Hi, everyone. Welcome. I'm so happy that you all were able to join us today for this really important webinar. I'm so excited with my colleague, Michelle Durham, to be giving this presentation today. So the title of our talk is Who Gets Left Out? Racial Inequities in Mental Health Diagnosis and Treatment. And before we begin, just a few housekeeping slides. I just want to let everyone know that the ability for the APA to provide this webinar today is through funding that was provided through SAMHSA. And also, please note that you're able to submit credit for continuing education, given that this is a program accredited by the Accreditation Council for Continuing Medical Education. So make sure that you are able to claim your credits for attending this webinar today. Additionally, I just want to let you know about some of the features with this platform that we're using today for this webinar. You have access to the PowerPoint slides that we'll be going through today in the form of a PDF handout. So just know that if you go to your features on the right side of your screen in this platform here, if you're using the desktop version of this platform, if you go all the way to the bottom, you'll see a tab for handouts. And you're able to double click on the PDF file and download it onto your computer. If you're using the Instant Join Viewer, you can see here in the slide the icon that you can click in order to access the handouts. And also at the end of this session, we'll have a Q&A session. I'm really looking forward to having a robust discussion with you all today in conjunction with Dr. Durham. And just know that, again, on this desktop platform for this webinar, if you just go down and look for the tab that says questions in the area of the attendee control panel, you'll be able to submit your questions, questions that may come up as we move forward through this webinar. I look forward to going through those questions, bringing them up for discussion. So make sure to insert your questions. And again, we have some instructions over here on the right if you're using the Instant Join webinar feature. And both myself and Dr. Durham, we do not have any financial disclosures to report. So I'll have Dr. Durham introduce herself. Hi, everyone. I'm equally as excited to be presenting today with Dr. Crawford, my colleague here at Boston University School of Medicine. I'm a clinical associate professor of psychiatry and pediatrics, and I'm also the vice chair of education in the Department of Psychiatry here at Boston Medical Center. At Boston Medical Center, I practice clinically as a child psychiatrist in our outpatient clinic, serving kids and families in our safety net hospital here, and as an adult psychiatrist in our psychiatric emergency room here at BMC. Dr. Crawford, I'll let you now introduce yourself. Excellent. So I'm Christine Crawford. I'm also an adult and child psychiatrist. I also work at a Boston Medical Center, and I see kids in our outpatient child psychiatry clinic there. I'm also an assistant professor of psychiatry within the Boston University School of Medicine, and really looking forward to having this conversation with you all today. First, I just want to outline our learning objectives, and we really hope to be able to touch upon all of these different points so that when you walk away from this talk, my hope is that you have a firm understanding of these three key points. So the first is to understand the historical context of structural racism and how that's impacted mental health diagnosis and treatment. We're also going to talk about different examples of bias and racism in common mental health diagnoses, and we'll discuss strategies to reduce bias and racism in mental health diagnosis and treatment. So I really hope that we'll be able to hit on all of these points today and to make this webinar quite memorable. Before I start off with any talk, I really think it's important for us to provide some definitions so that we're all on the same page about what it is that we're talking about, and the discussion today talking about the inequities within mental health diagnosis and treatment, it's important for us to appreciate the role that racism plays in all of this. So let's lay out the foundation by talking about what racism is. Now, it's an organized system of oppression that disadvantages certain racial groups designated to be inferior compared to those designated as superior, and the public health expert Kamara Jones has a beautiful definition that I really think reinforces the impact, the tremendous impact that racism has within our culture and society, and she defines it as a system. Again, notice that in both definitions we're talking about a system, and it structures certain opportunities, and it assigns value based on the social interpretation of how one looks, because when we think about race, it is a social construct, but we're looking at ways in which there are certain opportunities that are being given to certain people just because of the way that they look, and when we do this and when we continue to do this, it unfairly disadvantages some individuals and communities. It also advantages other individuals and communities, but what it does as a whole, because we're disadvantaging a whole group of people just because of the way they look, we're sapping the strength of the whole society, and we're essentially wasting vital human resources because we are not providing the opportunities for everyone, and I really want you all to think about that. When we're thinking about how we are providing clinical care, are we continuing to reinforce the system, making it such that certain people are advantaged, in a position of advantage and privilege, and others aren't? We need to hold this concept in mind. The other definition that is so important for us to cover today is talking about health disparity and comparing that to what health inequity is. I notice that there seems to be a lot of use of both terms, but they're used interchangeably, and it's really important for us to all be clear about what it really means, so a health disparity is thinking about a difference, simply looking at a difference with regards to health outcome, and the reason why we talk about health disparities is because we're looking at the difference in health outcomes based on various social determinants of health and how they impact different population groups, and when we see these disparities, we see differences in what the actual environments look like in which our patients live in. We are looking at disparities with regards