Dr Andrea Young Hello, everybody, my name  is Andrea Young, and I’m on faculty in the   Department of Psychiatry at the Johns  Hopkins School of Medicine, where I’m   also the Assistant Dean for Graduate Biomedical  Education and Graduate Student Diversity. And I’m   very grateful to have the opportunity to talk  to you about racial and ethnic disparities in   children’s mental health services’ use and  potential solutions. Thank you very much to   the Association for Child and Adolescent Mental  Health for inviting me to give this presentation. So, first, just a few disclosures. I’ve received  research support from the National Institutes   of Health and the Brain and Behavior Research  Foundation. I’m on the Board of Directors for   Helping Give Away Psychological Science, which,  actually, is an organisation very similar to the   Association for Child and Adolescent Mental  Health, but here in the United States. And   I’m on the Editorial Board for the Journal  of Clinical Child and Adolescent Psychology,   as well as, Evidence-Based Practice  in Child and Adolescent Mental Health. So, at the end of this talk, I’m hoping that  you will be able to describe racial and ethnic   disparities in access to children’s mental health  services, identify social structures that present   barriers or facilitators to children’s access to  health care, and identify one to two strategies   to help improve equitable access to children’s  mental health services. So, I want to leave you   with a few things, not only to describing the  problem, but also, leave you with a few things   that can be potential solutions to the problem.  So, to do that, we are going to first, review   some background and a brief history of health  disparities, including contributors to disparities   and the impact of racism on health. We will review  some research that I’ve done, briefly review   some research that I’ve done on racial and  socioeconomic disparities in access to care,   and then I’ll wrap up by talking about possible  solutions, specifically in research and practice. But first, I would like to start with a case  study. So, this is a picture of a young Black   girl, between the age of nine and ten. She  is posing with her mother at – and she’s   in about – in fifth grade, at a parade,  and she’s there representing the safety   patrols. And the thing that is unique about  this case study that I’m sharing with you is   that the little girl in that photo is me.  And so, I’m sharing this because I wanted   to describe some of the experiences that my  family and I have had in seeking health care. So, at – by the time I – of – I was this age, the  age that’s pictured here, it was pretty obvious   to my parents and other adults in my life that  I had some quirks. ‘Quirks’ is what my mother   called them, but using the knowledge that I  have now, I know that those quirks would best   be characterised as OCD, or obsessive compulsive  disorder. Having to make any decisions other than   the most perfunctory made me freeze, made me feel  panicky. Things had to be organised a certain way   in my room and in other places in the house,  and I had to very closely follow every rule,   and had a lot of trouble when other people didn’t,  and this first started for me around age four. I had a family history of mood and anxiety  disorders, and my family had experience   with mental health providers, but typically of  different racial backgrounds. I recently had a   talk with my mother about her experiences as a  caregiver, and she noted that for my siblings,   or cousins for whom my parents were guardians  at times. There were times when it was clear   to my parents that professional help  was warranted, but after starting care,   it often didn’t feel safe or didn’t  feel comfortable to remain in long-term. So, for me, my parents did their  best at home and luckily for me,   their best was pretty amazing. My mother  wouldn’t accommodate my compulsions by   making decisions for me. She would give me  a time limit to consider my options and make   a decision for myself. My parents helped  me to identify healthy coping strategies   to use when I felt panicky or overwhelmed,  and they helped me to identify my strengths,   and made sure I was using them in healthy  ways. So, in short, my parents were really   excellent Cognitive Behavioural Therapists,  without knowing it, and I’m very lucky. But what I’m hoping that we can do today,  what we can discuss today, is how we,   as mental health providers, Educators and  Researchers, can do better. For families of   colour like mine, who for generations have  experienced discrimination and oppression,   seeking professional care can feel and be  riskier than it should. Our care settings   feel less welcoming, understanding  and validating than they should,   and I want to use my mother’s words here, because  I think she put it so eloquently when she said,   “Our history is such that if there’s a problem,  especially with your child, you use the tools   you have. Especially if you’re not sure if  seeking professional help is going to do more   harm than good.” So, let’s talk today about how  we can do more good consistently and equitably. Next, I want to briefly review some background  and history of health disparities. So,   most of you will be familiar with some of  the things that we’re going to share today.   