Racism, Mental Health and Trauma Research Round Up

Young people in the UK are growing up in a context where racism continues to profoundly – and adversely – impact their development. Research has demonstrated that racism affects multiple domains of development – ranging from educational outcomes to mental health [1].

In this special issue, we focus on what we are learning from research on racism and trauma as well as mental health more broadly. This remains a relatively small but growing field of scholarship that seeks to shed light on how experiences of interpersonal and structural racism can in themselves represent forms of trauma, as well as act in ways which negatively affect access to, and experience of, treatment and support. Research is one part of a wider effort that is needed to better understand the ways that racism can impact mental health and mental health care, and ultimately inform how we could improve the accessibility and efficacy of services to better meet the needs of racially minoritised children and young people.

Racial trauma, or race based stress, has been defined as “…the events of danger related to real or perceived experience of racial discrimination” [2]. These include threats or actual events that can elicit shame as well as witnessing harm to others. As with all forms of oppression, such experiences often arise within an intersectional context, where different group memberships – including gender, sexual orientation and social class – can intersect in ways that amplify the adverse impact of discrimination. Racial trauma is characterized as involving ongoing exposure over time to experiences of stress or injury both direct and vicarious and is typically interpersonal in nature [2]. In this way, it arguably shares some features with complex trauma.

We have been selective in scoping literature for inclusion in this Research Roundup by prioritising studies that have focused on children and young people published between 2011-2021. We have intentionally cast our net wider than trauma per se in order to capture several important aspects of mental health that are equally relevant to issues around trauma. Articles are clustered into five themes:

1. Impact of racial trauma and discrimination on mental health
2. PTSD, race and cultural adaptation
3. Race and the client-therapist relationship 
4. Disparities in diagnosis and treatment
5. Interventions

The first theme introduces us to research on the impact of racial trauma and discrimination on mental health. These studies provide compelling evidence that racism and racial discrimination in particular can significantly impact mental health. The work of Anderson and colleagues (2015), for example, suggest that this may in part be mediated through the impact of racial discrimination on parents. They report an association between parental experiences of racial discrimination not only on their own mental health but that of their children. In another study in the same year Andrews and colleagues found that adolescents from minoritised groups, including those who were Black and Hispanic, tended to experience higher rates of trauma-related mental health difficulties, alongside higher levels of victimisation. Such findings were found to be even more salient in the context of juvenile delinquency (Kang et al., 2014). In 2013, Cooper and colleagues explored whether the impact of racial discrimination varied by gender, finding that there may be important gender differences in what factors promote positive psychosocial outcomes. This section ends with a meta-analysis by Pieterse and colleagues (2012) based on a sample of over 18,000 Black American adults, which provides compelling evidence demonstrating a link between perceived racism and mental health.

Our second theme explores the relationship between PTSD, race and cultural adaptation. The work of Roberts and colleagues (2021) presents striking evidence of racial disparity in treatment and risk of developing PTSD. They found that people from minoritised ethnic groups (including Hispanic, Black and Asian) were less likely to receive treatment for PTSD, despite being disproportionally affected by trauma. Other researchers have considered the need for cultural adaptations to approaches to treatment for PTSD. For example, Metzger and colleagues (2021) explored how racial socialisation principles may be integrated into Trauma-Focused CBT while Williams and colleagues (2014) have considered cultural adaptations in the context of prolonged exposure therapy. Finally, the work of Polanco-Roman and colleagues (2007) suggests that as therapists we may need to be mindful that race-based traumatic stress may be associated with different patterns of symptom presentation, specifically elevated symptoms of depression.

The third theme explores issues around race and the client-therapist relationship. This work has been instrumental in shedding light on the unconscious biases that can arise in clinical work and how these in turn can significantly compromise patient-therapist interactions, ultimately leading to poorer quality of care and poorer outcomes. Minnis (2021) has recently argued that unconscious bias can lead to assumptions about the origins of mental health problems in Black families and blind clinicians to the need to offer the same systematic assessments offered to White families; she offers practical advice and principles on how we can act to reduce racial stigma. This view is supported by the work of Hall and colleagues (2015) who reviewed fifteen studies of implicit racial bias. They found that healthcare providers typically showed negative unconscious biases towards people from minoritised groups. This conclusion was also drawn by Maina and colleagues in a more recent review (2018) who found that most healthcare professionals from different levels of training and disciplines were found to have positive implicit racial biases for White or light-skin people and negative implicit racial biases for people from minoritised ethnic backgrounds (Black, Hispanic, American Indian, and dark-skinned people).

