The Full Informed Consent: How Child Mental Health and Schools Intersect

This post is dedicated to Dr. Desiree Shapiro and all the UCSD CAPIE students who attended the Antiracism in Mental Health module we taught on 12/3/22. Your openness, courage, and presence inspired me to complete this post.

Working with schools is a hallmark of child mental health. Schools are important sources of collateral information that supplement parents’ reports about how their children are doing at home. If children are doing well in one space and poorly in another, that finding can help providers pinpoint root causes of distress and determine appropriate interventions. Child mental health providers routinely gather collateral from schools through phone calls to counselors, teachers, and school psychologists. Other sources of collateral information include individualized educational plan (IEP) and 504 plan meetings and reports, as well as assessments completed by teachers. Examples include the Strengths and Difficulties Questionnaire used to evaluate children’s mental health overall and the Swanson, Nolan, and Pelham (SNAP) Questionnaire used to diagnose attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). 

Unfortunately, these sources of collateral are frequently taken at face value by child mental health providers. Interrogating this information with the critical lens necessary for contextualizing, understanding, and protecting children against the oppression embedded within school settings is not a child mental health standard of care.

I once met with a ten-year-old child (they/them pronouns to protect identity) whose IEP indicated that they had ODD and ADHD and claimed that their mother gave birth while addicted to “crack,” a racist accusation that the child’s grandmother adamantly denied. The IEP report documented at length the child’s “defiance” and “aggression” towards peers and teachers. It made no mention of how their parent had died the year before after suffering from multiple chronic illnesses–nor how the child called 911 and tried to resuscitate their parent shortly before they died. This child’s  trauma–and their triumphant ability to persist by attending school at all–were completely erased from the school’s assessment. Their personhood was distorted and their behavior was diagnostically condemned. I saw no evidence of ODD, ADHD, or any form of psychopathology. Only a grieving grandmother putting her all into raising her grandchild while mourning the tragic loss of her child. And a delightful, polite, and gentle youngster who was the picture of wellbeing in the face of so much tragedy. Their grandmother described them as being a “perfect angel” at home, frequently caring for younger relatives in the family and checking in on how their grandmother was doing.

Through developmentally appropriate and sensitive antiracist questioning, I learned that the child was attending a majority-white school in which they were the only Black child in the classroom and all of their teachers were white. This information was crucial for understanding the anger and adultification biases teachers were hurling at them. The former was leading teachers to misperceive this child as angry, the latter was leading them to construe them as less innocent and more adult when compared to their white peers. They experienced multiple suspensions for being “defiant” against the teachers and school staff, who received no sanctions for racistly accusing their mother of being a “crack” addict while showing no knowledge–much less compassion–for their parent’s death. This damaging practice was consistent with national trends whereby schools over- punish, expel, and literally push out children of color–and Black children in particular–out from school settings.  

I’ve witnessed many child mental health providers who align and collude with schools’ negative and disorted conceptualizations of a child without any interrogation of the adults’ positionality, bias, and outright hostility towards children of color. After all, healthcare providers are just as prone to pro-white implicit biases leading them to view white children as more innocent, inherently “good,” and deserving of care and support when compared to minorityized youth. Furthermore, child psychiatry–and child mental health more broadly–are anything but antiracist. For example, most nationally recognized clinical standards and guidelines for providing high-quality mental health provide no guidance about how to invite the kind of contextual information I needed to understand and care for this child.  

Child mental health providers gathering school-based collateral for mental health evaluations must recognize how entrenched the American educational system is in white supremacy. Teachers’ anger and adultification biases, overpunishment and the school-to-prison pipeline, and the racist and racialized nature of standardized testing are just a few examples. Scrutiny of and attacks on minoritized children’s hair, clothing, speech, and behavior, constitute forced assimilation to whiteness, a practice with deep historical roots in the The American Indian Boarding School Era. The growing omnipresence of school resource officers only exacerbates the damage wrought by policing children of color’s existence in these spaces. Children frequently feel policed by teachers and principals, too. Gerrymandering continues to deepen schools’ racial segregation while hoarding billions of dollars more for majority-white districts when compared to relatively more minoritized ones.  

I recently co-wrote a paper codifying specific clinical practices for protecting children of color from school settings through psychoeducational strategies, bold letters of support, and “clinical activism.” In the case of this delightful child, I confirmed for their grandmother what she already knew: that all of the challenges at school–along with all of the success at home–pointed to a racist school aggressing her child, not a child who was aggressive and in need of mental healthcare. I wrote a letter of support drawing upon the child and grandmother’s expert input naming the traumas the child had been through and condemning the anger and adultification biases directed towards the child–as well as the racist trope hurled at their mother. I made it clear to the child that all of the messaging about their being a “bad kid” was patently false, stopped the clinic from ordering the routine urine drug screen it automatically does for all children, and ensured no condemning or judgmental language (e.g. “aggressive,” “oppositional,” “behavioral challenges” etc.) was entered into my notes. Finally, I encouraged their grandmother to switch to a school that felt more welcoming and if that opportunity proved elusive, to enlist the support of her local ACLU or NAACP chapter. 

I actively rejected my profession’s routine and standard practice of contacting the school for collateral information to avoid buttressing its agenda to police, condemn, judge, and push this child out. Instead, I embraced an antiracist standard to protect the child against it. 

Parenting Tip: When commencing a child's mental healthcare journey, ask your provider: “Can you please tell me about how you communicate and collaborate with my child’s school? How do you determine whether they are nurturing or hindering my child’s wellbeing? How do you determine how to use their reports and assessments about my child? Do you write letters to schools?”

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