This won’t be news or surprising to you, but  epidemiological studies show a high prevalence   of mental health problems but very low service  use among children, and adequate treatment is   related to reduced current impairment, as well  as reduced likelihood of having mental health   problems later in life. So, receiving adequate  mental health care early is extremely important. Unfortunately, we know there are disparities in  access to mental health care. So, community-based   studies show that correlates of children’s  outpatient service use include things   like socioeconomic status, parent education,  family structure and race and ethnicity. And   disparities in access to mental and physical  medical health care are well established. We   know that youth of colour are less likely to  initiate treatment, they’re less likely to   stay in treatment and less likely to receive  adequate care once they’re in treatment. So,   even families and youth who are able to overcome  significant barriers to initiating services   continue to experience barriers to remaining  in treatment or receiving adequate care. So, again, just noting, these disparities are  longstanding, and rooted in a history of racism   and discrimination, and here in the United States,  both the American Psychological Association and   the American Psychiatric Association in the past  couple of years have acknowledged their roles in   perpetuating racism and discrimination. They both  issued apologies, as well as some important action   items, which I appreciate. So, the recognition  that acknowledging is helpful, but it’s even more   important to have some action items to describe  how you’re going to remedy past errors. And in   the UK, the British Psychological Association has  made similar statements. So, there’s – they issued   a statement on racial injustice and that, also,  sort of, describes the history of the British   Psychological Society in the same – similar way  that the American Psychological Association did,   along with some action items that they would  be engaging in to help remedy past errors. So, one thing that – one question that people  often ask when I talk about disparities in access   to care, is, you know, people will say, “So,  we’ve known – you described that we’ve known   about racial disparities for a long time, they’ve  been longstanding,” I use the phrase longstanding   a lot, “so, what’s going on? What are people  doing about it, and have they improved over   time?” And the short answer to that question is  no. Unfortunately, racial and ethnic disparities   in access to mental health care have not improved  over time. So, this was one study that was done   in adults between the ages of 2004 and 2012,  and in that time, disparities did not improve,   and in fact, for Black and Hispanic people,  disparities were exacerbated over that period   of time. This study here, this Cook et al.  study, was – had an adult focused sample. So, let’s take a look at kids. So, this is a more  recent study that’s looking at service use in a   paediatric population. So, just to orient you  to the slide, I know it’s a bit small. Panel A   is showing any mental health care use by race and  ethnicity between the years of 2010 and 2017. So,   here, the blue line represents white youth, the,  sort of, reddish-orange line is Black youth,   and the grey line is Latinx youth. Panel B is any  outpatient mental health care – any outpatient   mental health care by race and ethnicity, and  Panel C is psychotropic medication use by race and   ethnicity. So, any mental health care, outpatient  mental health care, and psychotropic medicine use. So, what these – what the study found  was that Black-white and Latinx-white   disparities in both the 2010/2011 time  period, and the 2016/2017 periods,   for any mental healthcare use and any  outpatient mental health care use,   that they persisted. They persisted from 2010 to  2011 to 2016/2017. Look – focusing specifically on   psychotropic medication use, there were Latinx  and white disparities for both timepoints,   and Black-white disparities for the 2016 to 2017  period. And Black-white disparities in any mental   health care use and any outpatient mental health  care use were significantly exacerbated between   the 2010 and 2011 period and 2016/2017 period. So,  again, a similar story for kids as there was for   adults, not only are disparities not improving,  they actually have been worsening over time. And I just want to briefly touch on outcomes.  Sort of, one of the most important outcomes   that we consider in mental health is suicide.  Obviously it’s not the only outcome to consider,   but it’s one that we obviously work very hard as  mental health care professionals to prevent. So,   Jeff Bridge and colleagues recently did this study  examining youth suicide during the first year of   the COVID-19 pandemic. So, this is – these are  findings from a US national study that suggests   an overall increase in youth suicide deaths  across the first ten months of the pandemic. But there was variation across racial and ethnic  groups that was particularly concerning. So, here,   non-Hispanic, American Indian and Alaska Native,  non-Hispanic Black youth experienced significantly   more suicide deaths than predicted. So, again, we  have not just disparities in the access to mental   health care, but we’re also seeing disparities in  outcomes, and that suicide rates are increasing at   a disproportionate rate for some youth of colour.  So, it’s just especially important that we do a   really good job making sure that there’s equitable  access to mental health care, seeing as there are,   sort of, increasing – disproportionately  increasing rates of suicide among youth of colour. So, I want to talk a little bit about the impact  of racism on health and wellbeing. Before I do,   I just want to clearly – quickly, rather,  define racism. I know that that can mean   different things to different people. So, when I  say ‘racism’, I mean a system of repression that   categorises and strates – stratifies social  groups into races, devalues and disadvantages   those that are considered inferior, and  differentially allocates to them valued   societal resources and opportunities. So,  again, it’s not just categorising people.   It’s also devaluing them and differentially  allocating resources and opportunities. So, many racial minoritised youth experience  racial discrimination and victimisation as   early as the first decade of life, so before  their 10th birthday. Racial discrimination   negatively impacts the health and wellbeing of  minoritised youth and may create barriers to   accessing care. So, we’ll talk a little  bit about the research on this. So,   this first study that I want to quickly summarise  examined discrimination in mental health in a   representative sample of African American and  Afro-Caribbean youth, again, here in the US. So,   using a US nationally representative sample, they  found that 90% of African American and 87% of   Afro-Caribbean youth experienced discrimination.  