Disparities in treatment for substance use disorders and co-occurring disorders for ethnic/racial minority youth

Abstract

Objective

To review the literature on racial and ethnic disparities in behavioral health services and present recent data, focusing on services for substance use disorders (SUD) and comorbid mental health disorders for children and adolescents.

Method

A literature review was conducted of behavioral health services for minority youth. Papers were included if specific comparisons in receipt of SUD services for youth were made by race or ethnicity. The review was organized following the Sociocultural Framework.

Results

Compared to non-Latino Whites with SUD, Black adolescents with SUD report receiving less specialty and informal care, while Latinos with SUD report less informal services. Potential mechanisms of racial and ethnic disparities were identified in: federal and economic health care policies and regulations; the operation of the health care system and provider organization; provider level factors; the environmental context; the operation of the community system; and patient level factors. Significant disparities reductions could be achieved by adoption of certain state policies and regulations that increase eligibility in public insurance. There is also a need to study how the organization of treatment services might lead to service disparities, particularly problems in treatment completion. Institutional and family characteristics linked to better quality of care should be explored. Since treatments appear to work well independent of race/ethnicity, translational research to bring evidence based care in diverse communities can bolster their effectiveness.

Conclusions

Our review suggests promising venues to reduce ethnic and racial disparities in behavioral health services for ethnic and racial minority youth.

This paper reviews racial and ethnic disparities in behavioral health services, focusing not only on services for substance use disorders (SUD) but also on co-morbid mental health disorders for children and adolescents in the United States. Substance abuse remains a significant public health concern for ethnic minority youth. Our review emphasizes the urgency of early intervention to address service gaps, given that youth who have behavioral health disorders prior to age 18 have worse education, employment, and social outcomes than those with later onset or no SUD.^{1, 2} Data from the National Survey on Drug Use and Health (NSDUH) suggest that rates of adolescent past-month substance abuse among American Indians/Alaska Natives was 13.7%; 9.8% for Blacks, 8.9% for persons reporting two or more races, 8.5% for non-Latino Whites; 7.5% for Native Hawaiians/Pacific Islanders, 6.9% for Latinos, and 3.6% for Asians.³ Across all youth, 8.2% (~2.1 million) needed treatment for drug or alcohol use problems in 2006.³ Of these, only 181,000 (8.7%) received treatment at a specialty facility, suggesting a dramatic gap in unmet need for SUD services.

The Institute of Medicine (IOM)⁴ has demonstrated that minority youth have less access to, and lower quality of, behavioral health services compared to their White counterparts. Importantly, the IOM definition of disparities, described as differences in service use that are not justified by underlying health conditions or treatment preferences,⁵ includes all racial/ethnic service use differences that are not directly attributable to need for behavioral health services, such as socio-economic status (SES) or insurance. Still, modifications to the IOM model are needed before it can be applied to behavioral health services for youth. Family, lay system and community factors are not directly addressed in the IOM model but may act as mechanisms of disparities.⁶ Patient - preferences should also be treated as a mechanism because they are shaped by the same social structures that create disparities, and may be confounded by not knowing available treatment options or previous experiences of discrimination.⁷

We discuss racial and ethnic disparities in the context of the Socio-Cultural Framework of Health Service Disparities⁸ by organizing the literature in six levels: 1) Federal and economic health care policies and regulations; 2) the operation of the health care system and provider organization; 3) provider level factors; 4) the environmental context, such as the social and economic forces affecting ethnocultural populations; 5) the operation of the community system, including family, friends, and the lay sector; and 6) patient level factors. These factors appear linked in tandem to fundamental mechanisms in the development and maintenance of health service disparities. Some variables appear associated more with access while others relate to receiving quality services. We review research on disparities mechanisms in substance abuse services for racial/ethnic minority families by expanding upon this framework to elaborate the kinds of research questions, propositions and hypotheses linked to health care differentials among racial and ethnic minority youth. We emphasize that service disparities cannot be seen as a sequential linear process, but rather should be seen as an interrelated series of processes that appear to differentially affect the likelihood of accessing and receiving quality care. Considering multiple disparities factors can allow for a better empirical base to develop treatment, educational and policy interventions to close the disparities gap. We also provide recent comparisons of behavioral health service use data among culturally diverse youth using the NSDUH and then summarize perceived gaps and promising areas.

