Synopsis
In this framework, we synthesize the results of studies addressing racial/ethnic disparities in children’s mental health through four domains hypothesized to impact minoritized children and their families: 1) policies; 2) institutional systems; 3) neighborhoods/community system, and 4) individual/family level factors. We focus on children and adolescents, presenting findings that may impact mental health outcomes for major racial/ethnic groups in North America: Black/African American, Latinx, Asian, and American Indian youth. We conclude by suggesting areas for needed research, including whether certain domains of influence demonstrate differential impact for inequities reduction depending on the youth’s race/ethnicity.
Keywords: Racial and ethnic disparities, Youth mental health, Equity
Background
The 2020 United States Census1 indicates population growth among minoritized children. The child population is currently 25.7% Latinx, 13.9% Black or African American, 5.5% Asian, 1.4% American Indian and Alaska Native, 15.1% “two or more races,” and 10.9% “some other race alone.” Rising trends in diversity are especially important for clinicians given the significant racial/ethnic disparities documented in mental health disorders prevalance2 and access to needed services.3,4 For example, Latinx children use in-school mental health services at a significantly lower rate than their white counterparts.5 Similarly, significant differences by race/ethnicity were detected in out-of-school service use for each diagnostic group, illustrating unrelenting disparities in care.
The fact that disparities have persisted across settings emphasizes the importance of identifying and understanding mechanisms and alternatives to traditional care. In this paper, we elucidate the importance of a multi-pronged coordinated approach to restructuring mental health prevention and services for youth of color to tackle these inequities and ensure all children have optimal mental and emotional development. We draw upon theoretical models6,7 of the underlying mechanisms, with some evidence of what appears to amplify or reduce these disparities. The Integrative Risk and Resilience model8 builds upon Garcia-Coll’s seminal framework9 to describe ways racial/ethnic minorities’ mental health outcomes are shaped by factors at different ecological levels. Bernard and colleagues add that adversity-specific frameworks to understand child mental health outcomes need to capture racism, historical oppression, traumas, and social conditions (e.g., poverty) that racial/ethnic minority youth confront.10
An important first step to achieving equity across domains is recognizing that racism is a fundamental cause of inequities.11,12 Dr. Camara-Jones’ posits that “racism is a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call ‘race’), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.”13 We also follow Camara-Jones’ conceptualization of health equity, as “the assurance of the conditions for optimal health for all people.”14 The American Academy of Pediatrics acknowledged the fundamental role of racism in inequities15 and the importance of pediatric health professionals’ ability to engage in preventive strategies to optimize the way we design and conduct clinical care, workforce development, professional education, systems engagement, and research, to reduce the health effects of structural, personally mediated, and internalized racism.15 This is an important paradigm shift — from blaming children and families of color, to now focusing attention to the policies and systems that create and perpetuate inequities in mental health services and outcomes.
The Framework.
As illustrated in Figure 1, racial/ethnic disparities in children’s mental health can be understood within four domains: 1) policies, laws, and regulations; 2) institutional systems; 3) neighborhoods/community system, and 4) individual and family level factors. This model follows work we and others have published emphasizing how these four domains and life course perspective call for the study of human lives within the context of time, age, and social patterns that affect individual trajectories (see Figure 1).16 One key principle is that of “linked lives,” which assumes that individuals are interdependent with families and peers and are impacted by what happens in their communities and how the institutional systems and policy can influence their well-being. Applied to the problem of racial/ethnic discrimination-related stressors and health inequities by Gee and colleagues,17 the concept of linked lives implies that when one person encounters discrimination in housing or employment access, it can have ripple effects across their close social network, and over generations, that can impact family, peers, and even neighborhood experiences in mental health. To illustrate the framework, we begin with a discussion of the four domains and how each compounds experiences of disadvantage among minority populations. We then transition to a greater focus on modifiable factors that can promote change across domains.
Figure 1.