So, again, this is almost a universal experience.   And discrimination was associated with lifetime  and 12-month major depression, and lifetime and   12-month anxiety. So, again, almost all the youth  in this study had experienced discrimination,   and it was significantly associated  with worse mental health outcomes. This next study that I want to briefly describe  examined “COVID-19 Racism and Mental Health in   Chinese American Families.” So, in this study,  nearly half of parents and youth who participated   in the study reported being directly targeted  by COVID-19 racial discrimination online, and   higher levels of both parent and youth perceived  racism and racial discrimination were associated   with poorer mental health. So, again, experiencing  racism, particularly during the pandemic, for the   Chinese American families was fairly common and  associated with negative mental health outcomes. And this final study, here, on this slide that  I want to describe, is a really interesting one,   sort of, took things a step forward in  a way I’ll describe in just a moment,   but they examined “Racial and Ethnic  Discrimination and Mental Health in   Mexican-Origin Youths and Their Parents  Testing the ‘Linked Lives’ Hypothesis.” So,   here, among Mexican-origin youth, experiences of  discrimination were associated with depression,   but again, they took it a step further to look  at intergenerational discrimination and found   that fathers’ experiences of discrimination  exacerbated the link between discrimination   and depression for their children. So, it’s not  just one’s own experiences with discrimination,   but the experiences that their parents have had  with discrimination that could impact mental   health outcomes. So, those are just – I wanted to  briefly run through these studies, just to talk a   bit about how long history of discrimination  can contribute to mental health disparities. I also really like this figure  from the Kaiser Family Foundation,   that describes how – a little bit more how  health disparities are driven by social and   economic inequities. And so, again, when we  think about racism as a system of oppression   that differentially allocates valued  societal resources, like, this, sort of,   really highlights how these resources  might be differentially allocated. So,   there’s differentially distributed economic  stability, so thinking about employment,   income, debt, medical bills, and in the area  of neighbourhood and physical environment,   there are inequities in housing and access  to transportation, playgrounds, walkability. In education, there’s differential access  to things like early childhood education,   vocational training and higher education. In  the food area, there is increased risk for food   insecurity and decreased risk to – decreased  access to healthy food options. In community   safety and social context, there are disparities  in things like exposure to violence and trauma,   policing and justice policies. And most directly  relevant to the conversation that we’re having   today, there are inequities in the health care  system, including relevant to the United States,   things like health care coverage, provider  availability, which I’ll talk about a little   bit more in the next slide, access to  linguistically and culturally appropriate   and respectful care and quality of care.  These are all things that we will touch on. So, things that contribute to disparities are  so, the inequitably distributed financial or   logistical barriers, which could include things  like the distance from one’s home to a treatment   facility, the availability of appointment times,  of appointments at times that work for families,   or difficulty taking time away from work to attend  appointments. There are also systemic barriers,   such as provider bias, and what research shows is  a relatively smaller number of mental health care   providers practicing in areas more populated by  people from minoritised racial groups. And there’s   also some evidence that stigma and knowledge of  mental illness are contributors to disparities in   access to health care, but they often appear to  explain only a small portion of disparities. So,   they’re not – I think a lot of times are  the focus of research in mental health   disparities, but don’t seem to really  be explaining a lot of what’s going on. So, what I want to do next is briefly share with  you some of the rechurch – research that I’ve done   in this area on racial and socioeconomic  disparities in access to health care,   and I’ve specifically, done this using the LAMS  study, or the Longitudinal Assessment of Manic   Symptoms study data. This is a busy slide. I’m  going to walk you through the important pieces   here, but this is a longitudinal study with a  naturalistic design. All of the kids were between   the ages of six and 12 when they were first  assessed, when they were first screened, and they   were recruited during their first visit to one  of nine outpatient clinics associated with four   different universities here in the United States.  So, this is an entirely help-seeking population.   They were all recruited during their first  appointment in an outpatient mental health clinic. The sample was screen-enriched for elevated  symptoms of mania. It doesn’t mean that   all – everyone in the sample had bipolar disorder.  