What’s race got to do with it? A proposed framework to address racism’s impacts on child and adolescent mental health in Canada

Abstract

This commentary responds to current events that have highlighted the ways that systemic racism affects a wide variety of health outcomes. We specifically discuss how systemic racism adversely affects the mental health of children and adolescents in a Canadian context and use a structural framework to demonstrate how race is embedded in various Canadian systems and thus affects child and adolescent mental health in both conscious and unconscious ways throughout the lifespan. Experiences of systemic racism affect the mental health of Canadian young people in multiple complex and intersecting ways including access to care, experience of mental health services, and outcomes of care. We currently lack a national best practice framework for mental health professionals that unifies approaches to research, education, and clinical care for young racialized Canadians; in addition, concerted efforts to collect race-based data are lacking. We suggest that a blueprint for improved services for racialized young people in Canada would include: Development of a funded and sustainable research agenda responsive to community expertise, development and implementation of a Canadian Child and Adolescent task force focused on educational strategies on racism and service provision at both the postgraduate and continuing professional development (CPD) levels, and consideration of clinical parameters that improve access to, and experience of, care for Canadian racialized youth.

As Canadian Child and Adolescent Psychiatrists and members of the Canadian Association of Child and Adolescent Psychiatry (CACAP), who all also identify as racialized people, we were pleased to support a statement from CACAP in July 2020 acknowledging systemic racism in Canada as a public health issue impacting our young people “The CACAP Statement Against Racism” (CACAP, 2020). In this commentary, we explore the effects of systemic racism on child mental health and possible future directions to foster change. The emerging collective awareness of racial injustice triggered by the tragic death of George Floyd at the hands of police and spurred by on-going actions by the Black Lives Matter movement arrives with data on COVID-19’s disproportionate effects on the health and mental health of racialized people (Cheng, 2020; Centre for Addiction and Mental Health, 2020; Garcia et al., 2020; Tamene et al., 2020). Though attention is currently being drawn to the links between ill health and race, we note that racial discrimination is a public health determinant with social and structural antecedents that has been impacting children and adolescents in Canada for many years. The combination of these tragic events has led to a unique opportunity to address race-based discrimination in Canadian child and adolescent mental health with an impetus to ensuring clinical settings are designed to serve racialized youth as well as bringing an anti-racism framework to education, training, and research to child and adolescent mental health.

Research and medical education in Canadian child and adolescent mental health have until now rarely addressed the effects of structural factors and systemic racism on the mental health of young racialized Canadians despite the fact that visible minority and Indigenous youth make up approximately 30% of the Canadian population under the age of 25 (Government of Canada, 2013a, 2013b). The majority of research on racism and child and adolescent mental health in Canada is found in policy papers, grey literature, and interdisciplinary academic writings, and rarely in child psychiatric journals as evidenced by the fact that of 88 included papers in an international systematic review of racism in child and adolescent mental health published in 2020, only one was Canadian (Cave et al., 2020). Though we have recently updated clinical training guidelines for Cultural Psychiatry in Canada (Kirmayer et al., 2012, 2020), research data and papers on systemic racism’s effects on child and youth mental health, particularly investigating structural factors or using critical race theory perspectives, has been lacking in Canada. Our guidelines for postgraduate medical education fail to provide a blueprint on how to implement anti-racism teaching and training relevant to child mental health in Canada.

We may no longer assume systemic neutrality on issues of race and diversity as a principle of delivering care in a public health system. Theories developed by scholars from the field of Law and Sociology, including Critical Race Theory and Intersectionality, have been vital to deepening our understanding of these issues (Crenshaw, 1991; Delgado & Stefancic, 1998). Critical Race Theory argues that race is a social construction with political and historical antecedents rather than a biological entity that exists without context. Structural theorists have offered a reflexive stance to questions of race in medicine by drawing attention to the link between racial disparities and systems in society that reinforce these disparities (Delgado & Stefancic, 1998; Ford & Airhihenbuwa, 2010). Using Critical Race Theory allows us to focus on the ways that systemic racism shapes the lives of young Canadians across systems of justice, immigration, education, housing and health. These systemic influences contribute to structural barriers for young Black, Indigenous, and People of Colour (BIPOC) people leading to unjust and unequal experiences (Ford & Airhihenbuwa, 2010; Hardeman & Medina, 2019). Critical Race Theory, Intersectional Theory, and the framework of Structural Competency have given us tools to examine how systemic racism intersects in complex ways with (post)-colonialism, class, ability, and gender to shape the lives, experiences, and identities of racialized young people (Crenshaw & Bonis, 2005; Ford & Airhihenbuwa, 2010; Hardeman & Medina, 2019; Metzl & Hansen, 2014). Addressing racism with a structural lens promotes a greater understanding of how systemic racial discrimination continues to be consciously or unconsciously enacted upon racialized populations. This also leads us as mental health providers to examine how being embedded within these societal structures might unwittingly increase barriers or decrease opportunities for young racialized Canadians and thus affect their mental health and mental healthcare (Fernando, 1991, 1995; Moodley & Ocampo, 2014).

