Introduction to the Special Issue: Advancing Racial Justice in Clinical Child and Adolescent Psychology

ABSTRACT

Relative to White youth, racially and ethnically marginalized youth in the U.S. are less likely to initiate treatment, stay in treatment, and receive adequate care. This special issue attends to racial injustice in clinical child and adolescent psychology. While numerous factors drive these racial disparities, this special issue focuses specifically on opportunities and responsibilities we have as mental health providers, teachers, mentors, researchers, and gatekeepers to make our field more racially just. In this introduction to the special issue, we review barriers and solutions across multiple contexts including structural, institutional, and practice-based. We also discuss challenges and opportunities to diversify our field and increase the representation of racially and ethnically marginalized practitioners and scholars in clinical child and adolescent psychology. We then briefly review the special issue articles and make final recommendations for how to move the field forward.

Introduction

Research has consistently demonstrated that while mental health services are generally underutilized among all youth in the U.S. (Merikangas et al., 2010, 2013), racially and ethnically marginalized youth are at the greatest risk of not receiving needed mental health care (Alegría et al., 2010; Alexandre et al., 2009; Snowden et al., 2009; Young & Rabiner, 2015). Racially and ethnically marginalized youth in the U.S. are not only less likely than their peers to initiate treatment (Merikangas et al., 2010, 2011), but also to stay in treatment (Aratani & Cooper, 2012; Kapke & Gerdes, 2016; Young et al., 2016) and receive adequate care (Cummings et al., 2017; Fontanella et al., 2015; Saloner et al., 2014). Thus, even those youth and families who overcome significant barriers to initiating services continue to experience barriers to remaining in treatment and are more likely to receive inadequate care. Moreover, patterns of service use among many subgroups of racially and ethnically marginalized youth in the U.S. (e.g., American Indian, Alaska Native, Native Hawaiian youth) are severely understudied (Gone & Trimble, 2012).

The causes of disparities in access to services are multifactorial and systemic. Treatment preferences, stigma, and knowledge/understanding of mental illness are frequently investigated as contributors to racial and ethnic disparities in access to mental health services; however, these factors appear to explain only a small portion of racial and ethnic group differences in access to care (Cook et al., 2019). Further, focusing overmuch on these factors may pathologize medical mistrust in racially and ethnically marginalized communities and unduly place the burden of addressing disparate barriers to access on marginalized communities (Buchanan & Wiklund, 2020). Other research suggests that different approaches to treatment (including engaging family members, culturally tailoring treatment, and increasing mental health provider availability) may help reduce disparities in access to mental health care (Cook et al., 2019). Researchers have found that the availability of mental health providers is negatively associated with the residential poverty level and the concentration of African American residents (Brown et al., 2016; Ronzio et al., 2006). Research also has demonstrated the impact of provider bias on health disparities broadly (Chapman et al., 2013). There is evidence of such bias influencing clinical decision-making (Chapman et al., 2013; Merino et al., 2018). Mental health treatment may be more susceptible to provider bias as decisions about treatment access, diagnosis, and disposition are often made by a single provider, compared to the team-based approaches of many other disciplines (Merino et al., 2018). One study of implicit racial bias in physicians found that African American providers were the only racial/ethnic group that did not demonstrate an implicit racial preference for White Americans over Black Americans (Sabin et al., 2009), but African American providers are underrepresented in medicine and mental health. Of the U.S. psychology workforce, 84% identify as non-Hispanic White, 5% as Hispanic/Latinx, 4% as Asian, 4% as Black, 1.5% as multiracial, .3% as American Indian or Alaska Native, and 2% as other racial or ethnic groups (American Psychological Association, 2018). This distribution does not adequately represent the racial and ethnic diversity of the U.S. population.

This special issue centers on the ways in which our field (clinical child and adolescent mental health) contributes to and exacerbates issues of racial injustice. This special issue also highlights opportunities to reduce harmful practices and advance racial justice in our field. Accordingly, the special issue takes an inward focus on opportunities and responsibilities we have as providers, teachers, mentors, researchers, and gatekeepers. We seek to push the field to examine and change current practices that serve to create or maintain racial inequities in mental health access and treatment among youth and their families. We also implore the field to apply a sociohistorical and structural lens to service provision, research, and training in our field. Through our acknowledgment of our active and complicit roles in injustice, we can identify opportunities for repair and implement new practices that center racial justice.

The Need for Structural Interventions

Children and adolescents experiencing psychopathology are embedded in structurally oppressive systems. In many cases, structural harm is a contributing factor to mental illness (Wexler & Gone, 2012). In other cases, it is a complicating factor that may serve to exacerbate psychopathology (Kirkinis et al., 2021). Because oppression is baked into the foundation of our country, the historical and current impact of societal racism on racially and ethnically marginalized youth is profound (see Iruka et al., 2022 for a comprehensive review). The field of clinical psychology does not have a strong tradition of contextualizing youths’ experiences or centering the role of societal influences on youth well-being. At best, the field has attended to proximal settings, such as family and school with little acknowledgment or awareness of how larger structural forces shape youths’ experiences across these more proximal domains (Buchanan & Wiklund, 2020). Going forward, our field must do more to assess how structural oppression is shaping youths’ mental health. New measures of racial trauma have been developed that can be incorporated into research and clinical practice (Bernard et al., 2021; Fisher et al., 2000; Pachter et al., 2010; Waelde et al., 2010; Williams, Metzger, et al., 2018; Williams, Printz, et al., 2018). These measures will allow researchers and clinicians to factor in how structural racism may be impacting youth and incorporate this into case conceptualization and treatment (Bernard et al., 2021). Research connecting structural factors, such as systemic racism, to mental health is also needed to better highlight the need for structural interventions that can prevent mental illness and promote mental health among racially and ethnically marginalized youth. This research can facilitate an analysis of opportunities to increase the reach and effectiveness of mental health intervention with a greater eye toward prevention. In addition, some emerging research suggests that greater anti-Black cultural racism at the state level may render mental health interventions less effective for Black youth (Price et al., 2022) further underscoring the need to contend with structural factors, such as cultural racism both to reduce the onset of psychopathology and to more effectively treat it.

