Dismantling Structural Racism in Child and Adolescent Psychology: A Call to Action to Transform Healthcare, Education, Child Welfare, and the Psychology Workforce to Effectively Promote BIPOC Youth Health and Development

ABSTRACT

The field of clinical child and adolescent psychology is in critical need of transformation to effectively meet the mental health needs of marginalized and minoritized youth. As a field, we must acknowledge and grapple with the racist and colonial structures that support the scientific foundation, education and training of psychologists, and the service systems currently in place to support youth mental health in this country. We argue that to effectuate change toward a discipline that centers inclusivity, intersectionality, anti-racism, and social justice, there are four interrelated systems, structures, or processes that currently support racial inequity and would need to be thoroughly examined, dismantled, and re-imagined: (1) the experience of mental health problems and corresponding access to quality care; (2) the school-to-mental healthcare pathway; (3) the child welfare and carceral systems; and (4) the psychology workforce. A “call to action” is issued to address structural racism in these systems and recommendations are provided to guide clinicians, health care systems, educators, welfare and carceral systems, and those involved in training and retaining psychologists in the field in actions they can take to contribute to transformation. We assert that change will only occur when we individually and collectively take responsibility for the roles we have as agents for radical change within the personal and professional contexts in which we live and work. Only then will the field of clinical child and adolescent psychology be able to address the youth mental health crisis and effectively promote the health and well-being of all children.

We find ourselves at a potentially transformative inflection point in history – the recent global pandemic served to accelerate the further unveiling of intolerable experiences of racial and social injustice and shone a light on the pervasive level of racial inequities supported and perpetuated by current societal structures. The field of clinical psychology is no exception. The educational, academic, and medical infrastructures in which the field of psychology is embedded are fraught with systems and processes that maintain the underrepresentation of marginalized peoples and perspectives and the mental health disparities that plague our field. Buchanan and Wiklund (2020) aptly titled their paper on integrating intersectionality and social justice into psychology “Why Clinical Science Must Change or Die,” which captures the extent of dismantling and re-building that is necessary to transform the field into one that reflects and includes the diversity in our global community and one that effectively addresses the racial and social inequities in mental healthcare. We purposely propose language such as “dismantle” rather than “revise” to reflect the level of structural change needed – tweaking and revising a system that was built on principles of White superiority and Eurocentrism is unlikely to result in the transformative reparation necessary to meet the needs of those who have been systematically oppressed and excluded. This Future Directions paper seeks to describe a few of the most pressing issues affecting clinical child and adolescent psychology, and humbly suggests areas for focus as we begin the work of dismantling what needs to change and rebuilding the field to be one that more authentically and effectually embraces the core values of inclusivity, intersectionality, anti-racism, and racial and social justice. The Special Issue in which this paper is included aimed to highlight three critical areas contributing to the inequitable treatment of Black, Indigenous, and People of Color (BIPOC)¹ children and adolescents in our field: (1) Systemic racism and systems level issues that impact ongoing care; (2) racial/ethnic disparties in access to children’s mental health services; and (3) Workforce diversity, representation, and access to the field. While all three are crises within the field, it could be argued that mental health disparities, disparities in access, and underrepresentation in the workforce are all manifestations of the core underlying problem of pervasive systemic or structural racism. The structures born out of the racist and colonial value system, that valued some people more than others, are the bedrock of the institutions and systems that underlie our educational and healthcare systems and thus, provide the current container for the field of child and adolescent psychology. Therefore, this is where we must begin.

The Challenge: The Impact of Systemic/Structural Racism on Child and Adolescent Mental Health

One of the first definitions of racism described it as “the exercise of power against a racial group defined as inferior by individuals and institutions with the intentional or unintentional support of the entire culture” (J. M. Jones, 1972, p. 117). Since its conceptualization (within the context of its longstanding history extending far beyond the confines of academia and the written word), racism has been viewed as existing at multiple systemic levels. At the individual level, racism reflects both prejudice and discrimination, including both overt and covert actions rooted in beliefs that the minoritized or marginalized person is less than (i.e., having less power or worth than the other person), which has also been termed personally mediated racism (C. P. Jones, 2000; J. M. Jones, 1972, 2023). These experiences are then observed to become accepted and drawn into the self-conceptualization of individuals within these marginalized groups, resulting in experiences of self-stigma, shame, self-devaluation, and hopelessness, termed internalized racism, which has been linked to poorer mental health among BIPOC individuals (Iruka et al., 2022; C. P. Jones, 2000).

Structural racism has been defined as “a system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial inequity” (Aspen Institute, 2016). More specifically, institutional racism reflects rules and regulations that create barriers for BIPOC individuals accessing resources and lead to disproportionate negative outcomes (C. P. Jones, 2000; Thompson & Carter, 1997). For example, structural racism, which systematically leads to segregation of minoritized communities, particularly Black individuals (i.e., “redlining”), has led to significant gaps in access to fair housing, better education, and healthier living environments (Iruka et al., 2022). Such practices in the form of denying federally backed housing finances, property undervaluation, and charging higher interests on housing loans for Black individuals continues today (Bailey et al., 2021; Michney & Winling, 2020). Beyond structural/institutional racism, cultural racism, which is defined as the “individual and institutional expression of the superiority of one race’s cultural heritage over that of another race” (J. M. Jones, 1972, p. 6), has been identified as a significant driver of racism as it is perpetuated across racialized communities globally and remains quite entrenched in cultural values and ideologies over time (i.e., White supremacy ideology). For example, persisting stereotypes about BIPOC individuals result in fewer opportunities, mass incarceration, employment and educational attainment gaps, and inadequate access to health services (Iruka et al., 2022). Over generations, these gaps have gone on to contribute to severe racial and ethnic disparities in terms of economic, health, and mental health outcomes (e.g., Nardone et al., 2020; Yearby, 2018).

Conversely, anti-racism is an approach characterized by the acknowledgment of the persisting and pervasive nature of racism, practice of conscious unlearning of knowledge, beliefs, and practices rooted in colonialism, and understanding of the intersectional nature of oppression (Ben et al., 2020; Bonnett, 2006; Bowser, 1995). Aims of anti-racism include actively engaging in the learning of new theories and practices to identify oppression, developing new anti-racist norms and beliefs, and constantly engaging in self-reflection and challenging oppressive beliefs and practices anywhere (Oluo, 2019). For instance, within educational settings, anti-racism aims to both “love and protect students while dismantling harmful systems and building something better” (Mayes & Byrd, 2022, p. 24).

