Racial Disparities in Elementary School Disciplinary Actions: Findings From the ABCD Study

Mental Health Crisis Responses and (In)Justice: Intrasystem and Intersystem Implications

Mental health crises among people who are marginalized merit special consideration. These groups are both overserved and underserved by mental health crisis systems: over-represented in acute treatment settings by number while facing inequities in outcomes. The predisposing, precipitating, and perpetuating factors that contribute to crises, however, neither begin nor end with the mental health system. Rather, these factors are multisystemic. As an illustration of this concept, this article highlights select marginalized groups, those that have faced inequities in mental health diagnosis and treatment due to race, medical complexity, age, and criminal justice system involvement.

Youth Suicide and Preceding Mental Health Diagnosis

Importance

Suicide is a leading cause of death among US youths, and mental health disorders are a known factor associated with increased suicide risk. Knowledge about potential sociodemographic differences in documented mental health diagnoses may guide prevention efforts.

Objective

To examine the association of documented mental health diagnosis with (1) sociodemographic and clinical characteristics, (2) precipitating circumstances, and (3) mechanism among youth suicide decedents.

Design, Setting, and Participants

This retrospective, cross-sectional study of youth suicide decedents aged 10 to 24 years used data from the Centers for Disease Control and Prevention National Violent Death Reporting System from 2010 to 2021. Data analysis was conducted from January to November 2023.

Exposures

Sociodemographic characteristics, clinical characteristics, precipitating circumstances, and suicide mechanism.

Main Outcomes and Measures

The primary outcome was previously documented presence of a mental health diagnosis. Associations were evaluated by multivariable logistic regression.

Results

Among 40 618 youth suicide decedents (23 602 aged 20 to 24 years [58.1%]; 32 167 male [79.2%]; 1190 American Indian or Alaska Native [2.9%]; 1680 Asian, Native Hawaiian, or Other Pacific Islander [4.2%]; 5118 Black [12.7%]; 5334 Hispanic [13.2%]; 35 034 non-Hispanic; 30 756 White [76.1%]), 16 426 (40.4%) had a documented mental health diagnosis and 19 027 (46.8%) died by firearms. The adjusted odds of having a mental health diagnosis were lower among youths who were American Indian or Alaska Native (adjusted odds ratio [aOR], 0.45; 95% CI, 0.39-0.51); Asian, Native Hawaiian, or Other Pacific Islander (aOR, 0.58; 95% CI, 0.52-0.64); and Black (aOR, 0.62; 95% CI, 0.58-0.66) compared with White youths; lower among Hispanic youths (aOR, 0.76; 95% CI, 0.72-0.82) compared with non-Hispanic youths; lower among youths aged 10 to 14 years (aOR, 0.70; 95% CI, 0.65-0.76) compared with youths aged 20 to 24 years; and higher for females (aOR, 1.64; 95% CI, 1.56-1.73) than males. A mental health diagnosis was documented for 6308 of 19 027 youths who died by firearms (33.2%); 1691 of 2743 youths who died by poisonings (61.6%); 7017 of 15 331 youths who died by hanging, strangulation, or suffocation (45.8%); and 1407 of 3181 youths who died by other mechanisms (44.2%). Compared with firearm suicides, the adjusted odds of having a documented mental health diagnosis were higher for suicides by poisoning (aOR, 1.70; 95% CI, 1.62-1.78); hanging, strangulation, and suffocation (aOR, 2.78; 95% CI, 2.55-3.03); and other mechanisms (aOR, 1.59; 95% CI, 1.47-1.72).

Conclusions and Relevance

In this cross-sectional study, 3 of 5 youth suicide decedents did not have a documented preceding mental health diagnosis; the odds of having a mental health diagnosis were lower among racially and ethnically minoritized youths than White youths and among firearm suicides compared with other mechanisms. These findings underscore the need for equitable identification of mental health needs and universal lethal means counseling as strategies to prevent youth suicide.

Reconceptualizing the approach to supporting students with attention-deficit/hyperactivity disorder in school settings

The long-term academic outcomes for many students with attention-deficit/hyperactivity disorder (ADHD) are strikingly poor. It has been decades since students with ADHD were specifically recognized as eligible for special education through the Other Health Impaired category under the Education for all Handicapped Children Act of 1975, and similarly, eligible for academic accommodations through Section 504 of the 1973 Rehabilitation Act. It is time to acknowledge that these school-policies have been insufficient for supporting the academic, social, and behavioral outcomes for students with ADHD. Numerous reasons for the unsuccessful outcomes include a lack of evidence-based interventions embedded into school approaches, minimizing the importance of the general education setting for promoting effective behavioral supports, and an over-reliance on assessment and classification at the expense of intervention. Contemporary behavioral support approaches in schools are situated in multi-tiered systems of support (MTSS); within this article we argue that forward-looking school policies should situate ADHD screening, intervention, and maintenance of interventions within MTSS in general education settings and reserve special education eligibility solely for students who require more intensive intervention. An initial model of intervention is presented for addressing ADHD within schools in a manner that should provide stronger interventions, more quickly, and therefore more effectively.

