Access to mental health care for Black and Latino teens with anxiety and depression: a qualitative study

Abstract

Background

Anxiety and depression are common mental disorders among children and their prevalence has increased in recent years. Unfortunately, some children do not have access to mental health care. Black and Latino children have been reported to be more likely to have unmet mental health care needs than other racial or ethnic groups. This study sought to identify the influential factors in accessing mental health care for Black and Latino teens with anxiety or depression in Milwaukee, Wisconsin, and identify recommendations to improve access for this group.

Methods

Ten qualitative, key informant interviews were conducted between February 2022 and January 2023 and analyzed using thematic analysis as the research approach.

Results

Study findings were categorized into six themes:(1) Mental health during the COVID-19 pandemic, (2) First points of contact, (3) Preferences for mental health professional characteristics, (4) Adequate care: Culturally-appropriate, trauma-informed, and family-centered, (5) Community awareness of mental health and resources available, (6) Availability of mental health services.

Conclusions

Recommendations for public health policy and practice to increase access for these groups are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44192-025-00190-w.

Background

Anxiety and depression are among the most common childhood mental illnesses [1]. The prevalence of these conditions has been increasing in recent years (between 2016 and 2020) with childhood anxiety increasing from 7.1% to 9.2% and depression increasing from 3.1% to 4.0% [2]. Specifically among teens 12 to 17 years old, approximately one in five reported symptoms of anxiety and one in six reported symptoms of depression (during a two-week period between 2021 and 2022) [3, 4]. The COVID-19 pandemic brought unique risk factors for these conditions including social isolation and recreational technology use (such as spending time on social media, watching TV, and playing video games) [5]. Another risk factor for anxiety and depression, neighborhood violence exposure also increased during the pandemic, especially for non-White children [6, 7]. Furthermore, parents or caregivers reported that experiencing racial or ethnic discrimination increased among children by 16% from 2019 to 2020 [2]. Also, mortality rates due to COVID-19 were greater among Hispanic and non-Hispanic Black essential workers compared to non-Hispanic Whites [8].

Unfortunately, there is a need for more mental health care than is currently provided [9]. Black and Latino children have been reported to be more likely to have unmet mental health care need compared to non-Hispanic White children [10–16]. Important factors for accessing childhood mental health care include distance to provider [17, 18] and health specialist density [17] (accessibility); availability of providers [19] (availability); wait time for an appointment [18] and hours of operation [19] (accommodation); insurance [10, 19, 20], maternal employment [12], and cost of services [18–20] (affordability); stigma [18–20] and preference to handle problems on one’s own [18] (acceptability); and not knowing where to go [18] (awareness). Still, the most important factors influencing utilization of mental health care for Black and Latino teens with anxiety and depression are not well understood [21, 22]. Furthermore, the recent context of the COVID-19 pandemic brought additional barriers and facilitators to care that need to be examined.

The purpose of this study was to 1) identify influential factors in accessing mental health care for Black and Latino teens who have anxiety or depression during the COVID-19 pandemic from the teen, parent, and mental health professional perspective, and 2) identify recommendations to improve access. These findings may help focus public health interventions and funds to better serve this population of teens.

Methods

Recruitment and data collection

We conducted ten one-time key-informant interviews between February 2022 and January 2023. They were one-on-one, semi-structured, audio recorded, and held over Zoom or over the phone. Eligible participants included 1) teens 14 to 17 years old, with a self-reported diagnosis of anxiety or depression, who reside in Milwaukee County, and identify as Black, African American, Hispanic, or Latino; (2) parents or guardians age 18 or older that reside in Milwaukee County and have an eligible teen for whom they make health care decisions; (3) individuals age 18 or older that practice as a licensed counselor, psychiatrist, psychologist, or therapist or provide other mental health support to their community in Milwaukee County and serve Black, African American, Hispanic, or Latino teens with anxiety or depression. Teen and parent participants were recruited through flyers shared in pediatric clinics, by community mental health organizations, and schools. Snowball sampling was also used. Maximum variation sampling was used for mental health professional participants to increase the variability of work settings and geographic locations of work settings represented in the sample [23]. Mental health professional participants were contacted directly by email using publicly available contact information with an informational letter. Three mental health professional participants refused the invitation to participate and two did not respond. All individuals who contacted the research team and expressed interest in participating were screened for eligibility. Prior to the start of the interview, the researcher conducted the informed consent discussion with the adult participants (parents and mental health professionals) and noted verbal agreement in the study records. For the teen interview, the researcher conducted the assent discussion with the teen and parental permission with the parent prior to the interview. The researcher noted both of their verbal agreement in the study records. Interviews lasted about 45 min. After completing the interview, teen and parent participants received $20 gift cards. Mental health professional participants did not receive a financial incentive. This study was approved by the Children’s Wisconsin and Medical College of Wisconsin Institutional Review Boards.