Alegría et al. (2022) have outlined specific policies that advance racial justice in mental health that should be championed by mental health professionals. Moreover, they note the need for mental health professionals to advocate for policy change aimed at promoting racial justice across all domains that are central to youth well-being including environmental policy, economic policy, housing policy, educational policy, criminal justice system policy, child welfare policy, and health policy. Beyond just eradicating racist policies, there is a need for the implementation of new policies that advance racial equity. This can include allocating additional resources to meet the needs of racially and ethnically marginalized youth and implementing corrective policies aimed to reverse practices that have had disproportionate negative impact on them. This also includes centering anti-racism in the creation of new policies. Anti-racist policies and practices are more than just “not racist.” Rather, true anti-racist initiatives aim to dismantle racism wherever it exists and facilitate repair (Cooper et al., 2022; Kendi, 2019; Roberts & Rizzo, 2021). This requires recognizing racism; naming it and making it visible to others; and challenging the racist ideologies that undergird all policies affecting youth (Bonilla-Silva, 2006; Tatum, 2017). With proper training, child and adolescent clinical psychologists could be well-positioned to educate others and advocate for anti-racist reforms aimed to eradicate racial disparities in child and adolescent mental health. Reducing structural contributors to child and adolescent mental illness that disproportionately affect racially and ethnically marginalized youth must be undertaken alongside efforts to mitigate racial disparities in access and treatment.

The Need for Institutional Interventions

Mental health professionals also have a role in structuring service provision in a way that is maximally responsive to the needs of racially and ethnically marginalized communities. As a field, we must take up service provision models that effectively meet the needs of low-income communities (where racially and ethnically marginalized youth are overrepresented). This includes everything from where providers locate their offices to their hours of operation to the insurance they accept and the fee models they implement (Planey et al., 2019; Yusuf et al., 2022). Racially and ethnically marginalized youth who are experiencing poverty are frequently unable to access mental health care providers because they are not located in youths’ communities. When services are available, they may only be provided during working hours when economically disadvantaged parents are unable to leave their jobs to transport youth to these services (and transportation needs often exist, as well, with many economically disadvantaged families relying on public transportation to access needed services despite not all services being accessible by public transportation). When mental health care providers do not accept Medicaid and do not implement sliding scale fees (or offer pro bono services; Galán et al., 2021), these services become effectively unaffordable for racially and ethnically marginalized youth experiencing poverty (Planey et al., 2019). Inaccessibility issues lead impoverished racially and ethnically marginalized youth to seek mental health services in emergency departments where there is frequently limited follow-up or continuity of care (Brent et al., 2020; Chung et al., 2017; Fontanella et al., 2020). Moreover, many racially and ethnically marginalized youth face language barriers to accessing care due to an underrepresentation of multilingual therapists and lack of access to interpreters (Martin et al., 2020). Language mismatch is a problem when accessing any type of health care but makes the provision of therapy essentially impossible.

Clinical psychologists have long been calling for alternate service delivery models that could more effectively meet the needs of disenfranchised individuals experiencing mental illness, noting that traditional approaches to psychotherapy will never be sufficient to meet the existing need or reduce disparities in access and utilization (Kazdin & Blase, 2011). Youth-centered integrative and collaborative care models can be implemented in community-based health settings to address location and access barriers (Nocon et al., 2016). In addition, mobile crisis response services may play an important role in facilitating rapid access to treatment among youth in acute distress (Chen et al., 2023). By meeting youth in their own settings (e.g., home or school environment), they mitigate access challenges and facilitate immediate opportunities for stabilization. Among youth facing more severe or chronic psychopathology, models of care coordination (e.g., wrap-around services) often have the benefit of keeping youth in their communities and more meaningfully engaging youths’ families in their care (Olson et al., 2021).

Paraprofessionals and Lay Mental Health Workers

Yet these approaches still rely heavily on the availability and accessibility of licensed mental health professionals which hinders their possibility for meaningfully reducing racial disparities in access to treatment. In addition to the aforementioned coordinated efforts, there is a need for greater mobilization of paraprofessionals and lay mental health workers to help address the mental health needs of underserved racially and ethnically marginalized youth (Barnett et al., 2021; Kazdin & Blase, 2011). The incorporation of paraprofessionals and lay mental health workers into the promotion of mental health among racially and ethnically marginalized youth is critical for a number of reasons. To start, research suggests that racially and ethnically marginalized families are more comfortable with and trusting of informal mental health care providers relative to formal providers (Derr, 2016; Gone & Trimble, 2012; Turner et al., 2016). This may be especially true among immigrant families, particularly if they or others in their family are undocumented or have other concerns about how seeking professional help may increase their risk for legal problems or deportation. Additionally, paraprofessionals and lay health workers are more likely than licensed clinicians to share key social identities, languages, and cultures with racially and ethnically marginalized families (Gustafson et al., 2018). This may facilitate connection, culturally responsive care, and a stronger alliance.

