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COMMENTARY
The recently released Youth Risk Behavior Survey report shows us that markers of poor mental health, ranging from feelings of hopelessness to suicide attempts, have worsened over the past decade in teenagers or, at best, stayed the same.1 Indeed, we are in the midst of an adolescent mental health crisis. But if you look at media coverage, this seems to be code for “white adolescent mental health crisis.” From the images used to discuss concerning mental health statistics surrounding teen girls to the personal narratives highlighted of adolescents struggling, the plight of white children is commonly centered as the standard, delegating Black teens to the periphery.2-4
Black adolescents, as well as children, have been in crisis for a while now, far more than 10 years—more like 2 decades.5 The failure to prioritize the well-being of Black children is not just a reflection of the media coverage; the field of psychiatry is guilty of it, too. And that must change.
Of Racism and Suicidality
“Sometimes they say things about me…the children in my neighborhood. I can’t make friends so I have wanted to kill myself for a while now,” said my 10-year-old patient with beautiful, russet-colored twists. She bounced on a large yoga ball, clearly nervous, and did not meet my gaze.
“Can you give me some examples?” I asked. The little girl stopped bouncing and looked at me directly, her deep brown eyes glistening with tears.
“Well, they are all white kids. I am the only Black one. They say my skin color looks like poop and that I’m ugly. They say lots of things about how being Black is bad… they talk about my hair, too.” Her voice trailed off and a tear rolled down her cheek.
“Wow, those children are racist,” I replied. “But you know what? Brown skin and brown hair are wonderful. Brown is the color of my favorite coffee beans, of the soil where plants grow. Brown is a wonderful color, and don’t you ever let anyone convince you otherwise. By the way, twists are great, too,” I winked at her, gesturing to my own long twists.
My patient looked at me with a startled expression. “You really think so?” I nodded, smiling, but my heart was breaking. Her shock that Blackness can be beautiful was far too common. It was no wonder, with the constant societal messaging that Blackness is synonymous with inferiority.
Later, I pored over the patient’s chart to read what other clinicians had written about her suicidality. Not one had mentioned the racism she experienced while living in a predominantly white neighborhood—an experience that I believed was key to her resultant suicidality. I made sure to add this to my own note, hoping it would make a difference in her care.
Black Youth Mental Health
There is still a dearth of research targeting the mental health of Black youth, even though Black youth suicide rates are rising faster than those of any other racial or ethnic group in America.6 Twice as many Black children as white children lost caregivers to COVID-19, while also experiencing harmful vicarious racism as they bear witness to the widely televised murders of Black people, such as George Floyd and Breonna Taylor.7,8
Yet in psychological research, race is rarely mentioned and when it is, these race-inclusive articles are authored and edited by almost all white scholars.9 As a child psychiatry resident, I strongly feel that standard psychiatric training mostly focuses on the common perspectives of white children. There is no formal education on the mental health effects of anti-Black racism, and there is no training on how to help Black children navigate anti-Black racism, even though studies have shown that racism contributes to suicidal ideation, substance use, and many other adverse mental health effects in Black youth.10-12
Instead, as psychiatry residents, we are taught about developmental pathways that exist in “all children.” Yet these pathways were developed by white psychiatrists who studied white children from a white perspective, so how racism affects development is absent from the picture. Even the psychiatric interview leaves out important questions that I believe are crucial to conceptualizing the mental health sequelae of Black patients.
Of course, it is important to understand the plight and experiences of white children, but to say that their experiences are equivalent to those of Black children is inaccurate and leads to Black children receiving inadequate care. Psychiatry desperately needs to look to Black scholars and experts to understand how the development of Black children and their psychiatric illnesses, inextricably intertwined with the downstream effects of anti-Black racism, are different and warrant alternative approaches.
But psychiatry remains a white-dominated field. Just as breast cancer, which largely impacts women, did not get significant research funding until women took control, it so too seems that unless Black psychiatrists continue to demand that the mental health of Black children be centered, it will not. Of course, Black female psychiatrists like me make up less than 2% of psychiatrists, and perhaps an even smaller percentage of child and adolescent psychiatrists, so I often stand alone when advocating for Black children. We are scattered across white spaces and often worn down, silenced, and minimized. But we keep pushing.
When Black children are spoken about in psychiatry, I hear the same limited narrative. Black children are impoverished and have less access to mental health care. But what is not spoken about is that Black children and families are poorer than the average white family because of intentional economic oppression, driven by white supremacy, that set out to give white families advantages and harm Black families.13 And anyway, all Black children are not poor, and wealth does not protect Black children from the distinct impact of racism.14
And a major elephant in the room is that psychiatric care itself is harming Black children.
Black children are more likely to be physically restrained than white children and also more likely to receive a diagnosis of a disruptive disorder, such as oppositional defiant disorder, than white children, who are more likely to be diagnosed with attention-deficit/hyperactivity disorder.15,16 I commonly witness my Black child patients described in dehumanizing, animalistic terms in patient charts by medical staff, while white children using the N-word are described as “unsafe and struggling.” Indeed, it is documented that Black patients are more likely to be described negatively in medical charts.17 I commonly witness a lack of empathy toward Black patients, even children, yet it continues, with minimal accountability or repercussions.18
Concluding Thoughts
To be sure, certain media platforms centered Black-appearing children as a standard in some articles.19 I have some non-Black psychiatric colleagues who I firmly believe treat their Black patients compassionately and equitably. But sadly, they are the exception, not the rule. Because even if a colleague is not personally responsible for unnecessarily restraining a Black patient or speaking about them in a dehumanizing way, if they are silent while other colleagues are doing so, they are part of the problem. Silence is harmful, too.