Interview concepts for teen and parent interviews included initial realization of the teen needing support, who provided the diagnosis, types of support received and perspectives on utilizing them, impact of the COVID-19 pandemic on teen mental health and access to care, and thoughts on using telehealth. Interview concepts for mental health professionals included perceptions on access to mental health care for Black or Latino teens, the accessibility of their own services, and recommendations to improve access. The three interview guides were discussed with local community partners and members of the target population to evaluate the appropriateness of the content (Supplementary file: Appendix A).

Data analysis

Audio recordings were transcribed verbatim, and MAXQDA software was used for data analysis. The interpretive framework of this research is pragmatism, and the research approach is reflexive thematic analysis [23, 24]. Each transcript was coded using descriptive, structural, in-vivo, process, holistic, and provisional codes [25]. Then, thematic maps were used to organize codes into preliminary themes and test relationships between codes and themes [24]. Themes were refined and finalized through the writing process and by revising the original thematic maps [24]. Starting with codes related to the participant’s recommendations to improve access, quotes were collated for each code and multiple illustrative or representative quotes categorized by code were added to a document to begin summarizing and reporting findings. After adding participant recommendation codes and quotes to a document, the quotes were grouped based on meaning. Next, additional codes which grouped concepts patterned throughout the dataset, were added to the document. Final revisions of the results included selecting illustrative quotes and creating detailed descriptions of these patterns in the dataset. Filler words, repeated words, and false starts were removed from the selected quotes to improve readability. We acknowledge that thematic- and meaning-saturation as a metric of validity does not align with reflexive thematic analysis, which is a reflexive organic process in which the researcher generates meaning from the data and the interpretive process and makes interpretive judgements on when to move to the next phase of analysis [26]. In this manuscript, we chose to report themes that answered our two study aims and were supported by rich and illustrative data. Reported quotes were checked with the original audio recording for accuracy.

Finally, themes were contextualized using the Levesque, Harris, and Russell (2013) conceptual framework of patient-centered access to health care [27]. It portrays the process of accessing health care through five stages; starting at the left with having a need for care, next perceiving this need and desiring support, next seeking out care, then being able to reach available services, then being able to utilize the services, and finally receiving a positive impact from the services [27]. In addition, there are five dimensions of accessibility of services (Approachability, Acceptability, Availability and Accommodation, Affordability, and Appropriateness) and five abilities of the people engaging with the dimensions of accessibility to gain access (Ability to perceive, seek, reach, pay, and engage) [27]. This framework has previously been applied to contextualize efforts to improve access to childhood mental health care [28].

Results

One teen, three parents, and six mental health professionals participated in the interviews. All teen and parent participants identified as female, and half reported that the teen was experiencing both anxiety and depression. The mental health professionals were between 35 to 69 years old, and they were diverse in race. All were non-Hispanic, and most were female. Half served a majority Black population of teens, while the other half served a majority Hispanic population of teens or about equal proportions of Black and Hispanic teens. Half of the mental health professionals worked in schools. A third of the mental health professionals were an educator or advocate, a third were a master’s level mental health professional, and a third were psychologists. Participant’s work or residential locations were geographically diverse throughout Milwaukee County.

We developed six themes to categorize the findings, and we contextualized them in the Levesque, Harris, and Russell 2013 Patient-centered access to health care conceptual framework (Fig. 1). These themes were (1) Mental health during the COVID-19 pandemic, (2) First points of contact, (3) Preferences for mental health professional characteristics, (4) Adequate care: Culturally-appropriate, trauma-informed, and family-centered, (5) Community awareness of mental health and resources available, and (6) Availability of mental health services. Sub-themes identified in this study are categorized using this framework in Fig. 1.

Fig. 1.

Conceptual framework of access to mental health care for Black and Latino teens with anxiety or depression during the COVID-19 pandemic. This framework is adapted from the Levesque, Harris, and Russell 2013 conceptual framework of access to health care [27]. Participants reported factors (black boxes) influencing a variety of service and individual-related access constructs (the five dimensions of accessibility of services and five abilities of the people engaging with the dimensions of accessibility to gain access). Participants also reported solutions or recommendations for the future to address these aspects of access (orange ovals). Factors that participants reported were at least in part related to the COVID-19 pandemic have an asterisk

Mental health during the COVID-19 pandemic

Teen anxiety and depression

Study participants supported the need to improve access to mental health care for Black and Latino teens with anxiety or depression, noting that the COVID-19 pandemic exacerbated these conditions among children by forcing them to stay at home and away from friends. One therapist who works in schools reflected on what she noticed during the 2021–2022 school year (P05). She described teen mental health as having “spiraled” for reasons such as not being able to take a break from their home life by going to school or social events, fears related to the COVID-19 pandemic, and loved ones becoming sick or dying from COVID-19. She also noted that “parent’s anxiety and depression has gone up, which trickles to the child.” Through her work, she observed the number of children dealing with anxiety and depression triple since the pandemic. Although participants mostly associated the start of the pandemic with worsened mental health, for one teen switching to virtual learning brought relief from her social anxiety and peer conflict at school (P02).

Stress among adults who work with children

A clinician who works in a primary care setting shared that providing care for children who have experienced trauma can lead to stress and a secondary trauma response for herself and other therapists in Milwaukee, independent of the COVID-19 pandemic (P10). However, she noted that Black patients and families were experiencing “a lot of trauma” on a “day-to-day basis” during the COVID-19 pandemic.