Models for identifying and addressing structural racism are often organized within the ecological framework put forth by Bronfenbrenner (1979), which stratifies social processes and their influence on youth development into multiple contextual levels (i.e., individual, community level, social-historical level; e.g., Bernard et al., 2023). However, these models were developed predominantly with consideration for the experiences of White, U.S.-born youth, though more recent models have sought to include relevant social and historical influences on development for Black youth and other youth of color (Iruka et al., 2022; Stern et al., 2022; Torres et al., 2022). These seminal works include culturally-informed models, such as García Coll’s model for the study of developmental competencies in minority children and Spencer’s Phenomenological Variant of Ecological Systems Theory, which both aim to address the nuanced and unique experiences of BIPOC youth in the U.S. (García Coll et al., 1996; Spencer et al., 1997). Efforts to address structural racism and its deleterious impact on the health and wellbeing of BIPOC youth must consider and address systemic and structural barriers that contribute to mental health disparities.

While key efforts in the literature focus on addressing more proximal and individual factors, such as internalized stigma, attitudes toward mental health treatment, and provider biases, structural racism interventions target norms, processes, and practices at the institutional level that lead to disproportionate negative outcomes for BIPOC youth. However, to date, there have been limited efforts to synthesize these burgeoning efforts as a call for structural change and guidelines for future directions in the field of child and adolescent psychology. In alignment with research literature and conceptual contributions from other key stakeholders in the field, we propose that there are four interrelated systems within the field of clinical child and adolescent psychology that reflect structural racism and will need to be critically evaluated, dismantled, and rebuilt to create a discipline that is authentically anti-racist and inclusive. These are: (1) inequities in the experience of mental health problems and access to quality care; (2) inequities in the school-to-mental healthcare pathway; (3) inequities in the child welfare and carceral systems; and (4) inequities in diverse representation in the psychology workforce. We review each below and summarize the disproportionate impact of structural racism within these systems on BIPOC youth.

Mental Health Inequities and Access to Healthcare

BIPOC youth are disproportionately at higher risk for poor mental health outcomes compared to their White peers (Alegría & Green, 2015). The recently released Youth Risk and Behavior Survey indicated that persistent feelings of sadness and hopelessness have increased across all ethnic and racial groups over the past 10 years and are highest among nonwhite and non-Asian youth. American Indian and Alaska Native youth report the highest levels of poor mental health and the highest rates of suicidal ideation and attempts compared to peers in other racial and ethnic categories (Centers for Disease Control and Prevention, 2021). Although American Indian and Alaska Native youth are more likely to have significantly higher rates of mental health concerns, there are stark disparities in mental health funding, culturally responsive interventions, and mental healthcare access available to these youth compared to White youth, highlighting the importance of culturally-centered models of intervention development and dissemination (Gone & Trimble, 2012).

In their model for suicide prevention, Alvarez et al. (2022) identify the impact of structural racism on suicide outcomes for BIPOC youth using an ecological framework, which includes lack of access to culturally appropriate mental healthcare. Barriers to mental healthcare access also include negative experiences with systems of care, institutional mistrust, and lack of access to evidence-based care (Khuu et al., 2016). Despite more recent mental health parity laws, disparate coverage of mental health services, including high co-pays, limited sessions, and poor reimbursement often limit options for families, especially if out-of-pocket costs are prohibitive. Further, Black and Latiné² families are more likely to be uninsured or underinsured compared to White families (Cook et al., 2017). As a result of these structural barriers, BIPOC youth are even less likely to be able to access mental health services in a timely manner and have fewer options for providers with cultural knowledge or expertise (Galán et al., 2021; O’Keefe et al., 2021; Rafla-Yuan et al., 2022). Moreover, research within these monolithic, heterogenous communities highlights significant disparities in rates depending on country of origin, immigration context, and acculturative status. For example, within the Asian diaspora, increasing research indicates that though general rates of mental health-related symptomatology are lower among Asian youth compared to non-Asian youth in the U.S., greater rates of mental health issues have been observed among Asians who immigrated at younger ages (i.e., prior to age 12), those who immigrated from Southeast Asia (e.g., Vietnam, Cambodia, the Philippines), and those migrants of refugee status (Okazaki et al., 2014).

Racial/ethnic disparities in access to mental health services for BIPOC youth is a critical issue in the United States (Alegría et al., 2022). Historically, researchers have focused on individual-level drivers of these disparities, and much literature to date indicates that individual factors, such as few adverse childhood experiences, higher family socioeconomic status, and strong social networks are associated with decreased need for mental healthcare. However, recent research indicates that individual-level factors only explain approximately 60% of the variance in children’s access to mental health services, and it is important to note that both the conceptualization and measurement of these individual factors is heavily impacted by structural racism. The remaining 40% is explained by community and systemic factors (e.g., the education, healthcare, and welfare systems), all of which are heavily impacted by structural racism (Alegría et al., 2022; Cook et al., 2017). Lack of diverse representations in all levels of these systems has been identified as a crucial factor in the perpetuation of racial biases and barriers to access to care (Galán et al., 2021). To effect lasting improvement in access to children’s mental health services, it is imperative that clinicians understand the role of structural racism in community and systems-level barriers to mental healthcare.

Within a youth’s community, local primary care settings frequently serve as access points to formal mental healthcare (Collins et al., 2010; Hodgkinson et al., 2017; The White House, 2021). Integrating mental healthcare into general medical care settings has also been demonstrated as an evidence-based solution to reach minoritized youth and increase their access to mental healthcare (Asarnow et al., 2015; Hu et al., 2020). Research suggests that integrated models of care are also more efficient, such that youth can receive mental health treatment without needing to be referred to separate psychological services (de Voursney & Huang, 2016). Thus, regular mental health screening in the context of primary care visits can help identify youth who would benefit from additional mental health services. This model further addresses the issue of limited availability of providers in areas with higher concentrations of BIPOC families perpetuated by structural racism and socioeconomic inequality (Hodgkinson et al., 2017; McGorry et al., 2022). However, even with such models in place, racial disparities in access to care persist. Research indicates that racially and ethnically minoritized youth are less likely to receive psychiatric services in primary care compared to White youth (Costello et al., 2014), suggesting that shifting responsibilities to primary care settings is not an adequate solution to disparities in access and that larger structural change is needed (J. Moore & Krehbiel, 2016).