Moreover, paraprofessionals and lay mental health workers can work in collaboration with community mental health centers in ways that bolster and supplement more intensive treatment of children when that is needed. These collaborations also can provide opportunities for training and supervision of paraprofessionals and lay mental health workers by licensed clinicians. This is an important opportunity for the field to rethink the role of licensed professionals in service delivery. By using their high level of training and expertise to train and support others in the delivery of less skill-intensive interventions, the field of clinical child and adolescent psychology could dramatically extend its reach and potentially begin to shrink racial and ethnic gaps in access and service utilization (Kazdin & Blase, 2011).

Teletherapy

The potential promises of teletherapy for addressing accessibility issues have been further elucidated as a consequence of the COVID-19 pandemic and the accompanying rapid shift to virtual service provision in 2020. Notably, a small but growing body of research suggests that teletherapy with children and families is effective in treating a range of emotional and behavioral disorders (Ros DeMarize et al., 2021). Even prior to the COVID-19 pandemic, clinical psychologists have advocated for greater incorporation of virtual services as a means to reduce accessibility challenges that disproportionately affect racially and ethnically marginalized youth in economically disadvantaged communities (Kazdin & Blase, 2011). In addition to potentially eliminating some barriers related to accessing treatment stemming from location or transportation challenges, teletherapy also has the added benefit of increasing the ecological validity of treatments which may increase their effectiveness (Ros DeMarize et al., 2021).

Nevertheless, it is important to acknowledge that teletherapy is not without its challenges. For example, reliable internet access and adequate technology are required, and despite progress in closing the technology gap, economically disadvantaged families still lag behind more affluent families in this domain (Anderson et al., 2019). In order for teletherapy to truly reduce access issues, more efforts will be needed to extend affordable (or free) and reliable internet access to all families (in both urban and rural settings) and to increase availability of technological devices (e.g., programs that loan or donate used smartphones or tablets to underprivileged families; Aisbitt et al., 2022). Families also may need additional support and training to increase their technology literacy and familiarity with videoconferencing features. Lastly, teletherapy may introduce some new challenges to treatment if quiet and confidential spaces are not available in the home environment. Frequent disruptions to sessions can make treatment administration difficult and undermine the therapeutic alliance. As advances continue to be made in the teletherapy domain, it will be critical to ensure these advances are accompanied by explicit efforts to accommodate racially and ethnically marginalized families who are economically disadvantaged or live in rural communities. By centering a focus on racial justice alongside technological advances, we can be more hopeful that the opportunities presented by teletherapy to close racial and ethnic access and utilization gaps can be realized.

The Need for Practice-Based Interventions

Even when racially and ethnically marginalized youth overcome barriers to initiating mental health services, additional challenges may emerge in the context of treatment. A growing body of research implicates clinician racial bias as a potential driver of misdiagnosis (Bell et al., 2015; Hahm et al., 2015) and lower quality of care (Cummings et al., 2019; Wang et al., 2000) for racially and ethnically marginalized clients relative to White clients. Clinicians’ racial bias also may manifest as mistreatment in sessions (e.g., microaggressions; Hook et al., 2016; Owen et al., 2014) or active efforts to avoid discussing race-related experiences such as racism with clients. Receiving lower quality or harmful care both directly impacts racially and ethnically marginalized clients but also fosters greater mistrust among racially and ethnically marginalized communities, making them potentially less likely to seek mental health services (Dovidio & Casados, 2019). Although the American Psychological Association (2017) provides specific guidelines for practicing multicultural competence, there is little standardization or specific guidance for training programs in clinical child and adolescent psychology. Training experiences across programs are variable and data collected from trainees suggest that they may be receiving inadequate training in the provision of culturally competent care (Benuto et al., 2018; Gregus et al., 2020).

Structural Competence

Scholars have advanced a number of recommendations for improving the quality of and consistency across multicultural training programs. To start, there is a need for required coursework across all clinical training programs in systemic racism; the sociohistorical roots of inequality; and structural determinants of mental health (Galán et al., 2021; Gómez, 2022; Metzl & Hansen, 2014; Metzl et al., 2018). Without a thorough understanding of the deep roots of societal racism, child psychologists will be ill-equipped to properly respond to the ways it is impacting their clients and more likely to inflict harm on racially and ethnically marginalized clients (which can be perpetuated by well-intentioned but ill-informed mental health care providers; Fernando, 2017). Moreover, clinicians in training must understand that race and ethnicity (among other social identities) do not just have meaning in the context of the client–provider relationship, but meaningfully shape individuals’ lived experiences, positioning in society, and their possibilities for mental health. Clinical training programs should be designed to facilitate students’ development of structural competence, which refers to the ability of providers to 1) recognize the structures that shape clinical interactions (e.g., the ways in which racist belief systems and white supremacist ideologies may impact the quality of care that patients receive); 2) develop an extra-clinical language of structure (e.g., an ability to describe the ways in which structural hierarchies in society drive health and illness by shaping individuals’ choices, behaviors, and biologies); 3) re-articulate “cultural” formulations in structural terms (e.g., when considering culture, shift away from a sole focus on group-based beliefs, values, and practices to think more about how hegemonic ideologies are embedded in complex cultural structures of privilege and oppression that manifest and maintain societal inequality); 4) observe and imagine structural interventions (e.g., attend to social change interventions rather than exclusively focusing on individual change); and 5) develop structural humility (e.g., maintain a humble stance and always strive to learn more about the ways in which systems and structures shape clients’ mental health; collaborate with communities to identify opportunities for structural intervention; Metzl & Hansen, 2014).

