Structural Racism in Behavioral Health Presentation and Management

Racism is the process by which systems, policies, actions, and attitudes create inequitable opportunities and outcomes for people based on the social construct of race.¹  Racism is ingrained in society and functions as a core driver of pediatric health inequities in the United States.^2,3  Theoretical frameworks commonly describe 4 levels of racism—structural, institutional, interpersonal, and internalized (Table 1)—and aim to elucidate mechanisms underlying differential health outcomes by race and support the design of interventions to address racial disparities.^4,5  In discussing Nia’s story, we will focus on the influence of structural, institutional, and interpersonal racism on behavioral health diagnosis and management and the interplay between the health care, education, and juvenile criminal legal systems. Though related, the underlying drivers of racial disproportionality in child poverty or the child welfare system will not be addressed.^3,6,7 

Structural, institutional, and interpersonal racism in health care settings influence racial disparities in behavioral health, including referral to neuropsychiatric testing,^8,9  access to trauma-informed mental health services,^10,11  and the diagnosis and management of behavioral health conditions.¹²  For example, despite epidemiologic evidence demonstrating lack of racial differences in externalizing behaviors in children, attention deficit hyperactivity disorder (ADHD) is underdiagnosed and undertreated in Black and Latinx youth compared with White youth, whereas disruptive behavior disorders like ODD and conduct disorder (CD) are overdiagnosed.^13,14  ADHD is recognized as a neurobiological problem of attention, hyperactivity, and impulsivity, with established structures of academic and social support and a strong evidence base for improved outcomes with behavioral support and pharmacotherapies. In contrast, ODD and CD are defined as patterns of uncooperative, defiant, and angry behavior toward people in authority. These diagnoses often carry more stigma because they are conceptualized as part of a fixed identity, meaning they are inherent to an individual’s personality and less amenable to intervention.¹⁵  Notably, externalizing behaviors that characterize both ADHD and disruptive behavior disorders have substantial overlap, including emotional reactivity, difficulty following rules, and impulsivity. However, diagnoses of ODD and CD rely not only on assessing whether a child’s conduct deviates from age-appropriate behavior, but also on evaluating whether the child’s motivation for the behavior is willfully defiant, hostile, or purposefully aggressive.¹⁶  Such value-laden assessments may be influenced by implicit or explicit personally mediated biases and racism.¹⁷ 

Disproportionate diagnosis of Black youth with disruptive behavior disorders may also be a result of mischaracterization of normative reactions to trauma.¹⁸  Black children are more likely to experience multiple and persistent adverse childhood events associated with a range of poor physical and mental health outcomes.¹⁹  Pathologizing reactions to trauma as problems of self-control and regulation exposes youth to further stigmatization and fails to address trauma as the underlying etiology.²⁰  Diagnosis of a disruptive behavior disorder rather than a more treatable behavioral health condition, such as PTSD, ADHD, major depressive disorder, or generalized anxiety disorder, may also have potentially harmful clinical implications, including limiting access to evidence-based behavioral interventions, medication management, and other supportive services that can reduce mental health-related morbidity and mortality.^14,21  These diagnostic disparities can also compound into differential treatment and access to services beyond the health care domain, most notably in the education system.

Overdiagnosis of Black children with ODD/CD compared with White children may also reflect adultification bias, in which Black, Latinx, and Indigenous children are perceived as older than their actual age or developmental stage and less innocent or deserving of care or comfort.^22,23  This manifestation of racism can result in harsh reactions to what is actually developmentally appropriate behavior.^24–26 Adultification bias is particularly well documented among Black girls.²²  Examples of adultification bias abound in the media, such as in the case of a 9-year-old Black girl in Rochester, New York, who was handcuffed and pepper-sprayed by police after they responded to a call to her home for “family trouble.” During the recorded event, the child is crying and begging not to be pepper-sprayed. One officer says, “stop acting like a child,” to which the 9-year-old girl responds, “I am a child.”²⁷  Adultification bias may be enacted at the interpersonal level, as demonstrated by this example from the media or by racial disparities in pediatric anesthesia administration,²⁵  or carried out at the systemic level, as highlighted by higher rates of Black youth being transferred from the juvenile court system to the adult criminal legal system.²⁸ 

