Also In This Special Report
Frank A. Clark, MD
Geoffrey Z. Liu, MD; Margaret Cheng Tuttle, MD
Understanding a patient's sociocultural background will have an important effect on treatment, especially for Hispanic patients.
SPECIAL REPORT: MINORITY MENTAL HEALTH PART 1
According to the 2019 US Census Bureau population estimate, Hispanics comprise 18% of the total US population (61 million), with 31% aged less than 18 years, making them the nation’s largest and youngest racial and ethnic group.1 Since more than half of mental health disorders begin by age 14 years, and 75% by age 24 years,2 the role of culturally humble, curious, and attuned child and adolescent mental health professionals is critical.
Although we will use the terms Latino/Latina/Latinx and Hispanic interchangeably, there are distinctions between them: “Hispanic” refers to a common language and describes those whose ancestry derives from Spain or Spanish-speaking countries; “Latino/Latina,” most recently replaced by the gender-neutral alternative “Latinx,” refers to geography and indicates a Latin American origin.3 The federal government recognizes just 1 ethnic group in its classification system: according to the 2010 and 2020 Census, “Hispanic or Latino” is defined as “a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.”4 This one-size-fits-all definition of “Hispanic or Latino” and collective labeling of several self-sustained ethnicities can lead to overgeneralizations, misconceptions, and stereotyping of the diverse Latinx community. The prevalence and clinical presentation of mental illness, the willingness to seek and accept care, and lived experiences can vary significantly among Latinx subgroups. Given this heterogeneity, clinicians should embrace such diversity, recognizing the clinical importance of providing respectful subgroup-specific care (Table 1).
Latinx individuals often face inequities in education, socioeconomic status, insurance coverage, and even risk of death related to police intervention. Unfortunately, disparities are further exacerbated among Hispanics due to language barriers and undocumented immigration status. Patients with limited English proficiency or English as a second language struggle during mental health visits; communication of abstract concepts such as emotions and psychiatric symptoms in a language other than one’s mother tongue is extremely challenging, especially during times of internal distress.5
According to the US Census Bureau, Hispanics on average hold a lower educational level in the United States compared with other racial and ethnic groups.1,6 Hispanics also have the highest uninsured rates of any racial or ethnic group within the United States (19% of the Hispanic population was not covered by health insurance vs 6% of the non-Hispanic White population).1 Similarly, the unemployment rate and the percentage of individuals living at or below the poverty level are higher for Hispanics as compared with non-Hispanic Whites.1
Further compounding such disparities, food insecurity is associated with a heightened risk of past-year mood, anxiety, and substance use disorders in children.7 Poverty and mental illness interact in a negative cycle: Individuals who live in poverty are at increased risk of mental illness and, in turn, there is an increased likelihood that those living with mental illness will drift into or remain in poverty.8
Hispanics have the highest prevalence 17% of type 2 diabetes in the countryat 17%; for non-Hispanic Whites, the prevalence is 8%.9 Diabetes is also increasingly recognized as a risk factor for serious mental illness, depression being twice as high in individuals with type 1 or type 2 diabetes compared with the general population.10 However, given the diversity within Latinx/Hispanics, it is not surprising that the rates of illness can also vary significantly within subgroups. For example, Puerto Ricans are twice as likely as someone whose background is South American to develop type 2 diabetes9; Puerto Ricans also suffer disproportionately from asthma, HIV-AIDS, and infant mortality.1
Frank A. Clark, MD
Geoffrey Z. Liu, MD; Margaret Cheng Tuttle, MD
According to a 2019 US Census Bureau report, 24% of Hispanics, in comparison with 15% of non-Hispanic Whites, worked within service occupations; 24% and 45%, respectively, worked in managerial or professional occupations.1 These differences in occupations explain in part why Latinx parents have difficulties accessing medical care for themselves and their children: Hispanics are more likely to work in jobs that do not provide paid time off; at other times, they do not request sick leave due to fear of, or threats of, deportation by employers. Communication and language barriers, cultural differences between patients and providers, and historical and current discrimination in health care systems are other factors affecting access to health care, especially psychiatric care.