to access and utilization of quality care. Key word there is quality. We're also looking at differences with regards to health status and outcomes, but when we're talking about health equity, when we're talking about health inequity, we're really referring to a state of unfairness, and we're talking about differences in health, and I love this definition right here from Margaret Whitehead from the WHO in which she talks about these differences in health but talks about how they are absolutely unnecessary and they're avoidable, and they're considered to be unjust and unfair, again, because they're unnecessary and they're avoidable. We need to continue to educate ourselves so that we don't continue to fall down some of these pitfalls in which we are seeing these health outcomes that are totally unnecessary and avoidable, and these inequities, this state of unfairness can lead to a variety of disparities, and the disparities that it can lead to result in the choice of lifestyles that a lot of people have access to and the type of lifestyle that folks are able to live. It's severely restricted because of a number of structural reasons and issues and barriers. Exposure to unhealthy and stressful living and working conditions, that's simply unfair and something that can be avoided but leads to certain health outcomes and disparities within those outcomes. Inadequate access to essential mental health services and thinking about just social mobility, and that's one of the important parts within our society is having the ability to advance yourself, to advance your position for not only you but for your family and future generations, but thinking about how health and health outcomes can actually restrict one's ability to move up the social ladder here and thinking about that immobility. Going back to Kamara Jones, and she has that beautiful kind of allegory that she used to discuss structural racism, institutional racism, and she talks about a garden and thinking about our society as the soil and the opportunities that our society provides for individuals. And when there's a certain system that's in place that isn't uplifting, it's not enriching, it's not nourishing, we're going to see some differences in the outcomes. So I have this image of the flowers over on the left, just to exemplify that point of you can see that there are different flowers, that one seems to grow better than the other, and it makes you think, well, this red flower looks nice and tall and healthy, there must be something inherently bad about the pink flower. But we just are looking at the surface, right? And it's up to us as clinicians, as people in this society, to understand what is the type of soil that these seeds have access to so that it can flourish. And the same thing we need to keep in mind when we're thinking about our patients too, reflecting on the systems that have made it such that certain growth and progress has been stifled within certain communities, and thinking about our role as clinicians and how our biases and limited access to good quality care can also make it such that the opportunities for growth, for healthy outcomes, just aren't there because we, as clinicians, are getting in the way of that. When we're reflecting on psychiatry and the history of psychiatry, and thinking about some of the barriers that have made it difficult to see equitable health outcomes with regards to mental health, we got to think about the way that psychiatry viewed Black mental health from its beginning, when it established itself as a specialty. And if we don't have an understanding of how the system was created with regards to psychiatry, we tend to overlook how that history has impacted some of the outcomes that we're seeing today. Briefly, I just want to talk about how in 1851, there was a physician by the name of Samuel Cartwright, who talked about mental health conditions that were impacting Black people, that were impacting slaves. And he identified this mental health condition known as drapedomania, which was considered to be a disorder in which slaves would run away from their slave owners, enslaved people running away from their slave owners and seeking freedom. And so his thought process was the treatment for this disorder was to treat the enslaved individuals like children, to enforce them into submissiveness. And that was the form of treatment. And there was another disorder that was considered to be consistent with the idea that slaves were, enslaved people were lazy. They thought that this condition was due to a skin insensitivity. And so the treatment of choice was actually to stimulate the skin by slapping it with a leather strap and working it in the sun. And then kind of as we're moving forward through history, a number of psychiatrists and psychologists in the early years viewed that Black people were unable to experience more sophisticated disorders that required some abstract thought like depression. And so it's important to know that that's how psychiatry emerged, thinking about Black mental health in this sort of way. And we need to remember this history because it influences the way that we practice and influences the training that a number of clinicians have received over the years. Now, moving forward to areas within modern day psychiatry in which we see some of the manifestations of structural racism is looking at research. We know historically that research involving Black people, there hasn't been that much over the years. And a lot of the studies that we base our practice off of involve predominantly white individuals in these studies. And so one thing to think about when we are looking at the NIMH and their research domain criteria, RDoC, the participants are primarily white. And this is a study in which we are hoping to elicit incredibly helpful information about some of the physiological presentations, some of the physiological symptom clusters that we see. But the information that we're gathering from these studies only reflects that primarily of a rather privileged group with certain socioeconomic advantages. So we need to keep that in mind because it doesn't paint the whole picture. It's only reflecting the physiological responses of those who are in a position of privilege and in an advantaged position. And we have a very limited understanding of those from racially marginalized communities. Other areas that we see some concerning inconsistencies, especially within clinical care, and it makes you wonder about why it is we're seeing some of these differences. But just looking at the use of physical restraint