4) propose action steps to mitigate the impact of racism on pediatric mental health and healthcare.

Case Introduction

Nia* is a first-grade student who presents to the pediatric emergency department (ED) from school via emergency medical services (EMS) for psychiatric evaluation due to “out of control behavior.” Upon evaluation, Nia appears calm and in no acute distress. She states she was kicked by another student, whom she kicked back. She also kicked a teacher after the teacher restrained her by pinning her arms to her chest. The teacher then called EMS and Nia’s mother. In the ED, Nia reports shin pain where she was kicked with no other focal symptoms. On exam, she is chatty and cooperative. She has a small hematoma on her right shin. The rest of her exam is normal.

Further history reveals Nia was exposed to domestic violence earlier in childhood, after which she developed worsening tantrum behaviors. She is tall and overweight for her age, but otherwise healthy and takes no medications. Child Protective Services (CPS) is involved with the family because of the prior domestic violence report. Nia’s mother retains legal custody. The family lives in government-assisted low-income housing and receives cash assistance to meet basic needs. Nia qualifies for an individualized education plan and attends a special education program for children with behavioral challenges. She has a provisional diagnosis of adjustment disorder and is engaged with in-home therapy. Family history is notable for multiple family members with mental health concerns without specified diagnoses. Nia and her mother identify as Black.

While Nia awaits her mother’s arrival, ED staff search, confiscate, and store her belongings according to hospital safety protocol. On arrival, Nia’s mother is described as distraught to learn her daughter was sent to the hospital primarily for psychiatric evaluation rather than medical care. Following medical clearance, child psychiatry and social work evaluate Nia and meet with her mother. Together, they plan for discharge home and schedule a meeting between Nia’s mother, school staff, and her therapist.

As Nia progresses through elementary and middle school, she has over a dozen similar visits to EDs for evaluation following instances characterized in her records as “verbal and physical aggression” at school and home. Many of these visits involve administration of emergency involuntary medications, physical restraints, and presence of hospital security or police at the bedside. Frequently, visits result in prolonged ED stays or admission to the inpatient pediatric unit while awaiting transfer to inpatient psychiatric care or intensive outpatient treatment. As a result of these ED visits, multiple diagnoses now appear in Nia’s medical record—including oppositional defiant disorder (ODD), disruptive mood dysregulation disorder, and bipolar disorder—although her only diagnosis from a psychiatrist is post-traumatic stress disorder (PTSD) related to complex intergenerational trauma. Despite medication trials, treatment at residential facilities, and involvement of a mobile crisis intervention team, Nia continues to present for emergency behavioral evaluation and stabilization.

Root Cause Conceptual Discussion

Four Levels of Racism

Racism is the process by which systems, policies, actions, and attitudes create inequitable opportunities and outcomes for people based on the social construct of race.1 Racism is ingrained in society, and functions as a core driver of pediatric health inequities in the United States (US).2,3 Theoretical frameworks commonly describe four levels of racism—structural, institutional, interpersonal, and internalized (Box 1)—and aim to elucidate mechanisms underlying differential health outcomes by race and support the design of interventions to address racial disparities.4,5 In discussing Nia’s story, we will focus on the influence of structural, institutional, and interpersonal racism on behavioral health diagnosis and management and the interplay between the healthcare, education, and juvenile criminal legal systems. Though related, we will not address the underlying drivers of racial disproportionality in child poverty or the child welfare system.3,6,7

Box 1. Levels of Racism4,5.

Structural Racism
• Refers to the cumulative and compounding ways in which society fosters racial discrimination and white supremacy among institutions and across society
• Functions through mutually reinforcing systems, policies, cultural beliefs, and practices that either systematically disadvantage or privilege different groups of people based on racialized identity
Institutional Racism
• Defined as discriminatory policies and practices within institutions that result in “differential access to the goods, services, and opportunities of society by race”4
• Institutions or systems of power include but are not limited to healthcare, education, housing, employment, and the criminal legal system
Interpersonal, or Personally Mediated, Racism
• Represents dynamics between individuals, and refers to the differential assumptions about and actions towards others based on race
• Can be either intentional or unintentional
Internalized Racism
• Occurs within an individual and is manifested by thoughts and beliefs about personal self-worth or ability based on race, influenced by society
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Racial Disparities in Behavioral Health Diagnosis and Management