Racial Bias in School Discipline and Police Contact: Evidence From the Adolescent Brain Cognitive Development Social Development (ABCD-SD) Study

OBJECTIVE

Black youth are disproportionately exposed to school exclusionary discipline. We examined the impact of race on age at the onset of school disciplinary actions and police contact, and the rate of receiving increasingly severe disciplinary actions.

METHOD

Youth (N = 2,156) and their caregivers participating in the Adolescent Brain Cognitive Development Social Development (ABCD-SD) study reported on the occurrence and timing of disciplinary events and youths' demographics, delinquency, and neighborhood conditions. Experiences of exclusionary discipline were analyzed using logistic regression and Cox proportional hazards models.

RESULTS

Black youth reported significantly higher rates of almost all disciplinary events compared to White youth. In logistic regression and Cox models, Black youth experienced higher risk for exclusionary discipline and police contact (odds ratios from 2.47 [detention] to 5.16 [sent home]; hazard ratios from 1.36 [detention] to 4.71 [expelled]), even after adjusting for sex, delinquency, neighborhood conditions, and the interaction between race and sex. Black youth who received detention and suspension were at higher risk for additional, more severe school discipline than were White youth.

CONCLUSION

Consistent with a racial bias in exclusionary discipline practices and policing, Black youth, particularly Black male youth, were at a higher risk for experiencing almost all disciplinary outcomes and at younger ages than White youth, after controlling for delinquency, sex, and neighborhood factors. Compared to White students, school detention and suspension status predicted an accelerated cascade of school discipline outcomes for Black students, suggesting racial disparities in how the severity of school discipline escalates over time.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure that the study questionnaires were prepared in an inclusive way. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list.

National patterns of vulnerable decision points in school discipline

In this study, we identified the specific discipline decision situations (i.e., vulnerable decision points [VDPs]) that contribute most to racial discipline disparities from a sample of 2020 schools across the United States. We also examined how much VDPs contributed to overall discipline disparities and the extent to which there was similarity among the strongest VDPs within each school. Last, we directly compared the VDP that contributed most to disparities in each school to situations with the highest rates of office discipline referrals (ODRs) to identify the extent of agreement with overall school discipline patterns. We found the most common VDPs within schools to be subjective behaviors (e.g., defiance, disruption) in classrooms throughout the day, with ODRs for physical aggression contributing notably to disparities among the top 10 VDPs. The strongest single VDP accounted for an average of 17% of racial disparities across the school and the top three VDPs accounted for 37% of disparities. The strongest three VDPs within schools also were remarkably consistent across behavior and location. Finally, there was moderate agreement between situations with the most ODRs and those with the strongest racial disparities, with 63% of schools in the sample having VDPs identical to their situations with most ODRs. In the absence of prescriptive analysis of their own school data, the results of this study provide school leaders and intervention researchers with more precise, promising targets for intervention to increase educational equity.

Teachers' anti-black biases in disciplinary decisions: The role of mindfulness

Research suggests that disparities in exclusionary discipline can be explained, in part, by teachers' anti-Black biases in disciplinary decision-making. An emerging body of literature also speaks to the benefits of cultivating mindfulness for bias reduction. The present study adds to the literature by assessing whether mindfulness is associated with differences in teachers' responses to student disciplinary infractions as a function of student signaled race, which was manipulated as a between-subjects factor. We predicted that teachers with lower levels of mindfulness, as measured via self-report, would demonstrate greater anti-Black bias in response to students' disciplinary files than teachers with higher levels of mindfulness. Teachers (N = 179) completed the study via an online research participant platform. Consistent with hypothesis, we found that participants' self-reported mindfulness in teaching moderated their responses to a disciplinary file as a function of student signaled race, b = -1.05, F(1, 175) = 4.50, p = 0.035, η_p² = 0.03, 95% CI [-2.03, -0.07]. Specifically, participants with lower levels of mindfulness rated the disciplinary infraction as more severe if it was enacted by a Black boy compared to a White boy. At higher levels of mindfulness, however, the opposite pattern emerged; participants demonstrated more leniency if the infraction was perpetrated by a Black boy, relative to a White boy. Our research adds to the literature and suggests that improving teachers' ability to remain present in the classroom may improve their ability to make more equitable decisions in managing students' misbehavior.