Methods

Search Strategy

We performed PubMed searches using the Medical Subject Heading terms for substance use disorders, health services, adolescence, and health disparities. We repeated this search three times, substituting the terms “ethnicity” and then “poverty” for “service disparities.” This search was repeated using the PsycINFO database. Only studies that explicitly addressed racial/ethnic differences in behavioral health service use were included. Studies that did not include children or adolescents were excluded. We also searched national databases dedicated to the study of substance abuse/dependence, e.g. the Center for Substance Abuse Research, and reviewed recent results from national substance use datasets, such as the NSDUH and Monitoring the Future (MTF).

Results

Behavioral Health Services for Racial/Ethnic Minority Youth

Recent results from the NSDUH serve as context for understanding unmet need for behavioral health services. The NSDUH estimates the prevalence of substance use disorders and use of behavioral health services for the U.S. civilian, non-institutionalized population aged 12 years and older. In Table 1, we present 2005–2008 data on past-year substance use disorders, specialty treatment, and informal treatment. Compared to non-Latino Whites with SUD, Black adolescents with SUD report receiving less specialty and informal care, while Latinos with SUD report less informal services. Lower rates of specialty services for Black adolescents are similar to previous results⁹ and might be explained by a greater reluctance to receive psychotropic treatments.^{10, 11} This lower rate can also be attributed to African Americans’ greater participation with social services ¹² given a complex pattern of social and family needs. The lower use of informal services found for Black and Latino youth could well be justified by a greater self-reliance and an unwillingness to discuss substance symptoms with others.^13,14

Table 1.

Service use for adolescents with past year substance abuse or dependence

	Non-Latino White		Latino		Asian		Black
Total N	43778		10109		2481		12257
Past Year Substance
Abuse or Dependence	4000		529		119		1060
%	8.98%		4.98%		3.53%		7.69%
	Mean	SE	Mean	SE	Mean	SE	Mean	SE
NSDUH Specialty Treatment	7.09%	0.45%	5.16%	1.50%	9.48%	4.55%	4.46%	1.06%*
NSDUH Informal Treatment	5.19%	0.51%	2.96%	0.98%*	4.42%	2.67%	3.09%	0.78%*

Note: Specialty treatment in the last 12 months indicates any inpatient hospital overnight services, residential rehabilitation, outpatient rehabilitation, outpatient mental health facility, private doctor’s office for drugs or alcohol services and halfway house. Informal treatment indicates self-help groups and religious or spiritual services. NSDUH = National Survey on Drug Use and Health.

^*p<0.05

These results contradict some regional studies, like McCabe and colleagues, that found representation of Black and Latino youth in alcohol/drug treatment services at rates similar to those in the Census.¹⁵ Bui,¹⁶ and Sue¹⁷ also found White and Black youth over-represented, and Latino youth under-represented across most behavioral health treatment sectors. Other regional studies have found no behavioral service differences for African American youth as compared to White youth, particularly after adjusting for level of need.^18–20 Though most regional studies vary by geography and racial/ethnic composition or use different methods to assess need, they nonetheless form an important context for understanding potential mechanisms to explain differential treatment patterns.

Potential Mechanisms of Behavioral Health Service Disparities

Federal and Economic Health Care Policies and Regulations

Health care policies and regulations at the state and federal level aimed towards cost control and remediating budget shortfalls may result in healthcare access disparities.²¹ Examples include restrictions on Medicaid or on the State Children’s Health Insurance Program (SCHIP) eligibility criteria. More than 60% of the uninsured children are African American or Latino,²¹ of which three fourths are eligible for coverage under SCHIP or Medicaid. This demonstrates a serious barrier to access since SCHIP has demonstrated increased access for minority youth ²², including access for substance abuse treatments. Shone²³ and Szilagyi²⁴ uncovered racial/ethnic disparities in unmet need in minority youth that were effectively decreased after enrollment in SCHIP. A similar effect was observed in Kansas²⁵ where unmet healthcare needs were reduced by nearly 80% for Black children and by 36% for Latino children with the expansion of SCHIP.

The Operation of the Health Care and School-based System and Provider Organization

Reducing disparities is dependent on effective screening and referral. Schools are critical for early detection of behavioral health problems²⁶ since the majority of behavioral health services are received either at school or at the request of school personnel.^{18, 26–28} Anglin²⁹ described a cross-sectional sample of adolescents using school-based health clinics, finding that half of the population serviced was minority youth (22% Black and 28% Latino), with annual mean numbers of visits for mental health of 5.8 and 6.8 for substance abuse.

