Current State of Health Equity and Diversity Within Children’s Mental Health

SPECIAL REPORT: CHILD AND ADOLESCENT PSYCHIATRY

Over the past several years, our field has joined others in marching towards equity. In 1998, research by Fellitti and colleagues definitively linked adverse experiences occurring in childhood with later significant health challenges.¹ This original body of research connected the ways in which multiple childhood adverse experiences (Table), in an additive fashion, led to significant poorer health outcomes in adulthood, spanning the spectrum from cardiovascular health to mental health.²

The list of adverse experiences has grown from the initial 3 categories and multiple subcategories used in the original CDC-Kaiser Permanente ACE study to include other adverse childhood events incorporating various forms of racism, including structural and interpersonal.^3-5 Fellitti and colleagues’ research furthered decades of work highlighting the criticality of early experiences, connecting experiences occurring throughout childhood with later adult mental health.^6-8

As the science has advanced, and our ability to more thoroughly document adverse outcomes through technology such as neuroimaging and epigenetics, these discussions have become increasingly more nuanced.^9-11 Longitudinal studies continue to illustrate the harmful impact that these adverse experiences, including racism have on the developing brain.¹²

Rethinking Equity

As we pause and reflect on the tumult of the past 3 years, it is important that we continue to commit to ensuring diversity, inclusivity, and equity as a mission not yet complete. The United States has endured the experience of the global COVID-19 pandemic, whilst simultaneously grappling with historical endemic racism in multiple forms manifesting most brutally in the spring and summer of 2020, with widespread recognition of disparate and unequitable policing practices. In the midst of this national acknowledgment of the significant and long-standing inequities faced by historically marginalized Black and brown people, the field of medicine¹³ joined many other fields and industries in rethinking our processes with an eye towards equity.^14-16

The mental health field in particular has informed this national discussion and recalibration as we began a deeper dive into the existing health inequities that have plagued our nation and our field.^17-20 While all of this work began well before the so-called racial reckoning occurring in the United States, the recent national dialogue has led to a refocusing on ensuring equitable care for our psychiatric patients and their families.^21-23 Our current inward focus has also strengthened our continued incorporation supporting knowledge and practice in equity, diversity, and inclusivity across our field.²⁴

For those treating the youngest amongst us, achieving equity sooner rather than later is of utmost importance, especially when confronted by the evidence cemented by the ACE’s studyand other seminal research.^1,25,26 Moreover, the COVID-19 pandemic cast a harsh spotlight on these historical inequities with respect to the impact on child and adolescent mental health, with worsening outcomes under the breadth and weight of the pandemic.²⁷

Scientific advancements have further added to our haste as we continuously catalog the ways in which these continued inequities impair developing children and youth.²⁸ However, it is not enough to simply document and recognize the adverse impacts of social determinants of mental health and adverse experiences on neurodevelopment.²⁹

We must go a step further and ensure equitable care for our nation’s youth at all points of access. According to recent US Census Bureau populations estimates, 22.2% of Americans are under the age of 18.³⁰ The literature is clear that the developing brain is most sensitive to experiences, and our nation’s growing population of children and adolescents need us to do more to ensure their optimal and equitable mental health.³⁰

Concluding Thoughts

We have the tools in our toolboxes to improve our ability to identify, assess, diagnose, and ultimately treat children and adolescents.³¹ Standards exist to guide us in our practice towards equitable care for all of our patients, even the smallest amongst us.³² Our scientific journals and national academies have pledged to move to a more equitable and just stance; we can do no less than to join them.^33-36 Our fields’ excavation and thorough examination of the state of mental and behavioral health for young individuals has included and must continue to include innovative partnerships and collaborations.^37,38 At this moment in time, as our world attempts to recover and reset, we have an important opportunity to transform the ways in which we think about and deliver care. We have the ability to advance the field, even in the midst of what seems to be devolution and retrenchment in certain sectors.

In sum, we find ourselves at yet another crossroads. Our current discourse and the actions we take as a field will clearly impact the mental health of children and adolescents moving forward. It is past time that we acknowledge our missteps, and do what we do best—learn, adapt, grow, and change, allowing us to serve this nation’s incredibly diverse youth to the best of our abilities and ensure equitable care for all.

Dr Njoroge is an assistant professor at the University of Pennsylvania Perelman School of Medicine in the Department of Psychiatry; the Associate Chair of Diversity, Equity, and Inclusion for the Department of Child and Adolescent Psychiatry; the medical director of the Young Child Clinic; and faculty at the PolicyLab all at the Children's Hospital of Philadelphia. 

Acknowledgments: The author wishes to gratefully acknowledge Clinical Research Assistant Christina Alexandre for her assistance in the literature search.

References

1. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258.

2. About the CDC-Kaiser ACE Study. Centers for Disease Control and Prevention. Accessed March 21, 2023. https://www.cdc.gov/violenceprevention/aces/about.html

3. Jones CP. Levels of racism: a theoretic framework and a gardener's tale. Am J Public Health. 2000;90(8):1212-1215.

4. Paradies Y, Ben J, Denson N, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One. 2015;10(9):e0138511.

5. Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med. 2009;32(1):20-47.

6. Graignic-Philippe R, Dayan J, Chokron S, et al. Effects of prenatal stress on fetal and child development: a critical literature review. Neurosci Biobehav Rev. 2014;43:137-162.

7. Fraiberg S, Adelson E, Shapiro V. Ghosts in the nursery. A psychoanalytic approach to the problems of impaired infant-mother relationships. J Am Acad Child Psychiatry. 1975;14(3):387-421.