A fourth theme examines race and misdiagnosis. When examining the relationship between racial trauma and mental health, there is a conundrum – Black children under the age of 12 have better mental health than their White peers [3] yet, by adolescence, Black youth are more than twice as likely to be admitted to a psychiatric ward by compulsory means [4]. This could, at least in part, be due to racial bias at the point of psychiatric admission, but it could also be due to structural inequalities leading to missed diagnosis at an earlier stage in child development – at a time when intervention might have prevented more serious psychiatric disorder emerging. This view is supported by two studies (both from the US) that have documented delayed diagnosis of neurodevelopmental conditions in Black children. Angell and colleagues (2018) have shown that children from minoritised backgrounds are less likely than White children to be diagnosed with autism spectrum disorder (ASD), are more likely to be misdiagnosed, and are diagnosed at later ages than White children. Coker and colleagues (2016) have found that children from minoritised groups are less likely to receive a diagnosis of, and medical treatment for, ADHD than White children. Delayed diagnosis and misdiagnosis in Black children might stem, at least in part, from clinicians’ unconscious bias (that is explored in our third theme, above). It could also be construed as a form of racial trauma – a mechanism through which racial discrimination (theme one) has a negative impact on mental health.

Our final theme touches on novel approaches and interventions that may help young people in negotiating racial discrimination as well as reducing its occurrence in the first place. Anderson and Stevenson (2019) present a novel framework that focusses on how individuals may more adaptively navigate stressful racial encounters. Shonkoff and colleagues (2021) take a broader systemic perspective and consider how various forms of intervention – from housing to community resourcing – may be important in helping reduce the impact of racism on physical as well as mental health.

Collectively, these studies demonstrate that racism, mental health and trauma are deeply intertwined. Racism has profound effects on children and young people, and will have a long reach in influencing future developmental outcomes. Profound change is needed. Change is needed at the individual level – with respect to patterns of bias, stereotyping, and ignorance – so that better, more relevant research is carried out and delivered more effectively, so that there are more culturally informed clinical interventions (and systems of delivery) for children and young people who need help and support. The lack of UK-based research on racism and the mental health of children and adolescents is striking. Significant change is also needed in our mental health systems, with respect to data collection and use, resource allocation and the way in which care is (or is not) delivered through partnership, collaboration and mutual respect with those in need of support. Such change can feel overwhelming. One step forward that we can all take is to become familiar – and critically engage with – the research that is currently being conducted in this area. This research brings recognition to the reality of the impact of racial trauma and can help to catalyse the changes that are needed. We hope that this Research Round-up provides one small contribution to this effort.

Eamon McCrory, PhD, DClinPsy
Professor of Developmental Neuroscience and Pyschopathology
University College London

Helen Minnis, PhD, MBChB
Professor of Child and Adolescent Psychiatry
University of Glasgow

* For more information on the language used in these research summaries, please see this note.

Evidence

1. Gaylord-Harden, N. K., Barbarin, O., Tolan, P. H., & Murry, V. M. (2018). Understanding development of African American boys and young men: Moving from risks to positive youth development. American Psychologist, 73(6), 753–767. https://doi.org/10.1037/amp0000300  

2. Racial Trauma: Theory, Research, and Healing: Introduction to the Special Issue American Psychologist, 2019, Vol. 74, No. 1, 1–5. https://doi.org/10.1037/amp0000442   

3. Sadler, K., Vizard, T., Ford, T., Marchesell, F., Pearce, N., Mandalia, D., … & McManus, S. (2018). Mental health of children and young people in England: Trends and characteristics. Leeds, UK: NHS Digital, 2017. https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017#  