and emergency room settings, we know that Black male patients are actually at a higher risk of restraint compared to white males. And thinking about our youth, and I know that I've been talking about some topics that pertain to adults, but our adults, we're children as well. So we're also going to be focusing on the youth, but I'll be talking about what we're seeing in the adults because that's the downstream effects with regards to how things are impacting our children. But I'll back up a little bit and say that we know that Black youth and other youth of color receive more punishment and less treatment than white youth for substance use disorders and disruptive behaviors that we see in young people. For some reason, Black youth and youth of color who are engaging these behaviors are more likely to incur criminal sanctions than white youth. So we see that there's this repeated pattern of certain practices and policies that have been ongoing in nature that further disadvantages certain individuals. Black people continue to oppress and disadvantage them. And this is happening in 2022. It's happening today. Quickly, I just want to touch upon this figure that talks about the different levels in which we can experience racism. And I've been talking a lot about structural racism. Also, we have the role of institutional racism that's looking at various policies and practices that are in place that uplift and validate the white experience. And thinking about policies and practices that oppress and invalidate Black people, and these are within various institutions, such as the institution of medicine, our system of psychiatry. But it's also important to know that we need to hold individuals accountable, too, because certain individuals who have racist ideas, who engage in these racist acts through individually mediated racism, these are the same people who may also be informing some of the policies and practices that are in place within various institutions and systems. And then we also need to think about culturally, what sort of messages are we conveying to Black people, white people, all sorts of people within our culture that uplifts, invalidates the Black experience, and invalidates the white experience. So I just want to show this, that this occurs on multiple levels, and we need to keep all of this in mind. And we also need to reflect on the fact that structural racism, it does exist. And it's not just the individual, that bad apple, so that we all, as clinicians, can feel comfortable knowing, well, it's just that person over there. It's just that one bad psychiatrist who is engaging in poor treatment, who's providing low-quality care. And it allows us to not be active participants in that discussion on how we can dismantle racism within the system, within psychiatry, within mental health. We need to know that there's so much going on beneath the surface, there's so much going on that is difficult for us to observe and that's why we gotta keep talking about it. And those are thinking about the structural factors, the policies, the practices that are in place, the implicit attitudes and biases that are informing the way in which people are providing care. And we gotta think about this because structural racism, all of these policies and practices, thinking about our history that has continued to oppress people of color and black people within this country has led to all of these equitable outcomes, racial disparities within medicine, within the criminal justice system, within education. And what ends up happening is that as a society, we are primed to make these association between what it is, what it means to be black and what one's potential is. And these things are being reinforced in the media, it's being reinforced in what it is that we see in these environments. And it fuels some of the unconscious biases that people have. So when they are practicing psychiatry, when they're implementing certain policies, all of this is informed by what it is that they know, what it is that they've experienced throughout their life and what it is that they see. And that's why we gotta talk about this so that we can put a stop to this. Now, how are we going to achieve mental health equity? I'm really looking forward to Dr. Durham's talk and when she goes into a little bit more detail about this, but we need to know that there are serious consequences when we aren't taking any steps towards action with regards to providing equity within psychiatry. These are people's lives. And if we're not providing good quality care, we're going to see these downstream effects in these children growing up to be adults who are experiencing the consequences from clinician bias, from not being adequately treated and diagnosed. So we can't be silent to this any longer. We need to act and we need to acknowledge that racism exists everywhere, including here within psychiatry. And racism is a determinant of mental health and it influences clinical practice, has a profound impact on patients, and it is a system. And we also need to know that it's a system in which the clinicians, also are in a position of power, not only because psychiatrists, other mental health providers, have that clinical knowledge, that expertise that gives them a certain privilege or power, but also thinking about what it is that you bring to the table with your own race too. And being able to provide certain treatments, making certain diagnoses, you are kind of exerting a certain power you are kind of exerting a sense of power, right? And so we need to think about that power and how it's continuing to reinforce this ongoing system. Quickly, I'm just going to share some statistics about black mental health. Again, kind of thinking about more globally some of the downstream effects and what it is we're actually seeing. We're seeing these numbers, but we need to be curious about what is driving these numbers. What are the things that are driving these numbers that are difficult for us all to observe and for all of us to take note of? You know that black people represent about 13% of the population and nearly 20% of black people are impacted by mental illness. And what is interesting is that even though the prevalence rates are similar with regards to a variety of different mental health conditions, we see that there are differences with regards to utilization rates and access to mental health services. And also we see that the severity of the symptoms seems to be much greater in black people and that black people experience 20% are more likely to experience 20% more psychological