As Child and Adolescent Psychiatrists, we are in a unique position to apply both a developmental perspective and a structural lens to trace the impact of systemic racism on young people’s mental health throughout their lives from inception, attachment, and through stages of individuation (Jones et al., 2020). Race affects young people’s identity formation throughout the lifespan (Akhtar, 1995) and racism’s effects on children’s self-esteem and self-worth start as early as the age of four (Durham, 2018). The education system continues to promote the message that racialized young people are less capable while also limiting opportunities for advancement of Black and racial minority children with disproportionate use of exclusionary discipline (suspensions, expulsions) from elementary school (Durham, 2018; Hardeman & Medina, 2019). This particularly increases the risk for diversion of these youth to the criminal justice system and affects how racialized youth conceptualize their future options in mainstream society (Hardeman & Medina, 2019). In adolescence, these childhood experiences of racism continue with on-going institutional and interpersonal race-based violence and discrimination as well as police-involved violence towards racialized people; adolescents evolve with respect to language, identity formation, abstract thinking skills as they make sense of the systemic discrimination they have experienced (Jones et al., 2020). As a response to the distress, rage and hopelessness this realization engenders, depression and anxiety symptoms, increasing suicide rates, and increasing use of substances to cope start to emerge (Anderson & Mayes, 2010; Cave et al., 2020; Hardeman & Medina, 2019; Simons et al., 2002; Staggers-Hakim, 2016; Tynes et al., 2019). Data from the United States demonstrates that while rates of suicide among Black youth had previously been lower than rates in the general population, in recent years rates of suicide in young Black people have been substantially increasing. (Price & Khubchandani, 2019). Data examining whether a similar trend is present in Canada is lacking. Repeated and persistent exposure to the effects of systemic racism at crucial developmental stages is a form of chronic stress throughout the life of racialized young people and contributes to adverse health outcomes, particularly mental health outcomes (Jernigan & Daniel, 2011; Jones et al., 2020; Paradies et al., 2015).

In Canada, there can often be an impulse to deny that institutional and systemic racism are a public health concern. However, Black and Indigenous students continue to experience barriers to academic achievement in Canada which limits their potential. These students are more likely to be streamed out of academic level educational opportunities and to experience racism in an academic environment (Codjoe, 2001; Colour of Poverty – Colour of Change, 2019). People of colour and Indigenous people in Canada are additionally much more likely to live in poverty and Black and Indigenous children are clearly disproportionately involved in the child protection system in Canada (Adjei & Minka, 2018). In fact, the disproportionate involvement of Black children in the care of the Children’s Aid Society in Toronto is more pronounced than it is in the United States (Ontario Association of Children’s Aid Societies, 2016). Khenti (2013) described the situation of young Black people in Canada as “overpoliced and under supported” – describing the combination of both experiencing increased surveillance on a regular basis by police while simultaneously experiencing the distress of social exclusion from social, health, and educational supports in Canada (Khenti, 2013). Systemic racism is not exclusively an American problem, and its effects on our young people’s mental health deserves re-evaluation of Canadian policies.

Systemic racism clearly influence access to, and experience of mental health care for racialized Canadians. Black young people in Canada wait twice as long as other young Canadians to access mental health services (Fante-Coleman & Jackson-Best, 2020). Racialized people in Canada are heterogenous in their origins and cite experiences of racism, discrimination and lack of culturally competent care as barriers to accessing effective mental health care (Chiu et al., 2018; Fante-Coleman & Jackson-Best, 2020; Guzder et al., 2013). They are less likely to voluntarily access mental health services in Canada and are more likely to enter care through a hospital emergency department or through the criminal justice system (Anderson et al., 2015). Once racialized people do access mental health supports in Canada, they are more likely to have negative experiences and in particular discuss how their experiences of race-based discrimination are discounted – particularly when they are consumers of mental health care (Shahsiah & Ying Yee, 2006). Contributions from cultural psychiatry draw attention to how nuanced cultural aspects within communities can affect attitudes regarding help-seeking for mental health concerns, which can be further complicated by differences between first- and second-generation immigrant attitudes and by the fact that an Indigenous understanding of mental health may differ from the Western concept. While cultural and structural formulations can at times be seen at odds with one another, a structural formulation can also make space for culturally competent care that offers additional inter-disciplinary knowledge and acknowledgement of cultural complexities essential to our task of reconciling value based, person based and family oriented approaches to advance improved children’s mental health (Gajaria et al., 2019; Kirmayer et al., 2012, 2020).

