Hello, everyone. Thank you for joining us today for this webinar entitled Striking Mental Health Care Disparities Among Black Children and Adolescents. I'm Nicole Del Castillo. I am the Chief Diversity, Equity, and Inclusion Officer at Carl Illinois College of Medicine. And joining me is Dr. Durham. Do you want to introduce yourself? It's great to be with all of you today. I'm Michelle Durham. I'm a Child and Adolescent Psychiatrist. I also practice adult psychiatry and addiction medicine. And I'm currently in Houston, Texas, voluntary faculty at the Tilghman-Pertida School of Medicine. So we're going to go ahead and get started. To start, this is our great grant funding statement, which you all have this information. We also do not have any relevant financial relationships to disclose. All right. So in 2000, Dr. David Satcher, the Assistant Secretary for Health and the Surgeon General, released a report that stated that was on the National Action Agenda for Children's Mental Health. The report noted that the nation is facing a public health crisis in the mental health of children and adolescents. At that time in 2000, the United States statistics showed that 1 in 10 children and adolescents suffer from mental illness severe enough to cause some impairment. However, only about 21% of children who needed a mental health care evaluation received services. Unfortunately, these disparities still exist today. Now, one in six children are impacted by mental health and behavioral health conditions. Since 2000, we've seen increased emergency room visits for all mental health emergencies. Mental health has worsened due to social stressors. And due to this, Surgeon General Dr. Murthy issued an advisory statement about pediatric mental health crisis. In addition, in 2001, the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry and the Children's Hospital Association all declared a national emergency on children's mental health with a serious toll of the COVID pandemic on top of existing challenges. As many of you know, suicide rates are increasing and is the second leading cause of death among US adolescents 12 to 18. In addition, the inequities that result from structural racism have contributed to disproportionate impacts on children from communities of color, which is what leads us to this talk today. So our objectives today is that we will identify mental health care disparities data as it relates to black and indigenous people of color, including children. We'll describe why mental health disparities impact black individuals and why that exists. And then identify two strategies. Hopefully you come away with two strategies to eliminate mental health disparities impacting black children. I'm going to talk a little bit about really just setting the stage that we're all on level footing and thinking about what is a health disparity and how do we think about health care disparities in general. And as you can see, we've sort of noted that health disparity is really this high burden of illness, injury, disability, or mortality, that we're seeing this in many individuals. We're not just highlighting it for certain individuals, but across the board. We start thinking about health care disparities and what happens there. We're thinking about what other things are influencing difference between groups, whether is there a difference in how one group gets coverage versus another, essentially how people are getting any access or use of the care that is out there. Are there certain groups that are benefiting while others are not benefiting? And then also just the quality of care is when we start thinking about what is the disparity that's happening. And probably the language you've heard a lot, especially over the last few years, that there's been more of an increase, I think, in awareness, although as Nicole has mentioned, even decades ago, the Surgeon General's report has shown us a lot of issues with these particular topics and disparities, whether that be health insurance, access and use of care, and quality of care. And so what really just want to make note of thinking about what defining clearly for all of us about what are these health and health care disparities that we know very well and yet lots of research has been done and yet still have a lot of work to do. Moving on and when we think about health equity to provide a definition of that, as we sometimes hear these terms all used interchangeably, but equity really means that each individual or group of people is given the same resources or opportunities. Equality, I don't know if I misspoke there. Equality means that each individual or group of people is given the same resources or opportunities, whereas equity really recognizes that each person has different circumstances and that we need to allocate some resources and opportunities differently in order to reach the outcome for all people. I mean, this is a nice graphic that the Robert Wood Johnson Foundation over the last few years have really changed this graphic and many of you may have remembered one that just everyone was in a bicycle, but they've really looked at how people have reflected on this graphic, gotten the feedback and improved this graphic continuously over the years. But remembering that equity really thinks about different groups, different people, who are hard of hearing, what do they need in comparison to somebody who may not be hard of hearing, someone who can, has the ability to ambulate without difficulty versus someone who doesn't. And so I think the illustration really depicts that how do we really think about the resources that each individual needs in order for us all to be healthy. And then, you know, as we're thinking about, we're defining those terms, but then we're also moving into thinking about how does this relate to mental health and the disparities that we probably have all seen, unfortunately, through our time as clinicians, but also as we hear from the experiences of our patients as well. And these are all highlighted here that we know that in mental health, that disparities become pretty evident really quickly when people are just having a really difficult time accessing care. That no matter if they are interested in getting care, if they're saying, hey, I know that this is something I need, that it's really difficult to even find a provider that may take them, whether that be due to their insurance status, what providers can take, whether they have specialists in their area that provide the care that they need and the different subspecialties that are within psychiatry. The other big thing that we start seeing disparities, especially when we start thinking about Black people and other people of color, is that how do we get to the early on prevention, screening, and initial diagnosis? Quite difficult at times for people to even be in a place where there's prevention happening, where they