Cultural Humility

In addition to requiring core coursework in structural inequality, clinical training programs should infuse a multicultural and anti-racist focus throughout all the coursework and training experiences offered to students (Anderson et al., 2022; Buchanan & Wiklund, 2020; Galán et al., 2021). This includes de-centering whiteness and Eurocentric norms and privileging the perspectives of racially and ethnically marginalized groups. This can be accomplished by incorporating recorded lectures and assigning readings delivered/authored by racially and ethnically marginalized scholars; teaching students how to employ a critical lens in their evaluation of research and course material to better identify the ways in which both explicit and implicit racism manifest in our field; and including content that instructs students on anti-racist practices (Galán et al., 2021). APA has begun to compile resources for effective multicultural training on their website that can be utilized by training programs (American Psychological Association, 2023). Trainees also can engage in activities outside of coursework to advance their understanding of multiculturalism and anti-racism such as diversity journal clubs, intergroup dialogs, and participation in community-led social change projects. Throughout their training experiences, students should be encouraged to examine their biases and to consider the ways in which their own lived experiences may influence the care they provide to their racially and ethnically marginalized clients. This self-awareness combined with knowledge of broader cultural tendencies of diverse groups enables clinicians to practice cultural humility in their treatment of diverse clients (Galán et al., 2021). To fully practice cultural humility, clinicians also need to acquire the skills in assessment and treatment of issues that may uniquely impact racially and ethnically marginalized communities (e.g., racial trauma; Anderson et al., 2022; Jernigan et al., 2015). Cultural humility also can be developed and practiced through supervised case conceptualization and treatment planning. The success of these training endeavors is largely contingent on the extent to which program faculty and staff possess the necessary content expertise and facilitation skills for teaching anti-racism and cultural humility. Thus, efforts to transform clinical child and adolescent psychology training programs will rely on interventions with faculty and staff as a starting point (Galán et al., 2021; Neblett, 2019; Sue et al., 1992).

Treatment Approaches

Beyond improving clinicians’ cultural and structural competence, there is a need for greater attention to the treatment options available to clinicians working with racially and ethnically marginalized youth and families. Specifically, it is unclear whether evidence-based interventions (EBIs) are the most effective treatment approach when working with racially and ethnically marginalized youth and families given that clinical intervention studies are conducted with overwhelmingly White samples (Reding et al., 2018). Because racially and ethnically marginalized youth and families are so highly underrepresented in randomized control trials of clinical interventions, it is difficult to determine whether these tested treatment approaches will confer the same benefits to them as to White youth and families. Researchers have found that culturally tailored EBIs may be preferable and more effective treatment options for racially and ethnically marginalized clients (Huey et al., 2014; Smith & Trimble, 2015). Culturally tailored EBIs are typically developed through collaborations with community stakeholders, which can increase their relevance and credibility, particularly when the adaptations that are made are deep (rather than surface; Hwang, 2016). This may include incorporating changes pertaining to the underlying values of interventions; the extent to which the intervention incorporates cultural beliefs; the inclusion of the community context; or greater attention to sociohistorical influences (e.g., genocide, slavery, forced land removal; Kowatch et al., 2019; Wendt et al., 2022).

Nevertheless, culturally tailored EBIs run the risk of essentializing and homogenizing entire groups, as well as reifying cultural stereotypes. Typically, culturally tailored EBIs are not designed to attend to varying levels of acculturation or bicultural identities and they often neglect variability introduced by clients’ other salient identities such as gender, sexual orientation, socioeconomic status, or disability status (Hall et al., 2021; Park et al., 2022). Accordingly, scholars have advanced additions and alternatives to traditional approaches to culturally tailoring EBIs that incorporate more attention to individual difference such as incorporating a cultural assessment as a part of the pre-treatment assessment (Sanchez et al., 2022); building in decision-support tools for culturally tailored EBIs that facilitate decision-making about when and how to culturally tailor throughout the course of treatment (Park et al., 2022); preserving EBI principles as a part of a flexible framework for individualized intervention (Wendt et al., 2022; Wiltsey Stirman et al., 2017); and a personalized approach that leverages cultural group tendencies alongside individual characteristics (e.g., level of acculturation, other salient identities or characteristics) to increase personal relevance of interventions (Hall et al., 2021).

Yet regardless of the extent of modifications made, EBIs, at their core, tend to originate from White Eurocentric settler colonial ideologies and thus may continue to offer inappropriate or inadequate treatment for racially and ethnically marginalized families (Hall et al., 2016; Wendt et al., 2015). White supremacist ideologies (e.g., notions of White racial superiority, prioritizing Eurocentric values, treating whiteness as normative) have permeated our field and informed deficit-oriented approaches to treating racially and ethnically marginalized individuals; this orientation has resulted in treatment approaches that situate risk within the person rather than the context. Accordingly, treatment goals of interventions focus on changing individuals or at best, improving their ability to cope with adversity, rather than building on individual strengths and working to change adverse contexts (Buchanan & Wiklund, 2020).

A way forward may be to develop interventions in full collaboration with racially and ethnically marginalized communities (rather than only turning to them for input on cultural tailoring after interventions have already been developed and tested with predominantly White participants). Recently, scholars have been developing clinical interventions that are rooted in the strengths of racially and ethnically marginalized communities (e.g., racial socialization practices that happen within Black families (R. E. Anderson et al., 2019; Anderson et al., 2020; Coard et al., 2004, 2007; Metzger et al., 2021; Murry et al., 2007). Moreover, scholars have advocated for treatment approaches that meaningfully contend with the effects of sociohistorical and current oppression on racially and ethnically marginalized communities (Chavez-Dueñas et al., 2019). Rather than medicalizing historical trauma or conceptualizing it as an inherent personal deficit of racially and ethnically marginalized clients, clinicians must understand that historical trauma is a collective construct in need of collective solutions (Chavez-Dueñas et al., 2019; Gone et al., 2019; Hartmann et al., 2019; Wendt et al., 2022). Collective solutions can include reconnecting Indigenous youth with cultural identities and practices (Gone, 2013; Gonzalez et al., 2022) and community story-telling approaches that anchor historically accurate community narratives as part of the process in advancing community healing and social change in Africana communities (Chioneso et al., 2020). Collective solutions also can prioritize acts of opposition and resistance to structural oppression through activities, such as community organizing (Chavez-Dueñas et al., 2019). Clinicians can support their youth clients’ participation in advocacy and activism as a form of self-empowerment and a means to advance their own and their community’s collective wellness (Buchanan & Wiklund, 2020).