“I guess we haven't talked about this as much, but like, I think it's a really, really important one just talking with other therapists in the Milwaukee area. I think with the amount of violence right now, with the amount of issues along those lines, and just the general disparities especially for a lot of our Black patients and a lot of our Black families, there's a lot of trauma. There is a lot of trauma that our patients are coming in with on a day-to-day basis and so I think that takes an added toll in some ways on the therapists. And the therapists carry a lot of that.”

Mental Health Professional (Psychologist), P10

She also noted that more senior mental health professionals are less affected due to protected time for administrative tasks, teaching, or research in addition to seeing patients, while licensed social workers and graduate student therapists are seeing patient after patient with no time to address that added stress.

A mindfulness teacher noted that school principals and counselors were also feeling stressed during the pandemic (P07). Even though schools were reaching out and asking for his services, he encountered several instances where he never ended up working with the students, teachers, and staff, because the leaders were too busy and stressed out to get started. These examples illustrate that the COVID-19 pandemic was a stressful time for children, parents, mental health professionals, and school staff.

First points of contact

Reaching out to a parent

Initially, the teen participant did not want to reach out for help due to the stigma around mental health. When she realized she could no longer manage her mental health on her own, she talked to her parents about it. Her mother suggested talking to a therapist.

“At first I didn't really want to deal with it, because I felt like I would have been labeled as, I don't know, like 'crazy’ or something or people would start treating me different, and I really didn’t want to go through that. So, for a long time I would tell people that I was fine, and I was dealing with it. And then when I finally realized that it was getting too much, I went more to my mom and my therapist--and just more talking [*pause*] about it.”

Teen, 15 years old, P04

Reaching out for resources at school

This participant’s mother first reached out to the school after noticing her daughter was experiencing bursts of crying and frustration as well as peer conflict (P02). However, she ended up feeling frustrated and unheard when her concerns were dismissed by the school staff. In the end, she felt her ability to advocate for her daughter was essential to finding care for her daughter.

“I was just looking for a resource to know what direction I could go with the symptoms that I was seeing. And it was very frustrating to locate any resources. It did not appear that what I was saying was being taken seriously and even needing a resource. It was very well brushed off, because it was a behavioral outburst--it was always a peer-to-peer interaction where the issues would come up at school and then it was also that she excelled in all of her studies, right? So we have a straight-A student, but we had these other issues--behavioral issues--going on, and I think they wanted to attribute it more to her just not being challenged. Which I was not downplaying, but because of what I do and what I know, I was keenly aware that it was more than that. So, I felt like had I not been a parent that advocated for my daughter as much as I did in the schools, and not only in the schools but finding my own resources, that we wouldn't be where we're at today.”

Mother of 15-year-old, P02

This mother had experience referring individuals involved in the criminal justice system to mental health care through her work. However, she was not familiar with resources for her daughter who was not involved in the criminal justice system. Reflecting on her care-navigation experience, she shared that the lack of resources at the school was frustrating because although the staff were prepared to address behavioral conflicts, they weren’t prepared with guidance for parents on child mental health. In summary, helpful qualities for easing the care-navigation process at a first point of contact included an understanding of child mental health concerns, awareness of resources available, and the ability to connect the family to additional resources.

Mental health screening in primary care

Almost all participants mentioned child mental health assessments, typically in the primary care setting. These assessments served to identify or confirm that further mental health care should be sought by the family. After a teen confided in her mother that she wanted help with her mental health, the mother reached out to the pediatrician right away (P01). At the clinic the teen completed a mental health screener. Based on the results, the pediatrician recommended connecting with a behavioral health professional. The pediatrician made a referral to a therapist at the clinic’s behavioral health department.

“[The pediatrician] did the referral right there and then. She asked me who I wanted [my daughter] to see. The person that I wanted [my daughter] to see did not have openings--was not seeing any longer teenagers, so then she referred me to somebody else that was. And then that counselor called me to set up a phone interview. ... It was to get to know me and ask me questions about what I had seen and what I was looking for. And then I believe [the counselor] did have a phone interview with [my daughter].”

Mother of 14-year-old, P01

Preferences for mental health professional characteristics

One patient or family preference was finding a mental health professional of the same race/ethnicity or gender. It was important to one teen and her mother to have a Black, female therapist so the teen could talk to someone with whom she could relate and feel comfortable (P03). This made finding a therapist difficult at first, but she was able to find someone through her Employee Assistance Program. This mother’s experience further highlights the importance of guidance and resources at a first-point-of-contact to ease care navigation (discussed in the previous theme). Below the mother discusses why it was important for her that her daughter has a therapist of the same race and gender. She highlighted the importance of comfort when talking with a therapist and how working with someone that looks like you may help you achieve that comfort.