I think only, like, 20 to 25% of the kids in the   study had bipolar disorder. But they were screened  for things like having high levels of energy,   having difficulty sleeping, talking quickly. The  things that you would think of as mania but could   occur in any context for them to screen into the  study. So, actually the most common diagnosis was   ADHD. I think about 75% of the sample had  ADHD at baseline. So, there were 707 kids,   again, between the ages of six and 12, that were  assessed twice a year between 2005 and 2017. And   they’re – have detailed, valid, reliable measures  for diagnoses, psychosocial functioning and child   mental health services, including the KSADS  and the SACA, which is the Service Assessment   for Children and Adolescents. So really  great data to look at treatment engagement. So, what I was interested in, because a lot of  the data at the point that I was looking at these   data, have focused on, sort of, initiating care.  What I was wanting to focus more on was what keeps   kids in care? What are some of the things that  are associated with treatment retention? So,   my objectives were to examine the possible racial  and ethnic disparities in treatment retention,   as well as identify other sociodemographic  contributors and barriers to retention.   With the specific questions of whether  race, ethnicity, socioeconomic status,   caregiver, education, child diagnoses  and other clinical child and family   characteristics predicted treatment  retention over 12 months, and whether   parents’ perceptions – so I think the new thing  here is whether parents’ perceptions of how   well the treatment matched their child’s needs  contributed to the prediction above and beyond   those child and family characteristics that I  described. So, parents were asked to rate how   well the treatment their child was receiving  matched what they felt their child needed. So, just to review what we found, so most of  the kids were receiving outpatient medication   management and/or psychotherapy at  baseline, and only a third of the   parents recorded that the treatment matched  very well, so that their treatment matched   what they were expecting very well, which  to me, is quite low and a bit concerning.   523 had complete service use data at the 12-month  follow-up, and we found just under 70% continued   to use baseline services, which actually is  quite high. So, about 70% were retained in   treatment, so were using the same services they  were receiving at baseline 12 months later. The things that were associated with treatment  retention, so race, being a person of colour was   negatively associated with treatment retention,  so you were most likely not to still be receiving   the – your baseline treatment if you were a person  of colour. Kids whose parents were experiencing   more stress associated with parenting a child  with mental health problems were more likely to   continue to receive services. And interestingly,  parents, when there was a higher perceived match   between the treatment and what the child needed,  on the parents’ – from the parents’ perspective,   there was a greater likelihood of being  retained in treatment over 12 months. So, just to quickly review that in plain  language. Being a person of colour was   significantly associated with treatment dropout,   and this was even after controlling for  things like socioeconomic indicators,   so things like caregiver education and income, as  well as other clinical and demographic variables,   and even after adding treatment match to  the model. And so, what this means is that   there were barriers that weren’t examined in  these analyses that contribute to retention. The parenting stress findings that I reviewed  are consistent with previous research showing   that greater parent burden is associated with  increased service use. And I think the really,   sort of, novel finding here, which maybe  is intuitive, but novel all the same,   is that parents’ attitudes early  in treatment, so the perceptions   between match – so the match between parent  expectancies of treatment and the execution   of the treatment was an important indicator of  the youth’s likelihood to continue treatment. So, the implications of this, even families who  – I’ve said this before, and you’ll hear me say   it probably a couple more times before I’ve done  talking, but even families who overcome barriers   to initiate treatment face further barriers to  continued service use. So, I think for those of   us who are Clinicians tuning in, it’s important  to be sensitive to parents’ opinions and cultural   differences that may affect engagement, so what  we often refer to as ‘cultural humility’. It’s   important to carefully assess families’ treatment  barriers early in treatment and work together with   families to identify solutions to overcome those  barriers. And then, lastly, to really discuss,   carefully discuss, treatment plans with parents,  incorporate their opinions into the treatment   plan, when that’s appropriate, which I can  imagine is almost always appropriate. Explain the   rationale for the selected treatment modalities  and offer a choice of treatments when available. So, the next thing, so the last, sort of,  analyses that I’m going to describe that I did,   before we move on, is looking at adequate care.  So, we know that there are barriers to starting   care, there’s barriers to staying in treatment,  but for me, simply looking at retention alone   wasn’t really getting at what I really wanted  to know, which is, what are the correlates   of receiving good care and whether there are  racial disparities in receiving adequate care. So, there is a couple of different ways  to look – to define adequate care. So,   one of the common ways, common, sort  of, operationalisations of adequate care   is this minimally adequate treatment definition,  which is typically described as “receiving at   least four mental health care visits with any  mental health care provider if the person is   also receiving medication,” or in the absence  of medication it should be eight visits. And so,   there’s been lots of research studies examining  access to adequate care, using this definition,   and there have been racial disparities found  using that definition. And while I think   it’s a useful way to think about adequate  care, it doesn’t allow for any adjustments   for individual clinical characteristics,  so things like comorbidity and severity.  