Mental Health Disparities Among African American Youth

Introduction

African American youth continue to face significant disparities with regard to mental health challenges. Black American youth are less likely to receive mental health treatment compared to white adolescents. According to Lindsey et al. (2012), this unwillingness to provide treatment is usually not due to financial reasons, but rather due to the patient's race. Black Americans with mental health challenges often receive negative perceptions from providers, and the mental health problems they experience can cause them to stigmatize themselves (Lindsey et al., 2012). Wallace (2012) suggests that when African American youth do receive treatment, their mental health disorders are often diagnosed incorrectly or misdiagnosed, undertreated, or mistreated.

Apart from receiving minimal attention in regard to their mental health, African American youth are also less likely to utilize available mental health resources. According to Planey et al. (2019), this underutilization is especially concerning given the high prevalence of behavioral and mental health challenges among African American adolescents. Findings from the National Comorbidity Survey — Adolescent Supplement indicate that almost half of Black American participants had experienced a mental health problem before the age of eighteen. Despite this prevalence, only one quarter of Black American youths receive treatment when needed. Planey et al. (2019) found that Black American youths with major depressive disorder were less likely to visit a mental health unit or speak with a mental health professional compared to their white counterparts.

Beyond the disparities that African Americans encounter in mental health facilities, youths who are underserved in mental health services are also likely to be discriminated against in schools. Green et al. (2020) found that while most schools do provide mental health services to students, African American youths sometimes receive those services in separate settings from their white peers. Some schools also tie mental health services to certain negative outcomes such as trauma-informed practices (Joseph et al., 2020). Students of color face unique trauma experiences that expose them to externalizing behaviors, which can result in exclusion from school and increased risk of academic underperformance, future incarceration, fractured relationships, crime, and mental health strain (Joseph et al., 2020). The psychological well-being of youth of color is substantially affected by these trauma experiences.

The purpose of this paper is to examine the mental health disparities that African American youth experience in order to address those disparities and improve the psychological well-being and academic performance of Black youths. The study also includes some facilitators to seeking mental health services among African American youths, but primarily focuses on disparities. Findings from this research will help reinforce the need to eliminate barriers associated with access to mental health services among African American youths, and enhanced access to those services is likely to result in better academic outcomes.

Method

This study utilized a systematic review approach to locate relevant research studies related to the disparities that African American youths with mental health problems experience owing to their race. The databases used to search for articles were PubMed, EMBRACE, and CINAHL (Cumulative Index to Nursing and Allied Health). Key words used were: mental health, disparities, youth, and African American. Boolean operators were also used to extract the studies included — for example: disparities or barriers, and mental health or mental illnesses or mental disorders, and African American or Black American or people of color, and youth or adolescent. The search was limited to articles published between 2012 and 2020.

Journal articles selected for this study had to meet certain inclusion criteria. First, articles had to report on disparities related to seeking or receiving mental health services among African Americans. Second, articles had to report specifically on Black American youths who were 18 years of age or below. Third, articles had to report on the barriers that prevent African American youths from seeking treatment in outpatient mental health service systems. Articles also had to report on the experiences of the youths themselves, as well as those of their families and caregivers. All articles chosen were written in English.

Narrative Critical Review of Selected Studies

In a study conducted by Lindsey et al. (2012), the authors used four focus groups guided by the Unified Theory of Behavior (UTB) to understand the perceptions and help-seeking behaviors of Black youth toward mental health services. The four focus groups comprised two caregiver groups and two adolescent groups — with 11 participants in the caregiver group and 16 participants in the adolescent group. Participants were drawn from two elementary schools in an urban community. The adolescent group included 8 girls and 8 boys aged 11 to 14 years. The focus group method was well-suited to this study because it allowed participants to explore facilitators and barriers to seeking mental health services in a broad and open manner. The caregiver group included 10 male participants and one female participant aged 31 to 67 years. The adolescent group was used to capture experiences of help-seeking related to emotional health challenges, while the caregiver group helped determine how caregivers sought mental health services for their children. Facilitators of the focus groups were graduates in social work or psychology; social workers with doctoral degrees facilitated one caregiver group and one adolescent group. Each focus group discussion lasted approximately one and a half hours. Data were analyzed using template analysis in which elements of the UTB construct were applied. Themes related to behavioral intentions included: expectancies, attitudes, social norms, self-concept, affect, efficacy, knowledge, environmental constraints, and salience.

With regard to attitudes, most caregivers expressed positive attitudes toward seeking help, while a small number held negative attitudes. The adolescent group showed mixed reactions, but was generally positive that therapy could help resolve personal problems. With regard to expectancies, both groups had similar and varied voices about their expectations. Caregivers felt that seeking mental health services should depend on whether their children would be comfortable with the therapist, while the adolescents did not feel that the race of the therapist would prevent them from seeking help. Regarding social norms, caregivers were more concerned about negative views from those around them, while youth were more concerned about being gossiped about or teased by peers. With regard to self-concept, youths agreed they should seek help when needed, while caregivers reported feeling blamed for their children's mental health problems. On the topic of emotions, caregivers felt it was important to seek mental health services, whereas adolescents reported difficulty expressing their feelings. Concerning self-efficacy, caregivers believed seeking help was appropriate, but did not feel competent enough to assist their children directly. On the matter of knowledge, caregivers indicated they were unaware of the causes of mental health problems; some hoped that consulting therapists would help them gain this knowledge.