can get early screening and detection so that things don't lead to a crisis. And then quality and quantity of treatment received is also a major thing that unfortunately is reflected in many, for many folks that they may see providers and sometimes the quality or are they in, is that provider providing evidence-informed treatment, evidence-based treatment can be really difficult for some people to access depending on where they live and who they are. And then outcomes, if we're not getting the diagnosis right, if we're also, if folks aren't being treated with the best interventions available that we know from research and studies and other things, then sometimes outcomes, we see various disparities depending on the group and who the person is. Just honing in on this a little bit more and thinking about if we start thinking about what happens for Black people in particular, we know that Black people represent about 13% of the population with over 42 million people represented. About 20% of Black people are affected by mental illness. Black people in general, 20% more likely to experience psychological distress when compared to the general population. And even though psychiatric prevalence rates are similar between Black people and White people, utilization rates of mental health services is very illness greatly differ. And there are a myriad of reasons for that, that we can talk about and expand upon. But it's not always because utilization that they're not going in for that particular treatment, but maybe that provider, they aren't met with a provider that understands them or a provider that maybe minimizes their symptoms or doesn't believe their symptoms. And so we didn't start seeing right severity of illness be different and can differ when you're not getting the treatment you need and deserve. Many times, Black people are overrepresented in public mental health institutions. And although there can be some great institutions that are doing public health work, there can be other ones that aren't really thinking about the evidence base, or maybe that aren't as culturally attuned, or maybe not able to provide the best evidence-based treatment due to cost, insurance, and other things that unfortunately inhibit providers from sometimes doing the best care. And we also know there's also an overdiagnosis of when people do present. This has been a long historical reason, or long history, unfortunately, of Black people often being diagnosed with some psychotic process and schizophrenia in particular, and not thinking about the differential and the spectrum of illness and what characteristics we might see for Black people versus other people when we're always being compared to White people in particular and how their presentation is. So then when we think about this more broadly, there's a lot of things that are impacting Black people in particular, but we also think about how they're utilizing services overall. And this can affect Black people and their utilization rates, which I talked a bit about, but really, we need to acknowledge and appreciate that on many different groups, too. And when we think about mental health services, how are they receiving care, how are they accessing care, how do they utilize care? And generally, people of color and Black people overall are more likely to delay mental health care and drop out of mental health care services for many reasons that probably most of us can identify, but that we'll expand upon as we continue to discuss this topic. Then when we start thinking a bit more about kids in particular, Dr. Kadel-Kassih and I are both child and adolescent psychiatrists, and so when we think about kids that are presenting with us, many times kids are exhibiting a lot of trauma-related symptoms. And trauma-related symptoms really cross many diagnostic categories, if you will, if we just think about the symptoms in and of themselves. And then that causes, unfortunately, for a lot of maybe under-identified, under-diagnosed, or under-treated for many different disorders. And then being misdiagnosed with oppositional defiant disorder, excuse me, or conduct disorder, when their symptoms may be really rooted in many other things like anxiety, depression, post-traumatic stress disorder, they're less likely to receive outpatient treatment than their White counterparts. And we know a few years ago, I think at the height of the pandemic, the Congressional Black Caucus came out with their report on really thinking about this, as they put it, we ring the alarm, a call to action on the suicide rates that we're seeing in Black kids in particular, very young kids that we should all be quite astonished by, and really all feel this urgency or emergency, and why Black kids are twice as likely as their White counterparts. And depending on the age groups, are really just disproportionately affected by suicide rates. And so we should all be looking and advocating and thinking about how do we do this better? It's a real problem when we have six, seven, and eight-year-olds thinking about killing themselves or killing themselves at such a young age. When Black children do get some psychiatric care, it's usually in the juvenile justice system. It's usually in a residential treatment. It's unfortunately with increased utilization of medication or physical restraints. It's not met with the compassion that sometimes other groups of kids are. And this is in every sector, right? If we also think about the way the schools sometimes think about Black children, we know there's great data to support how from very young age, preschool, kindergarten, teachers are looking at Black little boys and Black girls very differently than they look at other kids in the classroom. And this bias, this racism, this unconscious bias, whatever we would like to call it, it's happening, and really need to think about what are ways to prevent that, to educate all of us, ourselves, but also as child's people to think about from a prevention and promotion standpoint too, and what can we do in schools and the community to educate people early on about this? And then last but not least, there's also delays in autism spectrum disorder screening and diagnosis, an average of a three-year delay. And we know that this particular diagnosis, like many diagnoses, it's critical to intervene early. The prognosis is better when an autism diagnosis is made very early to start getting all this sort of therapeutic services in place for those kids. But next slide is really talking about mental health services, youth among youth, and then thinking about Black and Hispanic youth in particular, that oftentimes when they do engage in treatment, there's sometimes there's fewer visits that they have as compared to their white counterparts, lower medical expenditures, less likely to be seen by a mental health specialist, less likely to be prescribed psychotropic medicines, less