Sociocultural Framework for Understanding and Addressing Racial and Ethnic Disparities in Children’s Mental Health
Policies, Laws and Regulations
A review of mental health and mental health care disparities research (across the lifespan)18 identified a need for studies focusing on policy-level predictors of mental health care disparities. Contemporary health disparities result from “the cumulative impact of centuries of systemic exclusion from legal protections, and restricted access to opportunities and resources that are protective of health” (p. 308).6 Understandably, more than five years are needed for most macro interventions to witness a reduction in disparities.6 For example, ParentCorps and Earned Income Tax Credit appeared to have no change in the short term (adolescence) but demonstrated significant change in mental health and reducing disparities in the longer term (adulthood). A policy is not likely to reduce racial/ethnic mental health disparities without explicitly prioritizing resources and opportunities for racial/ethnic groups19 who have been under-served and systematically under-resourced due to structural racism. Prior work has described public policies’ impact on improving the mental health of youth of color and reducing racial/ethnic disparities.20,21 Persistent issues in the enactment of equity-focused policies include the lack of earmarked funding, technical assistance, and lack of political imperative.
Modifiable Factors for Policy Change.
In an overview of recent policies that explicitly address racism in children’s mental health services, Alvarez and colleagues22 concluded that the policy with the most potential for broad and lasting impact is the Pursuing Equity in Mental Health Act (HR 1475) which was passed in the House (5/12/2021) and is awaiting vote in the Senate as of October 2021 (Congress.gov, HR 1475). The primary purpose of (HR 1475) is to respond to the mental health needs of youth of color. Stakeholders have discouraged “standalone” (i.e., one-time) policies to address racial equity in improving youth mental health 23 because they can relegate new practices to silos outside of mainstream funding and delivery mechanisms. Yet these limited-term policies have been important demonstrations for establishing the evidence base, such as the California’s Mental Health Services Act (Proposition 63) which was associated with increased access to care for Latinx and Asian youth and reduced disparities,24 and serves as the basis for implementing further reform to improve treatment quality.
Develop infrastructure for youth-centered models of integrated behavioral health and primary care.
(HR1475) also amends the Public Health Service Act (42 USC 290dd) Integrated Health Care Demonstration Program by adding $100 million in grants for inter-professional health care teams for the provision of behavioral health care in primary care settings in areas with high proportion of racial/ethnic minority groups, such as Federally Qualified Health Centers (FQHCs). FQHCs receive Health Research Services Administration federal grant funding to improve health of underserved populations, and serve 30 million people, including over 10% of all children, mostly children of color.25 Policy directions for reducing mental health disparities through integrated care include allocating state Medicaid funding for Accountable Care Organizations,26 bundled payments, and other integrated care payment mechanisms.19
Increase funding for research on racial and ethnic minority youth mental health.
The largest funding authorization in the (HR1475) is $650 million annually for five years to the National Institute of Minority Health and Health Disparities (NIMHD). The act authorizes additional funds for the NIH ($100 million annually for 5 years) to build relations with communities and conduct clinical research on racial or ethnic disparities in physical and mental health. Both are sorely needed given the shortage of evidence-based psychosocial interventions for minority youth.23,27 This policy is likely to improve mental health given that a large portion of culturally appropriate evidence-based interventions were developed or adapted with funding from the NIMHHD. This act also requires the NIH Director to partner with the National Academies of Medicine to conduct a study on research gaps in racial/ethnic mental health disparities, including structural racism.
Expand health insurance coverage and eligibility requirements.
The Children’s Health Insurance Program (CHIP) and Medicaid through the Affordable Care Act improved coverage, access, and quality of care, and narrowed disparities between White children and Hispanic and Black children across all 3 categories.28 The Early Screening Detection and Treatment (EPSDT) benefit under Medicaid enables Medicaid-eligible children to have access to preventive, diagnostic and treatment services for physical, mental, and dental conditions. Insurance coverage, combined with improving patient education and availability of community clinics, reduces service disparities across racial/ethnic groups, including removed disparity between Latinx and non-Latinx whites, while African Americans were 10% less likely to receive care compared to non-Latinx whites.29 Expanding Medicaid eligibility in states that have opted out of ACA Medicaid expansion19 might help reduce inequities, given the large numbers of uninsured Latinx families living in such states. 30
Operation of the Institutional Systems
Systemic sources of disparities are pervasive and complex, with the impact of separate institutions often compounding the negative effects of the others. For example, educational attainment has been shown to be an important contributing factor to one’s health31; however, youth of color face several barriers to learning (e.g., harsher discipline) that diminish the quality of their educational experience and that are associated with negative educational outcomes.32 This can result in long-term mental health consequences that are more likely to go unmet for these youth due to additional systemic barriers in the health care system.15 Moreover, it perpetuates a cyclical pattern of adversity and inequality that compounds poor mental health functioning of youth over time. This is important given that mental health concerns beginning in childhood and adolescence can cause problems that persist into adulthood and increase healthcare expenditures and economic burden.33
Educational systems.
