ATLANTA — 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,” Dr. 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, Dr. 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 tele-health visits with young patients and then, among themselves, discuss symptoms, diagnoses and the medications, if any, to prescribe.
Such dedicated care — with patients seen in depth, over years — 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 percent income bracket in the United States have a practicing mental health specialist. In contrast, among the poorest income quartile, only eight percent 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 shortage of child and adolescent psychiatrists is most acute in low-income communities of color, according to a study published in September in the American Journal of Preventive Medicine, which concluded that “decisive action is urgently needed.” Among Black adolescents, self-reported suicide attempts rose 80 percent from 1991 to 2019, far outpacing increases in other racial groups, according to a 2021 paper that drew from 183,500 high school students in the United States.
Dr. Vinson, left, with Dr. Brittany Stallworth during a client review session. “Brittany was a Black girl and a Black woman before she was a Black doctor,” Dr. Vinson said.
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,” Dr. 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.
Dr. Vinson, the 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,” Dr. Vinson said of Dr. Stallworth. “She brought that experience into the role as a physician.”
As important or more, Dr. Vinson added, was the time spent through practice and discussion, learning to take into account the societal forces, including structural racism and bias, that form the emotions and behaviors of children and adolescents.
“When you look at all these things, you can see that this is not something inherently wrong with the child but that could be an explainable, understandable response,” Dr. Vinson said. “When you don’t take the time to do this stuff, or learn it, you just end up throwing labels on a kid.”
The boy who nearly burned
On a recent Tuesday morning, Dr. Vinson listened as the other doctors described their cases. Dr. 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, a condition characterized by chronic hostility and lack of cooperation, Dr. 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.
Dr. Vinson suspected the boy was diagnosed with O.D.D. partly because he had reacted testily to the other clinician during examination. She was also concerned that the clinician improperly prescribed him an anti-psychotic 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, with his counselors advised by the Morehouse team.
During the recent Tuesday exam, the boy’s grandmother reported to Dr. Stallworth that his teacher said he had been acting out in class, having outbursts and speaking sharply to the teacher. Dr. 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.
“I think the grandma’s bar is really low,” Dr. Stallworth said to the group, referring to the caregiver’s relatively upbeat assessment.
“Yep,” Dr. Vinson said.
Dr. Stallworth recommended a slight increase in the Zoloft dosage, and Dr. 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 Dr. 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 O.D.D. and A.D.H.D. 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 percent 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”; 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,” Dr. 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, Dr. Ng said: “Poor kids and kids of color don’t have the luxury of time with us.”
Medical schools are increasingly aware of the problem. “People are saying they want to be more equitable in their care,” Dr. Vinson said. “But they often don’t know how or don’t have faculty with expertise.”
Dr. Vinson joined the faculty at Morehouse Medical School in 2015, after completing her residency at Harvard Medical School, earning fellowships in child and adolescent psychiatry and forensics at Emory School of Medicine and an undergraduate degree at Florida A&M.
Like Morehouse College, from which it grew, Morehouse Medical School was founded as a historically Black institution “committed to serving Black youth.” That has taken various forms over the years including regular work by Morehouse doctors at a local adoption agency, a primary care clinic and other settings.
In 2019, the opportunity arose to expand the work through cooperation with Fulton County. Dr. Vinson took over leadership of the Tuesday psychiatry clinic, and brought in fellows and residents. The clinic, supported largely by Medicaid and the county, conducts some 400 evaluations and follow-ups a year; as many as two-thirds are repeat visits. Patients are referred by schools, pediatricians or parents.
Dr. Vinson measures success by what she calls patients’ increased function — “Are they doing better in school? Getting along with parents, friends, staying out of trouble? Do they say they feel less anxious?” she said.
Her broader vision for the place was informed by an influential paper in 2014 that argued that medical education needed to teach not just “cultural competency” but also “structural competency.”
This entailed teaching medical professionals to think about the economic and political forces that shaped a patient’s experiences, willingness to trust a diagnosis, and financial ability to follow through on a plan of care.
“We hear that low-income African Americans are unable to comply with doctors’ orders to take their medications with food,” the authors wrote, “not because they harbor cultural mistrust of the medical establishment, but because they live in food deserts with no access to grocery stores.” Caregivers needed to be as sensitive to socioeconomics as to cultural heritage.
In 2021, Dr. Vinson and Dr. Ruth Shim, a psychiatrist at the University of California, Davis, published “Social (In)justice and Mental Health,” a collection of essays by various scholars, including Dr. Vinson, that helped to crystallize this medical philosophy in the field of mental health. She speaks regularly at conferences, with lawyers and judges interested in the role of systemic racism and bias on the judicial system, and medical students. In addition to her post at Morehouse and a private practice, she runs a mental health forensics company, Lorio Psych Group, that consults on legal cases nationwide involving juvenile sentencing and school discrimination.