Nia’s story is a case study of how structural racism manifests for an individual child, highlighting the propensity to mislabel Black youth with diagnoses characterized by fixed patterns of negative behaviors, as opposed to recognizing and meaningfully addressing normative reactions to trauma or other adverse childhood events—in Nia’s case, domestic violence, CPS involvement, and poverty.²⁴  Pathologizing and criminalizing Black children’s developmentally appropriate stress responses, rather than addressing the behaviors as manifestations of underlying trauma, has immediate and long-term impacts. Although Nia was ultimately diagnosed by a psychiatrist with PTSD, this case also illustrates the ease with which misdiagnoses are perpetuated in electronic health records because Nia’s record inaccurately listed multiple other diagnoses, including bipolar disorder and ODD.²⁹  This type of error is not unique to Nia. Although decision support systems can help merge outside records or recommend additional conditions based on prescriptions or recent encounter diagnoses, clinical problem lists often remain incomplete or inaccurate.^30–32  When inaccurate diagnoses persist in the medical record and interpretation of a child’s behaviors becomes disconnected from inciting traumas, labels such as ODD may come to signify unchangeable, negative characteristics that may not only influence clinicians’ decision-making and perceptions of children, but may also be internalized by youth themselves.

During Nia’s initial ED encounter, ED staff managed her as a potential danger despite her calm demeanor on arrival, searching her and confiscating her belongings. This was unfortunately only a prelude to future, potentially (re)traumatizing health care interactions that further restricted Nia’s autonomy, including use of restraints in subsequent encounters. Given Nia’s racial identity, adultification bias likely influenced her health care team’s responses to her behaviors, with the team potentially interpreting her actions as threatening or as willful aggression as opposed to stress responses characterized by anger and reactivity. Although hospital safety protocols that allow for confiscation of belongings and use of restraints intend to promote staff and patient safety, they may be unevenly applied and have adverse consequences. For example, at a systemic level, Black children have a higher likelihood than White children of emergency involuntary medication administration and physical restraint use during pediatric ED visits.^33,34  These disparities persist into adulthood, with increased restraint use and hospital security involvement for Black adults compared with White adults.³⁵ 

It is also important to consider Nia’s position as a Black student within an educational context that disproportionately disciplines Black children compared with their White counterparts and accelerates their connection with the criminal legal system. The “School-to-Prison Pipeline” refers to a US trend in which school-age children and adolescents are funneled out of schools and into the criminal legal system.³⁶  This phenomenon disproportionately affects children who identify as Black, Latinx, or Indigenous, children with disabilities, and those who live in poverty.

Young people with these identities are disproportionately pushed out of schools through several mechanisms. First, exclusionary school policies that criminalize typical child and adolescent behaviors as well as low-level offenses result in increased scrutiny, punishment, and exclusionary discipline starting as early as preschool.^37–39  Second, rather than receiving appropriate special education and mental health supports, children with disabilities (including intellectual and learning disabilities) may be disproportionately suspended or expelled when they engage in disability-related behavior, such as a child with autism running around and pushing classmates when overstimulated by noise.⁴⁰  Black children with disabilities are even more likely to experience disproportionate discipline compared with their White counterparts.³⁸  Finally, children from minoritized backgrounds are disproportionately moved directly to the criminal legal system through school-based arrests and referrals to juvenile courts.⁴¹  When taken together, disproportionate scrutiny and exclusionary discipline can lead to decreased engagement in school, lower levels of educational attainment, and a higher likelihood of criminal legal system involvement, all of which are known to have deleterious health effects.⁴² 

Medicalization and criminalization of unwanted behavior within the health care system through biased behavioral health assessments, use of involuntary medications and restraints, and overreliance on hospital security can further contribute to disparities in educational outcomes, criminal legal system involvement, and ultimately morbidity and mortality (Fig 1). Although health care professionals do not have direct control over school-based disciplinary actions, diagnostic mislabeling and the criminalization of mental and behavioral health occur in health care settings. The results of diagnoses made or actions (or inactions) taken in health care settings may then feed back into the school system or allow health care to serve as an entry point to carceral systems, including the child welfare and criminal legal systems.⁴³ 

Today, Nia is an adolescent who remains tall and overweight for her age. During her most recent presentation, Nia called 911 from home to request help for suicidal ideation but became agitated when EMS arrived accompanied by police. An altercation ensued, and she was escorted to the ED in handcuffs after hitting an officer. ED evaluation highlighted concerns for depression, and psychiatry recommended inpatient psychiatric admission. Nia boarded in the ED for 3 days before admission to inpatient pediatrics to continue awaiting psychiatric placement. Throughout her week-long hospital stay, Nia had numerous episodes of agitation and elopement attempts. Medication management was limited because of a lack of parental permission for use of oral medication to address depression, hyperarousal, or sleep difficulty or to be given as needed for anxiety or moderate agitation; with these restrictions, the inpatient team was limited to using involuntary intramuscular medications as a last resort in the case of imminent risk of physical harm to Nia or staff members. Nia consequently received intramuscular medications several times and was placed twice in physical restraints because of agitation that progressed to hitting and throwing food trays at staff members.

