For Those Who Experience Childhood Adversity, Who Is Allowed to be Depressed? Racial and Ethnic Disparities in Reports of Behavioral Health Diagnoses for Youth Exposed to Adverse Childhood Experiences (ACEs)

Background & Purpose: Adverse Childhood Experiences (ACEs) are an essential metric of childhood well-being. Research has elucidated the prevalence of ACEs for youth and exposed the proximal and distal impacts of ACEs across behavioral and physical health outcomes. Additional bodies of research have uncovered racial biases among mental health professionals’ diagnostic practices towards youth of color. However, less research has focused on the relationship between ACEs and the behavioral health diagnosis a child receives when considering racial discrimination practices. Therefore, this study attempts to fill gaps in the literature by examining the relationship between ACEs and race in parent-reports of a child’s diagnosis to identify patterns of racial disparities in diagnostic practices.

Methods: Data from the 2017 National Survey of Children’s Health (NSCH), a cross-sectional nationally representative survey of children aged 0-17, was utilized in the study. Data were collected from parent respondents. A sub-sample was drawn of participants who identified their children as “Black non-Hispanic”, “Hispanic”, or “White non-Hispanic” for a total of 18,227 youth (86.7% of total sample). The NSCH ACE index was used with a range of 0-9 adversities that were dichotomized and summed. Four dependent variables of internalizing disorders (depression, anxiety) and externalizing disorders (ADD/ADHD, behavioral/conduct problems) were assessed. Logistic regression, utilizing relevant control variables, was used to explore the association between ACE score and race of the child on the likelihood of a parent reporting a child had received one of the four diagnoses.

Results: As expected, the total ACE score was a significant predictor (p<.001) and presented a dose-response relationship for all four disorders. Race was also found to be a significant predictor with Black children being less likely to report a diagnosis of depression (odds ratio [OR] = .57, p<.001), or anxiety (OR = .39, p<.001) and more likely to report a diagnosis of behavior/conduct problems (OR = 1.2, p<.05) compared to White children. The differences in disorder reports between racial groups were most notable when examining higher ACE scores. For example, 2.9% of Black children and 6.5% of White children were reported to have anxiety when no ACEs were identified. However, at 4 or more ACEs, only 9.6% of Black children were diagnosed with anxiety compared to 31.2% of White children. Conversely, behavior/conduct problems were reported similarly across the racial groups with no ACEs but at 4 or more ACEs, 37.1% of Black children compared to 30.8% of White children reported the diagnosis.

Conclusions and Implications: ACEs profoundly impact the well-being of children, but the identification of internalizing and externalizing symptoms by providers appears to occur differentially based on race. Evidence suggests that Black children are less likely to be diagnosed with internalizing symptoms and more likely that to be diagnosed with externalizing symptoms relative to White and Hispanic children, even when comparing groups with the same ACE exposure. These findings produce crucial implications regarding potential bias among healthcare providers and suggest training and intervention changes are needed to ensure that appropriate diagnosis and subsequent treatments are used for all children.