“She’s an inspirational leader and a champion of health equity,” Dr. Ng said.
Dr. Eraka Bath, a child and adolescent psychiatrist at U.C.L.A., characterized the Morehouse team’s work as “anti-racist clinical care.” Dr. Bath was quick to emphasize that she was not suggesting malice on the part of other providers, only that ideas about behavior can become unconsciously hardened.
“Despite our best intentions, we can reinforce racism,” she said.
Dr. Ng agreed. “You don’t have to be of the same identity to make a therapeutic difference,” he said. But when it comes to the cultural issues: “You just have to be aware of it.”
‘Black man to Black man’
As midday approached on that recent Tuesday, Dr. Stallworth told the team about her exam with a Black middle-schooler with A.D.H.D. In the spring he had been bullied at school by gangs. This fall he changed schools, and now, Dr. Stallworth said, he reported being happy — playing football, making friends, and, according to his mother, coming home and doing his homework.
“He smiled, which was the first time I’ve seen him do that,” Dr. Stallworth said. “There was a pleasant little kid in there today. I saw it. That was so cool.”
Dr. Lewis spoke up. “I know you’ve had a lot of tough cases, Dr. Stallworth,” he said. “I want you to remember this.”
All of the doctors on the clinic team have faced racism. Dr. Lewis grew up in an upper-middle-class family in Parkland, Fla., among few Black peers, with white friends who called him “Oreo,” he said: “Black on the outside, white on the inside, not really Black.” In his high-school band, it was a tradition for the underclassman to give each graduating senior a gift. Dr. Lewis was given a watermelon, “because that’s what Black people eat,” he recalled.
Dr. Vinson described an encounter on her first job, at a major hospital in Atlanta, when an older, white social worker told her in a meeting that he “felt unsafe” with her, she said.
“I was like, ‘I’m a five-foot-two woman who has never raised my voice with you, never used inappropriate language, certainly never threatened you,’” Dr. Vinson said she responded. “‘You feel unsafe with me — it’s essentially calling me the angry Black women.’”
The fourth member of the team, Dr. Joshua Omade, grew up in a middle-class household in Bowie, Md.; he played rugby and football in high school and was big for his age. Once, at the mall, he was stopped by a police officer who demanded to know, “Why are you here?” he recalled. He was waiting for his mother to finish shopping.
But the doctors are still discovering that lower-income patients of color are dealing with additional challenges. “I’ve quickly learned how much medications cost, and how much the parents have been through,” Dr. Omade said. He added that he’d grown cautious about taking prior diagnoses at face value: “You have to give a kid a chance to explain.”
Late Tuesday afternoon, Dr. Omade conducted an initial diagnostic evaluation on a 17-year-old who had been expelled from school for fighting, then diagnosed with intermittent explosive anger disorder by a behavioral health specialist at a different clinic. The family came to the Tuesday clinic seeking a better understanding of the teenager’s condition and long-term treatment for it.
Dr. Omade described the exam to Dr. Vinson and Dr. Lewis. The patient was friendly, struggled in school, took Adderall for A.D.H.D, lived alternately with his grandmother and mother, played for the school’s basketball team and worked in a supermarket. When asked to explain the fighting, the boy said he was defending himself “against people trying to see how weak or tough he really is,” Dr. Omade reported.
He related other details: The boy expressed a dislike for the police, describing an encounter a few years earlier when an officer pulled a gun on him while he was “hanging out with his friends,” Dr. Omade said. His father had been arrested multiple times and told his son about being roughed up while in custody. He saw police brutality on Instagram. “You can see it everywhere,” Dr. Omade reported the boy saying.
“He does meet the criteria for the A.D.H.D. diagnoses,” Dr. Omade concluded. But, he added, he found the diagnosis of intermittent explosive anger disorder problematic: The boy appeared to be fighting when challenged, not unprovoked or with authority. “In my mind, he is more along the lines of fighting for survival, not someone who is constantly an aggressor looking for activity or action,” Dr. Omade said.
The problem isn’t pathological, he said, “given his family history, the geopolitical climate and his ability to see events on TV that have given him a heightened sense of being on edge.”
“It would make anyone hypervigilant,” he said.
Dr. Vinson nodded in agreement. The team refined the teenager’s medication prescriptions and, later, consulted with his counselor on the updated diagnoses.
Dr. Omade’s, in his discussion that day with Dr. Vinson, concluded with what he’d told the patient about being afraid of the police: “I told him, man to man, and Black man to Black man, this is something we all have to deal with.”