In addition to primary care settings, emergency departments often connect youth and their families to mental healthcare, particularly for high-acuity youth (Chen, Lui, Liu, et al., 2022). However, barriers to accessing other forms of mental healthcare have resulted in an overreliance on these systems by BIPOC youth, which may then contribute to overtaxed emergency services and potentially traumatic experiences for BIPOC families in these settings (Hoge et al., 2022; Snowden et al., 2008). The pathway between primary and emergency care and mental health services is particularly important for connecting BIPOC youth and families to mental healthcare (Chen, Lui, Liu, et al., 2022; McGorry et al., 2022; Rafla-Yuan et al., 2022). The need for timely mental healthcare for BIPOC youth is dire, as delays in care are a significant predictor for escalation of symptom severity, often leading to the more coercive, punitive, and traumatizing responses common in acute care and higher levels of care (e.g., residential treatment facilities). In their study, Javdani et al. (2023) posit that residential treatment facilities (RTCs) may play a significant role in a treatment-to-prison pathway, whereby BIPOC youth are disproportionately impacted by provider bias and subjected to severe negative consequences for behavioral infractions (ones that might be expected for youth with emotional challenges), and often leave these facilities with more legal consequences (including criminal charges) post-admission than prior. Structural change interventions to reduce reliance on these institutions are sorely needed, as well as efforts to disrupt the impact of cultural racism on the experiences of youth within these systems.

Moreover, additional research on evidence-based models of care and interventions are needed for under-served and under-resourced communities, such as Indigenous and immigrant youth, who, despite experiencing significant mental health disparities, are observed to have the least resources and time spent in developing culturally responsive interventions (e.g., Khuu et al., 2016; Toombs et al., 2021). Within these youth populations, there are further disparities in mental healthcare observed for youth with intersecting, marginalized identities (i.e., BIPOC youth who identify as part of the LGTBQIA2S+³ community). Within this expansive community exist wide-ranging experiences of gender, sexuality, and affectional experiences, which have historically been extinguished, oppressed, and marginalized by largely heteronormative, cis-normative, and colonial forces. This limited but rapidly growing area of research highlights stark disparities for LGTBQIA2S+ youth with studies highlighting that youth who identify as transgender, non-binary, and gender-diverse have the poorest mental health outcomes with high rates of depression, trauma, substance use, and suicidality (Newcomb et al., 2020; Parent et al., 2019; Pellicane & Ciesla, 2022). Within these groups, there are observed layers of impact associated with holding multiple marginalized identities, such that gender-diverse women and non-binary individuals report the worst outcomes, especially if they are also BIPOC (Park et al., 2022). Even with access to gender-affirming medical care, some gender-diverse youth continue to report significant mental health challenges that persistently and negatively impact their functioning and psychosocial development and lead to significantly more frequent and costly mental health service utilization (e.g., hospitalization, residential treatment; Aboussouan et al., 2019; Abramovich et al., 2020; Lam et al., 2022). Thus, additional research is needed to better understand and address the stressors, including ongoing and increasing political and societal oppression, associated with holding multiple marginalized identities for LGTBQIA2S+ and improve access to care for these youth.

Inequities in the School-to-Mental Healthcare Pathway

Educational settings are identified as major entry points for mental health services for BIPOC youth, as youth spend much of their time within these institutions. As such, teachers and school staff are well-poised to observe and identify potential mental health challenges for students. Youth are more likely to receive mental healthcare in schools than in outpatient, inpatient, and primary care settings, with schools often serving as de facto settings for youth mental healthcare (Duong et al., 2021; Schor, 2021). School counselors and psychologists are usually embedded within the school system, allowing the school to provide youth and their families with psychoeducation, assessment, and intervention in a familiar context (Kase et al., 2017). School-based interventions are often effective in helping youth manage a variety of mental health concerns, including emotion regulation difficulties, mood disorders, learning disorders, and executive function disorders (Castro-Olivo, 2017; Paulus et al., 2016). School staff also often help parents connect to specialized mental healthcare if the child’s needs exceed their scope or resources (Marotta et al., 2022). Thus, in an ideal school setting, a youth with mental health concerns would receive free support from the school counselor, and if the school counselor believed the youth to need more intensive care, they would help the youth’s parent find a psychotherapist or specialist to better meet the youth’s needs.

Despite these opportunities for intervention, research on K-12 educational systems has found insufficient staffing and training to address the mental health needs of its students (Stephan et al., 2015), particularly in more economically disadvantaged areas where schools receive less funding. While school funding is a chronic issue across the U.S., funding issues disproportionately impact BIPOC youth (EdBuild, 2019). This is particularly unfortunate given that research indicates that the school-to-mental-healthcare pathway is especially important for BIPOC youth (Planey et al., 2019). Critical race theory (CRT), a well-validated and effective lens for understanding the persisting impact of structural racism on society, posits that school systems are rooted in White supremacy and U.S. colonialism, which reflect policies, practices, and curricula that center Whiteness and decenter the needs of BIPOC individuals (Ledesma & Calderón, 2015). Thus, structural racism is a key driver in the breakdown of the school-to-mental-healthcare pathway for BIPOC youth and manifests across multiple areas in the education system, resulting in inequity in funding and implicit biases integrated into the very fabric of these institutions. Given the history of redlining neighborhoods and forced segregation of BIPOC communities, many BIPOC children grow up in disproportionately lower income neighborhoods, which results in lower property taxes and thus, less funding for schools (Burke & Schwalbach, 2021; EdBuild, 2019). Mental health services can be costly, and many schools do not have the budget to hire enough school counselors and psychologists to meet demand. Although the American School Counselor Association recommends a 250:1 ratio of school counselors to students (already a tremendous caseload), only five states meet this benchmark (U.S. Department of Education, 2021). This can result in long wait times for services and may lead to at-risk children falling through the cracks (Esquivel, 2022; Whitaker et al., 2017).

In addition, implicit bias from school staff also weakens the school-to-mental-healthcare pathway for BIPOC youth (Guo et al., 2014; Liu et al., 2022). Research strongly indicates that BIPOC youth are less likely to be referred to mental health services than White youth (Ho et al., 2007; Locke et al., 2017; Wood et al., 2005). A recent study by Wang et al. (2019) found that youth of Asian immigrant parents were less likely to receive school-based mental health services compared to their White peers, and this discrepancy was associated with limited parental mental health literacy, persisting stigma and shame around mental health, structural barriers (i.e., lack of access, limited culturally and linguistically competent providers, confidentiality concerns), and relational barriers (i.e., limited parent-provider connection and trust). Thus, while increasing access to school mental healthcare is paramount, there is an ongoing need to assess barriers to accessing and engaging in these services for specific BIPOC communities, including potentially gauging barriers and facilitators to mental health treatment through community-based needs assessment or focus groups with youth and parents.

Furthermore, research indicates that Black youth experience much higher rates of negative consequences in schools, including detentions, suspensions, and expulsions for the same infractions, compared to their White peers (Girvan et al., 2017; Morris & Perry, 2017). Black students are more likely to receive severe disciplinary consequences associated with zero-tolerance policies, as they are seen as more “disruptive” and problematic compared to their non-Black peers (Love, 2019; Martin et al., 2016). Moreover, Black youth are more likely to be referred to correctional systems than to mental health systems, while Hispanic youth are more likely to be referred to mental health services than Asian youth (Guo et al., 2014; Yeh et al., 2002). These childhood experiences are identified as lynchpin events that often thrust Black students through the school-to-prison pathway, whereby academic settings are viewed as entry points for carceral systems (i.e., juvenile detention). Thus, although schools have the potential to provide and connect BIPOC youth with accessible mental care, this potential is usually not fully realized.

