Introduction and Overview

As you have learned, developmental systems theory (DST) is an integrative model of human development that includes epigenetic and social contexts as ecological influences on behavior and psychology (Ford & Lerner, 1992; Griffiths & Tabery, 2013). In concordance with this theory, this chapter will explore the entities of race and ethnicity within the context of child psychopathology, assessment, and treatment. While race and ethnicity are certainly global constructs, this chapter will focus on the United States in particular. Specifically, this chapter aims to accomplish the following:

• Introduce the concepts of race and ethnicity, as well as racial-ethnic identity.

• Explore the impact of racism on the human psyche, including race-based traumatic stress and racial trauma.

• Utilize a developmental systems approach to understanding the influences of race and ethnicity on the development of psychopathology in children through the concepts of race socialization and racial identity development.

• Discuss implications for effective clinical practice.

Race, Ethnicity, and Social Science: A Brief History

The following section will cover the definition of race and ethnicity within a historical perspective of social science and racism; this will help us frame the impact of racism on help-seeking and mental health services. From a systems perspective, macro-level influences that have been shaped over time have a trickle-down effect on individual-level behavior. These contexts have vast implications on clinician approaches to care.

Defining Race and Ethnicity

How does one know their race? Is it determined by phenotype (physical appearance and attributes) or genotype (genetic expression)? Does someone tell us our race, or are we born with this knowledge? The United States possesses a long and complicated history pertaining to race and ethnicity. How we define race in this country varies across people, regions, and institutions. Many scholars and researchers rely on definitions from the government as these institutions fund grants and programs related to race and ethnicity. As such, race and ethnicity are defined by the Office of Management and Budget (OMB) and the United States Census Bureau using sociological and biological research support. Still, the OMB is rather ambiguous and discrete when explicitly outlining its methods for codifying racial-ethnic groups. The OMB produces categorizations of race and ethnicity used by the United States Census Bureau that combine ancestry, cultural identification, and sociological or scientific perspectives.

Currently, they are five main racial groups (on the US Census Questionnaire. These groups consist of White, Black or African American, American Indian or Alaska Native, Asian, or Native Hawaiian or other Pacific Islander. These large categories are further distinguished by country or region of origin. The questionnaire, which relies on self-identification, allows respondents to select one or multiple racial categories. The definition of ethnicity remains ambiguous although it generally refers to cultural commonalities such as religion, cultural origin, and language (Baumann, 2004). Only two ethnic categories comprise the US Census Report: “Hispanic, Latino, or Spanish: or Not Hispanic, Latino, or Spanish.”

In modern-day language, the term BIPOC has been used to describe “Black, Indigenous, (and) People of Color.” This term refers to historically marginalized racial-ethnic groups collectively while honoring the individual experiences of colonialism, racism, and discrimination which affect each racial group differently.

As you can see, navigating race and ethnicity can be complex, and it has implications for macro-level issues like how we govern ourselves as well as more local issues like everyday interpersonal interactions between individuals and groups of people. This is especially true for children and adolescents. Thus, it is crucial to develop an understanding of the impacts of race and racism to best understand child psychopathology. The following sections in this chapter explore child development and psychopathology using a racial perspective to provide you with the tools and background necessary to appropriately and effectively address diverse clients. As you read, we encourage you to think about your own racial and ethnic identity and how that may influence your approach to building trusting and affirming therapeutic alliances as a mental health professional.

Social Science and Racism: A Historical Lens

The macro-level of culture and power exerts influence on individuals and communities from the top down. The United States’ earliest history is engrained in White Europeans’ desire to categorize and control, and this includes conquest, colonialism, and the enslavement of Africans and Indigenous peoples. The brutal treatment and dehumanization of African and African American people are well documented in American history. Given the abrasive history of the United States, it is no surprise that the initial efforts of social scientists were motivated by claims of racial dominance to falsely prove White physical and intellectual superiority (Richard, 2003). Take the example of nineteenth-century physician and anthropologist Samuel George Morton (1799–1851), who serves as one of the earliest documented social scientists to use science to reify racism. Ostensibly, he studied learning and intelligence, but he is infamous for his use of craniology, the pseudoscientific study of cranium size, to prove the correlation between cranial capacity and intelligence or intellectual ability (Michael, 1988).