4. Walker, S., Barnett, P., Srinivasan, R., Abrol, E., & Johnson, S. (2021). Clinical and social factors associated with involuntary psychiatric hospitalisation in children and adolescents: a systematic review, meta-analysis, and narrative synthesis. The Lancet Child & Adolescent Health, 5(7), 501-512. https://doi.org/10.1016/S2352-4642(21)00089-4  

Impact of Racial Trauma and Discrimination on Mental Health

The experience of racial discrimination among caregivers impacts children’s mental health

In this study, Anderson and colleagues (2015) explored the impact of parental experiences of racial discrimination on parental practices. They also examined the impact of parental racial discrimination on parents’ and children’s mental health. 163 low-income Black families took part in this study (this study took place when all children were 7 years old; 53% female; caregivers’ age was 22-62; 97% female). The researchers found that higher levels of parent-reported discrimination was associated with higher rates of children’s emotional problems and parental symptoms of depression. Moreover, higher levels of parental depression was found to be linked to more undesirable parental practices which in turn contributed to higher rates of children’s emotional problems. This suggests that a caregiver’s exposure to racial discrimination extends beyond their direct experience and can impact their child’s well-being. In sum, the findings of this study provide evidence of how parental experiences of racism can have negative effects on children’s mental health.

Anderson, R. E., Hussain, S. B., Wilson, M. N., Shaw, D. S., Dishion, T. J., & Williams, J. L. (2015). Pathways to pain: Racial discrimination and relations between parental functioning and child psychosocial well-being. Journal of Black Psychology, 41(6), 491-512. doi:10.1177/0095798414548511

Ethnic minority status, victimisation and low household income contribute to trauma-related mental health problems

Andrews and colleagues (2015) investigated racial differences in trauma-related symptoms in adolescents. The authors also considered the role of household income and victimisation (traumatic events such as abuse, physical and sexual assault, and exposure to violence). 3,312 adolescents took part in this study (12-17 years old; 50% female; 71% White, 17% Black, and 12% Hispanic). The researchers found that, compared to White participants, Hispanic and Black adolescents experienced higher rates of trauma-related mental health symptoms (depression and post-traumatic stress disorder; PTSD), and reported exposure to more types of victimisation. Statistical analyses suggested that the tendency of Black and Hispanic young people to be exposed to a greater number of victimisation types contributed to higher levels of mental health symptoms. Moreover, the association between victimisation and mental health difficulties was stronger for those adolescents in low-income families. In sum, the findings of this study show that adolescents from minoritised ethnic groups tend to experience higher levels of trauma-related mental health difficulties, which were linked (especially in low-income families) to higher levels of victimisation.

Andrews, A. R., Jobe-Shields, L., López, C. M., Metzger, I. W., De Arellano, M. A., Saunders, B., & Kilpatrick, D. G. (2015). Polyvictimization, income, and ethnic differences in trauma-related mental health during adolescence. Social Psychiatry and Psychiatric Epidemiology, 50(8), 1223-1234. https://doi.org/10.1007/s00127-015-1077-3

Racial discrimination and psychosocial outcomes – the role of gender and social support

In this study, Cooper and colleagues (2013) explored how the negative effects of racial discrimination are influenced by gender and specific family and community factors. The researchers found that racial discrimination was linked with poorer psychosocial outcomes (e.g., greater depressive symptoms and poorer school engagement) in a group of African American adolescents (n= 1942, ages 12-18, 59% female). The researchers also found evidence for gender variation in how social support fosters positive psychosocial outcomes. While only maternal support was associated with better outcomes in boys, both maternal and paternal support was linked with better outcomes in girls. When specifically analysing factors that may buffer against the negative impact of racism among young people exposed to discrimination, the researchers found that the presence of paternal support fostered resilient outcomes only among girls. Finally, community support (religious connections or a mentor) was found to protect against the negative impact of racial discrimination only among boys. In sum, the findings of this study suggest that there may be gender differences in what factors promote positive psychosocial outcomes and reduce the negative impact of racial discrimination.