likely to receive high-quality evidence-based care. Some of these things I have alluded to in the other slides, but really thinking about there's a confluence of factors of why we're seeing this data reported and why, whether they're in areas that don't have child, child and adolescent psychiatrists, for example, don't have child psychologists, for example, we know those numbers are low nationally. But also even with certain diagnoses, even when the evidence base is there to prescribe, they're less likely to be even offered it, even if maybe the parent or guardian is not ready for medication. So there's a lot of work to do in thinking about, you know, how we can support families, but also in navigating this process, but also educating providers across mental health professions around this particular issue as well. You know, the findings from the Surgeon General's report from earlier really correlate with also a 2002 study that revealed that most children who need a mental health evaluation do not receive services. So overall, even though Black kids, other kids of color are overrepresented among the most vulnerable with high rates of mental health issues, more barriers to care, all of this together really supports the finding that, you know, they suffer essentially disproportionately. There's a high disability burden. And we also know when we think about kids not getting the care they need, and that on average, there's a 10 year delay between knowing when a kid needs help and 10 years before they actually get treatment, there are consequences beyond just the child and family. There are consequences in all aspects of our communities and what happens into adulthood and being able to really reach their full potential. Nicole, I'll pass it back to you. Yes. Thank you, Michelle. As we continue to build on the information that Michelle just shared, and just continue to think about those causes. I know Dr. Durham, Michelle shared a lot of information and highlighted throughout that the causes of these mental health disparities. And we're just going to continue to build on that. So if we step back for a moment and just think about in general, if we can kind of put them into a couple of buckets, as far as why do healthcare disparities arise? This is three reasons that Dr. Kamara Jones, who is a physician and the former past president of the American Public Health Association, highlighted these key reasons as to why disparities arise. She noted differences in life opportunities, exposures and stressors, differences in the quality of care received, and differences in access to care. In 2001, Dr. Satcher also released a report, a mental health report for the Surgeon General that highlighted ways to address, and within that, the causes of these mental health disparities and highlighted increased risk for mental health disorders, less access to and availability of mental health services, and less likely to receive needed mental health services. Individuals in treatment often receive poor quality of mental health care. And also noted the underrepresentation of minority or BIPOC mental health professionals and the underrepresentation of minority or BIPOC individuals or minoritized individuals in mental health research. So if we look at these two together, and if we could combine them in some ways and put them into kind of those areas, we can see that the differences in life opportunities and exposures and stressors really do relate to those increased risk for mental health or associated or relate to the increased risk for mental health disorders, differences in access to health care really are in relation to those mental health disparities that we saw where we had the less access to and availability of mental health services and the less likely to receive needed mental health services. And then that third category of the differences in quality of care received and how the impact of the quality of mental health care, the underrepresentation of mental health professionals, diverse mental health professionals, and mental health individuals in mental health care research from minoritized backgrounds. So let's first highlight as we look at why disparities arise, the differences in life opportunities, exposures, and stressors. So the reasons for increased risk for mental health disorders have been noted in a report on mental health, race, culture, or sorry, culture, race, and ethnicity. And this highlighted these three reasons that mental health disorders arise. Poverty, so people on the lowest socioeconomic status are two to three more times likely to have a mental disorder. Racism and discrimination, which adversely impacts one's health and mental health. And then mistrust of mental health services impacts treatment utilization. So racism, it's important too that we define as we're looking at health and health care disparities, health equity, defining racism. So Dr. Jones, Kamara Jones, I noted earlier, also has defined in ways racism as an organized system of oppression that disadvantages certain racial groups designated to be inferior compared to a designated superior group or to those who are designated as superior. And racism is really a system of structuring opportunities and assigning value based on the social interpretation of how one looks. This unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and stabs the strength of the whole society through the waste of human resources. So really looking at how the impact of racism doesn't only impact us on an individual level or interpersonal levels as we interact with individuals, but also as a system, as a whole society, how we all are impacted by racism. Many of you all, as psychiatrists, we often think about the biopsychosocial aspect of one's health and how we think about one's diagnosis or whatever it might be, just thinking through biopsychosocial and the importance of the social aspect to one's health. And also, I love this figure as it thinks about what are the aspects of the things that go into one's health as we think about the social determinants of health and how health care, the care that we provide in our health care system settings, only impact about 20% of one's health. And these other socioeconomic factors, physical environment, and one's health behaviors impact the majority of what goes into one's health. And even based on one's zip code or where they live can also impact about 50% of what goes into one's health. This figure, which is also came from the World Health Organization, looks at how one's social, economic, and political, so looking more at that structural aspects that impact one's health, not just the social aspects, but these structural or institutional aspects that might also, that also contribute to one's health. So these social, economic, and political positions which individuals might be in, or contexts, and the social, economic positions which one might