“Oh well, I just think sometimes a level of comfort or being able to identify with someone, not that we are not open minded, however a lot of times the young people, or just people myself included, you may believe that people that look like you are more relatable to things that you're dealing with, so I think that's important. It just kind of serves as like a baseline. I mean it's not indefinite, but I just think it's a good place to start. And I feel that especially with therapy you should be able to feel comfortable, like you shouldn't feel apprehensive by not just feeling comfortable with talking to someone. And so, I just think it's important.”

Mother of 15-year-old, P03

Conversely, the teen participant shared her experience with having a mental health professional of a different race than herself. She said her therapist’s race became less important as their relationship developed.

“Well at first, of course, when I was like back in middle school, because my therapist is White I thought that she wouldn't have been able to sympathize with some of the things that I was going through. But as our relationship developed over like these past three years, that doesn’t really matter to me anymore ‘cause I realized that at the end of the day we’re all human and we all go through our struggles.”

Teen, 15 years old, P04

Finally, one mother reported not initially having a preference for the mental health professional’s race/ethnicity or gender (P01). She reported her appreciation for his long professional experience and his clear and open communication, which he creates by involving the mother in the first half of the session.

Adequate care: family-centered, culturally-appropriate, trauma-informed

Challenges to adequate care

Another aspect of care that was important to participants was receiving or providing adequate care. Participants described the importance of family-centered, culturally-appropriate, and trauma-informed care. Some shared how experiences with poor quality mental health care can lead to clients feeling disengaged and not valued. For example, a therapist spoke for herself and the clients she works with when she highlighted that there is a lack of trust between her community and health professionals resulting at least in part from being talked “at” instead of talked “to” and not being involved in one’s own health care (P05). This example highlights the importance of family-centered care.

“I've had to call back the doctors and nurses and things like that to say, ‘Wait a minute, you didn't explain this to [my client]. You do not have the right to just talk at them. Talk to them.’ And that is part of what you learn [advocating for clients], so I see it every day. So, that's what I mean by that ‘inadequate care’.”

Mental Health Professional (Therapist), P05

Another reported challenge to adequate care was not enough mental health professionals trained in cultural diversity. A therapist, who is Black, described how she goes beyond her training materials to identify and understand the causes of anxiety or depression for Black and Brown clients.

“I don't feel that there's enough providers that are trained in the cultural diversity to understand what our--and I say our as in the Black and Brown population--anxiety and depression looks like, where it stems from, the situation that causes it. And every textbook is definitely not written to service the Black and Brown population. So that's what I mean by ‘adequate care’. The textbook does not help a lot. It helps with guidance and structure 'cause I have to use it, but then I have to go a little deeper and understand, ‘What is driving this anxiety? What is driving this depression?’ And I don’t think there’s enough people that are in the field that are trained in the cultural diversity to understand the Black and Brown culture.”

Mental Health Professional (Therapist), P05

In addition, participants commented on the need for greater diversity among mental health professionals. A psychologist shared about her experience as part of the Black, Indigenous, and Person of Color mental health professional community. She highlighted the importance for clients to be able to work with someone with whom they feel they can relate.

“We're few and far between, unfortunately. And so I think the need is even greater than that I, as a person of color, am able to provide and open that door for other people who identify as a non-majority or non-White. Because I think there are a lot of White providers who are well intended, but just may not understand and may not understand what they don't understand. ... So certainly, we can still benefit from having allies, but it's still very powerful for people--or at least people of color that I work with as their provider have told me how helpful it is to work with someone who understands their life experiences or who they feel like they can relate to more.”

Mental Health Professional (Psychologist), P09

This psychologist also commented on her experience as a first-generation graduate and a single parent. She shared that academia has a “natural weed out process for people who have other responsibilities beyond academic requirements, which then does not allow them to pursue something that they would be good at, just based on life circumstances” (P09). She received a fellowship grant during her training which allowed her to “just focus on school without having to do another job, beyond being a parent.” She recommended more opportunities for financial support to help other students of color enter the mental health field.

Ways to provide adequate care

In addition to these challenges, participants shared ways clinicians can provide adequate mental health care. One recommendation from multiple participants was being aware of clients’ needs. A therapist explained that her willingness to learn more about the needs of her community led her to seek out training in trauma-informed care, because for the clients she serves a lot of their anxiety and depression is tied to trauma (P05). She also makes sure to talk to the teens she works with a lot so they can educate her on what they are experiencing.

A community advocate shared three additional recommendations to provide adequate care for Black youth (P06). These strategies included showing genuine care and concern for the child’s wellbeing and educating children about their mental health in a culturally-informed way. She also underscored the connection between providing culturally-appropriate care and the need for more therapists of color, which was discussed above.

“And that's sometimes what you hear. ‘All they want to do is collect a check. Nobody cares about me. Nobody cares about what happens to me.’ And it's like, ‘Do we really care? Do we?’ Right? And people can feel that. And so I think it's just--even with Black youth is to really identify ‘This is what depression looks like, it doesn't make you weak, but this is why you're acting this way. This is why these things, your anxiety, this is why this is happening.’ And then the light bulb goes off. ‘Oh yeah, OK. So how do we treat it? Do we treat it with medication? Do we treat it without medication?’ We need more psychiatrists, more psychologists, more therapists of color, right? To really just help people through that process. And youth as well, and to talk about it, and to hear their voices.