Inequities in the Child Welfare and Carceral Systems

As with the education system, the child welfare system has the potential to help address youth mental health, both via social workers embedded in the child welfare system and through connecting youth and families to formal mental health services and resources in the community (Burns et al., 2004). However, a large body of evidence indicates that instead of mitigating mental health concerns, the child welfare system often exacerbates mental health concerns, especially for BIPOC youth (Dettlaff & Boyd, 2020; Dettlaff et al., 2020). Indeed, the child welfare system is often viewed as a link or pathway to the U.S. criminal legal system through the use of both systems to remove youth from their families and homes (Bauer & Thomas, 2019). BIPOC communities are inequitably impacted by the carceral system and are vastly overrepresented among the prison population compared to White or White-presenting communities. In one study, Muentner and colleagues (2022) found that BIPOC youth were more likely to be dually-involved (i.e., being in the child welfare system and having an incarcerated parent) compared to their White peers. Further, dually-involved BIPOC youth are less likely to receive mental health services compared to dually-involved White youth with the same service need (Kim et al., 2020). Within the welfare system itself, BIPOC children are also less likely to receive mental health services than their White peers (Alegría et al., 2012; Leslie et al., 2000; Wells et al., 2009). Disparities in services are particularly stark between non-Hispanic White youth and non-Hispanic Black youth, with non-Hispanic White youth more than twice as likely to receive mental health services in the child welfare system. This discrepancy widens the longer youth remain in the system (Kim & Garcia, 2016). Likewise, research indicates that child maltreatment exposure predicts youth internalizing symptoms across racial/ethnic groups; however, within the child welfare system, internalizing symptoms only predict mental health service use for non-Hispanic White youth, while Black youth are more likely to have increased mental health concerns upon release from the child welfare system (Dettlaff et al., 2020; Martinez et al., 2013). Thus, the system designed to protect youth from the deleterious impact of childhood abuse and neglect often becomes another institution that neglects and exacerbates the mental health needs of BIPOC youth.

Although programs in the child welfare system are often conceptualized as “diversion” programs or interventions to prevent worse negative outcomes, research consistently indicates that for BIPOC youth, the outcomes are disproportionately and significantly worse, with the potential for additional trauma, legal involvement, and loss of familial and social support (Anyon, 2011; Tilbury & Thoburn, 2009). For example, research has shown that economically disadvantaged Black families are more likely to be targeted for familial separation, have longer involvement with child welfare, and are less likely to be reunified with their family or adopted (Roberts, 2009). Overall, BIPOC youth are disproportionately impacted by the child welfare system with greater rates of being diagnosed with emotional and behavioral disorders once they enter the system (Havlicek et al., 2013). These outcomes are posited to relate to family economic hardship, biases within the child welfare system, and challenges with accessing timely and culturally appropriate mental health services, all of which disproportionately impact communities of color (DeNard et al., 2017). Youth in foster care are more likely to experience poorer educational attainment, worse mental health outcomes, and greater risk of involvement in the juvenile carceral system and later adult incarceration (M. Courtney & Dworsky, 2006; M. E. Courtney et al., 2007; Pecora et al., 2003), with even worse outcomes observed for BIPOC youth (Mountz, 2020; Washburn et al., 2022). In North America (i.e., Canada and the U.S.), there is a longstanding history of attempted physical and cultural genocide and forced displacement of Indigenous communities rooted in colonialism and White supremacy that resulted in Indigenous youth being disproportionately and forcibly removed from their families and often placed in “residential schools” or adopted into White families for generations (Dettlaff & Boyd, 2020; Dettlaff et al., 2020). Such historical trauma continues to negatively impact these communities today and has been linked with greater experiences of post-traumatic stress, depression, and substance use among Indigenous people, which has then subsequently been linked to child welfare involvement (Grinnell-Davis et al., 2023).

As noted, BIPOC youth are also overrepresented in the juvenile justice system, often receiving disproportionate legal consequences for similar infractions compared to White peers (Nicholson-Crotty et al., 2009; Skiba et al., 2018). Though youth of color comprised approximately 34% of the population in 2020, they constituted approximately 62% of youth in the juvenile justice system (Dragomir & Tadros, 2020). Further, these inequities lead to greater detention and incarceration of Black male youth compared to their non-Black peers (Rovner, 2021). A recent statement by the American Academy of Nursing (AAN) outlined a thorough review of systemic and structural factors leading to these racial disparities, including parental incarceration, parental mental health and/or substance use issues, housing and economic instability, and greater child maltreatment (Bonham et al., 2023). Despite more recent policies attempting to address overrepresentation of youth of color in the carceral system (Puzzanchera et al., 2022), opportunities for diversion from incarceration are influenced by parental legal literacy and financial means; namely, youth with greater economic resources are more often diverted to psychiatric care while economically disadvantaged youth are at greater risk for incarceration (Rovner, 2021; Sawyer, 2019). Greater involvement in the juvenile justice system (i.e., U.S. carceral system) has been linked to poorer physical and mental health, poorer familial relationships, decreased graduation and employment rates, and increased rates in violence (Choate & Manton, 2014).

Inequities in Psychology Workforce Representation

In addition to considering the role of settings that impact child mental health in perpetuating racial/ethnic inequality in pediatric mental healthcare, it is equally important to consider how the institutions involved in educating clinical psychologists, including the clinical science informing their education and the agencies that employ psychologists (both academic and clinical), perpetuate these inequities in the field. The gap between the demography of the U.S. and the demography of the field of psychology remains wide and threatens the future capacity of psychology to meet the mental health needs of racially and ethnically marginalized children and families. Currently, the workforce of clinical psychologists (and presumably child clinical psychologists, though specific data is scarce) is not keeping up with the rapidly changing demographics in the U.S. In 2021, U.S. population estimates were 59.3% non-Hispanic White; 18.9% Hispanic/Latino; 13.6% Black; 6.1% Asian; 1.3% Native American; 0.3% Native Hawaiian; 2.9% 2 or more races (U.S. Census Bureau, 2022), and 50% female. In contrast, the most recent data from the American Psychological Association (APA) suggests that the current psychology workforce is approximately 84% non-Hispanic White; 4% Black; 5% Hispanic/Latino/a; 4% Asian; 0.3% Native American; 1.4% 2 or more races; and 65% women (American Psychological Association [APA], 2018). The graduate school pathway indicates some advancement in the coming generation, but still significant underrepresentation in most minoritized groups, with 68.5% identifying as non-Hispanic White; 10.6% Black; 9.8% Hispanic or Latino/a; 7.2% Asian or Pacific Islander; 0.7% Native American; 3.2% 2 or more races; and 75% women (APA, 2018; Cope et al., 2016).