Structural, institutional, and interpersonal racism in healthcare settings influence racial disparities in behavioral health, including referral to neuropsychiatric testing,8,9 access to trauma-informed mental health services,10,11 and the diagnosis and management of behavioral health conditions.12 For example, despite epidemiologic evidence demonstrating lack of racial differences in externalizing behaviors in children, attention deficit hyperactivity disorder (ADHD) is underdiagnosed and undertreated in Black and Latinx youth compared to White youth, while disruptive behavior disorders like ODD and conduct disorder (CD) are over-diagnosed.13,14 ADHD is recognized as a neurobiological problem of attention, hyperactivity, and impulsivity, with established structures of academic and social support and a strong evidence base for improved outcomes with behavioral support and pharmacotherapies. In contrast, ODD and CD are defined as patterns of uncooperative, defiant, and angry behavior toward people in authority. These diagnoses often carry more stigma because they are conceptualized as part of a fixed identity – inherent to an individual’s personality and less amenable to intervention.15 Notably, externalizing behaviors that characterize both ADHD and disruptive behavior disorders have substantial overlap, including emotional reactivity, difficulty following rules, and impulsivity. However, diagnoses of ODD and CD rely not only on assessing whether a child’s conduct deviates from age-appropriate behavior, but also on evaluating whether the child’s motivation for the behavior is willfully defiant, hostile, or purposefully aggressive.16 Such value-laden assessments may be influenced by implicit or explicit personally-mediated biases and racism.17

Disproportionate diagnosis of Black youth with disruptive behavior disorders may also be a result of mischaracterization of normative reactions to trauma.18 Black children are more likely to experience multiple and persistent adverse childhood events (ACEs) associated with a range of poor physical and mental health outcomes.19 Pathologizing reactions to trauma as problems of self-control and regulation exposes youth to further stigmatization and fails to address trauma as the underlying etiology.20 Diagnosis of a disruptive behavior disorder rather than a more treatable behavioral health condition – such as PTSD, ADHD, major depressive disorder, or generalized anxiety disorder – may also have potentially harmful clinical implications, including limiting access to evidence-based behavioral interventions, medication management, and other supportive services that can reduce mental health-related morbidity and mortality.14,21 These diagnostic disparities can also compound into differential treatment and access to services beyond the healthcare domain, most notably in the education system.

Over-diagnosis of Black children with ODD/CD compared to White children may also reflect adultification bias, where Black, Latinx, and Indigenous children are perceived as older than their actual age or developmental stage and less innocent or deserving of care or comfort.22,23 This manifestation of racism can result in harsh reactions to what is actually developmentally appropriate behavior.24–26Adultification bias is particularly well documented among Black girls.22 Examples of adultification bias abound in the media, such as in the case of a 9-year-old Black girl in Rochester, New York who was handcuffed and pepper-sprayed by police after they responded to a call to her home for “family trouble.” During the recorded event, the child is crying and begging not to be pepper-sprayed. One officer says, “stop acting like a child,” to which the 9-year-old girl responds, “I am a child.”27 Adultification bias may be enacted at the interpersonal level, as demonstrated by this example from the media or by racial disparities in pediatric anesthesia administration,25 or carried out at the systemic level, as highlighted by higher rates of Black youth being transferred from the juvenile court system to the adult criminal legal system.28

Implications for Nia’s Story

Clinical Implications

Nia’s story is a case study of how structural racism manifests for an individual child, highlighting the propensity to mislabel Black youth with diagnoses characterized by fixed patterns of negative behaviors, as opposed to recognizing and meaningfully addressing normative reactions to trauma or other ACEs—in Nia’s case, domestic violence, CPS involvement, and poverty.24 Pathologizing and criminalizing Black children’s developmentally appropriate stress responses, rather than addressing the behaviors as manifestations of underlying trauma, has immediate and long-term impacts. While Nia was ultimately diagnosed by a psychiatrist with PTSD, this case also illustrates the ease with which misdiagnoses are perpetuated in electronic health records, as Nia’s record inaccurately listed multiple other diagnoses, including bipolar disorder and ODD.29 This type of error is not unique to Nia. While decision support systems can help merge outside records or recommend additional conditions based on prescriptions or recent encounter diagnoses, clinical problem lists often remain incomplete or inaccurate.30,31,32 When inaccurate diagnoses persist in the medical record and interpretation of a child’s behaviors becomes disconnected from inciting traumas, labels such as ODD may come to signify unchangeable, negative characteristics that may not only influence clinicians’ decision-making and perceptions of children, but may also be internalized by youth themselves.