distress when compared to the general population. And as you can see here on this figure, this is just looking at, now these are adults looking at mental health service use and particularly among those who are living with serious mental illness. And you could see, interestingly, that black people historically tend to use any form of mental health treatment at lower rates. But what we're seeing, including both outpatient and prescription medication, but also we're seeing that for some reason, black people are more likely to utilize inpatient services when compared to whites. Again, a reflection of the severity of the illness that people are presenting with. One out of black Americans who need mental health actually receive it. And we need to understand what those barriers are all about. And thinking about our children, and there's been a lot of discussion about this, how our children, our black children, now we're talking about kids between the ages of five to 12 are definitely impacted by this. Something is going on. I mean, all should be left scratching our heads wanting to understand why this is happening. But what we are seeing is that black children between the ages of five to 12 are two times more likely to die by suicide when compared to white children of the same age. We need to understand this. And we know that there are a number of common mental health conditions that children experience. ADHD, we have over 6 million children who have a diagnosis of ADHD. Four and a half million children have anxiety. But what we do see is that there are higher rates of anxiety disorders of black children when compared to white children. And we've also seen that over the course of the pandemic, depression and anxiety and those rates have certainly increased within our young black children between the ages of 11. So we know that the pandemic unmasked a number of structural factors that kind of contributed to all of this, but we need to understand this. And I'll end by just talking about ADHD, and Dr. Durham will go into this a little bit more, is that we do see that there are some differences with regards to the frequency in which black kids are diagnosed with ADHD when compared to white. Historically, white kids are more likely to receive that diagnosis. But when we look at some of the questionnaires that we use for diagnosis of ADHD, we do see that there are symptoms consistent with ADHD that's being reported in children, but they are less likely to be given that clinical diagnosis. So what I'm going to do is transition over to Dr. Durham, who will talk a little bit more about misdiagnosis or underdiagnosis. Thank you so much, Dr. Crawford, for really setting up what I'll be talking about in the next few slides is really thinking about some of the reasons for why and strategies that all of us as clinicians can use so that our black children and youth can get the services they need when they need it. And as we know, between the pandemic and prior to the pandemic, there's been an inability for folks to engage in treatment. And how are we as clinical providers, unfortunately, being some part of the cause of that? So in the next slide, I'm talking, my slides are set up to really think about this interplay between the symptom presentation of youth, clinician bias, and the stigma and treatment delays, and how they all interplay together to some of that data that Dr. Crawford presented, that youth are not, unfortunately, they're either getting misdiagnosed or underdiagnosed and sent down a very different route, which is not a treatment route, when they really need mental health care. So in the next few slides, I'm going to present some data and really looking at what we already know, and there's been good literature and evidence out there. And so what's missing, essentially, right? Some studies have suggested that black children and other children of color are overdiagnosed with neurodevelopmental disorders and disabilities. They're disproportionately represented in special education. We know that parents and teachers also may differ regarding their experiences and the knowledge that they have at appropriate expectations or child behavior at given developmental levels. As child psychiatrists, Dr. Crawford and I depend on teachers often to provide that sort of collateral information when we're looking at, when we're seeing children and families in our offices. Teachers can be a window into at least letting you know and understand this child at their developmental level because they see first graders or second graders all the time, sort of how are they different than the other kids in their class. But we also know that there's bias in teacher report, which I'll talk a little bit about. The parent side of this is that we know that many of our screening tools and the things that we use have been formed, if you will, for a white population. And so we do need more research and evidence and thinking about what is culturally different, how are parents viewing their kids, their family in the context of other kids and folks that they know in their own communities, and how do we better align to understand how the presentation and the symptoms may be different. We also know through some reports, and I'm going to have a lot of data in this Ring the Alarm, the crisis of black youth suicide in America, that we know that through this report that was done through the Congressional Black Caucus, really a call to action for all of us in the field, for those that work with children and adolescents, for people that are policymakers, for people doing research, that there is a lot that we need to do to think about how do we do this work better because we're failing our kids, we're failing our black youth. We can go back one slide. I wanted to talk a little bit about the black youth expression of depression in particular and thinking about the health symptoms different than white youth when we think about how they present with maybe externalizing behaviors that are different than their white counterparts. Next slide. So, black youth dealing with mental health issues are more likely to be referred to inpatient services than white youth. They're often pushed into the juvenile justicism where access to adequate treatment is even less available. The data from the National Comorbidity Survey Adolescent Supplement indicates that compared to their white counterparts, black adolescents are significantly less likely to receive care for depression. That externalizing behavior that we talk a lot about, so outwardly maybe, quote-unquote, disrespecting teachers, leaving