by Sydnee Akubuiro, MD; Wendy Clay, MPH, MD; Suzie Nelson, MD; and Allison E. Cowan, MD

Dr. Akubuiro is with Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine in Atlanta, Georgia. Drs. Clay, Nelson, and Cowan are with Department of Psychiatry, Wright State University in Dayton, Ohio. Dr. Nelson is additionally with Dayton Children’s Hospital in Dayton, Ohio.

Funding: No funding was provided for this study.

Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Innov Clin Neurosci. 2023;20(10–12):29–34.

Department Editor

Julie P. Gentile, MD, is Professor and Chair of the Department of Psychiatry at Wright State University in Dayton, Ohio.

Editor’s Note

The patient cases presented in Psychotherapy Rounds are composite cases written to illustrate certain diagnostic characteristics and to instruct on treatment techniques. The composite cases are not real patients in treatment. Any resemblance to a real patient is purely coincidental.

Abstract

The increase in mental health issues among children and adolescents has been declared a health crisis in the United States, and recent increases in key measures (e.g., self-harm and suicidal behaviors) have been found to disproportionately impact youth from minority backgrounds. Access to mental health treatment for youth is limited, but for minority youth, access to culturally sensitive care is even more limited. This article discusses the ways in which misdiagnosis and underdiagnosis of mental health conditions can occur in minority youth and provides key points for clinicians to consider while working with minority youth to improve mental health outcomes.

Keywords: Racial disparities, adolescent psychiatry, trauma, misdiagnosis, ODD, ADHD

The increase in mental health issues among children and adolescents has recently been declared a health crisis in the United States (US). Recent social events, such as the COVID-19 pandemic, the increase in mass shootings, and increasingly salient social injustices, have been attributed to this increase.1 The Children’s Hospital Association released a statement declaring that, “In the first six months of [2021], children’s hospitals across the country reported a shocking 45-percent increase in the number of self-injury and suicide cases in 5- to 17-year-olds compared to the same period in 2019.”2 According to a study published in JAMA Network Open, in a sample of 183,500 high school students attending US high schools, self-reported suicide attempts among Black adolescents rose by 80 percent from 1991 to 2019, far outpacing rates in other races.3 Exacerbating this mental health crisis is the insufficient number of child and adolescent mental healthcare professionals. Although the number of child and adolescent psychiatrists has increased in the last 10 years, there are still not enough to meet the growing demand. Thirty-six states have fewer than 10 child psychiatrists per 100,000 children. This shortage results in average wait times of 11 months in some of the most extreme cases and disproportionately affects communities of color.1,4 This disproportionate increase of mental health crises in youth with skin of color, combined with the inadequate number of mental healthcare professionals in minority communities, often results in an absence of culturally competent care for this population, leading to frequent misdiagnosis or underdiagnosis.5 These diagnoses, when misapplied, can have lasting and devastating effects on these individuals’ social outcomes. This article seeks to illuminate the areas in which misdiagnosis or underdiagnosis exist, how misdiagnosis or underdiagnosis may play out in clinical encounters, and key points clinicians can consider while working with youth from minority backgrounds.

Racial Disparities in Child and Adolescent Psychiatry

While the mental health crisis plagues children and adolescents across racial, ethnic, and economic groups, there are clear mental health disparities among these different groups. Access to mental health resources is a major predictor of mental health outcomes. Research shows that one-fourth of communities in the upper 25-percent socioeconomic income bracket in the US have access to a mental healthcare provider. In contrast, among the lowest income quartile bracket, only approximately eight percent have access to a mental healthcare provider.6 The child and adolescent psychiatrist shortage specifically is the most acute in low socioeconomic status, predominately minority communities.4 The shortage of mental health providers in these communities is of particular concern, given the acute mental health needs in these marginalized populations in comparison to other groups. According to a study completed in 2021, emergency department visits due to suicidal behavior in adolescents aged 15 to 19 years are on a steep increase, with the most prominent increases in Black and Hispanic youth. Specifically, Black male adolescents had the highest increase in suicide attempts, compared to all other sex and racial/ethnic groups studied.3