Schools play a decisive role in youth mental health outcomes with those that offer caring and nurturing relationships 34 and school safety35 demonstrating better outcomes than those missing these characteristics. But student’s perception of their school environment has been shown to vary by race/ethnicity, with Black youth more likely to report negative experiences than their White counterparts attending these same schools.36 Importantly, experiences of discrimination and racism, even indirectly as a bystander, can be deleterious to the health of students of color 15,32 and represent yet another threat to these students’ educational experiences. One source of these negative experiences is the differential treatment in school disciplinary action, which may account for almost half of the Black/White student gap in suspensions and expulsions.37
Juvenile justice and child welfare systems.
Degrees of disadvantage differs according to the stage (i.e., arrest vs. probation) and group of youth being observed but the consensus is that the juvenile justice system is less favorable to racial/ethnic minority youth compared whites.38 More evidence exists to suggest this is especially true for Black and Latinx youth, while significantly less work has focused on the impact on American Indian/Native Alaskan, Asian, and Native Hawaiian/Pacific Islander youth. In addition to the juvenile justice system, racial/ethnic minorities are also disproportionately referred to child protective services, particularly Black families. Dettlaf & Boyd39 highlight the importance of the intersectionality between race and socioeconomic status (SES), noting the associated risk factors (e.g., increased financial and parenting stress) that increase families’ vulnerability to maltreatment and child welfare contact. The juvenile justice system presents with an inordinate number of challenges that racial/ethnic minority youth and their families face in everyday life, which, when compounded by experiences of institutional racism and structural barriers that prevent these youth and families from obtaining equitable support, create the perfect storm for perpetuating systems of oppression.
Modifiable system factors.
Effectively addressing systemic disparities would require a multilevel approach and, to eliminate disparities in mental health, the reformation of multiple systems. While this represents a considerable undertaking, the literature has presented promising avenues for advancement. For example, efforts to reduce racial/ethnic disparities in the child welfare system have emphasized the importance of establishing long-term community collaborations, promoting workforce diversity, and enhancing cultural competency.40,41 Data-driven decision-making was also noted as an essential component due to needed adjustments as systems changed over time.40
Role of Neighborhoods and Communities
The vital role of neighborhood residence has been tied to mental health outcomes. Both the physical environment (e.g., pollution) and the social environment (e.g., exposure to violence) can change neurodevelopment, modifying epigenetic variation and biological systems that interact with development.42 For that reason, environmental variables operating at the expansive societal level and more proximal neighborhood level have been labeled the exposome.
Economic hardship.
A plethora of studies links neighborhood socioeconomic conditions and safety with children’s mental health outcomes.43 For example, Coulton and colleagues44 report how rises in vacant housing, neighborhood unemployment rates and extreme racial segregation appear related to upsurges in child maltreatment rates. Similarly, Hurd and colleagues45 found that greater neighborhood poverty and unemployment rates predicted greater internalizing symptoms due to lower social support and cohesion.
Discrimination.
Discrimination experienced in the neighborhood has shown a deleterious and pervasive effect on the mental health of minoritized youth. 46–48 But again, there is evidence that suggests that the discrimination experienced by minoritized youth might vary by racial/ethnic groups,49 with visible minority status and receiving context playing dynamically impacting youth mental health outcomes. Everett and colleagues50 found higher reports of perceived discrimination among Black youth, lower rates among Asian youth, and similar rates for Latinx youth as contrasted to non-Latinx White youth. In their study, discrimination had significant effects on depressive symptoms but not on anxiety symptoms. Work by others46,51 has found statistically significant relationships of discrimination on anxiety disorders on Latinx youth. Of interest is the finding that discrimination might have a more corrosive effect on majority than minority groups, partly explained by lacking mechanisms to cope with discrimination.