Mental Health Professional (Community Advocate), P06

Learning a new language or about a culture was another recommendation for providing culturally-appropriate care. A therapist shared what it is like to work with clients that have a different cultural background than herself (P08). Although her Spanish is not perfect, she receives positive feedback of gratitude that she’s trying.

“Usually when somebody hears my name, they can probably discern right off the bat that I'm not Latina. When they see me, they certainly can tell that I'm not. But I've actually had really mostly very warm and positive experiences with everybody that I've worked with, in the sense that my Spanish even isn't perfect. There's times where I get stuck on a word or I don't understand something, but I get a lot of grace--this is primarily adults 'cause most of my adolescents speak both languages, and many of them prefer actually English--but the adults will say something along the lines of ‘Well, you're trying, you're learning.’ And so there's a high level of appreciation. I think I certainly have been at the organization for [a long time], so I've definitely learned a lot of the cultural implications and cultural understanding of Mexico and Puerto Rico and Guatemala and everything in between. It's not like there's just one culture, obviously within Hispanic or Latinx community. So I think that that's appreciated as well, and people understand that we're doing our best. And if we don't identify or come from that background we're embracing it as much as we can.”

Mental Health Professional (Therapist), P08

A psychologist, who is also a non-native Spanish speaker, highlighted the benefit of being able to provide services in Spanish at a nonprofit organization which provides free mental health care to clients (P09). She said it is critical for her to remain in that setting to serve individuals who are undocumented and may worry about needing to provide legal documents to receive care or having their status exposed, because “the people on the margins or the most liminal populations are often the people who could benefit from having more support” (P09). She shared two recommendations to provide more culturally-appropriate services to a diverse population. The first recommendation is to openly discuss one’s own identity and the second is to be understanding of the barriers clients may have to access care and acknowledge their effort to show up to appointments.

“First is just recognizing one's own identity and stimulus value. So my colleague is a white cisgendered male heterosexual, and he's able to talk about that openly. And that's really beneficial to the majority of people that he works with, rather than shutting down conversation about identity and perceived power dynamics. So I encourage people to recognize ‘How am I being perceived or what's likely? And how do I talk about it and open that conversation?’ Additionally just recognizing where people are at in terms of ‘OK, maybe someone's 30 minutes late for an appointment,’ but considering ‘OK, did they have to take the bus here? Did they have to take off [of work]? Did they have to figure out childcare so they could bring this other kid?’ There's so many life circumstances that make it difficult for families to get a child into an appointment and so just being considerate or mindful of people’s struggles and how hard they work to just show up.”

Mental Health Professional (Psychologist), P09

Community awareness of mental health and resources available

Reducing mental health stigma by increasing community awareness

Although participants mentioned they believe stigma around mental illness is improving in general, they said there still needs to be a greater awareness and understanding in the community of mental health. A community advocate highlighted the importance of removing the barrier of stigma to accessing care, so Black youth can receive treatment for depression before it gets to the point of committing suicide.

“And I think that’s overall with suicide, I think we--as a society, not just the Black community--have to do a better job with educating about how does one get from point A to the point that you no longer want to be alive. And it’s to address those issues of depression. But, what is depression? I don't think a lot of people understand what is depression? What is anxiety? And not to make fun of it, right? Because I think a lot of people do that and even youth and Black--especially Black youth, because depression looks different in a Black youth because there’s a lot of anger attached to it. And I guess they look at their lives and the anger that they have. But to say, ‘Well, what do we need to do in order to get them to look past that and understand that you're dealing with depression. And it's OK, and you can get help and treatment and you can tell the truth about your life without being looked at differently. And not look at being strong, like “I gotta be a strong person here.”’ And even with anxiety, who wants to tell anybody that they're going through something because, shit, we make fun of people and laugh, and we don’t think it’s a big deal.”

Mental Health Professional (Community Advocate), P06

Strategies suggested by participants for increasing community awareness and identification of mental illness included pastors sharing mental health resources with their congregation, a play about youth mental health using music and stories with which children identify, and in-person recreational activities to provide meaningful connection for teens in a low-stakes setting and help them open up about their mental wellbeing.

In addition, the teen participant underscored the importance of reducing the stigma around mental health (P04). She said the one thing she would pick to better support her is more openness around mental health by normalizing speaking about it. She noted that a teacher at school helped support her mental wellbeing by being a mental health advocate at the school and by checking in every day to ask how the teen was doing.

Awareness of mental health services available

One mother shared her experience searching for information on available resources for her daughter (P02). This mother’s third point of contact for support with her daughter’s mental health was her daughter’s pediatrician (after the school and a friend who is a mental health professional). Unfortunately, the pediatrician was not familiar enough with mental health care to recommend treatment or referral options.

One way to become familiar with the available resources is to call services on resource lists. A psychologist shared that she encourages her Master’s students to do this so when they recommend the service to a client, they are able to provide them with guidance on what to say when they call in addition to general information about the resource (P09).