The Need to Diversify the Mental Health Workforce

It is well documented that racially and ethnically marginalized clinicians are vastly underrepresented in doctoral training programs (and experience higher rates of attrition from them relative to their White counterparts; Callahan et al., 2018) and the psychology workforce (comprising 40% of the U.S. population but only 17% of the workforce; American Psychological Association, 2020). As the U.S. population continues to become increasingly diverse, there is a growing need for better racial and ethnic representation in our field. Increased representation can increase racially and ethnically marginalized families’ comfort in seeking mental health services (particularly when families desire to receive treatment from a racially and/or ethnically matched clinician). Receiving treatment from racially and/or ethnically matched providers also may reduce clients’ mistrust in providers, reduce provider bias, and improve the overall quality of care racially and ethnically marginalized families receive (Cabral & Smith, 2011; Chapman et al., 2013). Increasing the representation of racially and ethnically marginalized groups in the field of clinical child and adolescent psychology is a moral imperative as their underrepresentation is the result of structural racism. Greater diversity in the field of clinical psychology also benefits all trainees as it enriches their collective training experiences (through greater exposure to diverse experiences and perspectives) and increases the likelihood that all trainees emerge from their programs with greater cultural humility and competence working with diverse families.

Recruitment

A number of solutions exist to diversify the field. Changes in the recruitment, admissions, and hiring processes (some of which are already being made at numerous programs) are a critical starting point. The vast majority of clinical training programs are housed at predominantly White institutions (PWIs) where racially and ethnically marginalized scholars will experience underrepresentation in their training program, department, and within the broader institution. Thus, racially and ethnically marginalized scholars will need to be actively recruited and meaningfully incentivized to join these programs as students or as faculty. Recruitment efforts should target historically Black colleges and universities (HBCUs) and other minority serving institutions (MSIs). In addition, programs designed for underrepresented scholars (e.g., McNair Program) and professional groups and networks of racially and ethnically marginalized scholars can be tapped into to recruit racially and ethnically marginalized students and faculty (Callahan et al., 2018; Galán et al., 2021).

Several clinical training programs have begun implementing annual visit days to intentionally recruit undergraduate students from underrepresented racial and ethnic minority groups to their doctoral programs (Grassetti et al., 2023). These visit days include sessions to help students prepare strong and competitive applications. Frequently, they also include opportunities for students to meet with current program faculty to further discuss their shared research interests and to learn more about the graduate program. These endeavors may increase underrepresented students’ likelihood of applying and being admitted to clinical training programs. Simultaneously, these events allow current faculty and graduate students to connect with impressive, underrepresented students and to play an active role in improving the departmental climate. Relatedly, departments and programs can host speaker series to invite advanced graduate students from underrepresented groups to present their research. These presentations can enrich the learning of faculty and students at the host institution while also increasing their familiarity with early career scholars who they may be able to recruit for faculty positions. Invited talks may even facilitate opportunities to recruit racially and ethnically marginalized scholars to target opportunity faculty positions which are funded by universities to increase faculty diversity. Another way to recruit talented racially and ethnically marginalized scholars to apply for faculty positions is to advance position descriptions that call for programs of research focused on race-related experiences, such as racism, anti-racism, and racial justice. These types of positions will be more likely to elicit applications from racially and ethnically marginalized scholars (Callahan et al., 2018).

Admissions and Hiring

Once underrepresented scholars have been identified and successfully recruited to apply, it is crucial that biased gate-keeping practices do not then exclude them from either admission to clinical training programs or receiving offers for faculty positions. Increasingly, scholars have called for holistic review approaches and elimination of the GRE requirement to avoid systematically and unfairly disadvantaging applicants from underrepresented racial and ethnic groups (De Los Reyes & Uddin, 2021; Dougherty et al., 2019; Galán et al., 2021; Gee et al., 2022; Gómez et al., 2021; Kent & McCarthy, 2016) with some preliminary evidence from psychiatry residency programs showing that holistic review may promote greater racial equity in the selection process (Barceló et al., 2021). When reviewing applications for faculty positions, a holistic approach to review should be implemented, as well. In both cases, special effort and training also should take place to increase reviewers’ awareness of common biases in the review process that tend to disproportionately negatively impact racially and ethnically marginalized scholars. This includes biases that privilege more prestigious educational pedigrees or letters of recommendation from more well-known psychologists (Galán et al., 2021). Given that systemic racism often precludes racially and ethnically marginalized scholars from having the same opportunities as their White peers, review processes should place greater emphasis on applicants’ accomplishments relative to the opportunities they have had and factor in challenges that applicants have had to overcome on their academic journey. Once selected for interviews (whether they are for graduate admissions or faculty positions), programs should make every effort to cover the cost of in-person interviews up-front rather than having applicants pay and wait for reimbursements (as this can be a lengthy process and place undue financial stress on the applicant).