Table 1.

Terms and definitions

When “racism” is used in this paper, it is used to refer to the concept of systemic racism

Systemic racism is used to refer to the concept that there are systems and structures within society that reinforce and promote discrimination on the basis of racial identity and that racism is not simply enacted by individuals. Examples of systems and structures include the healthcare system, the criminal justice system, and systems overseeing access to housing and education.

Racialized is a term used to refer to Black, Indigenous, and People of Colour (also called “BIPOC) that is used to highlight that “race” is a socially constructed category with political meaning, and that perceptions and attitudes around what it means to belong to this constructed category have often been placed upon racialized people by those with more power in society – a process called “racialization.”

While systemic racism affects all racialized people in Canada to varying degrees, Black Canadians are specifically affected by anti-Black racism and Indigenous people in Canada continue to process and suffer generational effects of colonization and the legacy of the residential school system. The situation of Indigenous people in Canada demonstrates why a structural lens regarding mental health care for young people in Canada is essential as Indigenous young people in Canada experience particular mental health challenges due to persistent unequal treatment across various Canadian systems occurring over many years of colonization, cultural genocide, chronic underfunding by the Canadian government, and the residential school system. This historical legacy has resulted in unequal treatment across various systems, including education, health, infrastructure, and the criminal justice system. As examples, some Indigenous children on and off reserve lack clean drinking water and stable housing and many receive inadequate funding for appropriate educational and child protection supports (Brittain & Blackstock, 2015). Any approach to the mental health of Indigenous young people in Canada must consider the impact of this systemic racism.

These embedded systemic problems require systems-level interventions and engagement to improve the well-being of young Indigenous Canadians. Solutions to addressing the disproportionately high suicide rates among Indigenous young people as well as the higher rates of mental health difficulties among Indigenous young people in Canada must include a consideration of historical and contemporary systemic factors and a comprehension of social realities on and off reserve (Kirmayer et al., 2003, 2012; Richmond & Cook, 2016). The Indigenous community includes hundreds of different nations each with their own histories and traditions (Government of Canada, 2017); as such, services for Indigenous people need to be adapted to unique communities and cultural diversities as defined by Indigenous peoples themselves. Systems of care for Indigenous children should be governed by principles of self-determination while receiving adequate funding (Richmond & Cook, 2016).

Despite significant evidence of systemic racism affecting young Canadians, our lack of a research agenda attending to the links between race and mental health in Canada limits the degree to which we can understand these problems and effectively intervene (Nestel, 2012). Collecting race-based data is not a substitute for action but collecting more robust race-based data is essential to approaching Canadian care disparities. Collecting quantitative data will allow us to identify whether clinical services include proportional numbers of racialized people, a qualitative approach can further our understanding of the experience of care for racialized minorities, and both approaches can help understand whether and why mental health outcomes differ on the basis of race. It is important to appreciate the resistances to collecting these data particularly in Indigenous and Black communities who have already been subject to increased police surveillance and who may experience data collection as another form of surveillance. These populations have also expressed skepticism of past research efforts that have often failed to appreciate the structural roots and relational impacts of racism while often inadequately attending to intersectional identities (The Black Public Health Collective, 2020)

Racialized individuals occupy complex and intersecting identities, a fact which should be taken into account when doing research in racialized communities, including when collecting demographic data and when shaping research questions (Sinai Health Systems on Human Rights and Health Equity Office 2017; Taylor & Richards, 2019). In addition, evidence-based approaches would benefit from incorporating developmental frameworks when addressing how systemic racism affects Canadian youth, from developing methods to specifically measure the effectiveness of care provided to racialized young people, and from understanding how racialized communities cope and demonstrate resiliency (Jones et al., 2020; Jones & Neblett, 2017; Shahsiah & Ying Yee, 2006). Given historical power imbalances, the complexities inherent in addressing effects of racism, and the mistrust that exists in vulnerable communities, research that engages the voice of our child and youth consumers within community-based research, qualitative, and mixed methods approaches may demonstrate researchers’ willingness to co-construct knowledge in a way that honours communities’ knowledge about their own experience (Jones & Neblett, 2017; Kirmayer et al., 2012, 2020). In addition, engaging with existing inter-disciplinary work alongside quantitative analysis will lead to better understanding of this complex issue (Jones & Neblett, 2017; Kirmayer et al., 2012, 2020).