Cooper, S. M., Brown, C., Metzger, I., Clinton, Y., & Guthrie, B. (2013). Racial discrimination and African American adolescents’ adjustment: Gender variation in family and community social support, promotive and protective factors. Journal of Child and Family Studies, 22(1), 15-29. doi:10.1007/s10826-012-9608-y

A systematic review of the impact of indirect racism on children’s mental health

In this systematic review, Heard-Garris and colleagues (2018) examined the association between vicarious racism (defined as second-hand or indirect exposure to racism, such as discrimination experienced by caregivers) and children’s health. Thirty studies were included in this review. They focused on infants, children and adolescents between the ages of 0 and 19; African American/Black participants were most commonly represented (70% of studies, n = 21), and five studies (17%) included an “other” racial/ethnic category; no information on gender was provided. About half of the studies found an association between vicarious racism and poorer child’s mental health and well-being. The authors also highlighted that the lack of widely accepted measures and definition of vicarious racism may account for some of the heterogeneity in the findings. In sum, the outcome of this review suggests that vicarious/indirect racial discrimination has a negative impact on young people’s socioemotional development.

Heard-Garris, N. J., Cale, M., Camaj, L., Hamati, M. C., & Dominguez, T. P. (2018). Transmitting trauma: A systematic review of vicarious racism and child health. Social Science & Medicine, 199, 230-240. doi:10.1016/j.socscimed.2017.04.018

The role of racial discrimination on mental health symptoms among juvenile offenders

Race-based traumatic stress, or racial trauma, is the traumatic response to stress caused by encounters with racial bias, discrimination, and hate crimes (Carter, 2007). In this study, Kang and Burton (2014) investigated the role of racial discrimination, childhood trauma, and trauma symptoms in juvenile delinquency. 189 male incarcerated African American adolescents (mean age 17) took part in this study. The researchers found that exposure to racial discrimination (e.g., being evaluated negatively based on their race, being subjected to negative racial comments, having been unfairly stopped by police), childhood trauma, and PTSD symptoms all independently contributed to higher rates of reported juvenile delinquent behaviour. Moreover, young people who reported higher rates of racial discrimination also reported elevated trauma symptoms and delinquency rates. In sum, the findings of this study suggest that race-based trauma may contribute towards racial disproportionality in juvenile delinquency.

Kang, H. K., & Burton, D. L. (2014). Effects of racial discrimination, childhood trauma, and trauma symptoms on juvenile delinquency in African American incarcerated youth. Journal of Aggression, Maltreatment & Trauma, 23(10), 1109-1125. doi:10.1080/10926771.2014.968272

A review and meta-analysis of the impact of racism on mental health among Black Americans

In this meta-analysis, Pieterse and colleagues (2012) examined the association between perceived racism and mental health among Black Americans. 66 studies published between 1996 and 2011 were systematically reviewed (for a total sample size of 18,140 participants; information on age or gender of the overall sample was not reported). The authors found that higher rates of exposure to and appraised stressfulness of racist events was associated with greater likelihood of experiencing mental distress. In particular, the authors found that perceived racism was most strongly associated with poor mental health outcomes and general distress, compared to low self-esteem and life satisfaction. In sum, the findings of this review suggest that there is consistent evidence for a relationship between exposure to racism and poor mental health outcomes.

Pieterse, A. L., Todd, N. R., Neville, H. A., & Carter, R. T. (2012). Perceived racism and mental health among Black American adults: a meta-analytic review. Journal of Counseling Psychology, 59(1), 1. doi:10.1037/a0026208

Racial discrimination is linked with greater experiences of dissociation

Carter (2007) proposes that exposure to racial discrimination is a form of psychological trauma (i.e., race-based traumatic stress or racial trauma) and may elicit responses comparable to PTSD. In this study, Polanco-Roman and colleagues (2016) explored if exposure to racial discrimination is linked with dissociation (a common response to traumatic stress which entails alterations of conscious awareness and control over thoughts, feelings, memories, and sense of identity). 743 young adults (18-29 years old; 65% female; 34% non-Hispanic Black, 30% Asian, 24% Hispanic/Latino, 6% non-Hispanic White, and 6% other) completed self-reported measures of racial discrimination, coping strategies, traumatic events, and dissociative symptoms. The researchers found that exposure to racial discrimination was linked with greater symptoms of dissociation, even after considering exposure to other traumatic events and demographic variables. They also found that use of passive coping strategies (i.e., accept racial abuse as a fact of life and keep it to oneself), versus active coping strategies (i.e., do something about it and talk about it), was associated with higher rates of dissociative experiences. In sum, employing active coping strategies in response to racial discrimination might reduce the risk of experiencing race-based traumatic stress symptoms.