So, another approach is the expert consensus  approach, which considers the appropriateness   of different therapies and the comprehensiveness  of care, given a child’s profile of comorbidities.   It is based on published practice guidelines  and recommendations, and this is the option that   I chose, if you can’t tell. And so, in this  instance, it included independent readings by   two licensed Clinicians, which were my – who were  myself and a Board Certified Child Psychiatrist.   So, we independently rated service use for  all of the kids on LAMS – in the LAMS study,   which I described earlier, and we had consensus  meetings to discuss any discrepant readings. So, the benefits to this approach is that it  allowed us to fully utilise all information   that was available in the record, to make  determinations about treat – patients’   treatment status. It allowed us the flexibility  to take into account patients’ comorbidities,   their age and other clinical  and treatment characteristics,   things like a recent inpatient  hospitalisation discharge. And   it allowed the utilisation of expert knowledge  of two Clinicians with complementary expertise. So, we categorised, again, independently,  and then we discussed discrepant readings,   we categorised each child service use into  one of five different rating groups. So,   there was standard of care, which meant that  the treatment that the child was receiving   was consistent with treatment guidelines, without  any clear evidence of any missing components. So,   this could be a child with a major depressive  disorder, who was receiving an antidepressant   and was also hav – receiving CBT. Adequate care  would be treatment for the primary diagnosis   that was consistent with treatment guidelines  and a secondary or less severe diagnosis that   was partially treated with no inappropriate or  contraindicated treatments. It could also mean   partial treatment received for an NOS diagnosis.  So, for instance, this might be a child who   has ADHD-NOS and was receiving behavioural  therapy but was not taking any medication. Inadequate treatment would be that there  was an indicated treatment component that   was missing. So, this could be a child with ADHD  combined type who wasn’t receiving any treatment,   or a child with a major depressive disorder not  receiving treatment. Inappropriate care would   be – would mean that at least one component of the  treatment provided was contraindicated or there   was polypharmacy that was not consistent with  treatment guidelines. So, an example of this would   be a child with, say, bipolar 1 disorder, who was  on an antidepressant in the absence of any, sort   of, mood stabiliser. And then the last category  was treatment pending. So, kids were per – given   this reading if there was a treatment that was  indicated and there – but there was evidence that   it was forthcoming and had not yet begun. So, this  might be a child who had in their service use data   that they had received an evaluation, or an intake  assessment, or that they had had an appointment   with say a Psychiatrist or a Psychologist,  but were not yet receiving active treatment. Ultimately, what we did, because this was  a lot of different treatment categories,   was collapse them into two categories, including  adequate, which was standard of care and   the adequate categorisation,  or inadequate/inappropriate,   which included inadequate/inappropriate and  treatment pending. Because ultimately, the   kids in the treatment pending were not receiving  the treatment that was indicated at the time. So, I want to note that all these treatment  ratings were provided at the kids’ baseli – from   using their baseline service use data.  Remember that they were all recruited from   – at the screening assessment when it’s  their first appointment in an outpatient   mental health clinic. And on average,  between that first initial screening,   into the study and the baseline, the baseline  assessment, there was a mean of about 45 days. So,   about a month and a half had passed since  their first appointment in a mental health   clinic and when we were rating the adequacy  of their service use and that amount of time   did not significantly differ across  the five treatment rating groups. Unfortunately, there was actually very little  variability in the treatment ratings for   psychotherapy, because caregivers did not often  report psychotherapy treatment modalities, so they   would frequently report things like talk therapy  instead of say CBT or DBT or parent management   training. And it could be because they didn’t  know, or perhaps they were never told, and there’s   actually good evidence to suggest that providers  aren’t actually adhering to what they say that   they’re doing anyway. So, we fose to – chose  to focus the analyses on the adequacy of their   medication treatment that they were receiving. So, this is, again, a busy slide, where I   just want to draw your attention to what the  significant findings were. So, we looked at what   was – what were the things that were associated  with receiving adequate care? And here we found   that youth who were African American or Black were  more likely to receive inadequate care than white   youth in the study were. Youth whose parents had  a bachelor’s degree or greater were less likely to   receive inadequate care, and youth who had an  anxiety diagnosis were more likely to receive   inadequate care. So, I’m going to explain all this  in, sort of, plain language here on this slide. So, only 53% of the kids had received adequate  medication for their diagnoses, which, again,   I think is too low. Of course, we want that  number to be much closer to 100%. In youth   whose caregivers had a bachelor’s degree or more  education were the most likely to receive adequate   care, which is consistent with prior research.  