Examining the Reality: The Influence of Social Inequities on Child and Adolescent Mental Health

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SPECIAL REPORT: CHILD AND ADOLESCENT PSYCHIATRY

Children’s mental health disorders are common, with approximately 20% of youth experiencing an emotional or behavioral disturbance annually.¹ In recent years, children and families have coped with both the global COVID-19 pandemic and the ongoing battle for racial justice amplified by the recorded police killing of George Floyd in 2020. The disruption and stress placed on families during this time led to heightened mental health concerns in children and adolescents. In 2021, the American Academy of Child and Adolescent Psychiatry (AACAP), the American Academy of Pediatrics (AAP), and the Children’s Hospital Association (CHA) declared a crisis in children’s mental health.² The pandemic highlighted the disparities in health (including mental health) access and outcomes for minoritized families driven by the social determinants of health (ie, financial security, stable housing, food security, and access to health insurance and health services).³ These disparities are particularly salient for children as they influence the developing brain and youths’ ability to achieve physical and emotional developmental milestones. The lack of these basic needs increases the risk for adverse childhood experiences, which have been well documented to increase adverse physical and mental health outcomes in childhood and beyond.⁴

Structural Determinants of Health

While racial disparities in access to mental health services have long been recognized, rarely do the interventions to address them target the upstream factors that drive these disparities. Underlying these disparities are what has been termed structural determinants of health, which the World Health Organization defines as “the governing processes, and economic and social policies that influence the distribution of the social determinants.”⁵ In the United States, these policies and societal norms perpetuate inequities by race, gender identity, sexual orientation, and other minoritized statuses. Subsequently, marginalized youth are more likely to experience 1 or more adverse structural determinants of health, driving persistent mental health inequities.

Educational System

One example of the impact of structural determinants on a child’s mental health is in the educational system. Access to quality education influences mental health outcomes across the developmental spectrum.⁶ Structural inequities in the school system contribute to mental disparities for children and adults.⁷ For children, who spend much of their day in school, these inequities have a significant and direct impact. From racial segregation to youth with disabilities being separated from their peers, we have seen the influence of structural determinants on the quality of education youth receive.

Case law and legislation such as Brown vs Board of Education, Every Student Succeeds Act, No Child Left Behind Act, and the Civil Rights Act have worked to reduce these disparities, yet youth continue to face challenges today.^8,9 The Fair Housing Act, intended to end residential segregation, unexpectedly led to its continuation with “economic segregation” by “White Flight” (“where white families moved to wealthier areas to raise their children”).^10-12 These areas, formerly occupied by white families, experienced disenfranchisement through harmful practices such as redlining and targeted disinvestment, leading to the decline of the property’s value. Since a substantial portion of public school funding is derived from property taxes, living in an area with low property taxes leads to lower funding for schools in that district.¹³ This leads to disparities regarding school resources in low socioeconomic areas despite often having larger student populations.

Teachers and staff are often the first to identify and refer students for mental health concerns. Underfunding paired with overcrowding of classrooms increases the strain on teachers and staff to meet the needs of children. This strain, coupled with societal stereotypes such as Black boys being viewed as older and teachers punishing Black students more severely than their counterparts, decreases the recognition of mental illness in students from marginalized communities.^14,15 In addition, this oversight means they are not provided with the proper services and are unfortunately diverted to a perpetual cycle of punishment for their behavior. For example, children who experience anxiety, depression, and trauma symptoms present with symptoms that are easily misinterpreted as disruptive behaviors. This means that instead of referral to care, they are seen as having a “conduct problem” and have increased contact with school policing. They are often excluded from school by detention, suspension, or expulsion, further increasing psychological distress.