Still, a mindfulness teacher commented how organizations work individually to provide care or improve access to care without realizing there are others doing the same work. He suggested that by collaborating, resources could be used more efficiently to keep progressing those efforts forward.

“I feel like Milwaukee is tired of having conversations. There’s this thing about, ‘We’re always talking about the work.’ It’s like, ‘Well, that's right, and there’s work being done that you're not even aware about, ‘cause we’re not talking about it, right?’ So figuring out some type of process of talking, collaborating, doing some work, measuring what's being done, and then adjusting it based upon the results that you get or you don't get. I mean, that's the type of cycle that I think we would need. And if you don't have one of those things happening, the work just kind of falls apart.”

Mental Health Professional (Mindfulness Teacher), P07

Availability of mental health services

Challenges to availability of mental health services

A psychologist noted that teens with Medicaid insurance coverage can have reduced options for care as not all mental health professionals will see patients with this insurance. The reduced options for care can lead to long wait times, and in her observation the situation seems to have worsened since the pandemic.

“It is common, the vast majority of patients that I see have state insurance and it can be really, really tough to find a lot of providers who accept that and who have availability. And it feels like it's worse, but again, a lot of these are like “it feels like it's worse.” I don't have great evidence saying it is worse. I try to refer within two different larger hospital systems, but also to some smaller outpatient practices that take Medicaid and things like that, but the waits seem to be very long at all of them. ... And then when I say it feels that [it’s gotten worse] there are multiple calls back and forth, sometimes between either me and the family [or] their doctor and the family, and the family saying, ‘We've called four places on the list that you gave us and none of them are taking new patients in the next three or four months.’”

Mental Health Professional (Psychologist), P10

In addition, a therapist shared her frustration with not finding grants to sustain her services resulting in her volunteering her time to try to meet the need for care in the community (P05). With more clinics from large healthcare systems opening in communities, some small, community-based organizations are struggling to show funders that they are still needed to meet the need for care. She recommended large and small organizations partner to share resources and serve more people.

Facilitators to availability of mental health services

Free mental health services at school were reported as a facilitator to accessing care for teens by a mindfulness teacher (P07). He explained that the school wellness program is free for students, and often for the school as well. The program’s model has a tiered approach allowing a small number of mindfulness teachers to reach a maximum number of students by working with the general student body in big groups and with students that need more support in small groups.

Furthermore, a therapist shared that she and the other mental health providers at her clinic started seeing patients remotely at the start of the pandemic, in March of 2020, and by February of 2021 all providers were back in the clinic and offering both in-person and telehealth services (P08). She noted that initially, convenience increased and cancellations and no-shows decreased as transportation barriers to care were removed. However, with the increased accessibility of services and added stress related to the pandemic, the demand for services also increased. Unfortunately, her clinic did not have the infrastructure to meet the high need and “sort of bottlenecked in the sense of being able to provide quick, immediate services to those who [were] looking.” (P08).

Participants commented on their perspectives of using telehealth for child mental health care. Some teens and parents shared that they disliked virtual mental health care and found it to be less engaging than in-person care. For example, one mother shared that virtual learning and therapy were not a good fit for her daughter.

“I didn't like it because it was virtually, and I kind of already had learned from the first year of my daughter doing school virtually that she's not a virtual person. She's more of like, you need to take her there and she’s gotta be with people. And because the program was completely virtually, even though it was nice for me, because I didn't have to use transportation because I don't drive. I use the bus. So it was convenient for me, but I didn't see she enjoyed it or I don’t think she really got the benefits of it, and I think it just had to do that it was virtually versus in person.”

Mother of 14-year-old, P01

The teen, a parent, and a psychologist shared other challenges of using telehealth. These included not wanting to share one’s screen on a video call, lower reimbursement for audio only sessions, greater opportunity for distractions like checking one’s phone hindering the ability to connect with the provider, not having reliable internet connections, not having access to a private location, and being able to make time to just focus on the session. When asked if teens a psychologist works with prefer virtual or in-person care, she responded that varies from person to person whether virtual care is a good fit.

“It's tricky. [For] some of the teens it's worked beautifully, and some of them have that preference because it's been easier for them logistically. A lot of the time, they're either able to do it right when they get home from school, some will even do an early session prior to going to school, so they're missing less school. For their parents that logistical barrier of transportation is taken out of it. Sometimes there's preference on the patient end, but not on my end, or not on the clinician end. Most patients do it from their phone and that works out fine. That's what a lot of people have a video on. A lot of people don't have a laptop with good Wi-Fi where they're going to be having a conversation like you and I are. This would be a great way to do virtual. So, some of them will set up their phone on a table in front of them and sit back far away from it. Many are holding it up like this, *raises hand up to her face* walking throughout the house. Getting the boundaries of doing virtual is doable for sure, but it's just an added challenge of having that time and space to really treat it like a session. And some adolescents respond really well to that and some don't. Every time you send them the link, it’s ‘Oh, I just woke up. Can you give me a little while?’ So that's just a different part of it. I've done virtual with adults as well. I don't know that there's a huge difference there between those things. I think for some people it's a great fit and for other people it's not a great fit. Yeah, in terms of just following the rules of it and adolescents not being out walking outside during a session or be in a car during a session with other people. Those aren't appropriate for a therapy session.”