This gap in demographics between clinicians and youth in need of services manifests in a variety of ways that negatively impact treatment. For example, as discussed above, families report often having a difficult time finding bilingual and/or bicultural therapists for Latiné clients and caseworkers describe often struggling to find culturally congruent resources for African American children in the welfare system (A. Garcia et al., 2012; A. R. Garcia et al., 2015). Conversely, having BIPOC providers with lived experience has been shown to buffer or reduce the experiences of negative bias and poor health outcomes for BIPOC individuals in treatment (Cooper et al., 2004; C. Moore et al., 2022). These experiences may reduce negative attitudes toward mental health treatment and stigma and increase institutional trust. It is critical to both increase the diversity of mental health providers while also providing training in order to identify, dismantle, and rebuild policies, processes, and systems that perpetuate structural racism (Castro-Ramirez et al., 2021). For these reasons, there have been repeated calls for increasing provider diversity in the mental health workforce. BIPOC clinicians comprise a small minority of practitioners despite the ever-growing diversity of the U.S. Such efforts will notably require significant disruption and dismantling of systemic and institutional barriers within the educational and workforce development structures supporting the field of clinical psychology. There appear two major pathways to increase diversity in the psychology workforce: (1) recruitment and retention in the clinical training pathway, and (2) retaining BIPOC psychologists in the field.

Recruitment and Retention of BIPOC Students in the Clinical Training Pathway

Students matriculated to graduate education in psychology do not adequately represent the race or gender make-up of the U.S. and are under-representative with respect to Hispanic and Latino/a, Native American, and Black individuals, and men (and this is likely accounted for primarily by men of color). There may be deeply entrenched reasons why BIPOC students are not pursuing (as well as not being admitted into) graduate study in psychology. For example, Galán et al. (2021) call attention to the fact that institutions of higher education are largely “ivory tower” environments, many of which perpetuate institutionalized forms of racism, oppression, and inequity – certainly not a welcoming or safe atmosphere for BIPOC students, and perhaps not a traditional White and European-centered paradigm they desire to contribute to upholding. There are also standard criteria on which graduate school admissions are based that have been clearly shown to disadvantage BIPOC applicants and that are representative of a quantitative, measurement-focused and competitive operationalization of merit that is not inclusive of students with cultural diversity (Wilson et al., 2019). Callahan et al. (2018) emphasize that the Graduate Record Examination (GRE) is full of racial and ethnic biases that clearly advantage non-Hispanic White and Asian students, which are the only groups of students not underrepresented in graduate education for psychology. In addition, Galán et al. (2023) surveyed almost 300 White and BIPOC graduate students and faculty in Clinical Psychology doctoral programs and found that BIPOC graduate students reported fewer recruitment and retention efforts, less sense of belonging, and greater perceptions of discrimination than White students. Cultural taxation experiences (i.e., additional labor expected or demanded of members of underrepresented or marginalized minority groups) were also reported as common among both BIPOC graduate students and faculty.

Once admitted to graduate school, the road for BIPOC students may only become more challenging. BIPOC students evidence disproportionate rates of attrition compared to White and Asian students during graduate school (Callahan et al., 2018). This phenomenon likely reflects a host of factors that have been thoughtfully articulated in previous papers (Callahan et al., 2018; Galán et al., 2021; see below). Unless effectively transformed, our field likely will remain a hostile environment for BIPOC psychologists, making it exceptionally difficult for marginalized children and families to find mental healthcare that is congruent with their lived experiences.

Retention of BIPOC Psychologists in the Field

Reasons for attrition of BIPOC individuals from the field are many but certainly include experiences with racial discrimination, underrepresentation, misalignment with cultural or personal values, and limited opportunities that are perpetuated by the current university or practice climates, traditional pedagogy, resource allocation, academic or organizational policies and practices. Indeed, a recent survey of child and adolescent psychologists highlighted various perceived individual factors (e.g., racial discrimination and microaggressions, feelings of isolation, otherness, and not belonging); institutional factors (e.g., racism in academia, racial underrepresentation, ethnocentric and culturally-biased training, biased admissions selection processes, financial barriers, and lack of institutional commitment); and nonspecific factors (e.g., values misalignment, hidden expectations, suboptimal mentoring, and limited research opportunities) that hindered retention of BIPOC clinicians and academics (Bernard et al., 2023). There are universal problems with respect to workforce development in behavioral health (and that are reflected in the lack of size and skills of the behavioral health workforce to address the current youth mental health crisis) that include noncompetitive wages, limited opportunities for professional advancement, poor access to supervision, burdensome paperwork, and large caseloads of people with high acuity problems, which leads to substantial burnout and a shocking lack of clinicians of color to serve the diverse population (Covino, 2019). Though these affect all psychologists, these burdens likely disproportionately affect BIPOC clinicians in the field.

One interesting theory with respect to the inability of the field of clinical psychology (and by proxy, the field of child and adolescent psychology) to adequately retain BIPOC professionals has to do with the underlying historical, theoretical, and cultural frame of clinical science, the scientific base informing the practice of clinical psychology. In a very thought-provoking paper, Buchanan and Wiklund (2020) assert that the field of clinical psychology significantly overemphasizes individual-level factors and mechanisms (e.g., rumination, hormones, neurotransmitters) and vastly underestimates the role of social and cultural factors that buffer or exacerbate mental health problems. They go on to state that clinical science’s failure to include macro-system level influences and systems of privilege and oppression in lieu of biological and micro-system-level contributors has restricted its ability to effectively address the problems in the field – including underrepresentation in the workforce as well as the field’s limited impact on reducing mental health disparities. These authors call for a much more explicit centering of theories of intersectionality and social justice into the field of clinical psychology and suggest that only then will our field accurately understand the contributions of social context and historical factors on culture, racial groups, and how individuals holding various identities are situated within society. This “radicalization” of clinical psychology will require resistance, questioning, openness to change, proactive dismantling of the current infrastructure, a reconciliation of the historical injustices perpetrated by our field, and a centering of theories of diversity, social justice, and intersectionality in psychology rather than their consideration as a peripheral and insubstantial contributor to the more powerful individual-level influences that currently sit at the center of our inquiry and practice.