Parent-Child Concordance and Discordance in Family Violence Reporting: A Descriptive Analysis from the Adolescent Brain Cognitive Development Study®

Childhood trauma exposure, including witnessing or experiencing family violence, is associated with a variety of poor outcomes such as increased likelihood of psychopathology and high-risk behaviors across the lifespan. Early treatment may help to buffer these effects, but parents and youth display only moderate levels of agreement in reporting family violence, making it more difficult to identify children who have been exposed. Additionally, most studies on family violence reporting have focused primarily on small samples in specific high-risk populations, and little is known about the generalizability of these findings. Thus, the present study assessed concordance in family violence reporting and its correlates using the population-based, demographically diverse sample from the U.S. Adolescent Brain Cognitive Development (ABCD®) study. Participants were 10,532 children between 9 and 10 years old, and their parent or guardian, from 21 sites across the United States. Overall, 30% (N = 3119) of the sample reported family violence and most of those reports (N = 2629) had discordant violence reporting, meaning child- and parent-report did not correspond with each other. Multinomial logistic regression was used to assess the likelihood of participants belonging in one of the following groups: no violence reported, concordant violence reported, and discordant violence reported. Results indicated that Black or Non-Hispanic children, male children, and children with greater externalizing problems were more likely to report family violence, and parents with lower levels of education and income were more likely to report family violence. These findings likely reflect differences in distribution of risk factors among racial and ethnic minoritized individuals including increased parenting stress and decreased access to mental health treatment. Among those reporting violence, Hispanic children and children with less externalizing problems were more likely to be in the discordant group. Findings suggest that both parent and child reports are needed to assess violence and screen for appropriate services.

Racial and Ethnic Disparities in Childhood ADHD Treatment Access and Utilization: Results From a National Study

OBJECTIVE

The study examined racial-ethnic disparities in access to and utilization of treatment for attention-deficit hyperactivity disorder (ADHD) and other psychiatric diagnoses among children with ADHD.

METHODS

Nationally representative, cross-sectional data from the Household Component of the Medical Expenditure Panel Survey 2011-2019 were used to examine racial-ethnic disparities in access to and utilization of treatment by children ages 5-17 with ADHD (N=5,838). Logistic regression models were estimated for access outcomes, and generalized linear models were estimated for utilization outcomes. Multivariable regression models adjusted for race-ethnicity, age, sex, and treatment need in accordance with the Institute of Medicine definition of health care disparities.

RESULTS

In adjusted analyses, compared with White children with ADHD, Black, Hispanic, and Asian children with ADHD had significantly lower rates of any past-year treatment visit for ADHD or for other psychiatric diagnoses. They also had lower rates of having accessed ADHD medication. Compared with White children, Black and Asian children with ADHD used fewer ADHD medications, and Black and Hispanic children with ADHD had lower overall mental health treatment expenditures.

CONCLUSIONS

Disparities in ADHD treatment among children from racial-ethnic minority populations may be driven primarily by disparities in access rather than in utilization. Once treatment had been accessed, disparities in utilization were largely accounted for by differences in socioeconomic status. These findings suggest that interventions targeting access to treatment among children from racial-ethnic minority populations may help close existing care gaps.

Disparities in Pediatric Mental and Behavioral Health Conditions

Mental and behavioral health conditions are common among children and adolescents in the United States. The purpose of this state-of the-art review article is to describe inequities in mental and behavioral health care access and outcomes for children and adolescents, characterize mechanisms behind the inequities, and discuss strategies to decrease them. Understanding the mechanisms underlying these inequities is essential to inform strategies to mitigate these health disparities. Half of United States children with a treatable mental health disorder do not receive treatment from a mental health professional. Children and adolescents in racial, ethnic, sexual, sex, and other minority groups experience inequities in access to care and disparities in outcomes for mental and behavioral health conditions. Suicide rates are nearly twice as high in Black compared to White boys 5 to 11 years old and have been increasing disproportionately among adolescent Black girls 12 to 17 years old. Children identifying as a sexual minority have >3 times increased odds of attempting suicide compared to heterosexual peers. Adverse experiences of children living as part of a minority group, including racism and discrimination, have immediate and lasting effects on mental health. Poverty and an uneven geographic distribution of resources also contribute to inequities in access and disparities in outcomes for mental and behavioral health conditions. Strategies to address inequities in mental and behavioral health among United States children include investing in a diverse workforce of mental health professionals, improving access to school-based services, ensuring equitable access to telehealth, and conducting quality improvement with rigorous attention to equity.

Spotlight on Juvenile Justice: How Did We Get Here?

Structural racism and inequity permeate the juvenile justice system. The earliest delinquency programs were developed at a time when slavery was still legal in the United States and Indigenous Americans were considered "savages," representing dehumanizing systems and beliefs that left lasting structural racism.¹ Nearly 200 years later, racism continues to shape and structure our juvenile justice system both directly and indirectly. This article will underscore the historical legacy of structural racism in the juvenile justice system, an understanding necessary to address systemic change.