Similarly, nineteenth-century American physician Samuel Cartwright conceptualized Drapetomania, a medical, mental illness characterized by an enslaved person of African descent attempting to flee his or her master to seek freedom (Willoughby, 2018). The medicalization of persons of color’s humanity and desire for freedom speaks to the bias and Eurocentric nature present in the foundations of American social science and mental health approaches. These claims, of course, lacked evidence and reflected the dominant White supremacist ideologies of the time, with science being mainly based on personal opinion, religious beliefs, politics, and chronology. However, it would take a long time for science to address the racism evident in its research methodology, practice, and implications. In fact, many would argue that social science has made little effort to remedy scientific racism and its effect on the field at large.

While steps have been taken in the present day to reduce racism and other forms of oppression in mental health and psychological research (e.g., retractions of some overtly racist articles and practices), discrimination in research and practice still largely exists today. Since World War II, psychological research has made little progress in dismantling misconceptions concerning racial differences in intelligence, intellectual capacity, or propensity for violence. Most notably, American psychologist Arthur Jensen published several works throughout the mid to late 20th century claiming genetic differences, not systemic racism, were the cause of Black-White disparities in educational attainment and scholastic achievement (Jensen, 1985). In the 1990s and early 2000s, Canadian psychologist J. Phillippe Rushton provided further support for Jensen’s claims of the intellectual inferiority of Black people. Rushton cited psychologist Glayde Whitney’s report that people of African descent were inherently more prone to committing crimes to support the notion of Black moral and intellectual inferiority (Rushton & Peters, 1995; Rushton & Jensen, 2005; Rushton & Whitney, 2002). In 2002, psychologist Richard Lynn published a paper that asserted “the level of intelligence in African Americans is significantly determined by the proportion of Caucasian genes” (p. 365), thus supporting the racist notion of genetically determined lesser capacity for intelligence in those of African descent (Lynn, 2002).

Given the racist history of mental health and psychological science, modern-day racial and ethnic minorities are subject to centuries worth of scientific discrimination and abasement. Despite recent efforts to advance towards equitable scientific practices, the foundation of mental health research remains oppressive, exclusive, and persecutory. The flawed foundations of social science have consequences to this day, and, of particular note for us, on help-seeking and mental health services.

Help-Seeking and Mental Health Services

Many barriers prevent members of racial-ethnic minority groups from seeking and receiving quality professional mental healthcare. Stigma, systemic racism, inaccessibility, disregard for culturally relevant and responsive care, and a lack of clinicians of color deter many members of historically marginalized racial-ethnic groups from seeking professional mental health services. Let’s explore ways in which minoritized groups have been discouraged or prevented from mental health services.

Stigma. The United States has yet to reach a place of complete cultural acceptance of mental health discussion and treatment. Broadly, mental health stigma refers to negative or unfavorable attitudes, feelings, behaviors, or perspectives concerning mental illness and any associated treatment or personal characteristics of mental illness (Overton & Medina, 2008; Penn & Martin, 1998). Communities of color often experience stigma both within and outside their social reference groups. Cultural values and norms, religious beliefs, and acculturation and language considerations pose further barriers to BIPOC populations seeking mental health treatment.

The African American community, for example, is traditionally one of high religiosity and spirituality. Historically, mental health challenges have been unfavorably regarded, often being considered as issues of faith and righteousness rather than of oppression, biochemistry, or interpersonal relationships (Ayalon & Alvidrez, 2007; Lukachko et al., 2015; Mojtabai et al., 2011). In Latinx families, mental health issues, especially if caused by intra-familial challenges, are often kept within the family and not brought to a mental health professional (Cabassa et al., 2006; Cabassa et al., 2007; Ramos-Sánchez & Atkinson, 2009; Villatoro et al., 2014). Those within the Asian American and Pacific Islander (AAPI) community are often confronted with the “model minority myth.” The model minority myth poses the idea that AAPI people are the epitome of the perfectly assimilated, productive, and high-achieving minority race in America (Yi & Museus, 2015). This myth trivializes the AAPI experiences, making it appear that AAPI individuals do not experience negative emotions, personal or relational struggles, or other mental health issues (Museus & Kiang, 2009). With such pressure to adhere to this myth, mental health treatment in the AAPI community remains highly stigmatized, thus further invisibilizing AAPI mental health (Lee et al., 2009; Shih et al., 2019; Yoo et al., 2010).

