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Currently, pediatric behavioral health care accounts for one of the fastest growing health care expenditures. Children representing racial and ethnic minority groups are still found to experience significant behavioral health needs. Primary health care represents the first level of contact with the health care system.
Method
The purpose of this systematic review was to synthesize articles discussing the behavioral health needs and treatment of racial and ethnic minority in primary care settings.
Results
Results yielded 40 articles meeting the inclusion criteria. Themes included: provider screening, provider selected treatments, prevalence and need, and stigma and patient-provider communication.
Conclusions
Themes were discussed through the Ecological Systems Theory lens. Study limitations included its exclusion of intellectual disabilities like Autism Spectrum Disorder, lack of literature utilizing large minority samples, and lack of attention to the intersection between race and/or ethnicity alongside other demographics of concern like gender, age, social class, and geographical location.
As the area of pediatric behavioral health care continues to gain momentum within the topics of assessment and treatment within primary health care settings (e.g.,
), children who represent racial and ethnic minority groups are still found to experience significant behavioral health needs that include being misdiagnosed (
Substantiating the need for primary care-based sexual health promotion interventions for ethnic minority adolescent women experiencing health disparities.
Journal of the American Association of Nurse Practitioners.2016; 28: 487-492
Does screening for and intervening with multiple health compromising behaviours and mental health disorders amongst young people attending primary care improve health outcomes? A systematic review.
) conducted to examine the behavioral health needs of patients within pediatric primary health care settings. As the behavioral health needs for racial and ethnic minority youth persist, there is a need to examine current literature to support the inclusive mental health treatment of these populations so they are not overlooked in pediatric primary care settings.
METHODS
As the theoretical foundation for this systematic review, Urie Bronfenbrenner's Ecologic Systems Theory (EST;
) conceptualizes the multilevel factors (see Figure 1) impacting racial and ethnic minority youth and their behavioral health needs in primary health care. As inclusive health care involves making sure there are supports for patient populations of various social locations (e.g., age, race, ethnicity, gender, sexual identity, immigration status, geographic locations, etc.), EST helps connect environmental factors and interpersonal relationships to guide professionals on how and where to intervene. The research question for this systematic review was, “what are the themes in the literature regarding behavioral health treatment of racial and ethnic minority youth in primary care health care settings that can inform clinical practice?” The aims of this systematic review are to (1) gather recent literature meeting specific inclusion criteria focused on racial and ethnic minority behavioral health needs in primary care, (2) thoroughly examine and summarize results through the EST lens, and (3) make recommendations for inclusive clinical practice and future research as it relates to racial and ethnic minority youth behavioral health in primary care and various levels of EST. To accomplish the aims of the current study, the authors employed
Studies included within this systematic review met the following criteria: (1) peer-reviewed; (2) written in English; (3) published in the last 10 years to obtain the most recent literature; (4) conducted in the United States to focus on a specific health care system; (5) original empirical research; (6) study sample of racial and ethnic minority youth represent 50% or more, or the majority, of the total sample included within the study; (7) either qualitative and/or quantitative research; (8) study conducted in primary health care/pediatric settings; and (9) articles discussing a mental, behavioral, social and/or emotional need. These inclusion criteria were added to ensure that the studies included were able to capture the needs of racial and ethnic minority youth. Although there are limitations to this methodological choice (i.e., the broad nature of all racial and ethnic minority youth vs. inclusion of a specific group limits generalizability), research with specific non-White populations is so limited that authors prioritized systematically reviewing all racial and ethnic minority youth literature regarding health care to enable a larger scope. Each minority group may be unique in need, language, etc., and thus researchers need to increase population-specific research within the health care context. Articles not included in this systematic review were articles that (1) presented youths with a developmental disorder (e.g., autism spectrum disorder or other intellectual disabilities) to define the scope of the study; (2) involving telehealth, case studies, and health clinics in juvenile or detention centers; and (3) peer-reviewed articles that were not studies (e.g., conceptual papers).
Search Strategy
Because this systematic review did not include human subjects, the protocol for this study was not submitted or reviewed by an institutional review board. There was also no conflict of interests related to this study, and there was no funding received for the completion of this study.
second step (e.g., searching the literature) yielded a six-database search: Medline via PubMed, PsycINFO via EBSCO, CINAHL via EBSCO, Scopus, ProQuest, and Google Scholar. Search terms included Medical Subject Headings relevant to “primary health care,” “behavioral health,” “racial and ethnic minority,” and “children.” The search was conducted between November and December of 2017. A university research librarian was consulted to ensure that the search was comprehensive, and the articles were analyzed between January and March of 2018. Articles were stored and organized using three programs, RefWorks, Rayyan, and Microsoft Office Excel.
Data Extraction and Analysis
The search yielded 2,016 articles, which was reduced to 1,660 articles once duplicates were removed. The articles were first examined on the basis of title and abstract according to
seven-step method. The articles that met all inclusion criteria after the titles and abstracts were reviewed and kept resulting in 168 articles eligible for full-text review. At this stage, many articles were excluded on the basis of the racial and/or ethnic minority representation within the sample. One of the inclusion criteria was to have a sample size of over 50% racial and/or ethnic representation. In many articles, this representation was identified within the abstract, whereas others only identified the representation within the full text. Articles were also excluded at this stage because they did not focus on behavioral health needs. Once the full-text review was complete, 40 studies remained meeting inclusion criteria. Articles yielded throughout the search process were presented in the PRISMA diagram (see Figure 2). Once 40 articles were obtained, they were evaluated, interpreted and the results were presented in common themes in keeping with steps four through seven of
. The creation of themes was grounded in EST, specifically using the six levels presented within EST as a guide to help cluster the articles included.