Differential referral from schools, healthcare and government organizations may operate as mechanisms for reducing or increasing access to substance abuse treatment. Among youth with alcohol abuse, Latino adolescents were less likely to be referred for treatment than Whites, even when they were already receiving mental health treatment.³⁰ Minority children are often under-identified by their schools.^{31, 32} Although teacher detection of student need is among the best predictors of youth service access,³³ it remains unknown whether teachers differ in their referral of ethnic minority youth..³⁴ Some studies suggest that teacher identification of problematic behaviors is associated with race and ethnicity³⁵ while others find that teachers accurately represent symptoms in ethnic minority youth.³⁶

Barriers to quality substance abuse treatment might also be due to how the provider organization structures treatment services. A recent study of 1088 adolescents in outpatient or residential substance abuse treatment found that ethnicity did not predict admission to treatment.³⁷ However, ethnicity was confounded with treatment site, and quality disparities appeared to exist at the system level. Garland studied a San Diego sample of youth in public systems of care, and found few racial/ethnic differences in inpatient substance abuse treatment; however, for outpatient, Asian American/Pacific Islanders had much higher rates of past year treatment, while African Americans had the lowest.³⁸ Heflinger found similar results in a 2006 study of Tennessee Medicaid data,¹³, where White youth had double the rate of outpatient treatment compared to Black youth. Clinician identification and referral bias was considered a possible explanation. Similarly, in a study of 664 youth receiving intensive case management (ICM), those with substance abuse were less likely to come from racial/ethnic minority groups.³⁹ These studies suggest that certain minority groups might be receiving less intense treatments in various sectors of care, possibly linked to lower quality of services.

Provider level factors

A disproportionably low geographic supply of providers, particularly of multilingual providers in diverse communities⁴⁰ also promotes service disparities in access. Communities with high proportions of African American and Latino residents are four times as likely as non-Latino White communities to have a shortage of healthcare providers, regardless of community income.⁴¹ Language concordance between client and provider may affect adherence to treatment, which is tied to receiving guideline concordant care.^42–44 Even when the youth is fluent in English, the inability of health professionals to speak the parents’ preferred language represents an important barrier to retention in care⁴⁵ and risks misinterpretations that can hinder correct diagnosis.⁴⁶

There are inconsistent findings on whether provider and youth ethnic and racial matching might be linked to quality care disparities. Flicker reported that ethnic match had a positive effect on self-reported substance use for Latino youth, but not for Anglo youth.⁴⁷ Nonetheless, Gamst found no evidence that ethnic match affected changes in Global Assessment of Functioning scores or service use in 1,946 adolescents in community mental health centers.⁴⁸ The Gamst study controlled for a number of relevant covariates (e.g. citizenship, trauma, referral source, language match, gender match, and diagnosis), which suggests ethnicity may be a proxy for such factors. The difference in outcomes for these two studies highlights how inclusion of certain confounders might change findings and the importance of consistently adjusting for the same confounders to improve comparability.

Provider attitudes can also be important determinants of quality of care. A small qualitative study explored concepts of “culture” among behavioral health providers for adolescents.⁴⁹ Providers assumed that Latino families avoided behavioral health providers, stigmatized mental illness, preferred clergy rather than formal treatment, devalued women’s health, and had lost hope for the future due to poverty. The authors saw these attitudes as missing the context of marginalization, discrimination and poverty that should be addressed in treatment services.

The Environmental Context, including Social and Economic Forces

The economic and social milieu can play a significant role in access and quality of services. Fiscal constraints and limitations in federal financing for the Indian Health Service⁵⁰ may mean barriers to substance abuse service delivery both in terms of access and quality. This could be critical given reports that Native American youth were up to 10 times more likely to abuse alcohol at early ages (9–13) than their White counterparts.⁵¹ Gone (2007)⁵² describes how: “the assertion that American Indians and Alaska Natives are ‘underserved’ with regard to mental health care in the United States glibly understates a national travesty (pg.13).” Federal and state initiatives that expand substance abuse treatment within correctional and school-based settings, given the shortage of providers can also increment treatment availability.