Future Directions: Call to Action to Address Structural Racism Within Child and Adolescent Psychology

For Clinicians and Systems of Care

For Professionals in Healthcare Systems

Given the intersecting nature of these structural and systemic barriers to care, initiatives to increase access to pediatric mental healthcare, particularly for BIPOC children, must exist at both the community and systems level. Historically, many clinicians have considered therapy separate from advocacy and case management (e.g., addressing housing instability, insurance status, involvement with welfare agencies); indeed, within most outpatient centers and behavioral health departments around the country, these services are often delivered by different providers that may be independently “housed” in different programs, contributing to additional barriers in care (Friedman et al., 2016; Lukersmith et al., 2016). However, considering how often issues assigned to case managers directly influence access to psychotherapy, a growing number of clinicians have begun to take a more active role in advocating for their patients across settings in their community (e.g., school, welfare system, etc.), including outreach and advocacy at systemic and institutional levels (e.g., working with policy makers). Some research indicates that the discrepancy in mental health service access between BIPOC and White children loses significance when community and systemic factors (e.g., urbanicity, poverty, and organizational-social context) are accounted for (A. R. Garcia et al., 2015). Thus, clinicians could work to increase access to care within their community by partnering with school systems to address gaps in care and advocating for additional staff, providing resources on trauma-informed care, bolstering community mental health resources, and training mental health paraprofessionals (e.g., in-class staff, behavioral coaches) in triaging immediate mental health needs.

Within health care systems, primary care providers and emergency room professionals should keep updated mental health referral lists on file, provide referrals to mental health practitioners at a range of price-points, and mandate mental health screenings as part of all patients’ yearly visits. These providers may also benefit from consulting regularly with mental healthcare professionals in the community to ensure the information they provide to their patients is accurate, culturally sensitive, and non-stigmatizing. Further, there is growing need for additional models of collaborative care that include nontraditional healthcare settings, such as schools, case management service providers, and community organizations (e.g., BIPOC-centered community centers, park and recreational center staff; McGorry et al., 2022; Rafla-Yuan et al., 2022). These efforts from providers are likely to be strengthened by state and nationwide funding and policy initiatives. For example, the Los Angeles County Department of Mental Health implemented a new emergency room follow-up protocol for youth who presented with psychiatric crisis and found that Latinx clients who received a follow-up after discharge from the emergency department were more likely to receive a beneficial dose of therapy than youth of other racial/ethnic backgrounds (Chen, Lui, Benson, et al., 2022).

One model for increasing anti-racist practice within pediatric settings encourages self-examination, prioritizing education and discourse on anti-racism as it impacts child health, and evaluating policies and practices through an anti-racist lens (Fix et al., 2022). While many institutions and organizations support reducing provider biases through continuous bias management training and focusing on cultural humility and self-awareness, growing evidence has highlighted how these trainings may often be ineffective at helping to uncover what is implicit and remains unknown to trainees, leading to a lack of sustainable change. Further, there is also evidence that in some cases implicit bias training can perpetuate the very harm it seeks to ameliorate (Cooper et al., 2022; FitzGerald et al., 2019). It is suggested that trainings focused on addressing bias should be grounded in understanding and acknowledging the rampant sociohistorical factors influencing modern day cultural racism to increase awareness and facilitate bystander intervention (Nelson et al., 2011).

Cultural humility, an approach or characteristic where providers focus on an “other-oriented interpersonal stance,” and practice an openness to learning about another’s identities from their perspective, can increase empathy and promote therapeutic connectedness compared to taking a stance of cultural competence or mastery (Hook et al., 2013). For instance, clinicians can incorporate the Cultural Formulation Interview from the DSM-5 to increase communication about the impact of cultural and systemic factors on mental health and/or receive training on treating racial trauma and coping with minority status-related stressors (Galán et al., 2021). Clinicians can further advocate for ongoing training and encourage self-reflection regarding the role of psychology in perpetuating racism and White supremacist policies and practices in clinical work and training (e.g., Carrero Pinedo et al., 2022; Fix et al., 2022). Moreover, clinicians should constantly engage in discourse and push for systemic change rooted in the principles of decolonizing mental health, integrating indigenous and cultural ways of healing, and recognizing the role of systemic oppression and harm in the development of trauma and mental health symptoms in BIPOC communities (Lewis et al., 2018; Malott et al., 2023; Millner et al., 2021).

For Professionals in the Education System

While it may be possible to strengthen the school-to-mental-health-services pathway for BIPOC youth via intervention at the community level (e.g., trauma-informed or implicit bias trainings for teachers, nonprofit involvement, etc.), sweeping, lasting change must also come from the education system at the state and national level. Enacting such change requires creative collaboration from clinicians, public health experts, legal experts, and policymakers to effectively pass and implement legislation in line with these goals. Examples of successful collaboration efforts include legislature passed in Colorado in 2020 that expanded eligibility for Medicaid reimbursable school-based mental health services to all Medicaid-eligible students (CS/HB 81—Health Care for Children, Florida House of Representatives, 2020). Similarly, Michigan doubled their 2019–21 state budget funding for school-based mental health programs. Wisconsin also provides funding for school districts and charter schools to collaborate with community agencies on providing mental health services to students (Legislative Fiscal Bureau, 2019; Wisconsin Department of Public Instruction, 2023). In March 2022, the U.S. Department of Health and Human Services announced a seven-aim, $35 million dollar funding package to increase support for pediatric mental health, which included funds to build sustainable infrastructure for school-based mental health programs (Substance Abuse and Mental Health Services Administration, 2022). It is imperative that school administrators, teachers, and psychologists continue to advocate for legislature such as these, and that these efforts be monitored to ensure the equitable distribution of these financial resources to the most underserved communities.

Still, it is recognized that even with funding, stark disparities exist in the identification and referral of students of color to mental health services; in fact, Black and Latiné students are more likely to receive punitive consequences for behavioral issues, pushing these youth down a pathway that results in greater contact with juvenile and later adult carceral systems (Love, 2019). These pathways have dire outcomes for BIPOC youth and thus, it is necessary to dismantle and rebuild educational systems that integrate anti-racist practices, restorative justice models, and pathways toward early identification and intervention of mental health concerns (Mayes & Byrd, 2022). As schools represent an important setting for screening and referral for academic, health, and mental health needs, it is imperative that these systems receive training and support as a potential positive force for providing equitable resources and linkage for marginalized youth (Duong et al., 2021).