Research shows that African American male individuals repeatedly tend to be disproportionately, and often incorrectly, diagnosed with more severe disorders, such as schizophrenia, compared to White male individuals due to the common bias among mental healthcare professionals that Black men are more likely to be violent and dangerous compared to White men.7 This trend appears to remain consistent in Black youth, with Black children being more likely to be diagnosed with a disruptive behavior, such as oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD), compared to their White counterparts, even when both groups demonstrate similar externalizing behaviors.5 These disparities in diagnosis among racial groups have lasting stigmatizing effects. Children who are diagnosed with ODD are at increased risk for consequent development of antisocial personality disorder, which increases their risk of partaking in criminal activities and resulting incarceration.8 Furthermore, a diagnosis of ADHD is associated with an increased risk of developing a mental health condition in the future.5 A diagnosis of comorbid ODD and ADHD in a child creates a higher risk for negative social outcomes.9 Literature shows that White children are more likely to be diagnosed with ADHD alone rather than ADHD with comorbid ODD or conduct disorder than Black children, further increasing the risk for negative social outcomes in children of color.5 A research study that explored the prevalence of mental disorders in youth from 2005 to 2011 found that behavioral or conduct disorder diagnoses were highest among Black children, with a lifetime prevalence of 8.1 percent, compared to 4.2 percent in White children and 3.9 percent in Hispanic children.10 Research has also shown that approximately 30 percent of children with behavioral disorders, specifically ODD, will eventually develop conduct disorder; this risk increases three-fold in children who were initially diagnosed at a very young age. Ultimately, approximately 10 percent of children diagnosed with ODD will eventually develop a personality disorder, such as antisocial personality disorder.11 These findings suggest an increased risk of behavioral disorder diagnoses in Black children that could potentially lead to stigmatizing diagnoses characterized by delinquent behavior later in life.

These disparities in diagnosis stem from a lack of cultural competence and diversity in the mental health field and prevalence of implicit bias in mental healthcare providers. These shortcomings cause the behavior of Black children to be viewed as dangerous and delinquent, thereby being characterized as a disruptive behavior disorder rather than as a neurodevelopmental disorder that is out of the child’s control.12 This implicit bias blatantly disregards the many factors that contribute to differences in clinical presentation among different racial groups, particularly the role that increased exposure to childhood adversity in minority youth plays in the development and display of mental health conditions.

Fictional Case Vignette 1

A psychiatry resident, Dr. A, conducted an intake interview with a 19-year-old patient, B, with multiple previous emergency department visits throughout the years for various reasons. The psychiatry resident noted that the patient had been on many antipsychotic medications over the years.

Dialogue 1

Dr. A: Hi, can you tell me a little about what brought you in?

B: Look, when I told them, “Y’all don’t care about me! I’m just going to leave here and end it all,” they got all upset and said that I had to come see somebody. But you know I was just upset because they weren’t listening and kept talking about stuff that wasn’t me. Like, I don’t have schizophrenia but they’re always talking about it.

Dr. A: Can you tell me a little more about what’s going on?

B: I’m really not doing well. The voices have been telling me to hurt myself.

Dr. A: Okay. That sounds rough.

B: Yeah. It’s been rough all around. I lost my job the day I came in, and I really don’t have anyone to talk to. I don’t really speak to my family, and I worry about bothering my friends.

Dr. A: It sounds like you feel really lost, and then on top of that, you felt unheard in the emergency department.

B: Yeah, I’ve never had hallucinations or delusions. Sometimes I lose my temper and I know I have anger issues, but I think it’s more about what all I’ve been through and not what they’re always assuming.

Practice Point 1

Transient psychotic and dissociative symptoms can occur following traumatic experiences; in Black and ethnic minority youth, these symptoms can be interpreted as schizophrenia or primary psychotic disorders, rather than exacerbation of posttraumatic stress disorder (PTSD). Establishing a therapeutic alliance remains of paramount importance in establishing care with a new patient. Particular care should be paid to previous diagnoses, with the understanding that implicit bias and misdiagnoses may occur.