This is one example of the many structural factors that drive the increased need for mental health care and barriers to access. Given that half of all mental health disorders onset by age 14, mental health professionals should be involved in advancing mental health equity for young individuals.16 If we address inequities in children, we can decrease inequities in mental health disorders across the lifespan. The first step is educating ourselves and our communities about the structural and social determinants of mental health and their critical role in mental health outcomes. It is also critical to study those factors that mitigate the impact of structural determinants on the communities that we serve. This means openly dialoguing with our communities about their specific needs and strengths.

Clinicians should approach each family they encounter from a stance of cultural humility. In contrast to cultural competency, cultural humility allows clinicians to avoid assumptions about their patients based on identified cultures. Clinicians, instead, should be curious about how patients’ lived experiences impact their clinical presentation and treatment plan. To do this, clinicians must examine how their own lived experiences may bias their view of the patients and families they serve.

Concluding Thoughts

We must advocate for youth who, unlike adults, do not have a voice in influencing the development of policies that promote their well-being. Clinicians should advocate for policies that foster access to youth-friendly and culturally oriented services that remove structural barriers to fostering the overall well-being of children and families. Advocacy can occur proximally within your clinic, hospital, or institution. This includes reviewing clinic policies for their intended and unintended consequences on marginalized groups, working with communities to develop culturally relevant quality measures, and examining how existing quality measures impact marginalized groups. Advocacy must also occur at the state and national levels. This includes supporting policies that enforce mental health parity so that mental health services are reimbursed at equitable rates. Other policies that support social determinants of health—like those that support housing and food access, living wages, universal daycare, and paid parental leave—can help decrease inequities. It is critically important to support funding for research into inequities, particularly in the aftermath of the COVID-19 pandemic.

To reduce the disparities in children’s mental health, we, both as clinicians and members of our communities, must act. We must become knowledgeable of the social and structural determinants of health and empower our communities to recognize their impact in their daily lives. We must take a multipronged approach that includes evaluating and addressing the biases and inequities within our communities and the systems in place that have created these disparities. Only then can we truly improve mental and physical health outcomes for all.

Dr Lewis is a graduating child and adolescent psychiatry fellow in psychiatry and behavioral sciences at Morehouse School of Medicine.Dr Williams is an adult, adolescent, and child psychiatrist as well as an associate professor in psychiatry and behavioral sciences at Morehouse School of Medicine. Dr Cotton is an adult, adolescent, and child psychiatrist as well as an assistant professor in psychiatry and behavioral sciences at Morehouse School of Medicine.

References

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2. AAP-AACAP-CHA Declaration of a National Emergency in Child and Adolescent Mental Health. American Academy of Pediatrics. Updated October 19, 2021. Accessed April 4, 2023. https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/

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8. Supreme Court. Brown v. Board of Education (1954). National Archives and Records Administration. Updated November 22, 2021. Accessed April 4, 2023. https://www.archives.gov/milestone-documents/brown-v-board-of-education

9. Laws & guidance. US Department of Education. Accessed April 4, 2023. https://www2.ed.gov/policy/landing.jhtml?src=ft

10. History of Fair Housing. US Department of Housing and Urban Development. Accessed April 4, 2023. https://web.archive.org/web/20120327032116/http://portal.hud.gov/hudportal/HUD

11. Blume H. Economic segregation in schools has worsened, widening achievement gaps, study says. Los Angeles Times. February 1, 2022. Accessed April 4, 2023. https://www.latimes.com/california/story/2022-02-01/economic-segregation-in-schools-has-worsened-study-says

12. Zou L. White flight may still enforce segregation. American Psychological Association. October 25, 2021. Accessed April 4, 2023. https://www.apa.org/news/press/releases/2021/10/white-flight-segregation

13. Chen G. An overview of the funding of public schools. Public School Review. Updated June 22, 2022. Accessed April 4, 2023. https://www.publicschoolreview.com/blog/an-overview-of-the-funding-of-public-schools

14. Black boys viewed as older, less innocent than whites, research finds. American Psychological Association. 2014. Accessed April 4, 2023. https://www.apa.org/news/press/releases/2014/03/black-boys-older

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16. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.