Finally, building upon the robust and crucial framework of Critical Race Theory, educational institutions should take an intentional and critical approach to evaluating current curricula and teaching practices in order to adequately and equitably meet the needs of the current U.S. student population. Further, the U.S. educational system also needs to address the systematic neglect and white-washing of curricula in order to incorporate the accurate history and cultural values of ethnically and racially diverse students; such efforts can be linked to greater ethnic/racial pride and better outcomes for young people (Brannon & Lin, 2021). Educational curricula must be transformed to tell the truth of the history of the U.S. rather than the often inaccurate and misrepresentative narratives that have been constructed in their place. For example, until very recently, all 4^th graders in the public school system in the State of California were required to do a “Mission Project,” which glorified the work of Franciscan missionaries and glossed over the brutal enslavement and abuse of indigenous people in the process (Keenan, 2021). Another example of racism that has become institutionalized by the educational system is indigenous sports mascots. Despite decades of advocacy and scientific evidence as to the blatant racism perpetuated by indigenous mascots and its negative consequences on the health and well-being of indigenous youth, there are still almost 2,000 K-12 schools in the U.S. that have not retired their indigenous mascots (Fryberg et al., 2008; Kempner et al., 2021; National Congress of American Indians, 2022). The continued emphasis by educational policy makers on the importance of “sustaining tradition” over the well-being of actual people is frankly shocking. As long as the public educational system that educates 90% of the nation’s youth, and almost all of the nation’s marginalized and minoritized youth (Bouchrika, 2022), continues to uphold racist and alienating ideologies such as these, it’s in explicit contradiction to anti-racism and likely to continue to perpetuate structural racism that oppresses its students and leads to negative emotional and behavioral health outcomes.

For Professionals in the Welfare and Carceral Systems

In their statement, AAN outline several key recommendations for anti-racist juvenile justice reform, including: (1) reducing referrals to law enforcement by implementing other responses, such as school-based restorative justice programs, to divert the school-to-prison pathway; (2) increase social and community programming and invest in creating safer communities to reduce opportunities for youth to engage in unsafe or risky behaviors and promote positive, prosocial activities; (3) shift rehabilitation models from larger detention centers to smaller therapeutic facilities with family-focused and community-oriented interventions; and, (4) increase mental health services within the community, including juvenile detention systems, to address potential etiology or risk factors that contribute to youth behavioral problems and subsequent legal consequences (Bonham et al., 2023). One example of an alternative response to legal involvement is the use of diversion programs, such as “teen courts” in California, which recommend therapeutic interventions, including counseling, mentoring, and case management, resulting in a 50% reduced recidivism rate compared to traditional juvenile justice programs (Choate & Manton, 2014). However, a critical lens must be employed in the use of such programs, not as the end-all-be-all, but as part of a shift toward dismantling so-called justice systems. Clinicians working with incarcerated youth must utilize an anti-racist approach in considering the systemic and structural factors that literally force BIPOC youth down the pathway to incarceration and question implicit biases regarding working with incarcerated populations, which then may impact the type and quality of care provided to these system-involved youth (Dragomir & Tadros, 2020).

Dismantling these systems also requires reflection on the history of colonialism and genocide, forced enslavement, migration detention, forced assimilation, and oppression of BIPOC individuals in the U.S. (Dettlaff & Boyd, 2020; Merritt, 2020; Misra et al., 2021; Pellow & Vazin, 2019; Smallwood et al., 2021). For instance, the Indian Child Welfare Act (ICWA) is a federal law enacted in 1978 that provides guidance to states around the handling of child abuse, neglect, and adoption cases for Indigenous children to support the placement of these youth with kin or other members of their community (Grinnell-Davis et al., 2023). This law is currently being challenged in federal court (and has been before), an effort which is viewed as a means of challenging the legality and sovereignty of the tribes of Indigenous people in the U.S., which would have significant negative implication for the health, well-being, and autonomy of Indigenous Americans (Linjean & Weaver, 2022; Sachs, 2022). As clinical psychologists, we should voice our concern for such efforts and engage in advocacy around policies and legislation that protect these youth and dismantle harmful systems that aim to perpetuate these disparities in child welfare and carceral involvement.

For Educators and Training Programs

As discussed above, until our field can recruit and retain a workforce that reflects the lived experience of the diverse society we serve, it will remain insufficient to meet the needs of children and families that are suffering. Previous manuscripts have thoroughly reviewed barriers to diverse workforce representation and made recommendations for strategies to reform the recruitment and retention of BIPOC students and professionals in workforce pathways; for example, Galán et al. (2021) reviewed best practices for radicalizing clinical science graduate education, and Callahan et al. (2018) proposed various strategies for improving BIPOC admissions and retention in the pathway from graduate school to professional. Rather than summarize their recommendations, we refer readers to their papers and will highlight here a few suggestions for transformation in critical domains for child and adolescent psychology training.

One recommendation made by Galán et al. (2021) is to engage in reform of both clinical training and graduate school curricula to center education and training in concepts such as cultural humility, anti-racism, and social justice. While standards for APA accreditation currently include a domain for competency in individual and cultural diversity, the fact remains that the knowledge or activities needed for “mastery” of this competency are not well-understood or defined, likely not consistently evaluated, and these topics are largely considered peripheral to the more central didactic education in psychological and developmental theories, and evidence-based assessment and intervention that forms the foundation of clinical psychology training. Buchanan and Wiklund (2020) propose that a course (or multiple courses) covering topics of social justice, mental health equity, and intersectionality be mandatory and central to graduate and early career training. A course like this taught early in graduate training (first or second year) could promote the critical examination through an anti-racist lens of everything that comes after – including theories for understanding child development, as well as methods for assessment, intervention, and the conduct of research. Curricula transformation for graduate students could be paralleled by required education and training for faculty and supervisors in modeling cultural humility and promoting intersectionality, social justice, and other important ideals into all graduate training experiences, as well as guidance on how to effectively engage students in dialogue that creates a safe and productive space for all. There are already some excellent resources to guide these efforts. For example, in their scoping review, Iruka et al. (2022) deliver an innovative and important model for understanding the impact of racism on child development. The Racism + Resilience + Resistance Integrative Study of Childhood Ecosystem (R³ISE) integrates key models of developmental science into a theoretical framework for examining the role of multiple types of racism, such as cultural and systemic racism, in shaping healthy development for BIPOC youth. It is recommended that education and research focused on BIPOC youth and mental health employ a critical framework, such as this, to acknowledge and address the impact of these multisystemic forms of racism (Iruka et al., 2022), as well as incorporate other frameworks and approaches to understand the experiences of BIPOC youth with multiple intersecting identities (i.e., LGBTQIA2S+; Hendricks & Testa, 2012; Meyer, 2003; Reed, 2022). In addition, curricula transformation could also involve the required inclusion of social-justice oriented research approaches effective in minoritized communities, such as qualitative and community-based participatory research (CBPR), in graduate research methods courses. For example, in research with indigenous communities, CBPR approaches are considered essential to building trust, engaging in authentic partnership that honors tribal sovereignty, enhancing community capacity, and encouraging space for indigenous ways of knowing in the research process, which is crucial to effectively meeting the developmental needs of indigenous children and families in a way that is culturally aligned and meaningful (Caldwell, 2005; Cochran et al., 2008). More traditional, hierarchical, and “researcher as expert” approaches are not acceptable in indigenous communities and do not facilitate the generation of useful knowledge; this is likely also the case in other communities that have been oppressed by mainstream society and abused by scientific research practices.