Polanco-Roman, L., Danies, A., & Anglin, D. M. (2016). Racial discrimination as race-based trauma, coping strategies, and dissociative symptoms among emerging adults. Psychological Trauma: Theory, Research, Practice, and Policy, 8(5), 609. doi: 10.1037/tra0000125

PTSD, race and cultural adaptation

Integrating Racial Socialisation (RS) and Trauma-Focused Cognitive Behavioural Therapy (TF-CBT)

In this article, Metzger and colleagues (2021) discuss how to integrate Trauma-Focused Cognitive Behavioural Therapy (TF-CBT), a well-established evidence-based trauma treatment for young people, with Racial Socialisation (RS), an empirically supported cultural practice. RS refers to the intergenerational process of transmitting race-related messages, culture, attitudes, and values about the meaning of race and racism among African American young people. RS is thought to be a critical developmental process that has been shown to promote young people’s ability to cope with stressors associated with racial discrimination and oppression. The authors, while encouraging consistency in the delivery of TF-CBT, make suggestions on how to adapt each stage of the intervention to promote culturally competent and person-centred treatment delivery. These include considering racial trauma during the assessment, discussing the impact of racism during psychoeducation, implementing culturally relevant relaxation techniques, helping clients identify feelings associated with the experiences of racial oppression, and sensitively considering the role of racism on trauma-related cognitions and memories. In sum, this article discusses ways to integrate RS principles into Trauma-Focused Cognitive Behavioural Therapy (TF-CBT).

Metzger, I. W., Anderson, R. E., Are, F., & Ritchwood, T. (2021). Healing Interpersonal and Racial Trauma: Integrating Racial Socialization Into Trauma-Focused Cognitive Behavioral Therapy for African American Youth. Child Maltreatment, 26(1), 17–27. doi:10.1177/1077559520921457

Racial differences in treatment and risk of developing PTSD

In this study, Roberts and colleagues (2011) examined sources of racial differences in relation to PTSD, trauma exposure, and treatment-seeking behaviour among Whites, Blacks, Hispanics, and Asians in the US general population. The authors used diagnostic interviews from a large population-representative sample of 34,653 people (all participants were adults; male and female participants were included; 58.2% White, 18.4% Hispanic,19.0% Black, 2.8% Asian). The findings suggest that the lifetime prevalence of PTSD was highest among Black people. They also found that while White people were more likely than other groups to experience any trauma, Black and Hispanic people were more likely of being exposed to childhood maltreatment (especially in the form of domestic violence). After adjusting for the characteristics of trauma, the researchers found that among those exposed to trauma, the likelihood of developing PTSD was highest among Black people. Finally, compared to White people, all minoritised ethnic groups were found to be significantly less likely to seek treatment (32-42%). In sum, the findings of this study suggest that people from minoritised ethnic groups are less likely to receive treatment for PTSD, despite being disproportionally affected by trauma.

Roberts, A. L., Gilman, S. E., Breslau, J., Breslau, N., & Koenen, K. C. (2011). Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States. Psychological Medicine, 41(1), 71-83. doi: 10.1017/S0033291710000401