Mental Health Professional (Psychologist), P10

Finally, a teen shared that based on conversations with friends, she noticed it may be more difficult to trust a therapist if starting therapy online. However, she personally did not have a preference for virtual or in-person care.

“I've noticed with some of my friends who also took therapy--in my case I had seen my therapist before the pandemic started so I knew her. But especially starting out with new therapy online, I do find that some people find it hard to connect or they're more closed off and it's harder to confide in their therapist, to trust them to say some things, even though that's what they're there for and everything’s confidential, it's more the distrust about it. Especially, if you're hopping on the Zoom call and you're like, ‘Oh, they could be recording this session’ or something. So that's what I see. But me personally, I like virtual and in person. I don’t really have a preference.”

Teen, 15 years old, P04

Discussion

This study identified influential factors in accessing mental health care for Black and Latino teens who have anxiety or depression during the COVID-19 pandemic. The switch to virtual learning negatively impacted the ability for teens to socialize with peers, however learning at home provided also provided relief from social anxiety and conflict with classmates. These and other factors that influenced teen health care need are listed in Fig. 1 in the black box on the far left. Moving to the right in the figure, teens represented in our sample first reached out to a parent for support, and some parents then looked to primary care clinicians or schools for resources (Ability to seek). Mothers were the primary care navigators for the teens represented in this sample. Our finding aligns with the 2020 Kaiser Family Foundation’s Women’s Health Survey, which found that about two-thirds of mothers reported having the primary responsibility for making decisions about their child’s doctor, taking them to appointments, and made sure the child received the doctor recommended care, compared to about 15% of fathers [29]. Their experience navigating care for their teen was influenced by how aware the person they reached out to was of the resources available (for example in the school or pediatric setting; Approachability). Some of the teens represented in this sample were screened for mental health conditions at the pediatrician, and this influenced the mother’s perception that specialty care is needed (Ability to perceive a need for care).

Moving further right on the arrow, when seeking out care from a mental health specialist, some teens and parents preferred to find a mental health professional with same race/ethnicity and gender as the teen (Fig. 1; Acceptability, Appropriateness). Participants noted that having this option is important for Black and Latino teens and suggested more financial support opportunities for students of color to enter the mental health field. Cultural congruence between clients and therapists has been associated with length of treatment among African-American, Mexican–American, White, and non-English-speaking individuals and treatment outcomes among Mexican Americans and non-English-speaking individuals [30]. Recommendations to diversify the mental health workforce include ensuring that student cohorts are diverse by race/ethnicity as well as and languages spoken by recruiting underrepresented students and expanding cultural and linguistic competency training [31]. Following the 2023 Supreme Court ruling to ban race-conscious admissions, recommendations for diverse student populations include focusing on measures of socioeconomic hardship, targeted outreach to underrepresented communities, financial aid opportunities, and a holistic approach taking into account personal character and values [32]. In addition to greater recruitment, efforts are needed to support and retain professionals of color by addressing the unique challenges they experience, including the racial trauma caused by anti-Black violence during the COVID-19 pandemic, the burden of representing and advocating for underrepresented minorities in majority-White workplaces, and the burnout of being highly sought by communities of color due to the lack of diversity in the workplace to begin with [33].

In our study, mental health professionals also highlighted the importance of adequate mental health care (defined here as culturally-appropriate, trauma-informed, and family-centered) including feeling valued and cared for (Fig. 1, Appropriateness). Examples of providing adequate care included treating the client as an equal partner in their healthcare and awillingness to learn about the client’s language, culture, and community-specific needs. Receiving family-centered care is associated with family satisfaction with care, improved health outcomes, and cost reduction for families as well as health systems [34]. Furthermore, for racial and ethnic minoritized students, a multitiered systems of supports (MTSS) model is one way to provide culturally responsive mental health promotion and intervention in schools [35]. This approach aims to mitigate the harmful effects of racism and other types of discrimination by incorporating students’ culture and experience of marginalization in the programming [35].

Participants also shared that there is still a need to reduce mental health stigma by educating the community on mental health (Fig. 1, Approachability). Community health workers (CHWs) may help fill disparities in care for underserved groups by providing mental health education as well as providing mental health care using evidence-based practices [36]. The Milwaukee Coalition for Children’s Mental Health is working to fill a gap in training for CHWs in child mental health by providing educational and connection events run by CHWs [37]. In addition, school-based resources are an affordable way to normalize mental health care by integrating it into student’s daily lives [38, 39]. Providing cost-free services was a key facilitator to care access for teens, mentioned by two mental health professionals in this study (Affordability and Ability to pay).

Furthermore, this study supported the need to educate primary care clinicians, mental health professionals in training, and community stakeholders on what services exist to promote more collaboration and less doubling of efforts (Fig. 1, Approachability). The Wisconsin Child Psychiatry Consultation Program is a service that provides primary care clinicians with mental health education, access to psychiatry consults, and a centralized list of vetted referral resources [40]. Clinicians reported feeling more than twice as confident meeting their patient’s mental health needs one year into the program compared to baseline [41].

