TABLE 1.

Lesson Confronting Suspected Racism in the Moment as a Bystander

Case 1: Overdiagnosis of conduct disorder in Black boys
Antecedent	Potential passive behavior	Potential consequences: Racism maintained	Potential active behavior: Facilitated by knowledge of what racism is	Potential consequence: Antiracism initiated
A 12-year-old Black boy with a history of early childhood abuse presents to a child psychiatry clinic for intake with a chart diagnosis of CD made by his pediatrician. His teachers report frequent verbal outbursts. His prior psychiatrist noted that his failing grades are attributable to “violent behavior in the classroom.” There is no prior workup or evaluation for ADHD, intellectual disability, PTSD, or anxiety.	Keep CD at the top of the differential diagnosis and start on risperidone daily while planning to obtain some information to evaluate for ADHD.	The patient and his family miss the next 2 appointments and the patient gains 25 lb in 2 months. His teacher expresses concern that he is falling asleep in class and failing tests. He is subsequently lost to follow-up, maintains a chart CD diagnosis throughout his adolescence, later dropping out of school and eventually becoming institutionalized in the juvenile justice system.	Re-evaluate the patient and family, probing for alternative explanations for the presentation with sensitivity to the overdiagnosis of CD in black boys. Obtain necessary information before initiating appropriate treatment.	On further evaluation, you find that the patient is experiencing hyperarousal stemming from PTSD, exacerbated by untreated ADHD. An intake for psychotherapy is arranged. Plans to target PTSD and ADHD with evidence-based psychopharmacology are developed in collaboration with the patient and parents. Psychoeducation is given to the family and patient. A letter is written to his school to advocate for an IEP. With medication changes and access to on-site learning therapists, the patient begins to improve his school performance. His temper outbursts cease. He receives all As and Bs on his report card and feels hopeful in his intelligence and abilities for the first time in his life.
Case 2: Delay in diagnosis of autism spectrum disorder
Antecedent	Potential passive behavior	Potential consequences: Racism maintained	Potential active behavior: Facilitated by awareness of harm caused by racism	Potential consequence: Antiracism initiated
A 17-year-old Black girl presents to the ED for evaluation of impulsive selfinjurious behaviors (cutting, head banging) in the setting of depression precipitated by a break-up. She is highly irritable on interview and endorses that her symptoms will “never” get better and has significant difficulty processing precipitants of her distress. She was recently evaluated by a therapist for lifelong interpersonal difficulties and was diagnosed with borderline personality disorder. On examination, you notice the patient’s cognitive rigidity, black and white thinking, and significant difficulty navigating social stressors.	Interpret your examination as further congruency with borderline personality disorder and make a referral to a DBT program.	The patient is promptly discharged from the DBT program for “treatment-interfering behaviors” related to poor attendance and verbal altercations with co-attendees. She becomes progressively more isolated and depressed, culminating in a suicide attempt.	You are aware that girls with autism can present with symptoms that resemble cluster B traits. You are also aware that Black youth are at high risk of misdiagnosis with regard to autism. With awareness of and sensitivity to these issues, you obtain a detailed history and examination.	Closer evaluation reveals a long-term history of social/emotional impairments, highly restricted interests, and behaviors focused on sameness and sensory avoidance. You review this information with the patient and her family and propose that autism may better explain her presentation than cluster B traits. You explain that this designation is important to ensure appropriate management. You provide the family and patient with educational materials on autism and refer them to outpatient specialists in ASD. The patient begins intensive psychotherapy with an ASD specialist. She begins to recognize connections between cognitive rigidity stemming from underlying ASD, symptoms of depression, and difficulty with problem solving. She gradually achieves remission in her MDD symptoms and embraces her difference thanks to community and online resources.
Case 3: Suicide risk assessment in multiracial youth
Antecedent	Potential passive behavior	Potential consequence: Racism maintained	Potential active behavior: Facilitated by desire to educate perpetrator	Potential consequence: Antiracism initiated
You are working in the ED with a white colleague. They are discussing the most recent patient they saw, a “Black” 16-year-old girl they were planning to discharge from the ED. Your colleague tells you that she came in with SI but that “the kid seemed fine.” Admits that the girl was not giving much information in the interview and seemed pretty shut down, but they were able to develop a safety plan with her and her mom.	You realize that your colleague was unlikely to have screened for multiracial identity and related suicide risk factors, such as sense of connectedness to community and belonging. You are worried they may be miscalculating suicide risk, but are not sure how to bring it up and think that it will probably be okay.	The patient is discharged from the ED. Five days later, the parents find a suicide note on her bed and she does not return home from school on Friday. Her suicide note describes intense feelings of loneliness and feeling like she “doesn’t fit anywhere." She describes the difficulty of not having a sense of community at school. She is eventually found unresponsive in a nearby park and brought to the ED for resuscitation owing to an intentional overdose on alcohol.	You recognize this interaction as an opportunity to provide education on suicide risk assessment in multiracial youth. In a nonjudgmental tone, you ask your colleague about the case, uncovering the assumption about the patient’s race and missing aspects of a comprehensive suicide risk assessment. You state the importance of these measures and ask them to clarify and repeat their reasoning for discharging the patient without more workup.	Your colleague initially seems aggravated, but goes to reevaluate the patient. They apologize to the patient for making assumptions about their race and finds that she is much more open than before. She reveals her plan to overdose at school on Friday and they both agree that she would benefit from admission at that time. Following inpatient stabilization and revealing difficulty with racial identity formation, the patient’s mother is encouraged to arrange therapy with a psychotherapist specializing in race conflict. This work builds self-esteem and helps to stabilize her dysregulation.

Note: ADHD = attention-deficit/hyperactivity disorder; ASD = autism spectrum disorder; CD = conduct disorder; DBT = dialectical behavioral therapy; ED = emergency department; IEP = Individualized Education Program; MDD = major depressive disorder; PTSD = posttraumatic stress disorder; SI = suicidal ideation.