Exposure to violence.
Neighborhood violence also appears to have negative consequences for children’s cognitive performance and self- regulatory behavior.52,53 Neighborhood violence seems to modify the social interactions in disadvantaged communities with increased experiences of discrimination, that augment neighborhood inequities in mental health outcomes.46 Evidence also shows that moving out of violent environments alters developmental consequences, with children who departed from extremely violent neighborhoods (to less violent ones) demonstrating improvements in cognitive skills and mental health.54 More recent research using social network analysis has found55 that patterns of everyday urban mobility are better predictors of homicides than fixed neighborhood disadvantage, with suggested explanations by authors including drug activity, gun crime prevalence, and interpersonal friction.
Social capital and collective efficacy.
The physical and social conditions of a child’s neighborhood impact the mental health of the child’s caregivers, the parental interactions with children, and mental health outcomes of White and Black children.56 Whether the effects of neighborhood social capital and collective efficacy are seen when Latinx children are older remains unknown. Also of significance is the interaction of maternal depression and neighborhood social capital for behavior problems in adolescents. For example, Delany-Brumsey and colleagues57 showed that living in neighborhoods with higher levels of social capital diminished the association between maternal depression and adolescent behavior problems. Latinx children’s neighborhood sense of community has also been identified as a buffer for children’s behavior outcomes.58
Ethnic density.
Who resides in the neighborhood matters. There is some literature showing how higher concentrations of Black persons and stable residents in one’s neighborhood relate to fewer internalizing symptoms among Black adolescent residents, via greater cumulative social support and perceptions of neighborhood cohesion. After adjusting for the material deprivation of the neighborhood, Latinx immigrant ethnic density in the neighborhood was found59 to be protective of Latinx immigrant youth’s lower odds of depression onset. However, this protective effect was not found for non-immigrant Latinx youth. The potential of Latinx immigrants to be a psychosocial resource in the neighborhood appears to offset the stress of Latinx immigrants possibly explaining positive mental health outcomes. In parallel, greater concentrations of Black and stable residents in Black neighborhoods has been associated with less internalizing symptoms among Black adolescent potentially explained by youth’s perceptions of greater social support and cohesion.45
Modifiable neighborhood factors.
There has been a meteoric growth in the literature identifying modifiable neighborhood factors linked to well-being and mental health outcomes. We draw attention to the physical and social environment as it conveys opportunities for prevention and remediation in mental health but importantly for mitigation of racial and ethnic disparities in youth mental health outcomes. Being able to identify how crime decline has impacted disparities in children’s mental health outcomes is also sorely needed. Work by van de Weijer and colleagues60 evaluated two large-scale data resources to identify environmental factors associated with well-being. In longitudinal analyses, the researchers 60 found that housing stock, neighborhood income, core neighborhood characteristics, livability, and socioeconomic conditions of the neighborhood in childhood were all associated with well-being in adulthood. This is important since residential segregation by income is increasing in the US.61 Once adjusted for individual and neighborhood income, only neighborhood safety and greater percentage of land dedicated to greenhouse horticulture were found to be significantly related with well-being.
Individual and Family Factors
Biological impact of stress and adversity.
Researchers have more recently focused on ways stress “gets under the skin,”62 altering biology leading to mental health outcomes and disparities. Most current risk and resilience research has focused ways stressors affect the hypothalamic– pituitary–adrenal (HPA) axis and how these are linked to mental health outcomes. Studies have found flatter awakening cortisol slopes among Latinx and African American youth, compared to their White peers 63,64. Flatter awakening slopes, or cortisol not appropriately peaking during awakening, is indicative of HPA dysregulation and has been previously linked to poor health outcomes and early death.65 Similar patterns of HPA dysregulation have been observed among American Indian young adults, perhaps indicative of heightened rates of chronic adversities during childhood.66 Experiencing discrimination has also been linked with HPA axis hyperactivity among racial diverse youth67 and young adults.68
Emotion regulation.