be in, which includes racism, all then contribute together with these social factors to contribute to one's health and well-being. And Dr. David Williams, who is a professor at Harvard, notes this and says, "'Not all discrimination is conscious, "'intentional, or personal. "'It is often built into institutional policies, "'practices, such as mortgage lending, zoning, "'or school funding practices, "'which in turn impacts where you live, "'the quality of education you receive, "'or access to public transportation or goods, "'which all impact one's health, "'or can be linked to one's health.'" So how does this, you know, when we think about it on an institutional level, racial discrimination or racism, it can cause differences in that institutional level in material conditions, such as poverty, education, employment, and access to care, as well as differences in power, such as access to information, control of media, political and social, and economic factors. And as we think about racism as a social determinant of health and how that plays out in some ways, racism can impact one's health condition, such as we see in those disparities, or disparities in differences in populations as it relates to birth rate, infert mortality, asthma, infectious disease, cancer, depression, how these disparities in these areas are related to racism. We can see also an access to quality, access to quality needs, such as one living in a food desert where they might not have access to food and fresh foods and things of that sort, and how that relates to, as we think about zoning and policies around where one is able to live and zoning practices, redlining, and things of that in the past can impact where one lives and then impact their ability to have fresh fruits and vegetables and so forth. Toxics environment, again, as we think about one's zip code and how that leads to the impact to one's health, depending on where you live can impact your exposure to lead and also impact trauma exposure, as well as greater risk for injury and suicide. As it relates to children, racial discrimination generates trauma in some ways fostering isolation, alienation, marginalization, psychological harm and perceptions of danger. It also can limit a parent or caregiver and communities to really protect their children and promote resiliency. It also creates a level of psychological distress that in combination with other factors may exceed a child's ability to cope and to respond effectively. So we highlighted previously how one's life exposure stressors can impact and increase one's risk for mental health disorders, especially as it relates to one's socioeconomic status, racism, and other external factors that might be impacting ones to be at a higher risk of mental health disorders. So next we're gonna transition to differences in access to health care, and as it relates to less access and less likely to receive needed mental health services. So, and Dr. Durham or Michelle highlighted a lot of this too previously, as we looked at differences or disparities in the access to care that could be insurance coverage, even though somebody, as many of you know, even though somebody might be insured, they might be underinsured, especially as it relates to mental health coverage. So even if someone has insurance, their coverage to receive needed mental health services might be challenging. And then other factors that might play into that include mistrust, fear, stigma, and so forth. So if we look at just general barriers for anyone who might be looking to seek mental health care, barriers include elevated cost of treatment, fragmentation of services, lack or the availability of services, and then social stigma towards mental health. We see that with the general population. And then as we look at black and indigenous people of color, minoritized populations, that mistrust and fear is also a part of the barriers that contribute to them seeking care, cultural ideas about illness and health and mental health, differences in health seeking behaviors and language and communication barriers, racism, as we mentioned before, and then varying rates of being insured, uninsured, underinsured, and all of those factors. And then finally, looking at differences in quality of care received. So that can include receiving poor quality of mental health care. So as again, Dr. Durham mentioned before, Michelle mentioned before, the quality of care that one receives can impact how one engages in treatment, follows up with treatment, their access to treatment, but then once they get in, the quality of care that they're receiving, as we can see, potentially misdiagnoses, over-diagnoses in some ways and things like that. And as we see here too, and this is something that Dr. Durham mentioned as well, as we look at black and Asian adults here in this graph here or this figure here, are more likely than white adults to report difficulty finding mental health providers who really understand their experiences. So not only finding a mental health care provider, but one that they feel can see them in a timely manner, one who can understand and relate to their background and their experiences, one that they can afford, and one that will take their health insurance. Other factors impacting disparities as relates to quality and access and so forth are the cultural and linguistic barriers as well as biases. So some of you all might be familiar with the report on equal treatment that came out in 2003. This was a report that came out through the Institute of Medicine that really highlighted disparities in healthcare and noted that minoritized Americans were less likely than white Americans to receive effective services across a variety of settings. So this was looking at pain treatment, disparities there, acute MI treatment, treatment for diabetes and so forth. And through this, they also found, it highlighted that these differences in quality of care were thought to be related to provider implicit bias. So many of you all might be familiar with implicit bias. Again, kind of making sure we're all kind of on the same thoughts as far as that definitions, but implicit bias are attitudes, stereotypes, and mental shortcuts that affect our understanding, actions, decisions, and in an unconscious manner. In some ways, right, like our brain is bombarded with a lot of information every day. And as we know, our brain makes mental shortcuts as a way of helping us to take in all this information that we receive. However, when we're under pressure, when we're tired, we're distracted and anxious, is when we can, these shortcuts that we can have, we can default to damaging biases and stereotypes that can really impact how we interact with others. So, and with unconscious bias, as you all likely know, oftentimes it is maybe not something that we, in our conscious mind, might think that we think that way or might not align