Programs also should consider incentives to increase the likelihood that applicants will accept offers to either join the graduate program or the faculty. Some universities offer additional funding packages that can increase the financial stipend and research funds available to underrepresented students which can be a strong incentive for racially and ethnically marginalized students, particularly those from economically disadvantaged backgrounds (Galán et al., 2021; Gee et al., 2022). Programs also can strive to admit diverse cohorts of students such that admitted students of color will know they will not be the only person of color in their cohort. Some universities, such as the University of Virginia, offer bridge to the doctorate programs which are specifically designed to admit small cohorts of underrepresented students who have not had access to the needed training experiences to successfully compete for graduate admissions. The two-year program provides the added training experiences needed to prepare students to successfully apply to doctoral programs. The cohort design ensures that students receive this additional training in the context of a supportive community of underrepresented students. Similarly, faculty positions that are part of cluster hires across the institution can incentivize applicants to accept faculty positions where they know they will be part of a community of similar others and can expect for their experience at PWIs to be less isolating.

Creating Diverse, Equitable, and Inclusive Departments

Feeling a sense of belonging and connection with others may be an important ingredient for the retention and success of racially and ethnically marginalized scholars at PWIs. This can be institutionalized through the creation of affinity groups and mentoring programs for racially and ethnically marginalized scholars (while also attending to other salient intersecting identities they may hold; Galán et al., 2021; Singleton et al., 2021). Supportive spaces are needed for nurturing community and connection but also can be places for racially and ethnically marginalized scholars (students and faculty) to strategize and take collective action (Louie & Wilson-Ahlstrom, 2018). Beyond building connections with similar others, racially and ethnically marginalized scholars are likely to feel a greater sense of inclusion and belonging when their department is supportive, inclusive, and committed to advancing racial equity. An inclusive and equity-focused departmental culture can be created through a multitude of initiatives and efforts, such as requiring all applicants to graduate programs or faculty positions to submit a diversity, equity, and inclusion (DEI) statement outlining the ways in which they can contribute to DEI efforts in the department (and meaningfully evaluating these statements as part of the review process; Galán et al., 2021); creating a departmental DEI mission statement to guide DEI efforts and promote accountability; ongoing DEI trainings and workshops for students, faculty, and staff; maintaining a repository of DEI resources available to all members of the department; institutionalization of directors of DEI positions at the graduate and faculty levels; creation of DEI committees (comprised of students and faculty) to distribute responsibilities for various initiatives across the department; including DEI contributions as a part of the annual evaluation criteria for all students and faculty in the department; the formation of ally groups who are committed to advancing justice-oriented institutional change; methods for safely reporting discriminatory experiences within the department that can be used to facilitate consequences and reparative action (Galán et al., 2021); advertising and celebrating DEI efforts on departmental websites and social media; and departmental annual DEI awards for graduate students, faculty and staff. It is critical that the responsibility for DEI initiatives be shared equally across all department members such that the burden of these tasks does not fall disproportionately on racially and ethnically marginalized students and faculty (Anderson et al., 2022; Buchanan & Wiklund, 2020; Galán et al., 2021). Moreover, properly supporting, financing, and rewarding such efforts ensures that service efforts in the DEI space are visible, valued, and properly credited. Implementing a leadership structure within various DEI committees can help to facilitate an equal distribution of the workload and provides structure and accountability for the work. Truly transforming departments into diverse, equitable, and inclusive spaces will require contributions from all department members. The task at hand is considerable, but if appropriately divided and managed, it is feasible.

Overview of Special Issue Articles

The articles in this special issue focus on addressing systems that contribute to racial inequity in our field. Specifically, the articles in this special issue focus on 1) strategies to address institutional and practice-based barriers that disproportionately impact racially and ethnically marginalized youths’ access to mental health services, and 2) approaches to increase representation of racially and ethnically marginalized mental health care providers. Notably, these articles focus on practices that are within our power to control as academics and providers. Each article also includes specific recommendations that can advance our field more immediately. In addition, this special issue concludes with a future directions commentary that attends to the promotion of racial justice in child and adolescent mental health across critical structures and settings (West et al., 2023).

Institutional Barriers and Solutions

Metzger et al. (2023) provided a critical conceptual review of client, provider, and organizational barriers and facilitators to accessing mental health services among racially and ethnically marginalized youth. Metzger and colleagues reviewed the literature on racial and ethnic disparities in access to children’s mental health services through a sociohistorical lens. Using the ecologically based Model of Treatment Initiation framework, they highlighted the impact of accessibility, availability, and appropriateness on mental health service utilization among racially and ethnically marginalized youth and made key recommendations for strategies and policies for clinicians, organizations, and systems to use to mitigate barriers to racially and ethnically equitable mental health care access. They situated the client in a broader ecological framework that acknowledges structural oppression and mandates that those in the mental health field consider opportunities to address societal injustices that negatively impact the mental health of racially and ethnically marginalized youth, as well as providing more culturally responsive treatment. They also emphasized alternatives to traditional therapeutic models, such as greater incorporation of paraprofessionals and lay mental health workers to expand the reach and impact of mental healthcare.

