The Full Informed Consent: The Unstated Legacy of Racism and White Supremacy in Child Mental Healthcare

Providers and health organizations alike encourage children and families to pursue mental healthcare as if it were universally healing. Amidst the pediatric mental health crisis–characterized by increased rates of anxiety, depression, and suicide attempts–”access to quality mental healthcare” remains the prevailing discourse. But what if child psychiatry was not originated or designed to protect and serve your children’s best interests. What if it refused to acknowledge the unique harms facing your child? What if it carried unstated risks of harm that are not accounted for in these general recommendations to pursue it? 

In 1953, the American Academy of Child and Adolescent Psychiatrists (AACAP) emerged. It has since become the pre-eminent child mental health organization in the country, issuing practice parameters to guide treatments, setting research agendas and providing their funding, and shaping the pipeline and training of future child psychiatrists. But for most of its existence, AACAP has largely ignored racism and remained silent regarding social issues impacting children of color. For example, its original constitution provided zero social justice agenda and made no mention of racism. Similarly, its official journal, the Journal of the American Academy of Child and Adolescent Psychiatrists (JAACAP) made no mention of racism from 1962-1967 despite the Civil Rights Movement and the related seismic racial reckoning transpiring nationwide. Black children like Ruby Bridges, Elizabeth Eckford (part of the Littlerock 9), and Walter Gadsden were being brutalized as their public schools were integrated and also by the police. Some were even being killed. Yet, AACAP had nothing to say. 

During its early stages in the child mental health conceptualized “normal” according to whiteness, construing of deviations from whiteness as pathology. Not surprisingly then, when it did concern itself with children of color, the locus of concern related to treating their aggression and delinquency. Early child mental health clinics forged partnerships with juvenile courts. The children seen here, many of whom were from poor or immigrant families, were thought to be deficient and deviant, and confining and incarcerating them was the logical solution. Early educational programs developed during the President Lyndon B. Johnson’s Great Society campaign (1964-1965), like Head Start, followed a similar logic of deficiency (called “cultural deprivation theory”) used to justify interventions directed at minoritized children. This model conceptualized Black children as deprived of the “normal” stimulating environment white children enjoyed and deficient in their capacity, aptitude, and intellect, relative to white peers. 

This origin story lives on in a variety of ways today. Myriad contemporary treatment interventions–similarly developed, researched, and implemented by white clinicians and researchers and practiced on families of color–are touted as wholly therapeutic because they fill perceived gaps and deficiencies. Multisystemic therapy and functional family therapy are two examples, both widely practiced across the United States. MST, in particular, targets children involved with the juvenile justice system, who are overwhelmingly Black and Brown. MST does not aim to protect children of color from the over-policing traumatizing them and devastating their health. Nor does it strive to end the school to prison pipeline, fueled by overpunishment of Black and Brown children at school. Instead, it locates pathology within these children and focuses on controlling their behavior, pointing the fingers of blame at them, rather than eliminating the assault perpetrated by these racist structures.

These days AACAP’s official journal has a clear stance on racism and antiracism, which emerged as a result of the 2020 racial reckoning provoked by George Floyd, Breonna Taylor, and Ahmaud Arbery’s deaths. However, training guidelines for child and adolescent psychiatrists and clinical practice parameters guiding the treatment for disorders like anxiety and depression lack any kind of antiracist orientation. The juvenile justice system and child welfare systems, whose racism related to over-policing and separating children of color from their families are well-established, are not systems that organized child mental health seeks to dismantle. Rather, it configures them as spaces where families and children can be targeted for treatment interventions teaching parenting and coping skills (e.g. Safecare). The logic is senseless, as it focuses on addressing symptoms of distress rather than targeting the root cause of distress and preventing further harm. Juvenile justice and child welfare involvement are traumatizing. Children and families do not need help coping with or within them. They need to not be subjected to them at all

Antiracist child mental healthcare must be heavily informed by knowledge of the histories of oppression coursing through child and adolescent mental health and their contemporary practices. Certainly this historical knowledge guides my care. Avoiding diagnostic condemnation of children of color’s suffering due to oppression, refusing to use racist diagnoses like oppositional defiant disorder, and renouncing clinical coercion and force are the most basic tenets I follow. Explaining to families of color with full transparency how these racist origin stories permeate contemporary child psychiatry is another. I am very transparent with children, families, and adults of color who have endured psychiatric trauma from their child mental healthcare. This profession was not created for them and many of its practices are dead on arrival in 2023. I say this because the ideas derive from scientific racism and other archaic ideas that have never been interrogated much less reimagined to promote a more affirming, nurturing practice.  

In 2021, both the American Psychiatric Association and the American Psychological Association offered official apologies for their role in perpetuating and upholding racism. By contrast, the American Academy of Child and Adolescent Psychiatry has neglected to engage in such reckoning. There has been no accountability related to peeling back its history and the extent to which racism and White supremacy inform current practices standards. This oversight should leave parents questioning whether child mental health practices do more harm than good and ensuring their providers are engaging in the same risk-benefit analysis.

Parenting Tip: When commencing a child’s mental healthcare journey, ask your provider: “Can you please explain to me how the legacy of racism and White supremacy live on in American psychiatry and in child mental health? How do you determine whether the evidence-based treatments and standards of care you are providing promote more benefit than risk for my child? How do you ensure that you are not over-pathologizing my child?”

To learn more about Dr. Legha’s related scholarship, please read “Nurturing Children’s Mental Health Body and Soul Confronting American Child Psychiatry’s Racist Past to Reimagine Its Antiracist Future,” available here.

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