During Nia’s initial ED encounter, ED staff managed her as a potential danger despite her calm demeanor on arrival, searching her and confiscating her belongings. This was unfortunately only a prelude to future, potentially (re)traumatizing healthcare interactions that further restricted Nia’s autonomy, including use of restraints in subsequent encounters. Given Nia’s racial identity, adultification bias likely influenced her healthcare team’s responses to her behaviors, with the team potentially interpreting her actions as threatening or as willful aggression as opposed to stress responses characterized by anger and reactivity. Although hospital safety protocols that allow for confiscation of belongings and use of restraints intend to promote staff and patient safety, they may be unevenly applied and have adverse consequences. For example, at a systemic level, Black children have a higher likelihood than White children of emergency involuntary medication administration and physical restraint use during pediatric ED visits.33,34 These disparities persist into adulthood, with increased restraint use and hospital security involvement for Black adults compared to White adults.35

Implications Extending Beyond Healthcare: The School-to-Prison Pipeline

It is also important to consider Nia’s position as a Black student within an educational context that disproportionately disciplines Black children compared to their White counterparts and accelerates their connection with the criminal legal system. The “School-to-Prison Pipeline” refers to a US trend in which school-age children and adolescents are funneled out of schools and into the criminal legal system.36 This phenomenon disproportionately impacts children who identify as Black, Latinx, or Indigenous, children with disabilities, and those who live in poverty.

Young people with these identities are disproportionately pushed out of schools through several mechanisms. First, exclusionary school policies that criminalize typical child and adolescent behaviors as well as low-level offenses result in increased scrutiny, punishment, and exclusionary discipline starting as early as preschool.37–39 Second, rather than receiving appropriate special education and mental health supports, children with disabilities (including intellectual and learning disabilities) may be disproportionately suspended or expelled when they engage in disability-related behavior, such as a child with autism running around and pushing classmates when overstimulated by noise.40 Black children with disabilities are even more likely to experience disproportionate discipline compared to their White counterparts.38 Finally, children from minoritized backgrounds are disproportionately moved directly to the criminal legal system through school-based arrests and referrals to juvenile courts.41 When taken together, disproportionate scrutiny and exclusionary discipline can lead to decreased engagement in school, lower levels of educational attainment, and a higher likelihood of criminal legal system involvement–all which are known to have deleterious health effects.42

Medicalization and criminalization of unwanted behavior within the healthcare system through biased behavioral health assessments, use of involuntary medications and restraints, and over-reliance on hospital security can further contribute to disparities in educational outcomes, criminal legal system involvement, and ultimately morbidity and mortality (Figure 1). While healthcare professionals do not have direct control over school-based disciplinary actions, diagnostic mislabeling and the criminalization of mental and behavioral health occur in healthcare settings. The results of diagnoses made or actions (or inactions) taken in healthcare settings may then feed back into the school system or allow healthcare to serve as an entry point to carceral systems, including the child welfare and criminal legal systems.43

Figure 1. Conceptual Model of Process and Outcome Disparities Resulting from Biased Interpretations of Child Behaviors.

Figure 1.

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Child behavior may be interpreted through the lens of racism, adultification, and other biases. Biased interpretations of behavior propagate through the education and healthcare systems via both personally mediated mechanisms and institutional policies, leading to disproportionality in school disciplinary practices and school exclusion, as well as disparities in behavioral health diagnosis and management. Interplay between these process disparities in the education and healthcare systems adversely impacts Black children, as well as other children of color and children with disabilities. Together, they contribute to racial disparities in educational opportunities and attainment, criminal legal system involvement, and morbidity and mortality. Finally, the intergenerational effects of racial disparities in outcomes feedback to influence child behavior.

Case Follow-Up

Today, Nia is an adolescent who remains tall and overweight for her age. During her most recent presentation, Nia called 911 from home to request help for suicidal ideation but became agitated when EMS arrived accompanied by police. An altercation ensued, and she was escorted to the ED in handcuffs after hitting an officer. ED evaluation highlighted concerns for depression, and psychiatry recommended inpatient psychiatric admission. Nia boarded in the ED for 3 days before admission to inpatient pediatrics to continue awaiting psychiatric placement. Throughout her week-long hospital stay, Nia had numerous episodes of agitation and elopement attempts. Medication management was limited due to lack of parental permission for use of oral medication to address depression, hyperarousal, or sleep difficulty or oral medications as needed for anxiety or moderate agitation; with these restrictions, the inpatient team was limited to using involuntary intramuscular medications as a last resort in the case of imminent risk of physical harm to Nia or staff members. Nia consequently received intramuscular medications several times and was placed twice in physical restraints due to agitation that progressed to hitting and throwing food trays at staff members.