Stigma may affect help-seeking behaviors as some potential BIPOC consumers avoid contact with a provider in fear of negative labeling or embarrassment (Sijbrandij et al., 2017). Attitudinal barriers have shown to be greater than structural barriers. Attitudinal barriers such as no or low perceived need for treatment or the belief that problems will alleviate over time have shown to have a great effect on racial or ethnic minorities’ treatment access and early termination (Green et al., 2020).

Systemic Racism and Socioeconomic Inaccessibility. As we have discussed, systemic racism permeates virtually every institution in global society, including access to quality mental health services. Research suggests that racial-ethnic minorities are 20-50% less likely to seek mental health treatment services (Mongelli et al., 2014). This leads to the phenomenon known as the treatment gap, an indicator of health disparities. Mental health disparities are influenced by factors such as socioeconomic status, adverse childhood experiences, health system and policy factors, socioecological context, race, and ethnicity (Glasgow et al., 2019; Park et al., 2020). The poverty rate is much higher for Black and Latinx youth, and children in poverty tend to have greater difficulty receiving care (Bickman, 2020). Additionally, there is more exposure to adverse conditions such as housing issues and community violence in impoverished communities (Glasgow et al., 2019). Research suggests that disparities will continue to widen for BIPOC populations as there is less engagement in mental health services (Park et al., 2020). Furthermore, when racial-ethnic minority youth do receive an evidence-based practice in mental health treatment, the effect size of that intervention is typically smaller than that received by their white counterparts (Park et al., 2020). This underscores the importance of culturally relevant mental healthcare and research.

The treatment gap impacts BIPOC youth especially. This is partially a result of factors such as overrepresentation in the carceral state and child welfare systems (Alegria, et al., 2010; Gustafson et al., 2018). Additionally, racial-ethnic minorities are more likely to receive mental healthcare via law enforcement than their White counterparts as a result of racial bias in policing practice and correctional policy (Maura & de Mamani, 2017). Black and Brown communities are among the most uninsured, often making mental healthcare financially unattainable. Barriers to mental healthcare access lead to a lack of identification of youth with potential mental health disorders. This is problematic, as youth who have delays in the identification of their mental health challenges or whose problems go undetected altogether can have poorer health outcomes (Glasgow et al., 2019). This affects a child’s overall life trajectory as undetected mental health problems tend to worsen and intensify as a child ages.

While the rise of teletherapy has increased accessibility and removed barriers related to transportation and time-related costs, these treatment modalities have been less researched on children and adolescents. Similarly, access to reliable internet and privacy remain a barrier when conducting teletherapy (Pickens et al., 2020).

Lack of Culturally Relevant and Culturally Adapted Care. While dominant in the United States, psychotherapy is not a globally exercised practice for treating mental health disorders (Koc & Kafa, 2019). Given this, the idea of talking to a stranger about personal and familial issues is unnatural and counterintuitive according to many cultures. Around the world, mental health is assessed and treated within the spiritual, legal, or family domain, or it is merely kept to oneself. While we know that talk therapy has proven to be effective (Durlak et al., 1991), most clinical samples are composed of majority White participants. Despite growing awareness of bias and the lack of cultural considerations, BIPOC populations remain disproportionately excluded from psychotherapeutic research. The lack of representation in these samples can be due to barriers such as lack of access to quality services, justified distrust of research participation, and limited parental mental health literacy (Glasgow et al., 2019).

This is precisely why we need culturally relevant and responsive care. Demonstrated cultural competency is rarely a required skill for clinical trainees. Culturally adapted assessment and treatment employs a multicultural lens that acknowledges cultural differences in mental health presentation and corresponding effective treatment. It is important to note that the Diagnostic and Statistical Manual of Mental Disorders (DSM) was developed with a Westernized, Eurocentric worldview. This further marginalizes BIPOC populations by using White individuals as the standard for normal and abnormal thoughts, emotions, and behaviors, often viewing cultural variances as deficits rather than strengths. Regardless of race and ethnicity, humans have universals; we all feel pain, happiness, jealousy, anger, and so on. However, the manifestations of mental illness or mental health issues can present differently.