with our values, though subconsciously we might harbor some of these thoughts. And again, when we're tired, under pressure, distracted, or anxious, it's when we might default to these unconscious biases that can be really damaging and impact how we care for patients and outcomes of how we treat patients and damaging outcomes. So, and then finally, in thinking about the, that ways of the other aspects of quality of care, how the under-representation of Black mental health professionals and Black individuals in mental health research really impacts the quality of care that we're able to provide Black patients. Research has shown that, not only that having more mental health care professionals impacts, creates improved outcomes for Black populations or minoritized populations by having increased diversity in healthcare providers, especially mental healthcare providers in our realm as well. And also the importance of having Black individuals involved in mental healthcare research that we do in pharmacological treatments, as well as our therapeutic treatments and in the wide gamut of research that we do, the impact of not having representation impacts in the quality of care that we're able to provide in Black individuals. So next we will, Dr. Durham will talk about eliminating mental healthcare disparities. So we've provided a background and our first part of this talk on where we are, some of the data and what is happening for many of the folks we see at an individual level, but also at a national level. I'm gonna walk through a little bit about thinking about how do we recognize and enhance and think about those protective factors. I think we often think about the things that aren't working well, and maybe even in our own clinical appointments and one-on-one encounters, how do we as child psychiatrists, and I know we do this hopefully really well of thinking about what are the strengths of the family? What are the strengths of the children? What are the things that they do really well and how can we highlight that? I just wanna make sure we're moving to the next slide. The one thing is thinking about how do we help with positive home and school environments? And so how do we work with families? How do we work with school systems in order for them to understand the kid that we're seeing, understand what is working, what isn't working and how can we advocate for them? There's many of IEP, so Individualized Education Plan meetings that I have attended, really being an advocate for the child and the parent in the room, especially when school may be part of the traumatic experience for the child. How can we be there to really foster more positivity in the school? The same is true in the home. Some states do have the availability to provide in-home services and therapeutic mentorship and other types of services, but for both the family and the child, even helping the parent, because this is all very hard work when your kid isn't doing well. But there are things that are working well and we always need to remember that when working with families and then also giving them the tools to be able to advocate when things aren't going well. The other thing that can be obviously very protective for the kid is stable parent mental health. A critical topic that we could probably have a whole talk about in and of itself. This is especially when we start thinking about early childhood, but across all ages, but in those pivotal points in development of thinking about how is the parent doing? The parent, maybe after giving birth, how are they doing? We know that that has effects on a baby and a toddler when the parent isn't doing well, all the way through adolescence into adulthood. So how do we help the parent become stable so they can better support their kid? And that can be so protective to the family unit when the parents are doing well. Social support and community involvement. If we think about of our treatment plans, they always really wanna think about what else is the family doing as a family unit, but also how can we make sure there's supports in the community? Social support is so important for everyone in their mental health and mental wellbeing. And so we can think of it as a toolbox, if you will, but how do we think about this kid in front of us, but all the systems that they're in from a system of care approach, and how do we make sure the parents are okay, their siblings are okay, the community, their school environment, do they have things to do outside of the home that can entertain them, that can help them feel good and be very protective for their own mental wellbeing? And then, last but not least at all is thinking really about that identity and whether it's racial and ethnic identity, but also who they love, who they are attracted to when you start thinking about adolescence, how do you help them navigate that process and support it and enhance and have protective mechanisms in place when they are struggling a bit with thinking about who they are in the world and how the world is looking at them. Unfortunately, these days it's become so polarizing and so difficult for kids to navigate in a world that also is so accessible from a social media standpoint. And so how do we recognize and enhance that all of these things need to be seen in a realm of support, highlighting the strengths from each identity and each sort of system that they're in so that we can get them all the tools they need for better mental health. Next slide. There was in the National Action Agenda for Children's Mental Health really provided a blueprint for change. And the report outlined goals and strategies to improve services for kids, for children and adolescents with mental health problems as well as their families. And you can see that it's pretty robust, promote public awareness of children's mental health issues. We talk about this time and time again, there is a continuum of care, I feel like the national agenda probably because of the pandemic has really been a crisis approach. But how do we really think about that whole continuum of care from a prevention, promotion, education standpoint so that we don't get people being in crisis when they really need services urgently because things are really not going well. How do we reduce stigma if we're thinking about a promotion and education sort of approach that's associated with mental illness? I think there's the population of children, adolescents, transitional age youth are doing much better than probably their parents and grandparents in thinking about stigma. They're asking for help earlier, they're seeking out help, they're questioning how they're feeling. And so how do we make a continuous process in reducing this stigma? We need to continue to develop, disseminate and implement scientifically proven prevention and treatment. I mentioned the Congressional Black Caucus report earlier, that was one