The Role of Early Trauma in the Clinical Presentation of Black Youth

Adverse childhood experiences (ACEs) and early trauma are terms that have recently gained increased attention in light of the youth mental health crisis in the US. ACEs can be defined as negative experiences that occur before the age of 18 years and include abuse (physical, sexual, or emotional), neglect (physical or emotional), household dysfunction (e.g., caregiver with mental illness or substance abuse, divorce, incarcerated relative, or domestic violence), and community violence.13 The long-term impact of exposure to adverse experiences during childhood is of major importance to public health, with many studies highlighting a strong relationship between childhood adversity and the occurrence of risky health behaviors and long-term poor physical and psychological health outcomes, including ischemic heart disease, cerebrovascular accidents, chronic obstructive pulmonary disease, hepatitis, intravenous drug use, depression, and suicide attempts.13–15

ACEs correlate to long-term negative health outcomes through the mechanism of toxic stress. Stress is defined as a “real or interpreted threat to the physiological or psychological integrity of an individual which results in physiological and/or behavioral responses.”16 The biological systems that facilitate normal stress responses are mediated by two main systems: the sympatho-adrenal-medullary axis, which makes the stress hormone adrenaline and hypothalamic-pituitary-adrenal axis, which makes the stress hormone cortisol.

Stress response systems have the ability to be protective when they are used to facilitate the fight-or-flight response; however, they can also have detrimental effects, particularly if they do not stop. The three major stress responses that affect the body are positive stress response, tolerable stress response, and toxic stress response. A positive stress response is described as brief increases in heart rate and mild elevations in stress hormone levels. This stress response is healthy in nature and can even be lifesaving when activated for brief moments. A tolerable stress response is characterized by more serious and longer lasting stressors that elevate stress hormones for longer periods. This type of stress response can be damaging when activated for longer periods, but it can be buffered by supportive relationships. Supportive relationships and nurturing environments can help regulate the stress response and bring stress levels back to baseline. Finally, a toxic stress response occurs when the stress response system is activated too frequently and intensely. This constant activation disrupts brain and organ system development during childhood and alters biological set points that govern functioning. Oftentimes, this leads to hypervigilance and anxiety throughout the childhood years into adult life. Without the buffering protection of resilience factors, such as supportive relationships, a toxic stress response can lead to lifelong physical, mental, and behavioral health problems.17

While the biological mechanism of toxic stress and the long-term physical outcomes tend to be similar across racial groups, the ACEs that precipitate these manifestations inherently differ between races. Additional categories of ACEs that specifically impact Black children have been of increased attention lately. These categories are of direct relation to the historical systemic oppression and intergenerational trauma that uniquely affect African Americans, such as racism, discrimination, microaggressions, and increased media exposure of social injustices, particularly police brutality toward people of color.15 When individual racism is added to the ACEs categories mentioned previously, a pattern is seen that shows Black children have a higher likelihood of having more ACEs, compared to their White counterparts.18 Discrimination in and of itself negatively impacts the health of individuals in many ways, particularly through its effect on psychological wellbeing, access to resources, and, sometimes, violence, which in turn can have detrimental effects on the quality of life of people of color. However, despite the growing knowledge of these unique ACEs and their subsequent long-term effects that disproportionately affect communities of color, none of the ACE scales take into account the experience of enduring the systemic racism that takes place in the US.19 This lack of acknowledgement of the unique experience of trauma in Black youth contributes to a decrease in the cultural competence that is necessary when treating this population, often contributing to misdiagnosis and underdiagnosis.

As previously mentioned, Black children and adolescents are more likely to be diagnosed with a disorder characterized by hostility or aggression, compared to their White counterparts, even when symptomology is similar. They are less likely to be diagnosed with internalizing disorders, such as depression and anxiety.5 However, these symptoms in Black youth are often the manifestation of PTSD secondary to the early trauma that many children in this population face.20

Fictional Case Vignette 2

A 9-year-old boy, C, presented to a psychiatrist with his mother due to problems at school. His pediatrician started him on methylphenidate, after which the patient had increasingly escalating behaviors, prompting the patient’s teacher to recommend referral for psychiatric evaluation. The patient’s mother noted that lately, the patient had been much more irritable, with frequent outbursts at school and home. During these outbursts, the patient was often asked to complete a task (e.g., transition to a new task at school, do a chore at home, etc.), but he often sat and did not comply with the request.

Dialogue 2

C: I don’t want to go talk!

Mother: I just don’t know what to do with him. I’m so sorry. This is the exact behavior that we’re here to talk about. He just never follows directions.