Cultural adaptations of Prolonged Exposure (PE) therapy for PTSD

In this article, Williams and colleagues (2014) provide an overview on how to culturally adapt Prolonged Exposure (PE) therapy, an evidence-based treatment for PTSD, when working with African American clients exposed to racism and discrimination. The authors argue that a culturally sensitive approach to PTSD treatment may facilitate the delivery of effective interventions to minoritised ethnic groups who are disproportionally affected by trauma and race-based traumatic stress (or racial trauma). The authors provide guidelines on how to adapt the assessment process as well as the treatment components of PE (such as exposure and processing). In particular, the authors suggest clinicians: (1) use psychometric measures of race-based traumatic stress, (2) offer more sessions at the beginning of treatment to facilitate rapport building, and (3) explicitly consider race-related themes and ask clients about race-related experiences of discrimination and oppression. The authors also highlight the importance of adhering to the PE protocol and recommend incorporating the suggested adaptations only when warranted; they also warn against the homogenous application of cultural adaptations, as there is significant heterogeneity within an ethnic group. Finally, two case examples are presented in which culturally-informed adaptations of PE were implemented. In sum, this article discusses ways to adapt PE to consider cultural differences and race-related trauma.

Williams, M. T., Malcoun, E., Sawyer, B. A., Davis, D. M., Bahojb Nouri, L., & Bruce, S. L. (2014). Cultural Adaptations of Prolonged Exposure Therapy for Treatment and Prevention of Posttraumatic Stress Disorder in African Americans. Behavioral Sciences, 4(2), 102–124. doi: 10.3390/bs4020102

Race and the client-therapist relationship 

A review of unconscious racial biases among healthcare professionals

Implicit attitudes are thoughts and feelings that are outside conscious awareness, but that can nonetheless influence human behaviour without conscious control. In this review, Hall and colleagues (2015) examined the prevalence of implicit racial bias among healthcare professionals, and its impact on health outcomes. Fifteen studies were included in this review. In most studies, healthcare professionals were White (75% to 80%), Asian (10% to 30%) and a small proportion were Black and Hispanic/Latino/Latina professionals (0%–10%). In most studies, the proportion of male and female healthcare professionals were about equal. Information on the age of healthcare professionals was not reported. In line with implicit bias scores in the general population, the authors found that in all but one study, healthcare professionals had low to moderate levels of implicit racial/ethnic bias (i.e., positive unconscious attitudes towards White people and negative unconscious attitudes towards Black and Hispanic people). Moreover, some studies found that negative implicit attitudes about people from minoritised ethnic groups were related to poorer patient-provider interactions, treatment decisions, treatment adherence, and patient health. In sum, the findings of this review show that most healthcare providers have negative unconscious biases towards people from minoritised ethnic groups.

Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., Eng, E., Day, S. H., & Coyne-Beasley, T. (2015). Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. American Journal of Public Health, 105(12), e60–e76. doi:10.2105/AJPH.2015.302903

Unconscious racial biases among healthcare professionals – an updated review

The results from the seminal systematic review on racial bias among healthcare professionals by Hall and colleagues (2015) (summarised above) were further expanded and updated by Maina and colleagues (2018). Thirsty-seven studies were included. The total number of healthcare providers participants was 10,013. Of 35 studies reporting sex, females comprised 58% on average (range 7–100%). Thirty-five studies reported race/ethnicity, with the majority of healthcare providers being White or Asian while only 9% were Black and 3% were Hispanic. The main findings were in line with the previous review by Hall and colleagues (2015). Most healthcare professionals from different levels of training and disciplines were found to have positive implicit racial biases for White or light-skin people and negative implicit racial biases for people from minoritised ethnic backgrounds (Black, Hispanic, American Indian, and dark-skinned people). Moreover, this review revealed that healthcare professionals’ characteristics influence racial biases – Black healthcare providers are less likely to show implicit racial biases compared to professionals from White or other ethnic backgrounds. In line with the previous review, the authors also found consistent evidence for a link between greater racial bias and poorer patient-provider interactions. On the other hand, there is limited and mixed evidence for the impact of implicit racial biases on patient care and outcomes – only some studies have found a link with poorer clinical outcomes. Finally, only two studies at the time of this review had investigated methods to reduce implicit racial bias and only one demonstrated post-intervention improvements. In sum, the findings of this review suggest that most healthcare providers have negative unconscious biases towards people from minoritised ethnic groups; such biases were also linked to poorer patient-professional interactions.