the classroom frequently, maybe not showing up for school, a lot of outward sort of behavior really gets misdiagnosed, if you will, for conduct or other behavioral issues. The court systems end up getting involved quite frequently. We know that our black youth are policed at much higher rates than other kids in the school system. So, this ring the alarm, the crisis of black youth suicide, really looked also in thinking about what's going on here at a broader level. We know that youth and caregiver mistrust of the mental health professionals. So, how we, as mental health professionals, whether we're psychiatrists, psychologists, social workers, there's a clear bias when folks present. But then also, why don't they present? Are they hearing things from other family members that have presented for care and were mistreated in some way? Their symptoms were not believed. We know there's a lot of data across many different specialties of symptoms just being not believed or being presented as something not really understanding how they're presenting with the symptoms and how this may be a reflection of their own cultural beliefs, how they grew up, and people just deciding, based on some subjective notion of what they believe certain symptom presentations are, that they don't get the treatment that they deserve. Black people, on average, also receive poor quality treatment compared to white people when they pursue mental health treatment. As I mentioned, our assessment tools may lack that nuance in being culturally specific expressions of depression symptoms resulting in this under misdiagnosis in youth for treatment. And then we also know for many Black adolescents, exiting treatment early is the norm, and poor engagement is a key influence on termination. How do we motivate people to stay engaged in care? Why are they not staying engaged in care? And we know that folks talk, we're from communities that engage in talking about our own experiences that sit around the table at holidays and other important events in our life to talk about the treatment that we received at certain clinics, certain hospitals, and certain systems. And are we preventing other folks in our communities from engaging in care whenever they do, and they're mistreated in many ways or not believed fundamentally? So, thinking about mental health diagnostic considerations in general, and there's a great review that Liang and colleagues completed, a systematic review that really focused on the current theory in our research, an attempt to answer two questions. What evidence exists that supports or contradicts the idea that racial and ethnic minority youth mental health problems are misdiagnosed? And what are the sources of these misdiagnoses? And we know, as some of the data, Dr. Crawford, and some of the data I'll present later, it's leading to folks not being able to engage and going down a route that has really lifelong consequences when they can't engage in treatment. So, a series of problem-based vignettes, a survey study found that mental health professionals, psychiatrists, social workers, psychologists, were more likely to assign a diagnosis to a non-Latinx white youth as compared to Black or Latinx youth. So, just not being able to even receive a diagnosis for presenting symptoms, which we know, once receiving a diagnosis, can help within the school system, can help with other systems that the person is involved in to get them the services that they need. After controlling for age, gender, functional impairment, and prior service use, Black youth in mental health services were less likely to be diagnosed with ADHD or mood disorder compared to white youth. After controlling for socioeconomic status, age, gender, and functional impairment, Black youth were more likely than their white youth to be diagnosed with disruptive behaviors and conduct-related problems. Black youth are shown to be more frequently diagnosed by their clinicians with conduct disorder and psychotic disorders and less often diagnosed with mood, anxiety, adjustment, or substance use disorders. In psychiatric inpatient settings, in this same review, they saw that Black male adolescents were more frequently diagnosed with schizophrenic spectrum disorders, while white adolescents were more often diagnosed with alcohol use, major depression, and bipolar disorder. And we know that there's, like, huge stigma in our society in general when we start diagnosing people with conduct, oppositional, schizophrenia, and is that clinician bias to give a less stigmatizing sort of diagnosis to white youth as opposed to Black youth. Also, not understanding the symptom presentation may be different. Asking questions in a way that the youth and their family can answer and feel that they're not being judged, that they're not being discriminated against, that their stories are seen as true. Are we thinking about the impact of racism and discrimination on the everyday life of the youth in our treatment centers? There's a delay in diagnosis for kids that have autism. For Black children, they were less likely than white children to receive an autism diagnosis at their first specialty care visit. We know that autism diagnoses early in life in that 0 to 2 age range are critical to the prognosis and to the services that kids receive. Black children are more likely to be diagnosed with adjustment disorder and conduct disorder than be diagnosed with ADHD. Cross-cultural studies in the U.S. have shown that children of color are assessed and treated at much lower rates than their white counterparts for ADHD symptoms in general. Last but not least, we can go back and just think of prevalence studies in general. We know that there are relatively few racial ethnic differences in the patterns of disorders. That's been studied time and time again, but diagnosis in treatment settings seems to indicate more racial and ethnic inequities. So how is clinician bias, treatment centers bias, playing a role when prevalence studies are saying all things are equal? We also know it's understandable that prevalence studies are often based in research diagnoses, which may have more rigorous and stringent diagnostic criteria. But they found that few racial and ethnic differences in diagnosis in clinical settings, where the criteria sometimes are less well-defined and vary across treatment settings, indicating more differences. How are we not or are we using our DSM, the criteria? How are we understanding this in the context of the patient presenting in front of us? Why are we as clinicians not using rigorous ways to evaluate