of their key findings as well. If we're gonna figure out how to do this work better for black people and other people of color, we need to invest in research that is understanding how this may look differently, how symptom presentation likely looks very different and the diagnosis then could be more accurately described. That racism discrimination can be a trauma in of itself. How do we think about interventions for black people and other people of color? And so there is a lot more work to do in developing and disseminating and implementing essentially evidence-based and culturally informed interventions. Improve the assessment and recognition of mental health needs in general. I'm gonna talk a little bit about the primary care setting, but I think that's one area to improve that sort of assessment and recognition. Eliminate, of course, racial and ethnic and socioeconomic disparities across mental health care services. And that's what I think all of us are trying to do day in and day out. We need our colleagues, whether they are of the same culture, ethnicity, race of the patient in front of them to be there, be curious, have cultural humility when engaging folks that are not from the same walk of life that they are from. Really improve the infrastructure for children's mental health services. I'm sure many of us have been in settings where everything from the waiting room to the clinical space looks very adultified in many ways, and it's not a place for kids. I'm gonna highlight a couple programs, drop-in centers. I know Massachusetts is one of the states thinking a lot of for adolescents and transitional age folks for drop-in centers. But there's Alcove out of California, you know, at Stanford that have done a lot of work in this too, of like, it's a welcoming space for people, for youth of color, for youth who identify as LGBTQIA. There's a different vibe to it, if you will. And so we really need to think about, are we making them welcoming spaces for different groups of people that have different needs and different cultural expectations? Increased access to and coordination of quality mental health care services. We presented, you know, in this talk, you know, a lot around the quality of mental health care, you know, in research, we see the data that it's always, it isn't great. And it specifically isn't great for people who are black and other people of color. They're not getting the services they need, even when they do show up for treatment, they're not getting all the information they need. They are misdiagnosed or over-diagnosed or just completely the wrong diagnosis, right? So there's a lot more work to do in that space. To train frontline providers to recognize and manage mental health issues. Educate mental health care providers about scientifically proven prevention and treatment services. So many a times, right, our academic centers are really the pinnacle of where research and evidence-based is happening, right? And really intervention. But how do we disseminate that to our federally qualified health centers, to our other community partners? How do we engage them in some of that work too? That it doesn't necessarily need to come from the ivory tower to do the work, but how do we really co-investigate with community partners who are on the front lines and help, we need to do that bi-directional learning in order to improve care. And then monitor the access to a coordination of quality mental health care services. Some of this is thinking a lot more about measurement-based care. So we use, we want that qualitative, we want to be able to engage and be curious and ask people, but the quantitative data too, how are we monitoring progress across our different systems? Next slide. Is really thinking about how do we provide culturally responsive services across the board? We really know that we need to improve the representation of people who are Black, other people of color, ethnically, linguistically. We have a healthcare system and then within the field of psychiatry and other mental health professionals, that there's just not enough representation. And I think that even goes back to how do we, as all of us as providers currently, and seeing the strain and seeing how people want people that either speak their language or look like them or have some affiliation and cultural understanding of who they are, how do we though get back and think about that pipeline issue? How do we encourage back to high school and college to come into mental health, come into the space, into the workforce? On the provider side of things too, addressing our own biases for people that don't come from the same walk of life as us, that we really need to be present and think about cultural humility and our own awareness of, yes, we're different. And I can ask questions and figure out who this person is in front of me and not apply generalizations or stereotypes, just because they may look like the first person I saw, the first patient I saw today or other patients I've seen. Each individual has a different story. And so how do we listen to that story with curiosity in order to make the right and the correct appropriate, the appropriate diagnoses and treatment recommendations? Encourage the development and integration of alternative approaches to mental health care. That was a little bit I was alluding, I mentioned earlier, there's drop-in centers where people can sort of come in, young people can go and not only, maybe there's a hint of something going on, but they have access to mental health resources, but also other things they may need for their quality of life. How to build a resume, how to get a job. We know that sometimes when people are affected by mental health symptoms and issues, it's really hard to do the other things and the planning and the execution. And how do we do team-based care more? A lot of models of care, when we think about research interventions that are being done, they're really thinking about community health workers as a part of the team, the therapist as a part of the team, the psychiatrist, case management services, but really how do we help people? And that might be a very different approach than what we're used to or have been doing across the years that we know from research and data to support now, isn't helping everybody the same way. Diverting youth mental health problems from the juvenile system is imperative, is important. How do we catch kids early? How do we work with schools in a different way? So they don't have a police response, but instead they have a mental health response to a kid that isn't doing well or behaviorally dysregulated in some way in the school system. Depending on the state you're in, uninsured kids, it's a diverse population that we really need to think about how do we get them access to care because they become adults in our system anyway. And so why don't start early thinking