Youth with anxiety were more – less likely to   receive adequate care, which I was un – not a  finding I was expecting, but perhaps anxiety   diagnoses were unrecognised or undiagnosed by  their treating providers, or perhaps caregivers   were resistant to indicated interventions  for those disorders. But consistent with   our hypothesis, Black youth were less likely than  white youth to receive adequate care, and white   youth and those who identified as American Indian,  Ala – sorry, American Indian, Alaska Native,   Asian or bi or multiracial did not significantly  differ in likelihood of receiving adequate care. So, unfortunately, the cell sizes, so the number  of participants we had who were – who identified   as American Indian, Asian and bi/multiracial  was so small that we ended up combining them   into one group. So, there were likely some  differences within that group that we – this   particular study would have been underpowered  to detect. But then we did find that Black   youth were less likely than white youth to  receive adequate care. And this persisted   with adjustments for Medicaid status, which  is an indicator or limited income. Medicaid   insurance is available to families in the  United States who have limited income. It   persisted with adjustments for caregiver  education and clinical characteristics. So, here we know racial disparities in  access to mental health care, again,   are well established, as these findings  are disappointing but not surprising,   and may originate from things like inequitably  distributed financial or logistical barriers and   systemic barriers. So, again, this replicates  racial disparities found in prior research,   and it’s a possibility that some of  what we’re seeing reflects possible   differences in patient and family treatment  preferences. But, again, as I mentioned before,   treatment preferences and stigma often only  – while they’re frequently investigated,   don’t ex – tend to only explain a small portion  of disparity. So, there are likely other things   at play here and there’s a clear need for  strategies to reduce barriers and bias. So, let’s talk a little bit more about that. So,  we’ve talked about the – some of the background   and history of health disparities and been able  to review some of the research that I’ve done in   this area. So, I want to spend the rest of  our time talking about possible solutions.   But first, I want to return to that quote  from my mother, when she said, “Our history,   history of people of colour is such that if  there’s a problem, especially with your child,   you use the tools you have. Especially if  you’re not sure if seeking professional   help is going to do more harm than good.”  So, how can we make sure we do more good? So, briefly touching on things like policy  changes. There’s definitely some policy changes   that I think would help, so things like making  treatment more affordable, increasing access to   insurance. Of course, these are changes that  are more relevant to here – to us here in the   United States, where we do not have universal  health care. But one thing that is probably   likely helpful, sort of, anywhere, is things  like incentivising mental health practice in   underserved areas, because as I discussed before,  there’s a relatively fewer number of mental health   care providers in areas more heavily populated  by people from minoritised racial groups. But I really want to spend more of our time  focusing on possible solutions that can be   driven by mental health care providers,  Researchers, Educators. So, the causes,   as we’ve discussed, the causes of the  disparities in mental health care are many   and varied and so must be the solutions,  so let’s talk about what we can do. So,   thinking about evidence-based practices, like,  how do we decide what is evidence-based? And we   decide that through randomised controlled trials.  So, we do a randomised controlled trial, if the   treatment looked like it was efficacious, then –  and, you know, there’s more studies showing that   it’s an efficacious or effective treatment, then  we decide that it’s an evidence-based practice. But one potential reason for racial and ethnic  disparities in treatment outcomes is the makeup   of our randomised controlled trial samples. So,  they are predominantly white and middle class,   which to me, begs the question for  whom practices are evidence-based. So,   I think that there’s a clear need to  make sure that when we’re conducting   randomised controlled trials that we  have a diverse participant population,   so that we can make sure that our  findings are more generalisable. Another strategy that has been posed and  implemented is culturally adapted versions   of evidence-based treatments. So, such treatments  have helped – have been developed to help address   the treatment gap that I just described. And  there are some culturally adapted intervention   that have shown – interventions that have shown  benefit over the traditional evidence-based   treatment or wait-list control, but there  are others that have found mixed results,   with really, no treatments being well  established for racially minoritised youth. The other thing about cultural adaptations is that  they could present a significant dissemination   barrier, as it really, sort of, necessitates  that there is no culturally relevant versions   of interventions for each of their patients. So,  if you think about providers who work in community   mental health centres, that might serve clients  from multiple different cultural backgrounds,   it would really require that they knew  culturally – several different culturally   relevant interventions to meet the needs  of all of their patients. The other thing   is that cultural adaptations don’t necessarily  allow for individuality within racial groups. There’s also some evidence that in some cases,  the standard evidence-based treatment actually   works better than the adapted version.  