Garcia et al. (2023) examined the additive benefits of lay mental health workers among youth and families receiving parent child interaction therapy (PCIT), a well-established intervention for pediatric behavior problems. In their studies, families of children aged 2–8 years old (mean age 4.7 years; 72% male; 76% Hispanic/Latino,18% Black, 12% multiracial, 2% American Indian, or Alaska Native) who were living in predominantly low-income neighborhoods were randomized to receive PCIT only or PCIT plus a “natural helper.” Natural helpers were trained as community health workers and visited families in their homes approximately once every other week to help families address treatment and resource access barriers; provide in-home support for using skills learned in PCIT; and facilitate culturally sensitive discussions of caregiving concerns and strategies. While families in both the “PCIT alone” and “PCIT plus natural helper” groups experienced improvements in children’s externalizing symptoms and parenting stress, youth who had the added support of a natural helper demonstrated greater reductions in behavioral problems and higher treatment retention. The benefits of natural helpers in improving treatment outcomes are promising, especially given the fact that Black and Latine families residing in low-income neighborhoods historically experience low access to mental health care.

Similar to lay mental health worker models, mobile crisis response (MCR) teams provide support within a child’s natural ecological environment. MCR teams provide urgent psychiatric crisis assessment; rapid-response services in home, schools, and community settings; and can help link youth to any needed follow-up care. Chen et al. (2023) examined use of an MCR program and racial and ethnic disparities in post-MCR follow-up appointments in Los Angeles County. They found that, out of over 20,000 youth who received MCR (mean age of 13 years; 53% female; 41% Latine, 14% Black, 10% White, 4% Asian American/Pacific Islander [AAPI], <1% American Indian/Alaska Native), 92% received outpatient services following MCR, but just over half had received more than one therapy session. A third (35%) of AAPI youth, 36% of White youth, 57% of Black youth, 61% of Latine youth, and 64% of American Indian youth receive at least 8 therapy sessions (often considered a standard for minimally adequate treatment). In contrast to prior research which typically has found relatively low rates of service youth among Latine youth, this study found that compared to AAPI, Black and White youth, Latine youth were more likely to receive ≥8 treatment sessions. The current study is unique in that it examined follow-up specifically from an identified psychiatric emergency (outside of the emergency room setting). Findings suggest that there may be unique factors, such as assessing youth in their usual environments (e.g., home or school) and providing links to follow up care, that facilitate treatment follow-up for Latine youth. The authors further note that the Los Angeles County Department of Mental Health has a significant representation of bicultural and bilingual providers, potentially facilitating access to care for Latine youth. The finding of low rates of service use among AAPI youth is consistent with prior literature and may reflect a shortage of clinicians who can provide services in Asian languages within LACDMH. While Black youth were less likely than Latine youth to receive adequate follow-up care, rates of service use appeared to be higher than in prior literature; authors note that, despite >50% of Black youth participating in ≥8 sessions, this is insufficient, especially considering the rising rates of suicide and suicide attempts among Black youth. Finally, unexpectedly, White youth were less likely than Latine youth to have participated in ≥ 8 sessions; authors note that White youth also had the highest rates of private insurance and might have been more likely to seek care outside of LACDMH (non-LACDMH service use was not captured in this study). The authors highlight a need for new strategies to engage youth in ongoing high-quality care after experiencing a psychiatric emergency as well as a need to examine provider bias in case disposition decisions following an emergency.

While a general goal of mental health service researchers and providers is to improve access to needed mental health care at all levels, it is important to note that some care types may promote harm and exacerbate mental health disparities. Javdani et al. (2023) aimed to address systems that promote inequity in our field with a focus on the role of residential treatment centers (RTCs). Placement in RTCs is a common outcome for youth involved in the family court system and for youth with serious mental illness who have not experienced progress in less restrictive treatment settings. However, unlike most other mental health treatment settings, Black, Latine and American Indian/Alaska Native youth are overrepresented in RTCs, making up 70% of the RTC population (Hockenberry & Puzzanchera, 2020; Sickmund et al., 2019). Moreover, youth can be confined in an RTC without an arrest, offense, or conviction. Javdani and colleagues assert that, while RTCs are conceptualized as treatment facilities, there is little research on their effectiveness. Moreover, findings from limited evaluative research are mixed in terms of documented benefits. Their scoping review of the literature on legal consequences of RTC placement suggests that rather than facilitating treatment and improving outcomes, RTCs may place youth at increased risk of contact with the juvenile justice system and penalization for normative adolescent behavior (e.g., risk taking) or behavior associated with a mental health crisis. In addition to their review of the literature, Javdani and coauthors examined the circumstances under which youth residing in RTCs were charged with delinquency offenses. Among 318 juvenile delinquency petitions reviewed (mean age of youth cited in petitions was 14 years old), 26% were made against youth living in RTCs and 95% were made against youth who were Black, Latine, or American Indian/Alaska Native. The researchers found that youth of color, and girls of color, in particular, were overrepresented among those met with punitive strategies (restraint, surveillance) to manage behavior associated with mental health challenges. They observed different patterns by gender such that girls of color were more likely to receive a delinquency charge within an RTC versus when they were living in the community, while boys of color were less likely to be charged with a new delinquency offense while residing in an RTC. The authors argue that the overreliance on punitive strategies to manage the behavioral challenges of youth of color (and girls of color, in particular) may result in youth obtaining criminal records while placed in their RTCs. This is particularly egregious given that when youth are placed in RTCs, they often lack a criminal record at the time of placement. Javdani et al. (2023) advocate for increased awareness of these issues among providers and the application of caution when considering referrals to RTCs.

