‘Disruptive,’ or depressed? Psychiatrists reach out to teens of color

The Hurt Building at Morehouse School of Medicine in Atlanta houses the psychiatry department on Oct. 4, 2022.

By Matt Richtel

Dr. Brittany Stallworth was in fifth grade when she received her first suspension. She and four girlfriends had worn lime-green shirts to school to celebrate the birthday of one of the girls, whose favorite color was green.

“We were accused of promoting gang activity,” Stallworth recalled recently. They were among just a handful of Black children in their private school outside Detroit. Later that day, at home, her parents warned her: “You have to understand how people are going to interpret things, how you are going to be perceived.”

Two decades later, Stallworth is a resident in psychiatry at Morehouse School of Medicine, where she is part of a team of mental health specialists, led by Dr. Sarah Vinson, that focuses on the needs of low-income children and teenagers of color, groups often overlooked in the ongoing adolescent mental health crisis.

Every Tuesday, the team runs a clinic from the 15th floor of an elegant high-rise in downtown Atlanta. There, they conduct telehealth visits with young patients and then, among themselves, discuss symptoms, diagnoses and the medications, if any, to prescribe.

Such dedicated care is unusual for all but the most fortunate. According to a study published in 2017 in JAMA Psychiatry, one-fourth of communities in the top 25% income bracket in the United States have a practicing mental health specialist. In contrast, among the poorest income quartile, only 8% of the lowest-income communities have such a practice. Across the country, the burden is often shouldered by school counselors and time-strapped primary-care doctors.

The lack of specialized and long-term care has contributed to poor teens of color being underdiagnosed or misdiagnosed. Black children and adolescents are more likely to be diagnosed with a disorder involving hostility or aggression than their white counterparts are, even when their symptoms are similar, according to an analysis published in 2019 in the journal Families and Society. And they are less likely to be diagnosed with “internalizing” disorders, such as depression and anxiety.

“What you’re seeing is that behavior that looks disruptive may be post-traumatic stress or depression,” said Dr. Warren Ng, president of the American Academy for Child and Adolescent Psychiatry and a psychiatrist at the Columbia University School of Medicine. This misperception may be the result of prejudice but also of the simple fact that, on average, teenagers of color spend less time being seen by the right mental-health professional. Diagnoses are being made by “people with different levels of training and also different levels of cultural training,” Ng said.

For adolescents, such a misdiagnosis can be a fork in the road, leading to the wrong care, improper medication, school detention or misperception by a justice system that is inclined to view adolescents labeled hostile as inherently threatening.

Vinson, interim chair of psychiatry at Morehouse School of Medicine, assumed leadership of the Tuesday clinic in 2019; their work addresses the inequity. All of the doctors currently on the team are Black, but she emphasized that a psychiatrist does not need to be a person of color to effectively treat adolescents of color. Still, she said, “lived experience” helps. “Brittany was a Black girl and a Black woman before she was a Black doctor,” Vinson said of Stallworth. “She brought that experience into the role as a physician.”

The Boy Who Nearly Burned

On a recent Tuesday morning, Vinson listened as the other doctors described their cases. Stallworth began: She had just finished a video session with a middle school boy who has been a clinic patient for almost four years. Several years prior, his mother set fire to the family’s house, with him in it.

At the time, a clinician at a different organization diagnosed the boy, then 9, with oppositional defiance disorder, or ODD, a condition characterized by chronic hostility and lack of cooperation, Vinson said. The boy’s family subsequently met with her, and she was dubious. Over several exams, she had observed symptoms beyond irritability: The boy slept poorly and, during the day, he sometimes banged his head against the wall.

Vinson suspected the boy was diagnosed with ODD partly because he had reacted testily to the other clinician during examination. She was also concerned that the clinician improperly prescribed him an antipsychotic medication and a mood stabilizer — medications, she said, “that have really substantial side effects and are used only when absolutely necessary.”

Eventually, the Morehouse team changed the boy’s diagnosis to anxiety and post-traumatic stress disorder, and prescribed him Zoloft, an antidepressant with anti-anxiety properties, and Clonidine, a sleep aid. He has been in biweekly talk therapy since 2019, interrupted briefly by COVID-19, with his counselors advised by the Morehouse team.

During the recent Tuesday exam, the boy’s grandmother reported to Stallworth that his teacher said he had been acting out in class, having outbursts and speaking sharply to the teacher. Stallworth talked with the boy at length, and the grandmother told her that the boy’s “mood is good” at home. The boy sometimes banged his head in his sleep, the grandmother noted, but she felt it was involuntary rather than self-harm and did not wake him.

Stallworth recommended a slight increase in the Zoloft dosage, and Vinson agreed, urging close supervision of the boy. “He can change up real fast,” she said. “He can go from being this good kid to getting arrested.”

Dr. Darron Lewis, who is completing a fellowship specializing in child and adolescent psychiatry and serves as Vinson’s aide-de-camp, said, “It’s not that he’s a bad kid.”

“His reaction might be a little bigger than someone else’s reaction,” he said. “And some might see that reaction as dangerous and call the cops. He’s not a criminal, nothing like that.”

‘A Harsher Diagnosis’

Going back a decade, research has highlighted an imbalance in the diagnoses that Black and white patients receive. The 2019 analysis in Families and Society, which found that diagnoses for ODD and attention-deficit/hyperactivity disorder, or ADHD, were unequally distributed between Black and white adolescents, concluded: “There are biases in the way people see Black children that have them receive a harsher diagnosis.”

Its conclusion built on prior research. A 2007 study examined the diagnoses of 1,189 children and adolescents, 74% of whom lived below the poverty line, and found that “Black and Native Hawaiian youth were more likely than white youth to be diagnosed with disruptive behavioral disorders.”

Another study, published in 2006, found that Black children and adolescents in two states, Indiana and New Jersey, were more frequently diagnosed with disruptive disorders than white patients were, and less frequently diagnosed with internalized disorders such anxiety and depression.

That study considered several possible reasons for the differences: Black children and teenagers faced more trauma that led to aggressive behavior; Black families or communities considered some behaviors acceptable that teachers or clinicians found threatening; a young Black person might not be acculturated to express sadness, so an unrecognized depression is overshadowed “when they are boisterous and acting out”; and clinicians were biased.

Of course, the diagnoses can be appropriate. But when misapplied, the consequences can be lasting, said Kess Ballentine, a researcher at Wayne State University and the author of the 2019 analysis. Teachers and law enforcement officials may be prone to see such diagnoses as an indication that youngsters are inherently hostile or aggressive — “born bad” — and funnel them into the justice system rather than into counseling. These diagnoses are “a tributary to the school-to-prison pipeline,” Ballentine said. “We need to do something about this.”

She also said such consequences may be lost on many well-meaning but time-strapped counselors whose diagnoses are aimed at getting help for children and teens who are acting out.

Quite often, what is lacking are mental health professionals with the bandwidth and expertise to get to the bottom of the problem, Ng said: “Poor kids and kids of color don’t have the luxury of time with us.”