So, another approach that has been offered   is person-centred approaches, which really  allows the – each patient to describe their   own experien – cultural experiences, their own,  sort of, cultural definition of their presenting   problems and treatment preferences and things like  that. So, when I say, ‘person-centred approach’,   I mean, showing empathy and unconditional  positive regard for patients, recognising   that each individual has their own identity,  their own needs and their own preferences. And you might say this is a complicated  thing to measure, to assess, and you   would be right in saying that, it’s certainly  true. But there are some tools, helpful tools,   in guiding this approach to assessing a patient’s  identity needs and preferences. And one of them is   the Cultural Formulation Interview, or the CFI,  which is published by the American Psychiatric   Association and it’s in DSM-5. And this is another  very busy slide, but I just wanted to, sort of,   show you what the different areas of focus  are in the Cultural Formulation Interview. So, it gives a patient and their parent  or caregiver the opportunity to provide   a cultural definition of the problem. So,  what does the problem look like from their   point of view? How would they describe it  to people in their community? What their   cultural perceptions are of the causes, con  – and contacts and support that they have,   so – and what do they think the causes are? What  are stressors that they might – perhaps culturally   relevant stressors that they might be facing and  supports that they have? What role does it – do   they see their cultural identity has on – in how  – in some of the experiences that they’re having? It also assesses cultural factors that  affect self-coping and past help-seeking. So,   it assesses what their current coping strategies  are, what their past experiences have been like   with help-seeking, what barriers that they have  experienced to seeking care. And then the final   area is cultural factors that affect current  help-seeking. So, what are their treatment   preferences? What are they expecting? What  concerns do they have about the Clinician-patient   relationship? So, really it, sort of, gives  the patient the power to describe what’s   happening to them, how they’re perceiving it,  how they’re experiencing it, in their own words. So, one – so the – while the Cultural Formulation  Interview has been around for quite some time,   there had not, previously to a couple of years  ago, been any, sort of, randomised control trials   looking at whether it was actually effective or  efficacious in improving outcomes for youth who   participated in it. So, Amy [means Amanda]  Sanchez and colleagues did such a study. So,   what they did was they randomised caregivers to  receive either whatever their usual assessment   was, so assessment as usual, or assessment as  usual augmented with the Cultural Formulation   Interview, which, again, as I described, is a  brief caregiver assessment of the cultural factors   that affect the child’s problems and family  help-seeking. After that intake assessment,   whether it was assessment as usual or assessment  as usual plus the Cultural Formulation Interview,   parents were offered a course of  Parent-Child Interaction Therapy,   or PCIT. Which is a well-supported behavioural  parenting intervention for child behaviour   problems and maladaptive family patterns,  which many of you are probably familiar with. So, among this sample of youth with behaviour  problems, most of whom identified with a racially   minoritised group, this person-centred, so  the CFI, the Cultural Formulation Interview,   this person-centred assessment at intake,  was associated with provider and caregiver   satisfaction, with better provider  understanding of the patient and family,   and improved patient and family engagement in  treatment. So, again here, there’s some evidence   that among the sample, pred – of predominantly  minoritised youth, being given the opportunity   to describe the presenting problems and  what their treatment expectancies were,   and, sort of, how they derive strength from their  culture and how their identity might be impacting   their presenting problems. So, both ha – giving  families the opportunity to describe that, and   the provider having the opportunity to understand  that, improved treatment engagement and outcomes. The other thing about this is that having  the Cultural Formulation early in treatment   can really selp – help to set the groundwork  and provide important context for discussions   of race-related high profile events that might  come up over the course of treatment. The other   thing that I want to note is that people, when  I talk about the Cultural Formulation Interview,   people will ask me, “Well, isn’t this going to  add so much time to my intake assessment?” And   in the study, it actually only took – I think on  average, it was 11 minutes, 11 minutes longer to   complete the Cultural Formulation Interview. And  if you have a chance to go and look at it, you can   do a Google search, it’s easy to find, if  you have a chance to go and look at it, the   questions – the areas that are covered are often  area – topics that you would cover anywhere in an   intake assessment. But it gives you the language  to help get, sort of the cultural formulation of   those items that you would assess anyway. So, it’s  really a nice supplement to what people typically   use in an intake assessment anyway, but provides  some rich cultural information along the way. Other important solutions – another important  solution is to increase workforce diversity. So,   again, won’t be a surprise to any of you that  people of colour are severely underrepresented   among the psychology workforce. So, the figures  that I’m presenting here are the US psychology   workforce. You can see that top bar is US  psychology workforce, the bottom is the US   population. So, you can see there’s significant  underrepresentation, particularly of Black and   Hispanic folks among the US psychology workforce.  