Workforce Barriers and Solutions

In their editorial-style manuscript, Bernard et al. (2023) note that workforce diversity is an ongoing challenge for our field. To explore barriers to diversity among clinical child and adolescent psychologists, the authors summarized their own experiences together with those of a small group of their colleagues (N = 17 clinical psychology faculty and clinicians). They identified interpersonal (e.g., discrimination, othering), institutional (e.g., racial biases in admissions and training, financial barriers), and nonspecific factors (e.g., unclear/hidden expectations, suboptimal mentoring) that limit diversity in clinical child and adolescent psychology. Bernard et al. (2023) note that facilitating meaningful change in the field will require a multi-pronged approach that has to be shared equally by all (including those who have been unfairly privileged by an unjust system). They offer specific recommendations for promoting a diverse psychology workforce in the areas of programming (e.g., pathway programs for undergraduates, training for faculty mentors on equitable admissions practices), policies (e.g., eliminating the GRE), practices (e.g., hiring and retaining faculty from historically underrepresented racial and ethnic backgrounds), resources (e.g., funds to support administrators in leading diversity efforts), climate (e.g., provision of safe spaces to share concerns and to foster intergroup dialogue), partnerships (e.g., partnerships with community organizations or local schools to teach diverse youth more about the field of clinical child and adolescent psychology), and inquiry (e.g., measuring progress toward improving diversity in the field).

Galán et al. (2023) examined perceptions of graduate students and faculty in clinical psychology doctoral programs across 103 unique universities (N = 297; 32% faculty; 10% Asian, 8% Black, 12% Latine, 65% White) regarding their departmental diversity, equity, and inclusion efforts. They also collected data on participants’ sense of belonging and experiences of discrimination within their departments/training programs. Graduate students and faculty participants completed online surveys. Results indicated that in some cases, relative to White scholars, scholars of color tended to have less positive experiences and perceptions of diversity, equity, and inclusion efforts in their departments. Regarding scholars’ sense of belonging and perceptions of racial discrimination, Asian, Black, and Latinx faculty and students reported weaker endorsements of belonging in their programs and greater perceptions of racial discrimination than White faculty and students. Two-thirds of the participants of color reported feeling pressure to take on additional services activities because of their race/ethnicity; a third reported they considered leaving their program; and nearly half reported they had considered leaving academia due to experiencing racism. Findings from this study suggest that there are important differences in the experiences of White scholars and scholars of color in clinical training programs. The authors suggest that meaningful change is needed to secure more equitable training and work experiences among clinical psychologists of color. Similar to Bernard et al. (2023), Galán et al. (2023) recommend providing students and faculty with safe spaces to connect, build social support, and promote wellbeing. They also recommend that efforts to advance DEI must be shared by department members so as to avoid placing an undue burden solely on students and faculty of color. Importantly, Galán et al. note that while there is much work left to be done, efforts of students and faculty committed to promoting diversity and inclusion have already led to meaningful progress (e.g., more inclusive admissions practices). It is important to take stock of such progress and use it to fuel ongoing efforts to advance racial justice in the field of clinical psychology.

Conclusion

Taken together, the collection of scholarship presented in this special issue highlights opportunities for centering racial justice in child and adolescent mental health. One common recommendation across the special issue articles is the need for providers to be aware of their own biases and how they might impact treatment decisions, referrals to the juvenile justice system, and case disposition after a crisis. Providers from racially and ethnically marginalized groups may be less likely to evidence racial and ethnic bias in clinical decision-making; however, American Indian, Alaska Native, Native Hawaiian, Black, and Latinx providers are underrepresented in the psychology workforce. Some of the special issue articles highlighted the ways in which our field’s current training programs and professional environments are harmful to racially and ethnically marginalized scholars and stressed the urgent need for institutional change that can address and repair these harms and ultimately, yield a more representative workforce.

As the causes of racial and ethnic disparities in child and adolescent health are multifactorial, so must be the solutions. The field of child and adolescent mental health must recognize its own history and role in perpetuating social oppression (American Psychological Association, 2021) and look inward to identify innovative solutions. Given the previously noted underrepresentation of racially and ethnically marginalized professionals in the mental health workforce, diversifying the field (including developing and expanding mental health career pathway programs) is critical. It also is imperative that we provide better training to mental health providers and trainees on racial bias awareness and provide treatment to racially and ethnically marginalized children and adolescents with structural competence and cultural humility. Our field must adopt an anti-racist approach to treatment that provides trainees and clinicians education on the mental health impacts of racial trauma and strategies to prevent and treat associated psychological distress. These strategies should include strengths-based approaches that capitalize on the resilience and rich legacy of racial/ethnic socialization among racially and ethnically marginalized families. As a field, we also must move beyond a limited focus on coping with and adapting to adversity to more fully consider the role of clinical child and adolescent psychology in changing society. We have many tools at our disposal to effectively intervene and address systemic oppression. Making our society more just and equitable is not outside of the bounds of our profession and ignoring these opportunities for action makes us complicit with systems of oppression. The time is now for us to more fully center anti-racism, racial justice, and equity in our clinical and empirical pursuits.

Acknowledgments

The authors would like to thank Andres De Los Reyes and the Journal of Clinical Child & Adolescent Psychology for the opportunity to guest edit this timely special issue. The authors also would like to thank the contributing authors for their time and effort in submitting their work to this special issue, as well as the reviewers for generously donating their time to strengthen the contribution of this special issue.

Disclosure Statement

Noelle Hurd is on the editorial board of the Journal of Clinical Child & Adolescent Psychology. Andrea Young has received research support from the Brain and Behavior Research Foundation, Supernus Pharmaceuticals, and Psychnostics, LLC. She has served as a consultant to NIH, PCORI, and the University of Montana’s American Indian/Alaska Native Clinical & Translational Research Program, on the Board of Directors for Helping Give Away Psychological Science, and on the editorial boards for the Journal of Clinical Child & Adolescent Psychology and Evidence-Based Practice in Child and Adolescent Mental Health.

Additional information

Funding

Andrea Young’s work on this manuscript was supported by the National Institute of Drug Abuse [K23 DA044288].