Don’t get me wrong; I am relieved that adolescent mental health is getting more attention and being recognized as a crisis. It should be. But I am not happy that the worsening mental health crisis of Black youth continues to fall through the cracks.
Dr Calhoun is an adult/child psychiatry resident at Yale Child Study Center/Yale School of Medicine. She is an expert on the harms of medical racism and the mental health effects of anti-Black racism in children.
References
1. Youth behavior survey: data summary & trends report. Centers for Disease Control and Prevention. 2021. Accessed February 27, 2023. https://www.cdc.gov/healthyyouth/data/yrbs/pdf/YRBS_Data-Summary- Trends_Report2023_508.pdf
2. Englander E, McCoy MK. Analysis: there’s a mental health crisis among teen girls. Here are some ways to support them. PBS. February 24, 2023. Accessed February 27, 2023. https://www.pbs.org/newshour/health/analysis-theres-a-mental-health-crisis-among-teen-girls-here-are-some-ways-to-support-them
3. McPhillips D. Teens, especially girls, are experiencing more violence, suicidal thoughts and mental health challenges, CDC survey finds. CNN. February 13, 2023. Accessed February 27, 2023. https://www.cnn.com/2023/02/13/health/teen-health-risks-cdc-survey/index.html
4. Richtel M. ‘It’s life or death’: the mental health crisis among U.S. teens. New York Times. May 3, 2022. Accessed February 27, 2023. https://www.nytimes.com/2022/04/23/health/mental-health-crisis-teens.html
5. Moyer MW. Suicide rates rise in a generation of Black youth. Scientific American. September 29, 2021. Accessed February 27, 2023. https://www.scientificamerican.com/article/suicide-rates-rise-in-a-generation-of-black-youth/
6. Ring the alarm: the crisis of Black youth suicide in America. National Action Alliance for Suicide Prevention. 2020. Accessed February 27, 2023. https://theactionalliance.org/resource/ring-alarm-crisis-black-youth-suicide-america
7. Treglia D, Cutuli JJ, Arasteh K, Bridgeland J. Parental and other caregiver loss due to COVID-19 in the United States: prevalence by race, state, relationship, and child age. J Community Health. 2022:1-8.
8. LaMotte S. Vicarious racism: you don’t have to be the target to be harmed. CNN. May 31, 2020. Accessed February 27, 2023. https://www.cnn.com/2020/05/31/health/vicarious-racism-wellness/index.html
9. Roberts SO, Bareket-Shavit C, Dollins FA, et al. Racial inequality in psychological research: trends of the past and recommendations for the future. Perspect Psychol Sci. 2020;15(6):1295-1309.
10. Walker R, Francis D, Brody G, et al. A longitudinal study of racial discrimination and risk for death ideation in African American youth. Suicide Life Threat Behav. 2017;47(1):86-102.
11. Gibbons FX, Gerrard M, Cleveland MJ, et al. Perceived discrimination and substance use in African American parents and their children: a panel study. J Pers Soc Psychol. 2004;86(4):517-529.
12. Racism and mental health. Mental Health America. Accessed February 27, 2023. https://mhanational.org/racism-and-mental-health
13. Weller CE, Roberts L. Eliminating the Black-white wealth gap is a generational challenge. American Progress. March 19, 2021. Accessed February 27, 2023. https://www.americanprogress.org/article/eliminating-black-white-wealth-gap-generational-challenge/
14. Calhoun A, Zang E. Wealth does not protect Black Americans from poor health— in some ways, it may make them sicker. Visible. September 15, 2022. Accessed February 27, 2023. https://visiblemagazine.com/wealth-does-not-protect-black-americans-from-poor-health-in-some-ways-it-may-make-them-sicker/
15. Yale study finds Black children most likely to be physically restrained in emergency department visits. Yale School of Medicine. September 13, 2021. Accessed February 27, 2023. https://medicine.yale.edu/news-article/yale-study-black-children-restrained-emergency-department/
16. Fadus MC, Ginsburg KR, Sobowale K, et al. Unconscious bias and the diagnosis of disruptive behavior disorders and ADHD in African American and Hispanic youth. Acad Psychiatry. 2020;44(1):95-102.
17. D’Arrigo T. Negative language in medical records more common for Black patients. Psychiatric News. September 26, 2022. Accessed February 27, 2023. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2022.10.10.17
18. Calhoun A. The life-and-death consequences of the shortage of Black mental health workers. Slate. January 24, 2023. Accessed February 27, 2023. https://slate.com/technology/2023/01/black-youth-mental-health-crisis-psychiatrist-shortage.html
19. St George D, Lewis KR, Bever L. The crisis in American girlhood. Washington Post. February 17, 2023. Accessed February 27, 2023. https://www.washingtonpost.com/education/2023/02/17/teen-girls-mental-health-crisis/
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