Dr. D: C, do you think we could head back to my office? I have some cool things that you might want to check out there.

C (walking along with mother and psychiatrist): I do NOT want to.

Dr. D: Well, you can leave any time you need to, but maybe we can just see if there’s anything here you like.

C (seeing popular action figures): I still don’t want to be here.

Dr. D: Yeah, I get it.

C: Okay, but I do love Spider-Man. I have a Spider-Man backpack. I saw the new movie. I’m not staying in this office long.

Dr. D: Oh! I saw it too. What did you like about it?

C (picking up an action figure): Miles was always getting in trouble at home. His parents were ALWAYS mad at him. But Miles was out there saving the world. All the time! But Miles’s parents only thought he was being bad. Miles had to keep secrets from his family. He didn’t know if he could tell his mom and dad the truth. When Gwen left, Miles felt like he didn’t have anybody to talk to.

Dr. D: Miles has to handle a lot by himself.

C: Yeah, I’m like that, too. I have to handle things, so my mom doesn’t have to.

Dr. D: Do you feel like you’ve been more irritable lately? Like your anger bubbles over?

C: That’s what happens. I get so mad so easily.

Dr. D: And your mom said you haven’t been sleeping much lately.

C: It’s really hard for me to go to sleep. She gets frustrated with me.

Dr. D: I bet that’s hard for you, too.

The psychiatrist and C went on to discuss symptoms of major depressive disorder. C endorsed decreased appetite, poor concentration, and increased guilty feelings, as well as the irritability and insomnia described in the vignette.

Practice Point 2

Depressive symptoms can be overshadowed in Black youth, resulting in diagnoses of conduct disorder or ODD. In this case, rapport building about shared experiences served as a touchstone to building therapeutic alliance. This allowed Dr. D to understand C’s symptoms.

As previously mentioned, Black youth are at increasingly high risk for exposure to unique trauma and ACEs, compared to their White counterparts; this often leads to hypervigilance and anxiety, which can present as externalizing behaviors, such as hostility and aggression. This can be further analyzed through the lens of critical race theory, which aims to understand how racism plays a part in the existence and perpetuation of racial inequality. The shortage of mental health professionals compounded by the lack of diversity in the mental health field results in the absence of specialized and culturally competent care of children of color. This lack of care leads to children of color often being diagnosed by mental healthcare professionals from a different racial group and thus being evaluated through a lens that is reflective of the nonminority clinician’s culture. Thus, Black children’s clinical presentations of externalizing behaviors, which are often perceived by predominately White diagnosticians, are most commonly linked to the diagnoses of disorders characterized by delinquent behavior, such as ODD and ADHD, two disorders that are associated with higher likelihood for diagnosis of future stigmatizing mental health conditions and negative social outcomes.5

Black children are often subjected to more frequent and unique childhood trauma that is not adequately acknowledged in the diagnostic literature, which leads to hypervigilance and anxiety and subsequently results in clinical presentations that are frequently characterized by hostility and aggression. Due to the lack of diversity and subsequent cultural competency in the mental health field, these clinical manifestations are often perceived through a predominately White lens that frequently views the behavior of Black children as dangerous and failing to meet social norm expectations of children. Consequently, this subconscious viewpoint leads to frequent misdiagnoses of socially stigmatizing mental health conditions that are often correlated with lasting and devastating social outcomes, further perpetuating the social consequences for people of color.