Historically, significant burden has been placed on racialized academics, communities, and community-based organizations to lobby for change (Shahsiah & Ying Yee, 2006). This work has often been unpaid and can negatively impact the career development of racialized professionals – a concept that has been termed the “minority tax.” In order to facilitate sustained change, those currently in leadership positions, particularly those who are not members of underserved communities, can act as effective allies by recognizing and elevating the expertise of racialized professionals with leadership positions and/or positions on policy committees, ensuring appropriate financial compensation for these roles, and by lobbying for adequate funding from academic institutions and granting agencies to ensure ongoing support and that this topic is given significant priority.

In addition to a renewed research agenda, postgraduate medical educators need to develop an educational strategy for Canadian Child and Adolescent Psychiatry inclusive of the effect of racial discrimination on children’s mental health. An effective educational model would include faculty development, resident didactic teaching and clinical experiences that includes anti-racism and institutional racism, building of advocacy skills, and using a structural competency approach to ensure an understanding of racism as a systemic and not individual-level determinant of health (Alang, 2019; Metzl & Hansen, 2014). Educational interventions at both the faculty and resident level should additionally include space for development of a “critical consciousness” and reflective spaces where learners have the opportunity to include their personal experience in relation to race and racism and engage in “critical self-reflection” about systemic racism, including in supervision (Guzder & Rousseau, 2013; Kumagai & Lypson, 2009; Schen & Greenlee, 2018; Wear et al., 2017). Education should be a combination of both didactic and reflective practice that both acknowledges and names the existence of systemic racism as a determinant of mental health while inviting participants to engage in authentic understanding of racialized peoples within a Canadian sociopolitical and historical context. Consideration should be given to the development of educational tools that promote continuing professional development on the effects of racism on children’s mental health that all practicing Child and Adolescent Psychiatrists can freely access, including those not associated with a university. The impact of racism in children’s development should not be an optional part of Child and Adolescent Psychiatry training but supported as an essential part of education from the highest levels of leadership within academic hospitals and departments of Child and Adolescent psychiatry (Kirmayer et al., 2012, 2020). One mechanism to ensure this topic is covered in postgraduate training for physicians would be for the Royal College to mandate this as a training requirement for all subspecialty Child and Adolescent Psychiatry residents.

Finally, access to care for racialized young people in Canada and the lack of diversity in health care teams remains a challenge. Increasing diversity of providers, particularly Black and Indigenous mental health providers, should be a priority for children’s mental health in Canada as should be concomitant improvement of culturally sensitive care. Anti-racist and diversity policies should not be present in name alone in children’s mental health care settings in Canada but should be meaningfully enacted from leadership down through to direct clinical care (Shahsiah & Ying Yee, 2006). In our experience, young people and their families benefit from providers who are willing to name experiences of racism and openly discuss how this might affect a young person’s mental health in a contextually sensitive way. Effective clinical intervention with racially diverse children and their families must include a commitment to cultural competency integrating the impacts of systemic racism as they apply to models of parenting, assessment of parenting capacity and family therapy (Steinhauer, 1991). Engaging diverse youth, their families, and communities in effective care delivery can assist in developing youth-friendly care that meets the needs of racialized youth and their families, following the example of the ACCESS model of care (Aery, 2019; Malla et al., 2016, 2019). Improved services for racially diverse young people also includes consideration of design of clinical settings - ensuring these spaces appear safe and inclusive to the diverse communities they serve, community outreach - locating high quality services in the communities in which these young people live, as well as potentially partnering with academic settings (Gajaria et al., 2018).

While additional resources from a stretched children’s mental health system appears challenging, a truly anti-racist approach asks us to re-envision the status quo. Young racialized Canadians are suffering – in many cases without the support of our mental health system. Canadian Child and Adolescent psychiatrists can more effectively use our privileged position in society to invest in a new public mental health framework that includes an anti-racist approach and improved intervention responsive to diverse children and youth.