Archibald (2008)⁵³ analyzed the association between community socioeconomic and racial/ethnic disadvantage across US counties from 2000–2003, finding no disparities in substance abuse treatment provision in poorer communities and those with higher concentrations of African Americans, but significant service disparities in communities with higher concentrations of Latinos. The racial and ethnic composition of the environmental context as well as economic and social characteristics might also influence identification of substance use problems. For example, youth living in counties with a higher proportion of single parent families, increased rates of drug related arrests, and higher proportions of minority residents have less likelihood of being identified for substance abuse treatments when in need of care.⁵⁴ Living in communities with higher median income, greater proportion of persons who graduated high school, and greater concentration of treatment facilities increases the opportunities of being identified if in need.

The Operation of the Community System, including Family, Friends, and the Lay Sector

Communities of color, which have endured long-standing barriers to care, may be more stoic and tolerant of suffering, thus increasing the threshold for bringing youth to treatment.⁵⁵ Gonzalez⁵⁶ studied help-seeking attitudes in behavioral health care and found more negative attitudes among younger English-speaking Latinos and African Americans than non-Latino Whites. Assessment models that are insensitive to cultural differences in youth development may over pathologize certain behaviors,⁵⁷ while under pathologizing genuine behavioral disorders.⁵⁸ African American families may decline care for fear their children will be coerced into treatment..⁵⁹

Service disparities are often created by barriers that dissuade parents from seeking services for their children.⁶⁰. Other barriers include parent inability to identify need of SUD, denial of illness severity, and the belief that problems would improve by themselves.⁶¹ Minority parents report less satisfaction with treatment when they perceive that providers have not considered their cultural values.⁶² Because these studies are mostly qualitative not comparative, less is known about how subjective and objective barriers vary by race/ethnicity.

Life stressors and other competing demands may also act as barriers to behavioral services,⁶³ limiting parents’ ability to maintain their children in quality treatment. Cornelius found that parental mental illness, substance abuse, and number of children in the home acted as barriers to receiving behavioral health services for African American boys.⁶⁴ Parent-perceived strain of child behavioral health needs may have a varied effect. In a large sample of youth, Shin used structural equation modeling to demonstrate that caregiver strain was a path to substance abuse treatment for African American youth, but that this strain was lower among African American parents.⁶⁵ This is consistent with other literature⁶¹ suggesting that extended social networks may diminish strain for African American families coping with hardship.

Given that parents are usually the ones who decide to engage services for their children,⁶⁶ parent perceptions of what is “typical” or “appropriate” behavior could also affect service disparities. ⁶² Minority parents may have a higher threshold for labeling symptoms as a problem that requires professional care,⁶⁷ a lower likelihood to medicalize problems,^{60, 68} or alternative conceptualizations of children’s problems.⁶⁹ Low healthcare literacy may also hinder parents’ ability to register for public insurance and understand coverage benefits and treatment directives.⁷⁰ Research in this area unfortunately does not estimate the use of behavioral health services as a function of these perceptions.

Patient Level Factors

Treatment preference is a relatively neglected area of study in service disparities. There are preliminary data on preference for alcohol treatment services among high school students.⁷¹ In study of 1147 students, African American, Latino, and “Other minority” more often preferred individual treatment sessions for secondary prevention of alcohol abuse compared to their White peers. The authors hypothesize that private settings offer a safer space for self-disclosure and avoidance of group setting stereotypes.

Matching type of service to clinical need is a potentially important, though understudied, area for disparities research. There is some evidence, in African American and White patients 17 or older, that matching services to clinical need (measured by a ratio of services received as reported by clients, to the services they reported needing) helps to retain patients in treatment and reduce post-treatment substance use.⁷² Similar results were found in a sample of highly-acculturated substance-abusing Latinos and White patients.

Adolescence is a critical stage for the identification of behavioral health problems.⁷³ Measures used to assess adolescent psychopathology may not have been sufficiently validated among various racial/ethnic groups. Research using Item Response Theory suggests a diagnostic algorithm that considers all abuse and dependence symptoms conjointly.⁷⁴ Wu et al. performed a similar analysis for opioid use disorders and found comparable results.⁷⁵ Further, African American and Latino adolescents showed different endorsement of dependence symptoms compared to White adolescents. More assessment studies of SUD measures for certain minority groups are needed to better address accurate detection.