Social Impacts of Disparities in Metal Health Diagnoses Among Minority Youth

Children with mental health disorders characterized by externalizing behaviors are at risk for serious negative consequences regarding their social outcomes, including long-term mental health, educational achievement, and level of community participation. Teachers, law enforcement officials, and even mental healthcare professionals might be socialized to see disruptive behavior diagnoses, which are more commonly diagnosed in Black children, as an indication that youth in this population are inherently hostile or aggressive.5 This perception often funnels patients into the justice system rather than mental health treatment due to the stigmatizing associations of these diagnoses with antisocial personality disorder and subsequent participation in criminalizing activities. These stigmatizing diagnoses are a direct pathway to the school-to-prison pipeline.8 The school-to-prison pipeline is a process in which youth who tend to experience punitive disciplinary actions in school are increasingly shuffled into the criminal justice system. Research shows that punitive disciplinary actions that involve exclusionary practices are connected to a plethora of negative outcomes, including lower levels of school attendance, low self-esteem, and worse academic performance, as well as higher levels of anxiety, delinquency, school dropout, victimization, and arrest.21 The school-to-prison pipeline disproportionately affects minority youth, and this disparity is compounded by the increased rate of stigmatizing disruptive behavioral diagnoses in this population. A study conducted in 2015 revealed that, in Southern states, Black male individuals comprised 47 percent of school suspensions and 44 percent of school expulsions from K through 12 public schools in the US, which were the highest rates among all racial groups studied. Additionally school administrators were more likely to rate Black children higher on symptomology characteristic of behavioral disorders than White children.8 Additional research showed that 50 to 70 percent of juveniles detained in the US have a diagnosable behavioral health disorder, and while Black youth make up only 16 percent of the total youth population of the US, they account for 37 percent of the detained population.22 These findings highlight the overrepresentation of Black children diagnosed with behavioral disorders that have been subjected to the school-to-prison pipeline.

By inappropriately diagnosing minority children with disruptive behavioral diagnoses at a young age, mental health professionals put these children at risk for a multitude of negative social outcomes that further perpetuate the achievement gap between minorities and their White counterparts.

Fictional Case Vignette 3

An 8-year-old boy, F, with a history of ADHD presented to an outpatient psychiatry clinic  with his mother and father.

Dialogue 3

Dr. B: How are you all doing today?

F (kicking the chair legs): Good, I guess?

Mom to F: Stop kicking your legs or you will be placed in time out.

F stopped kicking the chair legs for as long as he could.

Dr. B: I think the chair can take it. He’s not the first kid to do that and isn’t likely to be the last. But thank you for your concern. Could you tell me how things have been since your child was diagnosed with ADHD?

Mom: He was diagnosed in the middle of second grade. I always just thought he didn’t like following directions; he always takes his time doing his chores around the house. At school, his teacher was worried about how antsy he was in class and his difficulty paying attention to his lessons. When he started struggling with his reading and math lessons, she recommended we talk with his pediatrician. His pediatrician diagnosed him with ADHD and referred us here to you.

Dr. B: Were you given a prescription for a stimulant medication?

Dad: No, they just said that we would need therapy every other week for a year. We’ve been trying to do the strategies the pediatrician told us about, but they don’t seem to work for F.

Dr. B: I think it will be important for us to think about, medication in addition to other changes we make for your family.

F (kicking the chair legs again and finally getting up out of his seat): I try really hard to sit still but it just feels like I have tiny Hot Wheels in my skin, and they only feel okay when I’m doing something.

Dr. B: Oh, yeah! That a great description of it.

F (animatedly): I could tell you ALL about it. But everybody says I talk too much. So maybe I can tell you later.

Dr. B: I would like that.

Practice Point 3

Following diagnosis with ADHD, African American children are often recommended to initiate behavioral therapy as an initial treatment, rather than being prescribed stimulants, which are the standard of care. Reasons for this are multifactorial (e.g., clinician perception that behavioral concerns related to ADHD are secondary to poor parenting, parental concerns regarding medications and side effects23). Regardless of cause, this delay in standard of care treatment may lead to worse outcomes for children.

Conclusion

While the prevalence of child and adolescent mental health disorders is at an all-time high in the US, there are clear racial disparities within this health crisis. Minority youth, particularly Black youth, are at increased risk for mental health crises and suicide attempts. There are likely many factors that contribute to this disparity in prevalence, but a major factor is the increased frequency of childhood trauma exposure that is often not acknowledged in the research literature or by mental health professionals. This increased trauma exposure can often manifest as symptoms of anxiety and hypervigilance in children, leading to behaviors that are deemed as hostile or aggressive when diagnosed by mental health professionals who are not adequately trained in cultural competency.  Research confirms that there are many biases in the way people perceive Black children that result in this population receiving harsher diagnoses, which subsequently leads to more negative social outcomes.

Improved clinical training in cultural competence, as well as undertaking an active effort to increase diversity within the mental health field, is imperative to dismantling the structural racism within the field of child and adolescent psychiatry. These efforts will likely help minority patients receive safe and effective mental health care and address the mental health disparities in child and adolescent psychiatry.

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