Similarly, what is regarded as abnormal in one culture may be completely normal or even expected in another. Black and Brown people have the highest attrition rates in psychotherapy (Aggarwal et al., 2016). One reason for this may be the lack of cultural competency of their clinicians. It is the clinician’s job to make clients feel seen, heard, and affirmed in their experiences. When we are not using a multicultural lens in mental disorder assessment and treatment, we may be causing further damage and distress to our clients by perpetuating the same invalidation and marginalization present in our society.

Lack of Representation. The mental health field is an overwhelmingly White industry (Lin et al., 2018). Even with culturally relevant training, it can be challenging for children to trust clinicians who do not share similar cultural or racial identities. As mental health providers, we understand the importance of the therapeutic alliance in allowing clients room to explore and grow in a safe environment. While cultural understanding and humility go a long way in providing a safe atmosphere for clients, the truth is that clients often have a preference for clinicians who share similar identities. Clients may prefer not to have to explain cultural values or norms to their clinicians. For children, this is especially important as they may not have the capacity or verbiage to express race-related stress to their mental healthcare provider. Given the current sociopolitical landscape in America, BIPOC communities experience direct and vicarious racial trauma at high rates (Liu & Modir, 2020; Lund, 2020). A clinician who cannot empathize or understand how sociocultural factors are affecting the child risks missing important diagnostic information, which would then be used to formulate an effective treatment plan.

Unfortunately, many barriers in higher education prevent racial-ethnic minorities from becoming mental health professionals. While there have been increases in minority mental healthcare providers, in recent years, a majority of the mental health workforce in the United States is White (American Psychological Association, 2015; United States Census Bureau, 2021). With the lack of representation in the mental health field, many people of color wait to seek help until absolutely necessary or refrain from using mental health services altogether. When working with a client whose identity differs from yours racially, ethnically, or otherwise, it is essential to acknowledge that the same imbalances of power and privilege which govern our society are also present in therapy. Additionally, sharing identities with a client may not automatically lead to mutual trust and understanding. It is important to consider cultural values and norms, identity, levels of acculturation and enculturation, and other facets of multiculturalism when assessing and treating children of color.

Developmental Systems and Child Psychopathology

As seen above, there are systemic, upstream issues as well as local, downstream issues for mental health care and mental wellness promotion. These issues infiltrate the meaning-making system of an individual. For BIPOC individuals (and the collective), racism and racial trauma are a central consideration for meaning-making, and for clinicians in general, racism and racial trauma are a central consideration with any intervention. Given the weight of these considerations, we will detail the influence of racism and racial trauma in mental health encounters with BIPOC children.

Racism and Racial Trauma. Given the inescapable presence of racism in America, it is no surprise that the pervasive nature of racism and other forms of oppression are experienced as trauma, leaving psychological bruises on the human psyche. The effects of racism and other forms of oppression on the BIPOC human mind and body have been well documented in scientific literature (Pieterese et al., 2012; Williams & Williams-Morris, 2000). We know that exposure to racism is correlated with increased stress levels (Harrell, 2006; Peters, 2006), accelerated aging (Carter et al., 2019; Gee et al., 2019), and a variety of other mental health disparities in BIPOC populations (Jackson et al., 2010; Miranda et al., 2008). Racism may be experienced directly or vicariously and presents in various forms: interpersonal, systemic, institutional, and internalized.

When it comes to BIPOC children, the intersection of race, class, and gender is further nuanced by age, developmental status, and familial or community support and resources. According to a 2017 report from the US Department of Health and Human Services Office of Minority Health, suicide is the second leading cause of death in African Americans ages 15-24. Results from the 2011 CDC Youth Risk Behavior Surveillance Survey show that 14.3% of Latinx students (grades 9-12) had developed a plan for committing suicide at one point in their lives, and 10.2% had attempted suicide. Both rates of suicide ideation and attempt were higher than those reported by White and Black students.