For efforts in transforming child and adolescent psychology education and training to effectively center equity and anti-racism, there likely needs to be more top-down policies and guidelines reform to ensure that curricula are culturally-informed, sensitive, and appropriately standardized across training environments. For example, the American Psychological Association (APA), which sets the standards for graduate education in psychology, could require a course focused on racism and racial equity in psychology to be taught in the first or second year, and for certain critical topics to be covered in this course, and embedded in other central courses, to meet accreditation requirements. In addition, there would need to be more formal and defined processes for evaluating the delivery and effectiveness of this kind of curricula in producing graduate students who understand and embody these principles and can apply them effectively in their work.

Another obvious area in need of reform is in faculty and graduate student recruitment, retention, and success. The current processes for identifying and recruiting individuals into the field of psychology have resulted in a significant underrepresentation of people from marginalized and minoritized backgrounds. The first step here is for educational institutions, hospitals, health systems and other organizations who are recruiting graduate students and/or hiring psychologists to review their recruitment and admission or hiring practices through a critical lens with respect to diversity, equity, and inclusion (DEI) principles, and to be held accountable for doing so. Galán et al. (2021) suggest various strategies including eliminating the GRE in graduate admissions, adopting a more holistic view and contextual considerations of what constitutes appropriate prior experiences or success, developing an explicit strategic plan with respect to recruiting and retaining BIPOC students or professionals, and making a dedicated and concerted effort to identify and dismantle biased recruitment or hiring practices. The APA, which accredits most psychology graduate training programs and clinical internships, has formally and publicly committed to “prioritize efforts in training, opening pathways, and workforce development,” and promised efforts to expand opportunities for students of color to pursue careers in psychology; promote mentorship of psychologists of color; improve psychology graduate education and training to include diverse, non-Western cultural perspectives; increase mechanisms, strategies, and practices to raise participation and success rates for psychologists of color in academia, publishing, and governmental licensing; increase representation of communities of color throughout APA’s elected and appointed leadership; expand opportunities for leadership and leadership training for psychologists of color; and enhance the visibility of psychologists of diverse backgrounds (APA, 2021). As the primary policy and governance organization of the field of psychology, it would be helpful for the APA to consider radical change and action to actualize these commitments, and to guide the field in turning these ideals into structural change within the field. However, these top-down efforts would need to be met and paralleled at the local level of organizations and individuals in supporting structural change within their unique contexts of training or practice.

Conclusion

The challenges facing child and adolescent psychologists, clinical psychologists, and mental health providers more broadly are profound. In addition, the challenges within the institutions and structures in our field reflect the critical challenges within societal structures as a whole. As we peel back the layers and bring awareness to the colonial and racist infrastructure and White privileging that pervades psychological science and youth mental healthcare, the challenges only appear to amplify. In contrast to the monolithic and reductionistic approach centering the individual that traditional psychology has embraced, what is revealed as we begin to dismantle the infrastructure supporting this value system is a recognition of the critical importance of intersectionality – the understanding of the influence of multiple intersecting individual identities that collide with intersecting systems and structures, all of which are in dynamic relationship to each other.

Buchanan and Wiklund (2020) argue that conceptualizing intersectionality and its role in professional life is critical in understanding how it operates for children, families, institutions, and systems. Until intersectionality, critical race theory, social justice, and feminist psychology become the core focus in clinical psychology practice, research, and training, we will be unable to create a field and train a workforce that is representative and able to serve our diverse communities (Buchanan & Wiklund, 2020). Indeed, in October 2021, the APA issued a formal resolution apologizing to people of color for the APA’s role in promoting, perpetuating, and failing to challenge racism, racial discrimination, and human hierarchy in the U.S., and committing to a set of actionable steps to reject and dismantle racism and racist ideologies in all forms (APA, 2021).

The task is overwhelming. Indeed, even writing this paper has left our authorship team feeling heavy and overwhelmed by the prospect of effectuating this level of change. However, we argue that this task is not an option but a requirement for the viability of our field. We have attempted to integrate the literature and amplify the voices of other thinkers and advocates in the field to suggest concrete and actionable steps that range in magnitude and that can guide all of us forward. We all have the responsibility, power, and ability to be change agents within the various systems in which we work – as educators, as researchers, as clinicians, as advocates. Every action does not need to be far-reaching or massively impactful (though it can be!) – the size and scope of action will depend on one’s positionality, privilege, and access to power and influence. While widespread dismantling and radical transformation are needed, this can only happen when each of us takes responsibility for learning and deeply understanding the impact of structural racism on children’s mental health, and for the actions that we can take within the communities in which we live and work. Returning to the reference made by Buchanan & Wiklund, if the option for the field of clinical child and adolescent psychology is to “change or die,” we strongly advocate for doing the difficult work not only to survive, but also thrive, by transforming our field to reflect core principles of anti-racism, intersectionality, and social justice that will enable us to more effectively promote the health and well-being of all children and adolescents in our increasingly diverse communities.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

¹ Black, Indigenous, and People of Color has been more recently utilized to capture a range of ethnically and racially diverse communities, while centering those who have experienced the greatest marginalization and oppression. Even within the term “Indigenous,” there are a range of identities and cultures from hundreds of tribes across the Northern hemisphere. Despite the intention to develop an inclusive term, some view BIPOC as a term that is limiting and aggregating very heterogenous identities and cultures. In the present manuscript, we utilize this term in line with the intention of reflecting and centering marginalized communities while acknowledging its limitations and flaws (Deo, 2021; Halgunseth et al., 2022). We also wish to highlight that we alternate terms at times in this manuscript (e.g., sometimes use Indigenous, sometimes American Indian) to retain language from particular papers or studies, and to reflect the importance on how groups are defined and labeled within a particular study or manuscript for the statement and interpretation of information.

² The term “Latiné” has increasingly been used as a gender-inclusive term in place of Latino/a or Latinx to honor the Spanish language (Carbajal, 2020); we have strived to utilize this term throughout, though defer to the language used when referring to specific populations in specific research articles who were identified as Hispanic, Latino/a, or Latinx.

³ The term “LGBTQIA2S+” was developed to reflect an expansive and dynamic community of individuals who identity as lesbian, gay, bisexual, transgender, queer, intersex, asexual, two-spirit, and other sexuality-, affectional- and gender-diverse. While its use aims to be inclusive, there are limitations in terms of visibility and inclusivity for all individuals who may identify within these broad, scoping groups. For instance, while not all Indigenous individuals may identify as two-spirit, the term has been used to connect similar types of identities and experiences for people across Indigenous cultures; thus, some Indigenous individuals may or may not identify as two-spirit or with another term from their indigenous language along with other terms in this broader LGBTQIA2S+ community (Robinson, 2017).