about it from a prevention and promotion standpoint. And then what I have said is really increasing research across the board and for funders at the national level to really think about how this work is really important. They don't always fund Black researchers who are doing work around particularly a Black population or a Latino population or other people of color. And so we need to advocate for that, that we do need more research and data to support other interventions besides what has been the norm, if you will, but against a white cultural norm. The next slide is really about practitioners. How do we kind of do this work to eliminate disparities? And there was a practice parameter that's come out from the American Academy of Child and Adolescent Psychiatry in 2013. So it's been a decade, but it really outlines the clinical applications that we as mental health clinicians need to think about when we are assessing and treating folks who may not be similar to us in any way. Identify and address those barriers that may prevent diverse children and their families from obtaining mental health services. Make sure that we're doing it in a language that the family is proficient in. And there are challenges with that. We've all been in clinics where sometimes there's not an in-person interpreter, there's only phone interpretation. And so we all have to navigate this in that space, but how important is it to utilize a professional interpreter and not another kid in the family or someone else to really do that interpretation as it imposes a lot of difficulties when you do that as well. Be cognizant of the cultural biases that might interfere with clinical judgment. So we always have to start with ourselves. Always be challenging. Why am I thinking this way about this? And that's why I think our case discussions with diverse teams is important to make sure that our blind spots, our biases are being met and that are met with maybe a counter response from your team members when you're thinking a certain way. We need to assess though, especially for our immigrant populations about any trauma and community trauma for the child, the family. So our immigrant populations, but also our populations in the U.S. that sometimes people are living obviously in communities that have a lot of violence. But also I think even assessing this trauma for many people these days when we're witnessing things on TV in our neighborhoods, lots of storms and climate change. There's so many instances of which that we need to be making sure we're doing a complete assessment around what has been scary for that child, but also for the family. Evaluate and address treatments, the acculturation level and presence of acculturation stress as well that may have impacted the family. Making efforts to include family members and other members it's so important when you are in a room with folks from other cultural backgrounds. You see this a lot and not only Latino families, Asian families, Black families, that the decision makers may not be in the room with you for that particular visit. And it's important in asking who are the decision makers in your family? We're recommending these sorts of treatment, but who are you going to go home if they're not in the room with us today? Who else is going to help make the decision about how we move forward in treatment? Extremely important. Or you may totally miss the mark and think you've recommended all sorts of things and they are like, yeah, in their head they're like, I have to go talk to such and such before we actually make a final decision. So address it, be in the room and ask and see if they can be invited to meet next time with you all too as you think about treatment. Treat culturally diverse children and their families in familiar settings within their communities whenever possible. I mean, I think there's a big call for this in the last, you know, few years of like, how do we get out into the community more? Be in places where people feel comfortable getting treatment and making our spaces more friendly and inviting for treatment as well. The next slide really talks about disparities in pediatric mental health and behavioral health conditions. This is just really a reference from the American Academy of Pediatrics. Just more data and information really around what ACAP said too, but thinking about, you know, what examples that they, you know, giving a nice graphic, I should say, to the actions clinicians can take to improve and increase the needed resources and opportunities for minoritized youth. How do we, you know, it's really got, I'm really happy to see pediatrics, you know, doing a lot of this work too, but how do you just learn about and advocate for equity-focused policies where we each have a role to play in advocacy, especially when we're in clinical environments, seeing people day in and day out and see the stressors and the difficulties from both a provider side, but also from a family side of getting care. Join academic community partnerships, which I mentioned earlier, so important, but I would also emphasize the importance of, you know, co-collaborators and not one, the academic center telling the community what to do, but true co-collaboration and co-learning can go so far when we think about academic community partnerships. We can provide technical assistance in schools on trauma-informed care, how to reduce bias and prejudice among teachers and administrators, coordinate care with any type of coordinated care that we can offer in any of our clinical environments for families and minoritized kids in general can help, but this is all sorts of things, right? So from policies, from institutions and clinicians, from the neighborhood, from the family and the individual level, how we really all need to work together to make change more broadly in what's happening for youth of color. Moving on not to think, you know, this is really just to name, you know, the culture response of inclusive clinical practice in general really has a lot to do with how do we think about using the right, using appropriate language with people, right? Using, acknowledging and addressing our own biases. How do we have lifelong learning and humility and all that we don't know about every culture and experience that someone is going to have that's coming into our office and really taking it seriously that we have to come with it from a place of curiosity. So that's, you know, at the individual level being, you know, culturally responsive, but this inclusive clinical practice I've also alluded to and, you know, and thinking a lot about what our offices look like, how inviting are things, how do we go out into the community more, how do we bring our, what we know and our knowledge base to other forums besides just an outpatient clinical setting? And then when we think about achieving mental health equity, there's actions and inactions