And there is some hope here in that early career   Psychologists, so that’s the fourth bar down,  looks a little bit more representative of the   US population. So, maybe over time, that will  shift, and I think that that’s a good thing. There’s a similar story in the UK. So, I looked up  the racial breakdown of the Psychologists in the   UK, and it appears that there’s about – it’s about  92% white, less than 2% Black, and about 6.7% of   Psychologists in the UK identify with another  race. And I – well, the reason that I’m talking   about workforce diversity is not because I believe  that we – it is the case that every person from a   minoritised – with a minoritised identity has to  be treated by another person with a minoritised   identity, but there are many benefits to having a  diverse workforce, which we’re going to talk about   here in just a moment. So, we know that having  increased workforce diversity can also increase   things like creativity and productivity  and reduce turnover in the workplace. There’s also evidence of provider bias that  influences con – clinical decision-making,   and mental health treatment may be  more susceptible to provider bias,   as decisions about treatment are often made by a  single provider. So, decisions about things like   treatment access, diagnosis and disposition are  often made by a single provider, compared to the   team-based approaches of many other disciplines.  And there’s research sho – suggesting that Black   and Latinx or Latino, Latina/e providers show  greater cultural competence and are less likely   to display racial bias. So, promoting diversity  in the workforce is – can be an important   component of addressing racial disparities. So, along the same line, so increasing workforce   diversity is not just about increasing the number  of people who are in a particular profession,   and so, actually, sort of, nurturing people  along that pathway. It’s improving professional   development in working on, sort of, wellbeing and  retention among those along the pathway. And so,   I wanted to, sort of, briefly discuss some  folks who are doing this work really well. So,   there’s this one group here in the United  States, it’s a graduate student-led   – so I’ve been than – grateful to have been a  Faculty Adviser to this group called DiSSECT,   which is the Dismantling Systemic Shortcomings  in Education and Clinical Training. It’s again,   a US national graduate student-led  organisation that strives to create,   collate and disseminate open access resources to  measure, assess, evaluate and advance anti-racist   initiatives in clinical psychology and  related graduate training programmes. They have a toolkit, so a list  of resources that you can access,   both – including, sort of, assessments, as well  as different ways – they’ve, sort of, collated   research on different ways to support graduate  students from historically underrepresented   groups while they’re in graduate school, to  try to support professional development and   wellbeing among that group of students. So, you  can see the QR code at the bottom of the screen,   as well – I’m sorry, the QR code as well  as the weblink at the bottom of the screen,   if you’re interested in seeing the  information that they’ve pulled   together. They’ve done a really great job  pulling resources on this particular topic. Another resource that I would like to draw your  attention to – so I know we didn’t have a lot of   time today, but what I’m hoping to do is to  – I help you to identify resources that can   help you to learn more, if that’s something that  you’re interested in. But I’ve been very lucky to   have been able to co-guest edit a Special Issue  of the Journal of Clinical Child and Adolescent   Psychology on Advancing Racial Justice in  Clinical Child and Adolescent Psychology,   and I guest edited this issue with Dr  Noelle Hurd at the University of Virginia. So, this issue focuses on two areas that  hold the potential to reduce inequitable   treatment of children and adolescents of  colour in our field, including strategies   to address structural barriers that  disproportionately impact youth of colour,   and approaches to increase representation in  mental health care providers of colour. So,   again, there’s a – there’s the DOI at  the bottom and there’s a QR code. So,   all of the articles in the Special Issue are open  access, do you don’t – there’s no – you don’t need   to pay to look at any of them. So, you can see  the full issue for free, using that QR code. So, our goal in editing the Special Issue  was to really highlight that we must adopt   an anti-racist approach to treatment and  education that acknowledges racial trauma   and provides trainees and Clinician education  on the mental health impacts of racial trauma,   as well as strategies to prevent and treat  associated psychological distress. So,   as I said before, the causes of  racial disparities are varied and   so must be the solutions, and so, we did  our best to cover a range of topics here. So, just to summarise, we know that  racial and ethnic disparities in   access to children’s mental health care  are longstanding, and unfortunately,   they’re not improving. We really need innovative  solutions to create change. Addressing disparities   will likely require an all hands on deck  approach, with attention not only to policy,   but also to inclusive research practices, clinical  cultural responsiveness and workforce diversity. And lastly, this is a lot of names on the slide,   but I want to acknowledge all of the people that  I’ve worked with in – on a lot of the different   things that I’ve just been able to present  to you. And then, I also want to say thank   you to you. Thank you so much for tuning in.  I hope that you learned something new today,   and if you have questions or you’d like to  chat with me about anything that I said,   please feel free to reach out. I can be  reached at ayoung90@jhmi.edu. Thank you.