Maina, I. W., Belton, T. D., Ginzberg, S., Singh, A., & Johnson, T. J. (2018). A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Social Science & Medicine, 199, 219-229. doi: 10.1016/j.socscimed.2017.05.009

Racial stigma among UK mental health professionals

In this brief commentary, Minnis (2021)^* provides examples of how negative racial stereotyping (or stigma) can influence mental health professionals in their clinical judgment – biasing diagnosis and delaying (or even precluding) access to treatment. Stigma is more challenging to overcome when patients come from a culture or social class that is different from that of the mental health professional. Therefore, the author argues that in addition to raising awareness to reduce implicit (or unconscious) racial biases, a conscious effort should be made by all professionals to offer the best service to children and adolescents who come from a different background than their own. Using standardised diagnostic tools rather than relying solely on subjective appraisals in the assessment process can also ameliorate the impact of negative racial biases. Minnis (2021) argues that culturally competent clinical practice should be based on openness, sensitivity, and ‘respectful curiosity’ in the context of a collaborative relationship with patients. In sum, this commentary argues that racism is systematically and deeply seated within the UK mental health community and offers practical advice and principles on how to reduce racial stigma.

Minnis, H. (2021). Stigma in practice. The Lancet Psychiatry, 8(6), 466–468. doi: 10.1016/S2215-0366(21)00116-4

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Disparities in diagnosis and treatment

A review of disparities in autism spectrum disorder diagnosis and service access in racial and ethnic minority children in the United States

In this article, Angell and colleagues (2018) review knowledge relating to why children from racial and ethnic minority backgrounds are less likely than White children to be diagnosed with autism spectrum disorder (ASD) and are less likely to access relevant services. Parents of racial and ethnic minority children are less likely to report and have greater delays in reporting ASD concerns. This may be due to challenges with access to information, communication, navigating complex systems, as well as cultural stigma, distrust of providers and systems, and discouragement from family or community. Other causes for disparities in diagnosis of ASD in minoritised children include clinical bias, as well as racial and ethnic variability in behavioural presentations of ASD. Diagnostic disparities impact access to critical early intervention. Racial and ethnic minority children with ASD are less likely than White children to access healthcare services and intervention. This may be due to difficulties in accessing services and information, and cultural stigma. The authors highlight specific disparities in diagnosis and access to services and interventions for different racial and ethnic groups, highlighting the need to include culturally diverse populations in research relating to disparities and acceptability of services and intervention. Efforts to reduce ASD disparities include support for early awareness, screening and interventions that are culturally tailored. In sum, racial and ethnic minority children are more likely to experience disparities in ASD diagnosis and service access than White children in the United States. 

Angell, A. M., Empey, A., & Zuckerman, K. E. (2018). A Review of Diagnosis and Service Disparities Among Children With Autism From Racial and Ethnic Minority Groups in the United States. In R. M. Hodapp, & D. J. Fidler (Eds.), International Review of Research in Developmental Disabilities (pp. 145-180). (International Review of Research in Developmental Disabilities; Vol. 55). Academic Press Inc.  https://doi.org/10.1016/bs.irrdd.2018.08.003 

Disparities of ADHD diagnosis and treatment in African-American and Latino children in the United States

Diagnoses of attention-deficit/hyperactivity disorder (ADHD) have been increasing in the United States. However, African-American and Latino children have been found to have lower rates of diagnosis and medical treatment as compared to White children. This study by Coker and colleagues (2016) examined whether the disparity in ADHD diagnosis and treatment was due to underdiagnosis or undertreatment of African American and Latino children, or overdiagnosis or overtreatment of White children. 4297 children participated in all 3 waves (5^th, 7^th, 10^th grade; 10-12 years in 5^th grade [n=16 were 8-9]; 51.1% male; 44.4% Latino, 29.1% African-American, 22.1% White, 4.4% Other). The researchers found that African-American and Latino children were less likely to have received an ADHD diagnosis as compared with White children. African-American and Latino children who had a potential need for ADHD medication (owing to ADHD symptoms or diagnosis) were less likely than White children (with ADHD symptoms or diagnosis) to take ADHD medication. Among children without ADHD symptoms or diagnosis, there was no difference between African-American, Latino and White children in terms of medication use. Taken together, these findings suggest that the disparities in diagnosis and treatment are more likely due to the underdiagnosis/undertreatment of African-American and Latino children than the overdiagnosis/overtreatment of White children. The authors highlight the importance of actively engaging with parents, providing culturally relevant care, and linking parents with service providers as potential ways of reducing the racial/ethnic disparities in diagnosis and treatment of ADHD. In sum, African-American and Latino children are less likely to receive a diagnosis of and medical treatment for ADHD than White children in the United States. 