So, what does this tell us? The research indicates that the life and mind of a child are more complex and intricate than most acknowledge. The same structural factors which influence adults have an exacerbated impact on the formative years of childhood. As mentioned before, it is often not until adulthood (if at all) that people begin to realize the impact of systemic oppression on their life experiences and overall development. BIPOC children carry an enormous weight as they are often invisibilized in mental health treatment and research, forcing them to internalize oppression and cope alone. Addressing racial trauma in children can be emotionally difficult for both the child and the clinician, thus underscoring the importance of a strong therapeutic alliance, cultural competence, and cultural humility when working with BIPOC children.

Case Illustration of Developmental Systems Considerations: Chrystal

Let’s return to our case vignette with Chrystal. Unpacking race and ethnicity in children is challenging, albeit crucial. The DSM-V does not recognize racial trauma as a disorder. However, racism and discrimination are clinically acknowledged determinants of physical, mental, and emotional health. A comprehensive understanding of identity and the various systems that influence self-concept must be used to evaluate and treat children of color. While Chrystal explicitly shows signs of racial trauma and oppression-based anxiety, it should be noted that racism impacts each child differently. Many children cannot clearly link their sadness to racial injustice or oppression. They can, however, perceive differences in their treatment or the treatment of those who look like them when compared to others (Fox & Jordan, 1973; Stevenson & Steward, 1958). Unfortunately, children of color more than likely equate unfair treatment to personal attributions or self-worth rather than White supremacy, racism, or patriarchy. In other words, it is difficult for BIPOC children to differentiate the discriminatory treatment they receive from the humanity-affirming treatment they deserve. Therefore, the clinician’s job is to provide a validating therapeutic atmosphere using unconditional positive regard to facilitate emotional and mental liberation from external and internalized oppression experienced by BIPOC children.

As we know, developmental systems theory (DST) provides an ecological and lifespan framework for understanding child development and behavior. This approach is particularly useful for understanding BIPOC children’s development experiences as it relies on the integration of several sources of influence, both external and internal and interpersonal and systemic. While a person’s race does not change over time, their conceptualization and meaning ascribed to their race will continue to evolve throughout their lifespan. Thus, DST provides a critical lens at the intersection of biological maturation, time, and contextual factors of influence in understanding the nuances of race and ethnicity in the psychological development of children of color. Most salient are the concepts of racial identity and race socialization which synergistically contribute to a child’s understanding of self and race-related stress. These concepts will be critical in the evaluation and subsequent treatment of Chrystal and children with similar presenting symptoms.

Racial Identity. At the beginning of this chapter, we posed a question: How does one know their race? The Multidimensional Model of Racial Identity (MMRI) describes different stages of racial identity development experienced by people of color (Sellers et al., 1997). This model includes four aspects surrounding a person of color’s racial identity: Racial Salience, Racial Centrality, Racial Regard, and Racial Ideology. These aspects are critical in understanding how a person of color may view themselves and others within and outside their racial group throughout the life course (Sellers et al., 1997; Sellers et al., 1998; Sellers et al., 2006).

Racial salience is a contextual component of a person’s racial identity (Sellers et al., 1998). It refers to the extent to which a person’s race is pertinent to their self-concept at a discrete point in time (Sellers et al., 1998; Scottham et al., 2008). Literature suggests that an individual’s racial salience may be higher in situations in which they are surrounded by people who do not share their racial or ethnic identity (Douglass et al., 2016; Hurtado et al., 2015). Such may be the case for Chrystal as we know she experiences distress in a predominately White context.

Racial centrality refers to the extent to which a person underscores their racial group membership as a component of their comprehensive self-concept. Racial centrality contrasts from racial salience in that it is a more fixed factor of one’s racial identity (Scottham et al., 2008). It appears that Chrystal’s race is an integral component of her self-concept. As such, she is deeply affected by the brutal treatment of Black and Brown Americans and identifies strongly with her racial group.

Racial regard refers to how a person feels about their racial group membership. These feelings can be either positive or negative and are divided into two subcategories: private regard and public regard (Sellers et al., 1998). Private regard refers to how the individual themselves feels about their racial group membership as well as how they feel towards members of their racial group overall. Contrastingly, public regard refers to how positively or negatively an individual believes others view their racial group (Sellers et al., 1998; Scottham et al., 2008).