Striving for Equity in Community Mental Health: Opportunities and Challenges for Integrating Care for BIPOC Youth

Supporting the mental health of youth who identify as Black, Indigenous, or Persons of Color (BIPOC) continues to be a challenge for clinicians and policymakers alike. Children and adolescents are a vulnerable population, and for BIPOC youth, these vulnerabilities are magnified by the effects of structural, interpersonal, and internalized racism. Integration of psychiatric care into other medical settings has emerged as an evidence-based method to improve access to psychiatric care, but to bridge the gap experienced by BIPOC youth, care must extend beyond medical settings to other child-focused sectors, including local governments, education, child welfare, juvenile legal systems, and beyond. Intentional policy decisions are needed to incentivize and support these systems, which typically rely on coordination and collaboration between clinicians and other stakeholders. Clinicians must be trauma-informed and strive for structural competency to successfully navigate and advocate for collaborative systems that benefit BIPOC youth.

Racism and Cardiology: A Global Call to Action

Racism and racial bias influence the lives and cardiovascular health of minority individuals. The fact that minority groups tend to have a higher burden of cardiovascular disease risk factors is often a result of racist policies that restrict opportunities to live in healthy neighbourhoods and have access to high-quality education and healthcare. The fact that minorities tend to have the worst outcomes when cardiovascular disease develops is often a result of institutional or individual racial bias encountered when they interact with the healthcare system. In this review, we discuss bias, discrimination, and structural racism from the viewpoints of cardiologists in Canada, the United Kingdom, and the US, and how racial bias impacts cardiovascular care. Finally, we discuss proposals to mitigate the impact of racism in our specialty.

Editors' Best of 2021

There is, in the content of the Journal, an embarrassment of riches, and picking a "best" seems to demand a certain qualification: is the "best" the most interesting, most surprising, most educational, most important, most provocative, most enjoyable? How to choose? We are hardly unbiased and can admit to a special affection for the ones that we and the authors worked hardest on, hammering version after version into shape. Acknowledging these biases, here are the 2021 articles that we think deserve your attention or at least a second read.

Editorial: The Hidden Costs of Being A Black Student

Ideally, schools are learning environments that promote intellectual growth while nurturing healthy social and emotional development. Schools are also a microcosm of the bigger world in which students live, mirroring the best and worst of our society, including the debility of systemic racism. One way in which this inequity is perpetuated within schools is through exclusionary discipline practices, and the disproportionate impact these practices have on Black and multiracial Black children, as well as on single-parent families.

Parental Educational Attainment, the Superior Temporal Cortical Surface Area, and Reading Ability among American Children: A Test of Marginalization-Related Diminished Returns

BACKGROUND

Recent studies have shown that parental educational attainment is associated with a larger superior temporal cortical surface area associated with higher reading ability in children. Simultaneously, the marginalization-related diminished returns (MDRs) framework suggests that, due to structural racism and social stratification, returns of parental education are smaller for black and other racial/ethnic minority children compared to their white counterparts.

PURPOSE

This study used a large national sample of 9-10-year-old American children to investigate associations between parental educational attainment, the right and left superior temporal cortical surface area, and reading ability across diverse racial/ethnic groups.

METHODS

This was a cross-sectional analysis that included 10,817 9-10-year-old children from the Adolescent Brain Cognitive Development (ABCD) study. Parental educational attainment was treated as a five-level categorical variable. Children's right and left superior temporal cortical surface area and reading ability were continuous variables. Race/ethnicity was the moderator. To adjust for the nested nature of the ABCD data, mixed-effects regression models were used to test the associations between parental education, superior temporal cortical surface area, and reading ability overall and by race/ethnicity.

RESULTS

Overall, high parental educational attainment was associated with greater superior temporal cortical surface area and reading ability in children. In the pooled sample, we found statistically significant interactions between race/ethnicity and parental educational attainment on children's right and left superior temporal cortical surface area, suggesting that high parental educational attainment has a smaller boosting effect on children's superior temporal cortical surface area for black than white children. We also found a significant interaction between race and the left superior temporal surface area on reading ability, indicating weaker associations for Alaskan Natives, Native Hawaiians, and Pacific Islanders (AIAN/NHPI) than white children. We also found interactions between race and parental educational attainment on reading ability, indicating more potent effects for black children than white children.

CONCLUSION

While parental educational attainment may improve children's superior temporal cortical surface area, promoting reading ability, this effect may be unequal across racial/ethnic groups. To minimize the racial/ethnic gap in children's brain development and school achievement, we need to address societal barriers that diminish parental educational attainment's marginal returns for middle-class minority families. Social and public policies need to go beyond equal access and address structural and societal barriers that hinder middle-class families of color and their children. Future research should test how racism, social stratification, segregation, and discrimination, which shape the daily lives of non-white individuals, take a toll on children's brains and academic development.