Latinx Victims of Police Shootings
According to data compiled by The Washington Post, 111 children have died by police use of force in the United States over the past 6 years; 22 of those children were aged less than 16 years, and three-quarters of these 22 were children of color.11 One of those children was Adam Toledo, a Latinx 13-year-old boy who, although unarmed, was shot and killed by police in Chicago after an officer believed the boy was holding a weapon. A recent study published in Pediatrics found that Black and Hispanic adolescents are significantly more likely to die from shootings related to police intervention compared with non-Hispanic White adolescents.12 Compared with non-Hispanic White children, Hispanic children had a risk of death due to legal intervention almost 3 times higher. These disparities are clear and unacceptable, and they should alarm clinicians, especially those caring for children and adolescents of color.
These data are not only heartbreaking but point to inescapable effects on the mental health, physical health, well-being, and overall future of the family members left behind. The death of a young Latinx male, often the primary breadwinner for immigrant or first-generation families, leaves a void within the family system and the overall community. The offspring of the young victim grow up without a male role model, directly affecting the overall sense of safety offered by a tight-knit family. It also leads to the need for single mothers to take multiple jobs to make ends meet, causing a rupture in the family system, with older siblings often taking the role of primary caretakers for younger siblings, in turn increasing the likelihood of dropping out of high school and decreasing the likelihood of college attendance; lower levels of educational attainment limit future job options and lead to lower-paying or less stable jobs.
The alarming frequency of young Black and Hispanic individuals’ deaths by gunshot wounds during police encounters have a wide-ranging impact on the entire community, exacerbating feelings of hopelessness, oppression, discrimination, and distrust in the legal system. In our clinical experience this, in turn, can have the unwanted effect of further alienating communities of color from medical and political systems that are often viewed as complicit, leading to fewer medical check-ups, less openness to seek medical or psychiatric attention when needed, and even less likelihood to vote, further perpetuating the cycle of discrimination and isolation for generations to come. Research has shown that police violence can take a toll on the mental health of communities; police brutality and killings can be associated with greater risks of distress and suicide attempts.13
Race and COVID-19
The year 2020 saw 2 major cultural phenomena: the COVID-19 pandemic, and a resurgence of the conversation around racial equity and structural racism in the United States.2 The synergistic nature of the health and social problems facing people of color, as well as the toxic stress resulting from racial and social inequities, have been magnified during the pandemic, bringing to the forefront disparities in access to care among Latinx communities.
According to data gathered through March 2021, Latinx Americans had experienced 18% of COVID-19–related deaths in people of known race.14 Latinx individuals were held in precarious and at times inhumane conditions in US Immigration and Customs Enforcement (ICE) detention facilities, and individuals in ICE facilities had rates of SARS-CoV-2 infection that were 6 to 22 times higher per month than those of the general population between April and August 2020.15 Children and families in immigration detention settings and those experiencing homelessness and living in shelters endured similarly disproportionate risk of exposure.
Latinx youth and their families have been impacted severely by COVID-19, with Centers for Disease Control and Prevention (CDC) data showing disproportionate hospitalization rates (more than 3 times higher compared with non-Latinx Whites), and death rates that are more than twice as high.16 Latinx children had higher pediatric case rates, hospitalizations, and virus-related complications.17 Poor access to reliable or sustainable telehealth technology among Latinx children worsened health care access and exacerbated gaps in educational attainment, especially throughout the multiple lockdowns and in-person school cancellations during the COVID-19 pandemic.18
Health care barriers, including lack of insurance and immigration fears, have also contributed to the worsening of preexisting health conditions (eg, asthma, diabetes) and delays in COVID-19 treatment during acute illness and for aftercare.16 In addition, Latinx individuals, especially undocumented immigrants, have limited job options, do not have paid sick days, and often endure unhealthy work environments in which employers use threats or fear of deportation to their advantage. When they do get sick or are symptomatic, they continue working, increasing their own risk of worse outcomes from COVID-19 and potentially spreading the virus among coworkers.