Different patterns of comorbidity might also introduce uncertainty in the diagnosis of minority youth with SUD. Up to 80% of youth receiving substance-abuse treatment have co-morbid mental disorders.⁷⁶ Chisholm⁷⁷ found that African Americans, Latinos, and mixed-race adolescents in substance abuse treatment are more likely than Whites to have co-occurring internalizing problems (depression or traumatic stress), even when accounting for family substance use, juvenile justice involvement, and single-parent household.⁷⁷ African Americans and American Indian/Alaskan Native were less likely than Whites to have co-occurring externalizing problems or both internalizing and externalizing problems. These findings may impact service use.⁷⁸

Interestingly, evidence suggests no difference in perceived need by ethnicity/race.⁷⁹ A longitudinal study of 208 young adults found that subjective unmet need for behavioral health services was not related to ethnicity, but rather to lifetime mood and substance dependence disorders. This suggests that both majority and minority youth alike may perceive unmet need, with common barriers being attitudes toward treatment, not knowing where to obtain help, financial concerns,⁷⁹ and belief that the mental health system is not an important or accessible resource⁸⁰ or that problems can be solved without professional assistance.

Treatment completion is an important indicator of quality of care. Preliminary evidence from the Treatment Episodes Data Set (2001–2004) of over 73,000 adolescents showed significantly lower treatment completion rates among African Americans (33.5%) and Latinos (39.4%) compared to non-Latino Whites (45.1%).⁸¹ A smaller study of 419 adolescents treated in private treatment facilities found similar differences.⁸² Compared to non-Latino Whites, Native American adolescents were less likely to continue treatment after initiating (OR= 0.35) and African Americans spent 50% less time in treatment (mean 8.4 weeks for African Americans vs. 16.3 weeks for non-Latino Whites). In a prevention study with African American youth, Zand⁸³ found that those with lower family conflict and less family relocation were easiest to retain in treatment.

What can Child and Adolescent Psychiatrists do about Substance Use Service and Quality Disparities?

A number of treatment approaches have good evidence for reducing substance abuse. According to Huey and Polo’s review,⁸⁴ multidimensional family therapy (MDFT⁸⁵) and multisystemic therapy (MST) were classified as “probably efficacious” for drug-abusing ethnic minority youth. Liddle⁸⁶ found MDFT led to more rapid decreases in drug use than group-based CBT. In a meta-analysis, Huey and Polo did not find that treatment outcome across a number of disorders is moderated by youth ethnicity or “culture-responsive” treatment status. Resnicow⁸⁷ describes a similar culturally sensitive intervention that addresses “surface structure,” or the social and behavioral characteristics of the target population, and “deep structure,” or the cultural factors of the target population that influence health behaviors. Other study adaptations are the inclusion of cultural values and concepts, providing care in the patients’ native language, and matching patient-provider ethnicity.⁸⁸ This meta-analysis recast Huey’s findings by noting that minority youth tend to be more acculturated than adults, and culturally sensitive adaptations work better for less acculturated populations,⁸⁸ indicating that interventions involving less acculturated parents might benefit from such tailoring.

An important gap identified by Huey and Polo is the lack of culturally validated measures for assessing and tracking substance use outcomes. Their review demonstrated that reliability and validity of measures are not routinely assessed in cross-cultural intervention research. Kurtines and Szapocznik⁸⁹ have described the necessary approaches, including back translation, cross-cultural validation, and inclusion of population-specific and immigrant-specific measures. These may include variables related to discrimination, ethnic mistrust, ethnic orientation, acculturation, and acculturative stress.⁹⁰ Gil’s study of a brief motivational, cognitive behavioral intervention among minority juvenile offenders showed associations between ethnic orientation/pride and reductions in alcohol use among US-born Hispanics.⁹⁰ However, even recent reports of interventions among minority samples offer little comment on tool adaptation.⁹¹ There are examples from the adult literature of rigorous cultural adaptations of common measures, such as the Alcohol Use Disorder and Associated Disabilities Interview Schedule.⁹²

MST is also more successful than “usual” services (minimal mental health or substance abuse treatment) at decreasing drug use following treatment⁹³ and four years later.⁹⁴ Ethnicity (African American vs. White) did not moderate outcomes.^{93, 94} Similarly, Brief Strategic Family Therapy has been shown to reduce marijuana use and behavior problems among a sample of school-referred Latino adolescents with externalizing behavior problems and substance abuse.⁹⁵ This family-centered treatment has been refined to better address the social ecology of substance-abusing youth, in a treatment called Structural Ecosystems Therapy (SET⁹⁶), which attempts to restructure maladaptive interactions and relationships within the family, peer social group, school, and involved agencies (e.g. juvenile justice). An 18-month randomized trial among African American and Latino substance-abusing adolescents showed that SET was more effective than family-process therapy or controls, but only for Latino participants.⁹¹