folks that identify as Black or other people of color? We need to think about that when we're in our clinical settings. Misdiagnosis by mental health professionals due to cultural biases, racism, or stereotypes may over or underestimate pathology and impairment. As diagnostic assessment errors in either direction obviously create really unique and problematic challenges for people that are presenting for care. And then, you know, as I'm discussing that interplay, right, we have clinician bias, we have the symptom presentation, that systematic reviews have seen time and time again. But there's also that interplay of once-in-treatment, sort of what happens for folks. And there's data to support that once-in-care, Black people and other people of color receive less information about treatment. They're more likely to give inappropriate treatment referrals and recommendations for their presenting problems and are misdiagnosed when they have the same presenting symptoms as White people. They don't feel like the clinician is listening. We hear this and there's good evidence and research to support time and time again, that there is a misalignment between the person presenting, the clinician and the tools that are used to come up with an appropriate diagnosis and treatment plan. So what are the consequences of underdiagnosis and misdiagnosis? There are several and we all need to be a part of advocacy and thinking about how do we do this differently because there are lifelong consequences for folks. The main one that we hear very often is the school to prison pipeline. Kids that are misbehaving in school, that aren't doing what the teacher says, that are getting pulled to the principal's office time and time again, that can't stay in their seat. As child psychiatrists in particular, we know that behavior means something. How do we get our school folks also on board with thinking about what does that behavior mean for this kid in front of us? But that is not happening at that level. Black students are suspended and expelled three times more than white children, almost three times more than to be involved in the juvenile carceral system once they have a suspension or expulsion. And sometimes that's only one. In the next year it's good evidence that if they have been expelled or suspended once in that year, that the next year they'll be involved somehow in the carceral system. There's really harsh school discipline policies that overuse suspension and expulsion. There's this zero tolerance policy that really criminalized minor infarctions for kids. And we also know that we hear time and time again, the adultification of our black children, that six, seven, eight, nine, 10 year olds are being seen and harshly punished and criminalized as if they're adults. They are not. We need to figure out a better system for getting them the care that they need instead of using the carceral system to control, if you will, this behavior that they're exhibiting in the school system. And since the 1960s, the U.S. Department of Education has conducted the civil rights data collection to collect data on key education and civil rights in U.S. public schools. This particular slide is showing the school expulsion rate by race and ethnicity. We know that black students who account for about 15% of total student enrollment were expelled at rates that were more than twice the share of student enrollment. 38, almost 40% of expulsions of kids with educational services and about 33 that don't have educational services. So when we think about there's educational services, there may be an individualized education plan, which is part of federal guidelines for school to give students what they need and supports they need to learn. So we're saying they've met the criteria for some type of educational service. And yet they're being treated with expulsion instead of another mental health, maybe evaluation, maybe more supports in the school system. And even though they have the educational services, folks know that there are some issue with their learning. They're still being expelled from school. The next slide really, it also, you know, thinks about how these inequities start so young. I don't think I'll ever get over the fact that little kids, preschoolers are being expelled from school. There's huge disparities in this. There are about 18% of preschoolers enrolled, but they represent 38% of those that get expelled from school. Two times the black preschoolers were expelled than the rest of preschool enrollment. We need to think about that for a second. These are kids that are three, four, five years of age getting expelled because of their behavior in school, not getting the treatment, not figuring out what's going on with the family, what supports the family and the system may need, but just getting expelled. The next slide shows the suspension rates for preschoolers. Again, 18% are enrolled in preschool and they account for 43% of those being suspended two and a half times than their counterparts, than their white counterparts in school. Huge inequities in how this is happening. One thing to talk about in this disparities and suspension and expulsion is that we know that teachers have a lot to do with this as well and that Walter Gilliam and his colleagues at Yale in about 2016 did a standardized vignette of preschoolers with challenging behavior. They were randomized to receive the vignette with the child's name implying that they were either maybe a black boy, a black girl, a white boy or white girl. They were randomized to different teachers in the school system that they were utilizing, but this was preschool. And the findings revealed that when there was some challenging behavior, teachers gazed longer at the black children in the vignette, especially black boys, especially black boys. This is happening for kids already at three and four years of age, that they are being seen as bad, being seen as needing some type of discipline and not necessarily further or at least an evaluation for some type of mental health treatment. And so we know that there are huge costs, the consequences of these inequities and our biases and our treatment delays in us inadequately or inadequately being able to identify how the symptom presentation may be different than their white counterparts has huge consequences into adulthood, work productivity, incarceration rates or five times their white counterparts. Substance use disorder. We know untreated, for example, ADHD, anxiety disorders, depressive disorders can lead to folks using substances to cope. We can lead to chronic