My Black patient spent most of February in a locked inpatient psychiatric ward. Well, he wasn't my patient anymore, but he had been at one time. As a resident working with hospitalized children with severe mental illnesses, he was one of my very first patients. He helped me to become a better doctor. I wish I could have helped him more, too. But the medical system failed him.
He was only 9 years old then, and I'd spent weeks advocating for him, encouraging the medical team to understand him as a little boy who struggled with transitions, possibly with a diagnosis of autism spectrum disorder, rather than a "violent terror." Even though he was a child, he was often described as if he were a tyrannical adult, capable of making the same decisions and given the same emotional tools to handle life's challenges as a privileged health professional with no mental illness.
In reality, he was a rosy-cheeked child with sad eyes. He had a substantial family history of severe mental illness, and desperately needed help. I had managed to form a good therapeutic alliance with him, and we would make up games together on the unit. He required a specific approach, not a "one size fits all" plan. Staff who understood that, mostly Black, helped him the most. Staff who yelled at him to force him to follow rules, mostly white, did more harm than good. He was hospitalized because his mother was at her wit's end. At home, she sometimes heard him talking to himself. At school, he had emotional breakdowns, threatening to harm others and himself.
I had seen some of those episodes myself. Sometimes he would scream so much that he would make himself vomit. I worried that he was responding to auditory hallucinations. But he never once harmed me, and I was never concerned he would. I knew how to approach him with respect and compassion. Often, after he calmed down, I would spend extra time with him, and we would go on walks or play his favorite games.
But I wasn't sure how to help him live a better life.
A couple of weeks ago, I saw him in the hospital again while I was there as the on-call psychiatrist. He was 12 years old now, with the same sad, taupe eyes, rosy cheeks, and umber-colored curly hair. I observed him from afar, not wanting to pull him from his activities, and chatted with a nurse with long braids.
"He's back, huh?" I said, sighing.
"Oh yeah. He's been shuttled back and forth from hospital to hospital. He's an institutional kid now," she replied.
"I just hope staff are nice to him," I said.
"Mmm hmm. You and me both." The nurse and I exchanged knowing looks.
I believe that many children, especially Black children, become institutionalized, whether in a hospital or in a juvenile detention facility, because the medical system has failed them. And we can, and must, do better.
Black children are more likely to be diagnosed with disruptive mood disorders, such as oppositional defiant disorder (ODD), than white children with similar behaviors, who are more likely to be diagnosed with attention-deficit/hyperactivity disorder (ADHD). Psychiatric diagnoses, as described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), are still somewhat subjective. The aggressive, externalizing behaviors of ODD can also be seen in ADHD. But ADHD is tied to far more services and support. ODD is an empty diagnosis to me, and a lazy one.
I have seen ODD weaponized against Black children far too many times, as a marker of a "bad child." My Black child patient who punches a wall and ignores adults who show them little respect is slapped with the diagnosis of ODD. Yet, a white child who calls Black staff the N-word and destroys property receives the diagnosis of ADHD. It is often evident, from how the patient is described in their medical chart, who is treated with compassion and who is villainized. In fact, it is documented that Black patients are more likely to be described poorly in their medical records. These words trickle down to real-time behavior, as I watch predominantly white staff treating white children with compassion and respect, and Black children with fear and disdain.
"He just won't listen," a white mental health tech said one morning about my 9-year-old Black patient. Her eyes flashed with anger and her lips formed a sneer.
"How do you know he can help it? He may be struggling with autism or possibly experiencing auditory hallucinations that distract him," I replied.
"Oh, he can help it," she said resolutely. "He is just oppositional."
Black children are also less likely to receive a timely diagnosis of autism spectrum disorder compared to white children. While this is often explained away by stating that Black children are poorer with parents who are less educated, the reality is that the diagnosis of autism is missed in Black children because of a lack of compassion for Black suffering, and a lack of investigation into the cause of a Black child's behavioral dysregulation.
Until we have anti-racist staff, who truly treat all children with empathy and compassion, Black children will continue to lack informative diagnoses. This leads to incorrect conceptualization of the child and ineffective approaches by staff who often exacerbate their behavior. For a child who struggles with externalizing behaviors, yelling at them to comply with rules at school or in the hospital may not work as it does with other children. It may lead to them becoming more dysregulated, aggressive even. Add to that the fact that Black children are more likely to be physically restrained in emergency departments and suspended from school, compared to white children with similar behaviors, and you've created the perfect storm.
To be sure, the children I see in inpatient psychiatric hospitals are complex and challenging. Gone are the days, one of my supervisors once said, of straightforward depression and ADHD. We see children who are struggling with a complex web of trauma, autism, learning disabilities, and even psychosis. We see children, like my patient, who have spent months in the hospital because we cannot find a safe place for them that has the resources to care for them. The problem does not only lie in inadequate, racist psychiatric care. It lies in the medical system and its lack of support for many of the children who need it the most.
We need more community resources outside of the hospital that are well-equipped to help children who have challenging behaviors that are not calmed by our psychotropic regimens. But we also need to adequately compensate and train staff, in the hospital, on how to approach these children safely with an anti-racist approach: one that treats every child with respect and compassion and pays particular attention not to perpetuate the poorer treatment of Black children.
Until we have a medical system, and society, that treats Black children fairly and kindly, and more people in power who invest time and funding to make it happen, Black children, whether with severe mental illness or not, will continue to suffer.
Amanda Calhoun, MD, MPH, is an adult/child psychiatry resident at Yale School of Medicine/Yale Child Study Center, and a member of MedPage Today's "The Lab." You can read more of her writing in her column, The Activist Psychiatrist.