Coker, T. R., Elliott, M. N., Toomey, S. L., Schwebel, D. C., Cuccaro, P., Tortolero Emery, S., Davies, S. L., Visser, S. N., & Schuster, M. A. (2016). Racial and Ethnic Disparities in ADHD Diagnosis and Treatment. Pediatrics, 138(3), e20160407. https://doi.org/10.1542/peds.2016-0407 

Interventions

RECAST – clinical and practical application of Racial Socialisation (RS) to reduce the impact of racial stress and trauma

Many parents from racialised/minoritised ethnic groups use racial socialisation (RS; the verbal or non-verbal communication about racialised experiences) to help their children cope with the stress caused by direct or vicarious racial discrimination. In this theoretical paper, Anderson and Stevenson (2019) argue that current research has established the association between RS and adaptive outcomes in young people. However, it remains unclear how RS is transmitted, received, and applied to reduce racial stress and trauma. The authors propose a novel theory – Racial Encounter Coping Appraisal and Socialisation Theory (RECAST) – in which RS is proposed to reduce the impact of racial stress and promote coping by fostering racial self-efficacy (the belief that one can control or manage a racial stressor). A crucial element of this model is also racial literacy, that is the ability to read racially stressful encounters (e.g., decode and interpret), recast (e.g., reappraise stigmatising narratives), and resolve (e.g., engage in problem-solving and healthy decision-making). The authors also propose ways to integrate RECAST in trauma-focused clinical interventions for young people. In sum, the authors argue that RS promotes the wellbeing of young people by fostering confidence in their ability to detect, understand and cope with racial discrimination.

Anderson, R. E., & Stevenson, H. C. (2019). RECASTing racial stress and trauma: Theorizing the healing potential of racial socialization in families. American Psychologist, 74(1), 63-75. doi: 10.1037/amp0000392

A review of interventions aimed at reducing the impact of racism on mental and physical health

In this review, Shonkoff and colleagues (2021) examine the evidence of the negative impact that early adversity, racial discrimination, and racial trauma have on the developing brain and other biological systems. They do so by reviewing the evidence about how physical and mental health is negatively impacted by different forms of racism, including institutional/structural racism, residential segregation, racism within the criminal justice system, immigration policies, cultural racism, interpersonal discrimination, vicarious racial trauma, and racism-related exacerbation of common stressors. Specific demographic factors, such as age and gender, were not systematically considered. The authors conclude by reviewing the evidence (and suggesting future research priorities) of interventions aimed at reducing the occurrence or impact of racial discrimination. These include housing programmes aimed at reducing residential segregation, community-based intervention aimed at improving local resources and opportunities, interventions aimed at reducing cultural racism by promoting intergroup contact, and interventions aimed at promoting resilience in the face of interpersonal discrimination (for example by enhancing psychological and coping skills). In sum, this article reviews the evidence of the negative impact of early adversity and racism on health and examines current and potential areas for intervention.

Shonkoff, J. P., Slopen, N., & Williams, D. R. (2021). Early Childhood Adversity, Toxic Stress, and the Impacts of Racism on the Foundations of Health. Annual Review of Public Health, 42, 115–134. doi: 10.1146/annurev-publhealth-090419-101940

A note on the language:

Each summary lists the size, age, ethnicity, and gender of the sample according to the terms given in the source literature. However, we recognise that there is not a clear consensus on how these terms are (or should be) presented in the literature, and that in some cases terminology and categorisation may cause unintended offense or harm. We are continuously discussing how to use language addressing race, ethnicity and gender when writing about research and are open to feedback to how this can be improved in our research communication and dissemination. Please send feedback on language or our approach to uktc@annafreud.org.