medical conditions. If there's depression or untreated anxiety, people have a hard time taking care of themselves and their medical conditions can cause lots of family and community disruption. There's a loss fundamentally of academic achievement. We know that poverty results when people can't work and function at their level and at their capacity. We talked earlier a little bit about the black suicide, youth suicide rates. We can't stress that enough that black youth under 13 are twice as likely to die by suicide. We know that suicide death rates among black youth have been found to be increasing faster than any other racial and ethnic group. We also know that half of the lifetime cases of mental illness begin by the age of 14 and three quarters by the age of 24. And despite the availability of treatment we delay, there's a delay of about 10 years between the onset of symptoms and the intervention. Mental illness creates enormous social and economic cost. And we really need to think about these consequences for youth when we are not diagnosing folks appropriately, we are misdiagnosing them that they end up in the carceral system or some other system and don't get the appropriate treatment that they deserve. And for those that think from an advocacy policy and sort of public health lens, these early onset of behavioral mental health issues, the Institute of Medicine actually estimates that their subsequent indirect and direct costs, all of us as a society, about $247 billion annually, just because people aren't able to get appropriate treatment. And when they go to treatment, we are not treating them fairly or equitably in treatment diagnosis. Okay. So what are the strategies? We have a few. I'm hoping that we can engage in some conversation about what other folks think might be helpful as we, as we move forward and hopefully provide some solutions to the problem of youth, black youth in particular, not getting the treatment that they need. I think it's across four different areas. Research, access, thinking about workforce. And lastly, I'll talk a little bit about cultural humility. When I think about research, there are two main things that, you know, we're, we're, we need to do. I mentioned earlier, our assessment tools, that may not be totally culturally validated for, for all people and for black people in particular. How do we think about more research that looks at the lack of cultural relevance of empirically supported approaches, looking at the absence of, we really don't have a lot of evidence-based approaches. I like to use the word evidence informed for a lot of the communities we served. So we're basing some of our interventions on evidence that has predominantly been around a white population. So we need more research funding to going into thinking about how black youth, other youth of color present, how their symptom presentation may be different, what validated tools we can use, and what are some of the evidence treatments, evidence-based treatment once research is done, that may be more appropriate for those folks. I mean, not just using a one size fits all that we're doing now that works maybe for a white population, maybe some of our black youth, maybe some of our other youth of color, but it is not working for the majority of black youth. We need increased funding at the NIH and all levels in general. There was in 2019, a publication about research and thinking about why NIH dollars are not really supporting black investigators and other racial groups. Black scientists are more likely than another scientist to investigate topics such as racial discrimination and health inequities because in part it affects us. We want to study it. We want to help our communities, but yet grant applications in these domains are less likely to be funded. There was a study in 2019 by Hoppe and colleagues. We also need to think about who gets to make these decisions about research, who are in the review committees. They are predominantly white men making these decisions. And so we all need to advocate at the research level to get more funding, to study our communities better. Secondly, I would, you know, wanted to talk about access. We need to improve access for our youth, our black youth in particular that they can not only once ready for treatment, that they can be engaged in access, the treatment that they need and so rightly deserve. Medicaid plays a substantial role in covering and paying for behavioral healthcare. In the U S we know, unfortunately, you know, in the communities, marginalized communities specifically, and people who may have money and have private insurance, they're still unable to access access treatment for their mental health issue. So how do we advocate for mental health parity and reimbursement services for all insurance providers, whether that's Medicaid or whether that's a family that may be privately insured? We know there are other barriers to care where I work here as a safety net hospital. How do we think about if people do want to engage in treatment, childcare issues, they have multiple jobs, they have difficulty leaving work. And how do we create programs in schools and community centers in the churches and have stopped having people always have to come to a clinic or hospital setting to get the care that they need. Thinking about integrating mental health services into primary care with a focus on screening and assessment to engage families in further treatment and or prevent severity of illness. How do we start early from that prevention and promotion have screeners that are happening in the pediatric primary care settings to note even an inkling of something happening with a youth or family that they can start getting the education they need that they may be able to sit with a clinician and start talking early on about some of the difficulties before it reaches a point of severity of suicidality of a suicide attempt. Last but not least, we have a mental health system that's weighted heavily towards white people and not towards people, black people or other people of color. It was created our systems, our health care systems with white people in mind. So we really need to think about how do we at our clinics, our hospital settings, invite community to make some of the decisions on our policies, how people are accessing care. We need to re-imagine the way mental health care is delivered in the U.S. The workforce is another big task that we all, if we're going to have less clinician bias, racism, stereotypes having in those clinical encounters, we do need to recruit and retain a