Finally, racial ideology comprises the most extensive dimension of the MMRI. Racial ideology refers to a person’s guiding philosophy or principal beliefs regarding how members of their racial group should act and comprises four subcategories. Nationalist ideology is characterized by a desire to highlight the uniqueness and specialness of one’s racial group; those who endorse this Ideology believe that their racial group’s experiences are unlike those of any other group. This may be demonstrated through support for race-based organizations (Scottham et al., 2008; Sellers et al., 1998). Parham (1989) also found that ascribing to this Ideology may serve as a mechanism of resistance to racial oppression. Similar to the nationalist ideology, those who endorse the oppressed minority ideology are also critically aware of their racial group’s marginalization. However, the oppressed minority ideology emphasizes the sameness between one’s experiences in their racial group and those of other oppressed racial minority groups (Sellers et al., 1998). Assimilationist ideology highlights the similarities between African American and mainstream American society (Scottham et al., 2008; Sellers et al., 1998). While Sellers and colleagues (1998) maintain that this ideology does not imply a lack of critical consciousness or awareness, they suggest that those who adopt the assimilationist ideology may be more likely to support interactions and relationships with the dominant racial group. Lastly, the humanist ideology highlights the similarities among all people regardless of their racial group membership. People who endorse humanist ideology as their primary philosophy are less likely to define themselves and others by group memberships and more likely to emphasize individualistic qualities (Sellers et al., 1998).

Each of these domains relates to how a person relates to their race or ethnicity, which then corresponds to their psychological functioning, including a person’s thoughts, emotions, and behaviors within a socially unjust and oppressive society (Sellers et al., 2006). BIPOC children begin to form their racial identities as early as three years old (Fox & Jordan, 1973). As clinicians, it is imperative to cultivate knowledge of racial identity to facilitate a meaningful bond and provide effective interventions for the child.

Race Socialization. Race socialization describes the process by which children begin to learn about race through messages received by the media, peers, caregivers, and other institutions. Race socialization also encompasses the values, attitudes, and behaviors transmitted to a child concerning their racial group (Lesane-Brown, 2006). While much research has focused on the family unit as the primary bearer of racial messages, children spend an increasing amount of time online and at school, making these institutions grounds for race-related communication (Brown et al., 2007).

In Chrystal’s case, it is essential to acknowledge her racial-ethnic minority status within a predominantly White learning environment. While it is unknown whether her peers or school personnel have said anything directly to her related to race, it is common for racial-ethnic minority children to feel isolated and excluded due to their appearance, linguistics, or other cultural differences (Killen et al., 2002).

Chrystal demonstrates a heightened awareness of racial injustice and maltreatment of people of color. However, it remains unknown how Chrystal has been racially socialized within her home. Notably, silence around race or race-related challenges is one of the most common race-based messages that children of color receive (Rollins & Hunter, 2013). That’s right! Race socialization is not always a conscious or explicit act of communication. The case description does not provide us with knowledge of Chrystal’s relationship with her parents. However, as clinicians, we must be conscious of how race socialization may affect a child’s conceptualization of race-related discourse and stress. In counseling Chrystal, you may ask her, “Have you ever discussed these scary feelings with your parents?”, “Do you think anyone at school feels the same way you do about the news?” or “Who do you go to when you feel scared or sad?” to evaluate her sources of social support or feelings of isolation.

Implications for Clinical Practice

This chapter barely scratches the surface of examining race and ethnicity in clinical practice with children. By now you understand that addressing race and ethnicity when working with children can be challenging yet incredibly rewarding. Exploring race and ethnicity in an open and supportive environment can allow the child to feel confident and reassured in the often-silenced experiences of racial discrimination and oppression. To do this, clinicians must engage in self-reflection and develop critical consciousness around race, power, and privilege in order to provide the most effective treatment for BIPOC children. Talking about race may be a new and scary experience for children as few spaces allow for this level of vulnerability. Because of this, it is important that clients maintain cultural humility, utilize strengths-based approaches to counseling, and work collaboratively with the child in emotional exploration and problem-solving. Finally, it is essential that in developing cultural competency, clinicians acknowledge the vast diversity that exists within and between racial-ethnic groups so as to not over-generalize or over-individualize the child’s worldview or experience. Sound like a challenge? It certainly is! However, facilitating holistic, positive growth in children requires patience, adaptability, reflexivity, and a relentless commitment to social justice.

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