8. Shonkoff JP, Garner AS; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-246.

9. Geronimus AT. The weathering hypothesis and the health of African-American women and infants: evidence and speculations. Ethn Dis. 1992;2(3):207-221.

10. McDermott CL, Hilton K, Park AT, et al. Early life stress is associated with earlier emergence of permanent molars. Proc Natl Acad Sci U S A. 2021;118(24):e2105304118.

11. Colich NL, Rosen ML, Williams ES, McLaughlin KA. Biological aging in childhood and adolescence following experiences of threat and deprivation: a systematic review and meta-analysis. Psychol Bull. 2020;146(9):721-764.

12. Berry OO, Tobon AL, Njoroge WFM. Social determinants of health: the impact of racism on early childhood mental health. Curr Psychiatry Rep. 2021;12;23(5):23.

13. Fontanarosa PB, Flanagin A, Ayanian JZ, et al. Equity and the JAMA Network. JAMA. 2021;326(7):618-620.

14. Ely RJ, Thomas DA. Getting serious about diversity: enough already with the business case. Harvard Business Review. December 2020. Accessed March 21, 2023. https://hbr.org/2020/11/getting-serious-about-diversity-enough-already-with-the-business-case

15. Cochran G. Revisiting the problem with diversity, inclusion, and equity. The Scholarly Kitchen. May 3, 2021. Accessed March 21, 2023. https://scholarlykitchen.sspnet.org/2021/05/03/revisiting-the-problem-with-diversity-inclusion-and-equity/

16. Karnik NS, Cortese S, Njoroge WFM, et al. Editorial: analyzing treatment and prescribing in large administrative datasets with a lens on equity. J Am Acad Child Adolesc Psychiatry. 2021;60(7):818-820.

17. Harris TB, Udoetuk SC, Webb S, et al. Achieving mental health equity: children and adolescents. Psychiatr Clin North Am. 2020;43(3):471-485.

18. Marrast L, Himmelstein DU, Woolhandler S. Racial and ethnic disparities in mental health care for children and young adults: a national study. Int J Health Serv. 2016;46(4):810-824.

19. Bath E, Njoroge WFM. Coloring outside the lines: making Black and Brownlives matter in the prevention of youth suicide. J Am Acad Child Adolesc Psychiatry. 2021;60(1):17-21.

20. Jordan A, Shim RS, Rodriguez CI, et al. Psychiatry diversity leadership in academic medicine: guidelines for success. Am J Psychiatry. 2021;178(3):224-228.

21. Butler M, McCreedy E, Schwer N, et al. Improving cultural competence to reduce health disparities. Agency for Healthcare Research and Quality (US). 2016 Mar. Report No.: 16-EHC006-EF.

22. Braveman PA, Kumanyika S, Fielding J, et al. Health disparities and health equity: the issue is justice. Am J Public Health. 2011;101 Suppl 1(Suppl 1):S149-155.

23. Bailey ZD, Krieger N, Agénor M, et al. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453-1463.

24. Sudak DM, DeJong SM, Bailey B, Rohrbaugh RM. Training psychiatrists to achieve mental health equity. Psychiatr Clin North Am. 2020;43(3):555-568.

25. McDonald SW, Madigan S, Racine N, et al. Maternal adverse childhood experiences, mental health, and child behaviour at age 3: the all our families community cohort study. Prev Med. 2019;118:286-294.

26. Van den Bergh BRH, van den Heuvel MI, Lahti M, et al. Prenatal developmental origins of behavior and mental health: the influence of maternal stress in pregnancy. Neurosci Biobehav Rev. 2020;117:26-64.

27. Benton T, Njoroge WFM, Ng WYK. Sounding the alarm for children's mental health during the COVID-19 pandemic. JAMA Pediatr. 2022;176(4):e216295.

28. Geronimus AT, Hicken M, Keene D, Bound J. "Weathering" and age patterns of allostatic load scores among blacks and whites in the United States. Am J Public Health. 2006;96(5):826-833.

29. Shonkoff JP, Garner AS; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-246.

30. Population Estimates Program (PEP). U.S. Census Bureau. Accessed March 21, 2023. https://www.census.gov/quickfacts/fact/table/US/AGE295221#AGE295221

31. Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126-133.

32. National standards for culturally and linguistically appropriate services in health and health care. HHS.org. Accessed March 21, 2023. https://thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedNationalCLASStandards.pdf

33. Stewart AJ. APA on its 175th anniversary: examining our past to ensure a strong future. Am J Psychiatry. 2019;176(8):603-605.

34. Novins DK, Althoff RR, Cortese S, et al. Editors' Note: First Annual Report Regarding JAACAP's Antiracist Journey. J Am Acad Child Adolesc Psychiatry. 2021;60(12):1448-1451.

35. Ng WYK. Presidential Address: CAPture belonging. J Am Acad Child Adolesc Psychiatry. 2022;61(1):10-14.

36. Stewart AJ. Response to the Presidential address. Am J Psychiatry. 2018;175(8):726-727.

37. Ring the alarm: the crisis of black youth suicide. The Action Alliance. Accessed March 21, 2023. https://theactionalliance.org/sites/default/files/ring_the_alarm-_the_crisis_of_black_youth_suicide_in_america_copy.pdf

38. Gordon J. Addressing the crisis of black youth suicide. National Institute of Mental Health. September 20, 2022. Accessed March 21, 2023. https://www.nimh.nih.gov/about/director/messages/2020/addressing-the-crisis-of-black-youth-suicide