Nia’s behaviors represent externalizing manifestations of PTSD and complex, intergenerational trauma. At present, there is inadequate availability and access to high-quality, trauma-informed therapy and other supportive services for youth like Nia, resulting in more children and adolescents presenting to pediatric EDs and inpatient medical settings for evaluation, stabilization, and boarding.^44–46  Given the ongoing youth mental health crisis, a growing number of children and adolescents will continue to present to acute care facilities. As such, we need to ensure that we do not perpetuate diagnostic disparities, compound trauma, or contribute to the criminalization of child behavior when they present for care. We propose action steps at the structural, institutional, and interpersonal levels to mitigate the impact of structural racism on child mental health (Table 2).

Implementation of racial equity-oriented policy may reduce negative interactions at the interface of health care, education, and the criminal legal system for children like Nia. For example, several states and municipalities have passed legislation banning suspension and expulsion of young children from school, acknowledging the harmful effects of school exclusion and its role in perpetuating racial disparities in life outcomes.^47–49  Health care professionals can support bills, such as H.3876 currently in the Massachusetts legislature and H.R.2248 in the US Congress, which ban or disincentivize school exclusion.^50,51  In addition, because school referral to the ED for agitation and aggression may be a preventable cause of missed school days, we can also advocate for school districts to improve data collection and transparency to understand the scope and impact of school-to-ED referrals for behavioral concerns and associated disparities.^52,53  For children in need of evidence-based mental health care services, clinicians can also advocate for strategies to expand access, as outlined in a recent declaration of the national emergency in youth mental health.⁵⁴  Promising strategies include increasing funding for community- and school-based mental health programs, expansion of mobile crisis intervention programs, supporting mental health/primary care integration, and addressing mental health care workforce shortages through innovative trainings, loan repayment strategies, and recruitment of clinicians from diverse backgrounds.^55–60 

Hospital systems can address institutional racism by developing standardized, developmentally appropriate, and trauma-informed approaches to pediatric behavioral dysregulation.⁶¹  Such practices may include reducing police and security presence in hospitals and establishing behavioral emergency response teams consisting of mental health professionals trained in pediatric-specific deescalation techniques.^62–64  In addition, hospitals should consider development of clinical pathways to ensure a standardized approach to patients presenting with acute agitation or aggression,^65,66  with a goal of reducing subjectivity in interpretations of behavior and action steps taken, such as use of restraints or filing a CPS report. Evidence for success of similar pathways includes reduction in racial and socioeconomic disparities associated with screening evaluations for potential nonaccidental trauma.^67,68  Hospitals may couple clinical pathway implementation with team-based quality improvement efforts to collect and monitor institutional data, an approach with demonstrated success in reducing physical restraint use without a corresponding increase in staff injuries in one children’s hospital.⁶⁹  Finally, innovative educational programs like Health Equity Rounds can be a platform to bring together stakeholders and highlight opportunities for system improvement to advance equitable patient care.⁷⁰ 

Clinicians should intentionally reflect on how racism and adultification bias affect how they care for Black and other minoritized children. One approach to reducing bias is to avoid linguistic bias during electronic health record documentation. Use of linguistic devices—such as quotes, judgment words, and stigmatizing language—is more prevalent in Black compared with White patients’ notes.^71,72  These linguistic devices have the potential to negatively affect other clinicians’ attitudes and behaviors.⁷³  Particularly in the emergency and inpatient care settings, where clinical care teams rely heavily on the electronic health record for history and context, accurate verification of previous mental health diagnoses is critical. Involving family members, primary care providers, and other team members in the care of children with behavioral dysregulation can help verify active problems, provide additional context, and share existing behavioral plans with emergency medications individualized to patient symptoms and therapeutic goals. Members of clinical teams may also engage with medical-legal partnerships to ensure that a child’s right to education is not violated and the child receives the supports needed for success in educational settings. When discussing or documenting a child’s needs, clinicians should aim to provide recommendations that are not limited in scope by perceived resource limitation of the school district. For example, if a child needs a small, trauma-informed school where students are never restrained, the clinician should convey this recommendation regardless of whether they believe that it is realistic. This allows medical-legal partnerships to advocate more strongly for a child’s true needs and puts the onus on school districts to meet them.

In summary, pediatricians along the full care continuum encounter children like Nia. By improving our understanding of racism’s role in both the care we deliver and health care’s interactions with other systems, we will be better poised to disrupt racism’s impact on our patients’ health and provide Nia and other children like her with the support, care, and resources they need to thrive.

The authors acknowledge Dr Mary Brown, who provided her expertise as a guest panelist for the initial Health Equity Rounds conference presentation, and Drs Elizabeth Hutton and Alison Duncan for their contributions to conference preparation. The authors also thank Drs Bob Vinci and Catherine Michelson for their institutional leadership and support of Health Equity Rounds at Boston Medical Center.