Environmental constraints were also cited as a hindrance to seeking treatment, including the lack of a nearby mental health facility. The UTB construct's dimension of salience revealed that adolescents preferred to remain silent about their mental health issues, believing that disclosure would lead to negative outcomes. However, adolescents reported feeling safe discussing mental health concerns with family members. Despite the value of this study, female participants were largely underrepresented, which means the results may not fully reflect the factors hindering African Americans from seeking help. Additionally, the authors were unable to include all intended participants — only seven adolescents and five caregivers met the inclusion criteria, which limits the alignment between sample composition and study purpose. Furthermore, because the adolescents were aged 11–14 years, the study does not capture the full range of the target age group.

In a study by Wallace (2012), the author sought to determine the role of resiliency in mental health among African Americans. Using secondary data from the Youth Risk Resiliency Survey (YRRS) 2003, the study included a total of 1,500 participants aged 15 to 18 years. Data were analyzed using SPSS version 18.0. Level of education and age were used to measure behavioral characteristics; gender was treated as a binary variable; and community connectedness, spirituality, and mindset were used as outcome measures. A Likert-type response scale with scores ranging from 1 to 6 was used to assess mindset, and a subscale using the same range assessed spirituality. Scores ranging from 1 to 7 were used to measure community connectedness. Pearson's correlation, analysis of variance, and Student's t-test were applied to compare individual characteristics across these domains.

With regard to mindset, Wallace (2012) found that participants who had positive feelings about education received higher grades than those with negative feelings. Female participants tended to have more negative feelings and lower grades, suggesting that females may demonstrate lower resiliency and academic confidence compared to their male counterparts. With regard to spirituality, no significant gender differences were found; however, students aged 18 had higher spirituality scores and lower academic grades compared to younger students. These results led the author to suggest that an individual's spiritual connectedness is associated with their level of resiliency.

A study by Planey et al. (2019) examined the barriers and facilitators to mental health help-seeking and service utilization among African Americans, using a systematic review of 15 studies conducted between January 2000 and May 2017. Included studies used empirical mixed-method, quantitative, and qualitative designs. Qualitative studies helped identify specific barriers and facilitators to mental health service use, while quantitative studies described correlates and predictors of service use and help-seeking behavior. Participants in the qualitative studies ranged from 11 to 100 individuals, while those in quantitative studies ranged from 96 to 1,005. Samples were drawn from mental health centers, juvenile detention centers, schools, and local communities in both urban and rural areas. The review identified barriers to help-seeking related to the following themes: social networks, the school system, accessibility, availability and affordability of treatment, religion and spirituality, stigma, clinician and therapeutic factors, and child-related factors. Facilitators to seeking mental health services included: geographic region, referrals and mandates from parents and gatekeepers, religion and spirituality, therapeutic factors, supportive social networks, caregiver experiences, and the severity of the child's mental health condition.

Green et al. (2020) analyzed a sample of adolescents and parents using the National Comorbidity Survey — Adolescent Supplement to determine differences in the type of mental health services that students receive in schools. The goal was to develop strategies for schools to better serve underserved youths. The study employed a face-to-face design with youths aged 13 to 18, involving 9,224 youths and a national household sample of 904 adolescents. A fully structured interview and a Composite International Diagnostic Interview (CIDI) were used to assess mental illnesses according to DSM-IV criteria. Disorders assessed included conduct disorder (CD), oppositional defiant disorder (ODD), hyperactivity disorder, dysthymic disorder, eating disorders, anxiety disorders, and mood disorders. Parent and adolescent surveys were used to evaluate whether youths received competent mental health services. School-based services were classified as school counseling, placement in a different classroom, or placement in a different school. Race was assessed via self-report, and discrete-time survival analysis was used to estimate the probability of various placements.

Results showed that one in five respondents had received mental health services in their lifetime. Among students who reported being placed in separate classrooms or separate schools due to behavioral problems, 357 and 268 students were identified, respectively. Students aged 16 to 18 were disproportionately represented among those receiving services in separate settings. Notably, Black adolescents reported being placed in separate classrooms more frequently than their white peers. A limitation of this study is that it does not adequately address strategies for reducing mental health disparities among Black Americans, which was an explicitly stated goal.

Joseph et al. (2020) also found that African American youths face racial bias when receiving mental health services, and thus proposed discipline interventions to help schools incorporate racial equity into their mental health service delivery. The authors drew on restorative practice philosophies, trauma-informed practice literature, and critical race theory (CRT) to identify practices that can promote racial equity. Using CRT, the authors argued that the experiences of African American students must be incorporated into disciplinary decisions and school policies. They also argued that the notion of "color blindness" must be eliminated and that social workers should be trained in trauma-informed practices so that those practices can be effectively implemented in racially equitable ways. While the study provides practical strategies for reducing racial bias in schools, it does not directly address mental health disparities — the primary focus of this review.