Lastly, a variety of issues impacted availability of services during the COVID-19 pandemic. Access to care opened up with the greater convenience of telehealth, however the increased need for care led to difficulty finding services in a timely manner (Fig. 1; Availability and Accommodation, Ability to reach). This aligns with the finding from another study that children with anxiety or depression were less likely to have unmet mental health care need if they had used telehealth in the past year [16]. This study adds to the literature perspectives on using telehealth for child mental health care which is a relatively new option for care. Telehealth worked well for teens that found it to be a more convenient option, had a reliable internet connection, and were able to maintain boundaries with attending in a private location (Availability and Accommodation, Ability to reach and engage). Using data from the first six months of 2020, one study found that telehealth allowed the provision of ongoing behavioral health services during the COVID-19 pandemic and was a format more acceptable among children for psychiatric and support services than for psychotherapy [42]. The findings of that study align with our findings of increased care accessibility and some teen preferences of in-person therapy. Finally, it is important to note that disparities in internet access preclude some communities from having the option of using telehealth. For example, Hispanic individuals have been less likely to use telehealth due to lack of devices or access to broadband internet [43–46].

Limitations

This study included English-speaking participants only, and although some participants discussed language barriers to accessing care, access for non-English speakers could not be investigated in depth. Furthermore, most participants identified as female. Although some participants discussed access to care for boys, no boys or parents of eligible boys participated to share their first-hand experience. Perspectives on access for trans or non-binary children were also not included in this study. Only one teen participated and shared what access to mental health care is like from a youth perspective. The importance of engaging and hearing from youth on their mental health and access to care was highlighted by several participants and should continue to be a goal for future programs and research. All parent participants had some exposure to mental health care either through their work or personal experience. Therefore, these findings may not be applicable to families with no prior experience with the mental health system, for whom navigating care may be more challenging. Finally, the conceptual framework for this study suggests that the process of accessing care is linear (Fig. 1; arrow starts on the left and points to the right). However, the results of this study show that it is an iterative process with care seekers cycling through the different levels of access. In addition, participant-reported examples of the five dimensions of accessibility of services and five abilities of the people engaging with the dimensions of accessibility to gain access may appear to be exclusive of one another. Although the black boxes in the figure are separate from one another, some examples fit in multiple boxes. For example, telehealth fits in Availability and Accommodation and Ability to engage.

Conclusion

This study highlights the need for improved access to mental health care for Black and Latino teens in Milwaukee County. Participants recommended reducing stigma, increasing awareness of services available, encouraging collaboration between schools, health professionals, and mental health promotion organizations, and supporting students of color to become future mental health specialists and serve a diverse population. Much of this work is being actively pursued by community advocates, health care professionals, and other champions of children’s mental health. The Levesque, Harris, and Russell 2013 conceptual framework of access to health care, although simplistic can serve as a tool for stakeholders to design interventions targeting specific types of access, measure outcomes, and report back to each other. Still, challenges remain that need more attention like growing the workforce and access to telehealth services.

Future research should investigate policymaker willingness to work on proposed solutions, such as enforcing mental health parity. This may help characterize the current political will on the topic and if facilitators, such as increasing awareness of the issue, may be effective. Similarly, the desire and ability for community stakeholder organizations including schools, health systems, and community-based advocacy and treatment services to collaborate and share their resources and knowledge should be investigated to understand if this is a feasible point of intervention. Furthermore, additional research is needed to evaluate interventions aimed at improving child mental health professional retention and recruitment. Finally, the ability of community health workers to help address disparities in access to child mental health care is a growing body of research [36]. More research is needed to understand how to sustainably and effectively integrate community health workers into mental health care [36].

Authors information

The researcher’s credentials at the time of data collection and analysis were BS for LD and PhD for the remaining authors. This study is part of the doctoral dissertation of LD. LD’s training for this work includes coursework in qualitative design and analysis and experience conducting qualitative analysis for another study. There was no prior relationship established between LD and the research participants. At the time of data collection, the participants were informed that LD is a doctoral student and research coordinator for the study.

Author contributions

LD conceptualized the study, conducted the interviews and data analysis, and wrote the original draft. All authors (LD, DN, JS, and SY) contributed to the study design and development of the methodology. All authors (LD, DN, JS, and SY) read, reviewed, edited, and approved the final manuscript.

Funding

This study was unfunded.

Availability of data and materials

The dataset generated and analyzed during the current study is not publicly available nor available upon request to protect the confidentiality of study participants.

Declarations

Ethics approval and consent to participate

The Medical College of Wisconsin Institutional Review Board #7 approved this study (PRO ID: PRO00044134) by determining the project satisfies requirements of 45 CFR 46.111 by expedited review Categories 6 and 7. Informed consent was obtained from all participants before each interview. If the participant was under 18 years old, assent was obtained from the child participant, and parental permission was obtained from their parent or legal guardian. All study procedures were conducted in accordance with the US Federal Regulations for the Protection of Human Subjects and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.