Adding insult to injury, there is a large gap in COVID-19 vaccination rates for Hispanics. Black and Hispanic individuals have received a smaller share of vaccinations in proportion to the cases and deaths in their populations, and, in most states, in proportion to total population. Across 42 states, the percentage of the White population that has received at least 1 COVID-19 vaccine dose (39%) was roughly 1.5 times higher than the rate for Black (25%) and Hispanic individuals (27%) as of May 3, 2021.19
Racial and Ethnic Trauma
The American Academy of Pediatrics published “The Impact of Racism on Child and Adolescent Health” in August 2019. This policy statement, endorsed by both the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association, states that “racism, which is mediated through implicit and explicit biases, institutional structures, and interpersonal relationships, is a social determinant of health that undermines health equity for all children, adolescents, emerging adults, and their families.”20 The race-based traumatic stress theory suggests that some racial and ethnic minority individuals may experience racial or ethnic discrimination as a psychological trauma, as it may elicit a response comparable with posttraumatic stress.21 These experiences of racial or ethnic discrimination include threats of harm and injury, humiliating and shaming events, and witnessing harm to other people of color due to real or perceived racism.
Experiences of marginalization and discrimination have led to chronic and toxic stress, and they have shaped social and economic factors affecting the health and well-being of Latinx communities. Maladaptive reactions to racial and ethnic discrimination through use of avoidant or passive coping strategies may render minority groups, particularly youth, more vulnerable to negative mental health outcomes, including posttraumatic stress and dissociative symptoms. Flores et al found that Mexican American adolescents who reported racial discrimination also reported more posttraumatic stress symptoms, and in turn, greater drug and alcohol use—a common avoidant coping strategy evident in trauma-exposed individuals.22 Factors including a strong racial/ethnic identity, ethnic/racial socialization within family, and religiosity/spirituality have shown to be protective against the damaging effects of racial and ethnic adversity.23
Historical bias, lack of culturally humble and aware providers, inadequate or misinformed care, fear of deportation, language barriers, and underrepresentation of Latinx child psychiatrists are just a few of the factors that exacerbate disparities in access to care among Latinx communities. Clinicians should use a cultural component in their formulation when conceptualizing clinical presentations, thinking ethnographically while remaining patient-centered so that patients and families can teach providers about their own culture. Clinicians should not shy away from asking patients about experiences they have had in facing racism, discrimination, or hierarchical mistreatment. An understanding of patients’ sociocultural background, including experiences of discrimination and racial/ethnic trauma, will have important effects on treatment adherence and the likelihood of seeking future care.
We should continue working to address existing socioeconomic, health care, and structural inequities, which place so many children and families at risk of poor outcomes (Table 2). Health interventions that consider the nuances of race, ethnicity, culture, and community differences, provided by self-aware and culturally humble clinicians, have a vital role in reducing health disparities, promoting health equity, increasing trust in systems of care, and improving both the physical and mental health of Latinx children, adolescents, and families.
Dr Lisotto is a board-certified adult and child/adolescent psychiatrist. She is an instructor in psychiatry at Harvard Medical School and an attending at the Massachusetts General Hospital Chelsea Health Center. She also has a small private practice in Boston. Dr Martin is the Riva Ariella Ritvo Professor in the Child Study Center and director of the Standardized Patient Program, Teaching and Learning Center, both at the Yale School of Medicine. He is also medical director of the Children’s Psychiatric Inpatient Service at Yale-New Haven Hospital. Dr Martin served as editor-in-chief of the Journal of the American Academy of Child and Adolescent Psychiatry from 2008 to 2017.
1. Profile: Hispanic/Latino Americans. US Department of Health and Human Services, Office of Minority Health. April 5, 2021. Accessed June 2, 2021. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64.
2. Al-Mateen CS, Parekh R, Lisotto MJ, Carter RD. Introduction to cultural psychiatry. In: Parekh R, Al-Mateen CS, Lisotto MJ, Carter RD, eds. Cultural Psychiatry with Children, Adolescents, and Families, 1st ed. American Psychiatric Association Publishing; 2021:1-20.
3. Lisotto MJ, Fortuna LR, Martin A. Bridging the gap in psychiatric care of Latinx youth and families. In: Parekh R, Al-Mateen CS, Lisotto MJ, Carter RD, eds. Cultural Psychiatry with Children, Adolescents, and Families, 1st ed. American Psychiatric Association Publishing; 2021:71-92.