that have consequences, right? For a racial equity, we have to acknowledge that even within psychiatry, that racism exists in the field of medicine. And there has to be an acknowledgement of this in order to move forward. You have to acknowledge the past and where we are and where we're going. Recognize that racism is a determinant of mental health. It influences clinical practice and has a profound impact on patients. This is really thinking about that structural racism piece that it is embedded in our policies and it's embedded in all the work and how we've gotten here. Some of us may be unaware of it until we really start doing the work and understanding that the structures that are in place and have been in place for centuries, there's a lot to be undone. It's an organized system, right? That we know empowers white patients and mental health providers and disempowers patients and providers of color. And so we really need to call that out at all opportunities to understand our history of how we got here, but also to help us move forward. The other thing I want to talk about is just this notion of implicit bias. It's really deeply entrenched in everybody. And so whether we want to call out, sometimes things are blatantly racist. Sometimes it feels very unconscious. Sometimes it's unclear what is happening for maybe your colleague or you or someone you're seeing in your circle or within patient care. But we need to remember that to successfully mitigate this, we need to concentrate, pay attention, take time. We have to acknowledge that we all harbor some bias or stereotype or racist sort of thoughts. And then we have to be motivated to change. You have to pay attention to your own triggers and know your own responses and what's activated in you when maybe someone says or does something. And practice taking time to really reflect on your own automatic associations when you see a person or when you see something that may be different from you and that you go strictly maybe to that stereotype or racist belief immediately. It's okay, but check it, understand it, and do better for that next encounter. Listen and learn. Remembering to listen, respect, ask, appreciate, reflect, and grow. I'm not going to focus too much on this slide for the sake of time, but that we all have a lot to do in this space. There's so much work that continues to need to be done in general. But reflective listening is such an important thing that we all know about in our training and that we need to use it in everyday practice with our colleagues, with other people. And some of this is thinking a little bit about that upstander, bystander. We need to call out when things are not right so that we all have the opportunity to reflect and grow. Writing, publishing, sharing patient vignettes, participating in advocacy. APA has a lobby and advocacy day. One is coming up at the end of this particular month that we're doing this presentation. It's so important. Be active. You are seeing patients and families day in and day out. You're working with your colleagues who are stressed and frustrated by the system as well. So we have a lot of work to do, and it takes all of us to be at the table to do that. And the last couple of slides, I just want to highlight that in schools, in primary care settings, there are a lot of places where some of this work to eliminate disparity, to increase access to care is happening. And it's really important. School models based in Texas. There are school models in many other states. But I know the places that I have lived and trained in Massachusetts, thinking about access lines and thinking about integrated care models of bringing mental health clinicians to the pediatric primary care setting are super important, and there's evidence to improve access and equity in those spaces. Last but not least, just in concluding, we appreciate your attention today. There's an increasing number of children that are suffering secondary to their emotional, behavioral, and developmental needs. We have a lot of work to do. It's imperative that we assess the causes to the disparities, the difficulties that they're having in access and health equity. We need to improve and understand our own biases, advocate for more representation, not only in our field, but also thinking about how do we do this work better from a research perspective too. And then, you know, it takes all of us, every single one of us, to really eliminate these disparities. Thinking about how do we work with schools and communities, families, and colleagues to keep moving and passing the baton, if you will, to make this work better, but also to improve quality of care for all families and kids. Thank you so much for your attention today. Thank you all. So, now we will transition to one question for today. One of the things that I was thinking as we were going through that last bit in recommendations that you were highlighting, Dr. Durham, I was thinking about also the cultural formulation interview and how that could also be a resource for people to be more culturally informed and to get just the relationships with their patients. So, just wanted to share if you had any thoughts about that and maybe we could just highlight that for folks as well, the cultural formulation interview as a potential resource for people. Yeah, it's at the, you know, the DSM has that at the end of sort of as a guide. So, for clinicians that need another resource of thinking about how do I make sure I'm covering all aspects of this family, from religion to their background, to the languages that they speak. If you feel like you need, you know, to make sure you're honing in on all the right questions and topics to ask, it's a nice guide for clinicians to use and can be really helpful if you are starting, if this feels new and feels maybe like you're not asking the right things. I think it's a wonderful guide that is easily accessible to folks to really think about how do I assess this family, but also how do I formulate this case and make sure I'm not missing anything. Yeah, I agree. I think it's a really great, for any clinician, I love how, you know, not just psychiatrists, right, like even though it's in our DSM, but really for any clinician who is wanting to connect better with their patient, the family, and to really ensure that they are understanding the needs and in all aspects, especially those social aspects that really might impact, you know, those biopsychosocial, all of those aspects to ones that goes into one's health and that impact one's health. And so, I do help, think that those questions help to providers to be able to connect and ask those questions a little bit. So, thank you all for today, for joining us today, and thank you again.

Mental Health

Black Children

Adolescents

Disparities

Structural Racism

COVID-19

Suicide Rates

Cultural Responsiveness

Equitable Access

Advocacy