School-based substance use prevention curricula have the potential to reach ethnic minority youth who might otherwise not attend clinic-based treatment. Botvin achieved one year decreases in polysubstance use⁹⁷ and two-year decreases in binge drinking⁹⁸ using a cognitive-behavioral, school-based prevention approach among African American and Latino inner-city youth that was adapted with language and role-play scenarios. Similarly, a prospective, randomized controlled trial of a culturally adapted prevention curriculum among Alaskan youth showed six-month decreases in use of inhalants and medications.⁹⁹ Surveying a group of experienced teachers, Ringwalt¹⁰⁰ identified several reasons for adapting prevention curricula to youth racial/ethnic context: youth violence, limited English proficiency, and cultural diversity in the school body. “Hybrid prevention programs” have used community-based participation to identify local preferences while still maintaining appropriate implementation and program fidelity.¹⁰¹

Discussion

Nationally representative studies that test the proposed mechanisms of behavioral health service disparities for minority youth with SUD are needed. Identifying such mechanisms is of particular concern so that outreach, treatment completion and effective referral interventions can be designed. Parental perceptions and beliefs surrounding need for care are central to engaging minority youth, though further research is needed to quantify their impact. Schools are crucial referral sources, and further research may help clarify how school staff can influence successful engagement in SUD treatment. Agencies such as SAMSHA should offer incentives which train school staff to facilitate early interventions, effective referral and engagement.

Item response theory of probes for screening and accurate SUD diagnoses can improve the application of new criteria to culturally diverse populations. Determining whether universal or ethnic specific probes are needed should be studied. Assessing co-morbid conditions is also important in identifying need for substance use care.

Barriers to care remain a pressing issue for minority families. Minority youth are disproportionately affected by social forces such as police detainment that can influence coercive access to treatment and negative experiences in care. Yet coercive treatments for substance involved offenders have been shown to produce considerable improvement in level of substance use and lowering criminal involvement¹⁰² suggesting the role of coercive treatments as a public health intervention. One alternative is to study and improve SUD services in education and community settings for minority youth. Additional data are needed to establish whether, and what type of, ethnic matching of youth and provider results in improved service outcomes.

SUD treatment quality appears to be worse among minorities. There are potential ethnic-specific targets for intervention, such as structural or motivational barriers to engagement for Native Americans or retention in care for African Americans and Latinos. Equally important is the identification of institutional and family characteristics linked to better quality of care. Fortunately, there are a number of evidence-based therapies that improve outcomes and appear to work as well, or better⁹¹ for minority youth.

Our review suggests a number of important areas for research and policy, although the literature is sparse. Santisteban¹⁰³ has outlined issues in the transfer of empirically-supported technologies for substance abuse treatment in Latino populations, which seem relevant to other racial/ethnic minority youth, including testing established treatments specifically in minority samples both with and without elements of cultural competence. There may also be treatments that do not meet stringent empirically-supported criteria, but demonstrate an adequate balance of internal and external validity with ethnic and racial minorities.

Overall there appear to be many promising venues to reduce ethnic and racial disparities in behavioral health services for ethnic and racial minority youth. Significant disparities reductions could be achieved by adoption of certain state policies and regulations that increase eligibility in public insurance and allocate necessary funds to guarantee coverage and availability of basic substance abuse treatments, including language concordant services. There is also a need to study how the organization of treatment services might lead to service disparities, particularly problems in treatment completion. Findings that the context in which one lives relates to whether or not substance problems will be identified should be linked to public health initiatives for identification and referral of SUD. Ethnic and racial differences in parental perceptions of when substance use symptoms require professional care and caregiver’s health literacy should be explored as venues to reduce service disparities, as well as minority youth’s treatment preferences and matching services to their specific needs. Evaluating mechanisms to encourage minority youth to not depend only on self-reliance but to seek care is another promising area for disparities reduction. Our review emphasizes the accomplishments in identifying potential venues for disparities interventions for future testing. This is critical since the trends in healthcare disparities for ethnic and racial minority youth remain stagnant. ¹⁰⁴