4. About Hispanic origin. United States Census Bureau. Updated October 16, 2020. Accessed April 20, 2021. https://www.census.gov/topics/population/hispanic-origin/about.html
5. Bauer AM, Alegría M. Impact of patient language proficiency and interpreter service use on the quality of psychiatric care: a systematic review. Psychiatr Serv. 2010;61(8):765-773.
6. U.S. Census Bureau releases new educational attainment data. News release. United States Census Bureau; March 30, 2020. Accessed April 29, 2021. https://www.census.gov/newsroom/press-releases/2020/educational-attainment.html
7. McLaughlin KA, Greif Green J, Alegría M, et al. Food insecurity and mental disorders in a national sample of US adolescents. J Am Acad Child Adolesc Psychiatry. 2012;51(12):1293-1303.
8. Lund C, De Silva M, Plagerson S, et al. Poverty and mental disorders: breaking the cycle in low-income and middle-income countries. Lancet. 2011;378(9801):1502-1514.
9. Hispanic/Latino Americans and type 2 diabetes. CDC. Updated April 7, 2021. Accessed uly 1, 2021. https://www.cdc.gov/diabetes/library/features/hispanic-diabetes.html
10. Ducat L, Philipson LH, Anderson BJ. The mental health comorbidities of diabetes. JAMA. 2014;312(7):691-692.
11. Tate J, Jenkins J, Rich S. Fatal force: police shootings database 2015-2021. The Washington Post. Updated May 29, 2021. Accessed June 2, 2021. https://www.washingtonpost.com/graphics/investigations/police-shootings-database/ .
12. Badolato GM, Boyle MD, McCarter R, et al. Racial and ethnic disparities in firearm-related pediatric deaths related to legal intervention. Pediatrics. 2020;146(6):e2020015917.
13. DeVylder J, Fedina L, Link B. Impact of police violence on mental health: a theoretical framework. Am J Public Health. 2020;110(11):1704-1710.
14. APM Research Lab Staff. Color of coronavirus: COVID-19 deaths analyzed by race and ethnicity in the U.S. APM Research Lab. March 5, 2021. Accessed June 2, 2021. https://www.apmresearchlab.org/covid/deaths-by-race
15. Erfani P, Uppal N, Lee CH, et al. COVID-19 testing and cases in immigration detention centers, April-August 2020. JAMA. 2021;325(2):182-184.
16. Risk for COVID-19 infection, hospitalization, and death by race/ethnicity. CDC. Updated May 26, 2021. Accessed June 2, 2021. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
17. Aguilera E. The virus and the vulnerable: Latino children suffer higher rates of COVID-19. CalMatters. July 7, 2020. Accessed June 2, 2021. https://calmatters.org/children-and-youth/2020/07/the-virus-and-the-vulnerable-latino-children-suffer-higher-rates-of-covid-19
18. García E, Weiss E. COVID-19 and student performance, equity, and U.S. education policy: lessons from pre-pandemic research to inform relief, recovery, and rebuilding. Economic Policy Institute. September 10, 2020. Accessed June 21, 2021. https://www.epi.org/publication/the-consequences-of-the-covid-19-pandemic-for-education-performance-and-equity-in-the-united-states-what-can-we-learn-from-pre-pandemic-research-to-inform-relief-recovery-and-rebuilding/
19. Ndugga N, Pham O, Hill L, et al. Latest data on COVID-19 vaccinations race/ethnicity. Kaiser Family Foundation. Updated June 30, 2021. AccessedJuly 1, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-race-ethnicity/
20. Trent M, Dooley DG, Dougé J; Section on Adolescent Health; Council on Community Pediatrics; Committee on Adolescence. The impact of racism on child and adolescent health. Pediatrics. 2019;144(2):e20191765.
21. Carter RT. Racism and psychological and emotional injury: recognizing and assessing race-based traumatic stress. The Counseling Psychologist. 2007;35(1):13-105.
22. Flores E, Tschann JM, Dimas JM, et al. Perceived racial/ethnic discrimination, posttraumatic stress symptoms, and health risk behaviors among Mexican American adolescents. J Couns Psychol. 2010;57(3):264-273.
23. Neblett EW Jr, Rivas-Drake D, Umaña-Taylor AJ. The promise of racial and ethnic protective factors in promoting ethnic minority youth development. Child Development Perspectives. 2012;6(3):295-303. ❒