diverse workforce for the betterment of all folks that are ready to engage in treatment. The diversity of our current workforce is very low. 21% of psychiatrists come from a diverse background with only 2% identifying as black. There's about 3% of social workers from a diverse background, 6% of psychologists, 6% of advanced psychiatric nurses. So we have a long road ahead of us to figure out how we recruit more folks into the mental health field that reflects essentially the browning of America. America is no longer going to have a predominantly white population and we need to be prepared to meet people and to have a conversation with them about how we can be prepared to meet people and to have access and to feel that people want to engage with us because they have folks that look like them on the treatment teams. Last but not least, thinking about cultural humility. This is where likely many of us have to start in our practices. There is a lot, as the previous slide mentioned, a lot more white people providing care than people of any other background. So we have to take time to understand what people think about the diagnosis, the treatment and what they can do. Follow their lead, I think families and we should listen, we have to listen more and we have to engagement in that treatment plan. We also have to remember our own biases, racism that might be at play. Talk to other colleagues in your practice when making a diagnosis to make sure it is the accurate one and that we're not misdiagnosing or undiagnosing people. We really need people to get the treatment that they need and deserve. There's also variations in the interpretation of behavior that not only among parents, but people from different cultural backgrounds and think about how school personnel and health care providers are thinking about that family that's presenting to you. Both people need to collaborate and learn from each other for the best outcomes. Cultural humility is really taking a step back and thinking about what don't I know? I don't understand everything about this person's culture. We also have to remember that the kid from a wealthy family, maybe in San Francisco, is different from a kid from the rural South, different from a kid that's here in the Boston area, that being black does not mean that every person presenting is the same. You have to have some humility to think beyond that surface presentation, that phenotype of the person, and really dig deep with the family to get to the best point where we're making the most accurate diagnosis. And it's a treatment plan that can work for that family and youth. I leave with thinking a little bit about that some of this, you know, the next slide really is thinking about, you know, there's a power dynamic in the relationship with children and families and that provider. We need to remember and reflect on that power dynamic as well. In the last slide, you know, again, we come back to Dr. Camara Jones and that we really, if we're feeling uncomfortable, that, you know, she tells us to lean into that discomfort. We don't know what we're doing in a clinical encounter with a particular family. We need to get some other folks involved. We need to talk about our cases with other providers because health outcomes are at risk when we don't do the right thing by our patients. I mean, go against that growing edge. We all need to grow in doing this work better. And if we have and hold and didn't know that we held racist beliefs, it is affecting our black youth in particular. We need to do better by them, our families and our communities that we serve. With that, we're going to open it up for any questions. I know we have a couple of minutes left and I hope that we have some good questions that we can answer. We thank you all for your attention today. And thanks so much for that, Dr. Durham, because I do think that all of the strategies that you discussed today, my hope is that some of our listeners will take these strategies to heart and to try to incorporate them into their daily practice. And in the minute that we have remaining, you know, one of the things that I imagine that came up from one of our from one of our attendees was just kind of thinking about any potential tips for treating parents who have a child who may have received a misdiagnosis. So how do we advise our parents who have children who might not have received the correct diagnosis at first? Yeah, I think that's twofold, and I think that's a fantastic question, and I'm interested to hear your thoughts, too, Dr. Cropper. But I think two things happen, right? As clinical as providers ourselves, we end up with families that may have been diagnosed prior to us. And we think the presenting problem that we see is very different. And something that I always engage families in is like what I'm seeing now. And I always think it's really important to to let families know all the information we gathered to come up with this particular diagnosis in this moment of time. How do we not think also about what happened previously? Sometimes I do know that we gather more data and information when the person's in front of us and me. Diagnostically, it may be something different that we think. But I think being completely transparent ultimately with a parent about what what do we think is going on? Why do we think it's going on? Recommendations for treatment and what do they think they can engage in? I think it's just really, really important. There are many times families come to us and they are like, I have no idea what's going on as if they never even were told diagnostically. And, you know, as we talked about in the presentation, there are many black families from you know, research and questionnaires and surveys that have been done were never really even explained what was going on. We have to do a better job of that psycho ed piece of our work. Absolutely. Well said. And we just need to empower the families that we work with, with this knowledge and to make sure that when they leave our offices, they have a clear understanding as to what's happening with their with their kids. So I want to make sure that everyone is aware that they can obtain credit for watching this webinar today. You can see the instructions here on the screen. So make sure to contact this email address here if you happen to have any questions about how you can claim credit for today's webinar. So thank you so much for for attending today.

webinar

racial inequities

mental health diagnosis

structural racism

biases

ADHD

mood disorders

misdiagnosis

black youth

cultural relevance