A Call to Action

Nia’s behaviors represent externalizing manifestations of PTSD and complex, intergenerational trauma. At present, there is inadequate availability and access to high-quality, trauma-informed therapy and other supportive services for youth like Nia, resulting in more children and adolescents presenting to pediatric EDs and inpatient medical settings for evaluation, stabilization, and boarding.44–46 Given the ongoing youth mental health crisis, a growing number of children and adolescents will continue to present to acute care facilities. As such, we need to ensure that we do not perpetuate diagnostic disparities, compound trauma, or contribute to the criminalization of child behavior when they present for care. We propose action steps at the structural, institutional, and interpersonal levels to mitigate the impact of structural racism on child mental health (Table 1).

Table 1.

Action Steps to address racism’s impact on mental and behavioral health for youth

Actions to reduce the impact of structural racism on mental and behavioral health
    Support legislative efforts to disrupt practices that contribute to educational and health inequities, such as the “Ending PUSHOUT Act” or bans on school expulsion below 5th grade50,51
    Invest in alternatives to law enforcement-based responses to mental health crises in the community, such as mobile crisis intervention units55 and trauma-informed school-based behavioral healthcare practices56
    Advocate for improved and equitable multi-domain mental health funding to increase accessibility of mental health resources, such as in-school evidence-based therapies
    Improve data collection and transparency in order to understand the scope and impact of school-to-ED referrals for behavioral concerns52
Actions to dismantle institutional racism in at the intersection of healthcare and education
    Disrupt healthcare’s contribution to criminalization of mental health problems and trauma responses by decreasing police and security presence in healthcare settings10,74
    Establish developmentally appropriate and trauma-informed approaches to managing children with behavioral dysregulation in clinical care settings, such as youth-focused behavioral response teams63,64 or the Boston Medical Center Autism Friendly Initiative75,76
    Reduce the impact of structural racism on behavioral health diagnosis by revising diagnostic criteria for disruptive behavior disorders with a goal of promoting trauma sensitivity18
    Use quality improvement methods to measure and track institutional data on key equity-oriented process and outcome measures and address areas in need of improvement, including racial disparities in mental health diagnosis, treatment, and use of restraints69
    Create partnerships between pediatricians, teachers and school leadership to improve communication between the school and healthcare domains
    Invest in school-based restorative justice programs, such as Positive Behavioral Interventions and Supports77,78
    Implement action-oriented and introspective educational programs like Health Equity Rounds to educate healthcare professionals and identify opportunities for institutional improvement or advocacy70
Actions to reduce the impact of interpersonal racism on patient care
    Be aware of the risk of adultification of Black, Latino, and Indigenous children and actively challenge yourself and colleagues to resist this bias22
    Maintain a healthy skepticism of diagnostic labels for disruptive behavior disorders, with an understanding of underlying racial disparities, and remove unverified diagnoses from electronic health record problem lists
    Follow best practices documentation recommendations to reduce stigma and perpetuation of bias electronic health records79,80
    Engage longitudinal outpatient clinicians, including primary care and mental health providers, for valuable context for pediatric inpatients
    Provide anticipatory guidance and education to patients and families about developmentally appropriate behavioral redirection and their rights within the educational setting
    Provide resources for medical-legal partnerships to families concerned about racist treatment in school or healthcare settings
    Mediate and mitigate the potentially traumatizing experiences with police, security, and public safety officers in hospitals
    Familiarize yourself with hospital resources able to assist with behavioral health patients, including social work, psychologists, psychiatrists, Child Life, etc.
    Educate yourself and your multidisciplinary clinical teams on how to discuss racism with colleagues and with patients children and families81–83
    Refer behavioral health patients who may qualify to Supplemental Security Income (SSI) to help alleviate family poverty
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Structural Action Steps