Aspects of emotion regulation, such as effortful control, can protect Latinx youth exposed to stressors from poor mental health outcomes.69 Latinx immigrant youth, who may experience higher acculturation and assimilation related stressors, are more likely to have high levels of emotion regulation if they have positive social relationships, have a sense of purpose, and are adaptable to environmental demands.70 Black youth with good emotion regulation skills showed adaptive cortisol levels irrespective of degree of psychosocial stressors experienced.71
Modifiable individual and family factors.
A protective factor particularly salient to youth of color is having a strong sense of their own racial and/or ethnic identity. 51,72,73 Positive perceptions of one’s race/ethnicity have been linked to improved self-esteem, better academic outcomes, and decreased internalizing and externalizing problems.51,72 For example, in their cross-sectional investigation, Zhen-Duan and colleagues73 found that Puerto Rican girls who had a greater acceptance of their ethnic identity reported higher self-concept despite experiencing elevated levels of cultural stress. Social networks within and outside of the family unit have been shown to facilitate racial/ethnic identity promotion74 via socialization messages.72 An important commonality underlying these constructs is that they are all central to how racial/ethnic youth perceive and experience the world around them. Unfortunately, achieving acceptance of one’s racial/ethnic identity can be challenging when messages of positivity being conveyed by close friends and family are directly opposed by surrounding messages in the external environment.
Summary
Mental health disparities among racial/ethnic minority children and youth continue to widen,2 and the fact that these disparities continue to persist highlights the need to engage in efforts alternative to traditional care. Clinicians hold critical roles in evoking change at the policy, institutional, neighborhood and individual levels we have outlined in this manuscript. Future work will require centering attention on policies to address structural racism and work towards equity.75 Clinicians can use their expertise to advocate for equity-focused policies and further the development of methods to assess ways structural racism impacts youths’ mental health.76 Clinicians can also initiate, or be part of, community and clinical interventions to develop “nurturing neighborhoods”77 (e.g., to minimize physical and social toxic exposure, strengthen prosocial and resiliency outcomes, and ensure psychological safety and well-being for minoritized children) in an effort to promote healthy development. Clinicians can provide consultations for community-based prevention and intervention work that would help mitigate racial/ethnic disparities. Specific to mental health delivery, the field should be moving towards integrated/collaborative care models, with youth-centered models of integrated behavioral healthcare at the forefront, which have been found to reduce disparities by making care more accesible to marginalized communities.25
Key Points
1. Policies:
We present evidence of programs proposed within the Pursuing Equity in Mental Health Act (HR 1475) and related policies that would expand services and mitigate disparities for youth of color.
2. Systems:
Systemic sources of disparities are pervasive and complex, with the impact of separate institutions often compounding the negative effects of others; this necessitates both multi-level and -system interventions to effectively improve the mental health trajectories for youth of color.
3. Neighborhoods:
Interventions directed at the physical and social environment where youth of color reside can advance opportunities for prevention and remediation in mental health problems and mitigate racial and ethnic disparities.
4. Individual:
Childhood adversities can alter bodies at a molecular level and change the way the body’s stress response system works. Growing research has elucidated potential biological pathways linking stress and adversity and mental health disparities among youth of color.
Clinics Care Points
Pitfalls - DON’T…
Fail to conceptualize youth of color’s mental health needs within the context of policies and laws that perpetuate the cycles of oppression and marginalization.
Approach clinical care without addressing the intersecting systemic risks that maintain cyclical pattern of adversity.
Ignore neighborhood and community characteristics that contribute to clinical presentations and oppress families and youth of color.
Overlook ways stressors can be embodied and carried throughout development of children of color.
Pearls – DO…
Advocate for policies and practices that are more responsive to addressing racism and mental health issues afflicting youth of color.
Support an overhaul of institutions youth of color come into contact to address biases and practice a nurturing neighborhood and community to ensure mental health development.
Use your voice to support more modifiable neighborhood and systemic factors that will promote mental health.
Encourage youth of color to tap into cultural factors that will buffer stressors both biologically and psychologically.
Footnotes
Disclosure Statement: The Authors have no conflicts to disclose.
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