Implementation of racial equity-oriented policy may reduce negative interactions at the interface of healthcare, education, and the criminal legal system for children like Nia. For example, several states and municipalities have passed legislation banning suspension and expulsion of young children from school, acknowledging the harmful effects of school exclusion and its role in perpetuating racial disparities in life outcomes.47–49 Healthcare professionals can support bills, such as H.3876 currently in the Massachusetts legislature and H.R.2248 in the US Congress, that ban or disincentivize school exclusion.50,51 In addition, since school referral to the ED for agitation and aggression may be a preventable cause of missed school days, we can also advocate for school districts to improve data collection and transparency to understand the scope and impact of school-to-ED referrals for behavioral concerns and associated disparities.52,53 For children in need of evidence-based mental healthcare services, clinicians can also advocate for strategies to expand access, as outlined in a recent declaration of the national emergency in youth mental health.54 Promising strategies include increasing funding for community- and school-based mental health programs, expansion of mobile crisis intervention programs, supporting mental health/primary care integration, and addressing mental healthcare workforce shortages through innovative trainings, loan repayment strategies, and recruitment of clinicians from diverse backgrounds.55–60

Institutional Action Steps

Hospital systems can address institutional racism by developing standardized, developmentally appropriate, and trauma-informed approaches to pediatric behavioral dysregulation.61 Such practices may include reducing police and security presence in hospitals and establishing behavioral emergency response teams consisting of mental health professionals trained in pediatric-specific de-escalation techniques.62–64 In addition, hospitals should consider development of clinical pathways to ensure a standardized approach to patients presenting with acute agitation or aggression,65,66 with a goal of reducing subjectivity in interpretations of behavior and action steps taken, such as use of restraints or filing a CPS report. Evidence for success of similar pathways includes reduction in racial and socioeconomic disparities associated with screening evaluations for potential non-accidental trauma.67,68 Hospitals may couple clinical pathway implementation with team-based quality improvement efforts to collect and monitor institutional data, an approach with demonstrated success in reducing physical restraint use without a corresponding increase in staff injuries in one children’s hospital.69 Finally, innovative educational programs like Health Equity Rounds can be a platform to bring together stakeholders and highlight opportunities for system improvement to advance equitable patient care.70

Interpersonal Action Steps

Clinicians should intentionally reflect on how racism and adultification bias impact how they care for Black and other minoritized children. One approach to reducing bias is to avoid linguistic bias during electronic health record documentation. Use of linguistic devices—such as quotes, judgment words, and stigmatizing language—is more prevalent in Black as compared to White patients’ notes.71,72 These linguistic devices have the potential to negatively affect other clinicians’ attitudes and behaviors.73 Particularly in the emergency and inpatient care settings, where clinical care teams rely heavily on the electronic health record for history and context, accurate verification of prior mental health diagnoses is critical. Involving family members, primary care providers, and other team members in the care of children with behavioral dysregulation can help verify active problems, provide additional context, and share existing behavioral plans with emergency medications individualized to patient symptoms and therapeutic goals. Members of clinical teams may also engage with medical-legal partnerships to ensure that a child’s right to education is not violated and the child receives the supports needed for success in educational settings. When discussing or documenting a child’s needs, clinicians should aim to provide recommendations that are not limited in scope by perceived resource limitation of the school district. For example, if a child needs a small, trauma-informed school where students are never restrained, the clinician should convey this recommendation regardless of whether they believe that it is realistic. This allows medical-legal partnerships to advocate more strongly for a child’s true needs and puts the onus on school districts to meet them.

In summary, pediatricians along the full care continuum encounter children like Nia. By improving our understanding of racism’s role in both the care we deliver and healthcare’s interactions with other systems, we will be better poised to disrupt racism’s impact on our patients’ health and provide Nia and other children like her with the support, care, and resources they need to thrive.

*Name and identifying details have been altered so that the child and family are not identifiable based on the information included in this article. In addition, we note the patient’s self-identified racial identity as necessary context for our discussion of racism.

Acknowledgements:

The authors would like to acknowledge Dr. Mary Brown, who provided her expertise as a guest panelist for the initial Health Equity Rounds conference presentation, and Drs. Elizabeth Hutton and Alison Duncan for their contributions to conference preparation. The authors would also like to thank Drs. Bob Vinci and Catherine Michelson for their institutional leadership and support of Health Equity Rounds at Boston Medical Center.

Funding/Support:

Dr. Heather Hsu is supported by a career development award from NIDA (K01DA054328).

Role of Funder:

The funder did not participate in the work.

Footnotes

Conflict of interest disclosures:

The authors have no conflicts of interest relevant to this article to disclose.

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