FIGURE 2PRISMA diagram for systematic review
aSome records were excluded for multiple reasons. bOther reasons for the title and abstract articles exclusion included: the article not being a study, systematic review, case report, book, meta-synthesis/meta-analysis, book review, and/or being aged more than 10 years.
Forty articles were identified at the end of the search. All 40 articles fit within four themes: screening (n = 9), treatment (n = 13), prevalence and need (n = 10) and stigma and patient communication (n = 8). Among the articles included, the participants’ ages ranged from 1 to 20 years. All studies included racial and ethnic minority youth samples that were either predominately African American and/or Latinx American. Each racial and/or ethnic group used within this review will be identified with the same label used within each respective manuscript.
Microsystem: Provider Screening Tools
Nine articles were found addressing inclusive screening for racial and ethnic youth (see Table;
The concurrent validity of the Problem Oriented Screening Instrument for Teenagers (POSIT) substance use/abuse subscale in adolescent patients in an urban federally qualified health center.
The concurrent validity of the Problem Oriented Screening Instrument for Teenagers (POSIT) substance use/abuse subscale in adolescent patients in an urban federally qualified health center.
). The Child Behavior Checklist was used alongside several measures to validate them in screening Latino youth specifically: the Spanish versions of the Reporting Questionnaire for Children (
Unified Reporting Questionnaire for Children- Spanish (RQC-SP) and Pediatric Symptom Checklist-Spanish (PSC-SP)
Psychopathology in children and adolescents
Spanish-speaking parents; ages of children unknown (n = 22)
The PQC-SP and PSC-SP were found to be readable and comprehendible among the parent sample. Validation was conducted alongside the Child Behavior Checklist (CBCL)-Spanish
Internalizing, externalizing, and attention deficit hyperactivity disorder (ADHD)
Predominately African American youth (63.2% aged 4–7 years, 51.3% aged 8–12 years; n = 1274)
Supports the validity of the BHCL as a screener for behavioral health concerns among youth 4–12 years old in urban and suburban communities. Validation was conducted alongside the CBCL
Screen for Childhood Anxiety and Related Emotional Disorders (SCARED)
Anxiety Disorder
Predominately Minority Sample (Hispanic 33.2%, Asian/Pacific 10.5%; Biracial 8.5%, Black 5.0%; n = 515); aged 8–12 years
Across all racial/ethnic groups, children reported higher levels of anxiety than the parents included in the study. Overall, there were no significant differences among child or parent reports among the various racial/ethnic groups. However, there were generally higher scores among the Hispanic group and lower scores among the Asian/Pacific group
The concurrent validity of the Problem Oriented Screening Instrument for Teenagers (POSIT) substance use/abuse subscale in adolescent patients in an urban federally qualified health center.
Problem Orientated Screening Instrument for Teenagers (POSIT) 17-item scale substance use/abuse subscale; revised 11-item version of the POSIT subscale
Substance use disorder and cannabis use disorder
Predominately African American (93%); aged 12–17 years (n = 525)
When compared against the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Substance Use Disorder criteria, both the 17-item subscale and the revised 11-item subscale were found to be valuable in screening youth for substance use concerns
Types of interview styles: the Diagnostic Interview Schedule for Children (DISC), Child and Adolescent Psychiatric Assessment (CAPA), and Development and Well-being Assessment (DAWBA); CBCL, Multidimensional Anxiety Scale for Children (MASC); Vanderbilt ADHD Diagnostic Parent Rating Scale (VADHD); and Mood and Feelings Questionnaire (MFQ)
Data collection to make a clinical diagnosis; Behavioral and/or concerns; anxiety (MASC); attention deficit and hyperactivity disorders (VADHD); recent feelings and behaviors (MFQ)
Predominately racial/ethnic minority (58.6% non-White; among those minorities, African Americans were largely represented); aged 9–12, and 12–13 years
Among the various demographic variables, including race/ethnicity, there was no difference in the prevalence of mental health concerns
Adolescent Report of the Visit Survey which was specific California Health Interview Survey (CHIS) items; Center for Epidemiologic Studies Depression scale (CES-D)
Emotional distress (report items from the CHIS); depression (CES-D)
Predominately racial/ethnic minority (29.6 % Latino/Hispanic, 22.9% African American, and 15.2% Asian) Aged 13–17 years
Latino adolescents were 1.5 times more likely to receive a depression screening than White adolescents African American teens were less likely to be screened for emotional distress than White adolescents. After controlling for age and gender, There were no significant differences in provider rates of screening
). The role that parents play in reporting behavioral health concerns to their health care provider is key in activating available resources and treatment options.
Stigma was found to be a barrier for African American caregivers in discussing behavioral problems with their health care provider (
) which both limit inclusive health care practice. Higher self-efficacy was significantly associated with the likelihood for African American mothers of children aged 2–5 years in disclosing psychosocial issues (
). The articles found within this theme indicate that identifying behavioral health concerns in primary care is a multidimensional issue. It not only consists of parents and children coming to primary care with behavioral health concerns but also feeling comfortable enough to talk about them with their health care provider. As the family system encounters the health care system, open and clear communication is a key factor in obtaining behavioral health treatment. Among a sample of predominately Latino parents that spoke Spanish at home were less likely to discuss behavioral problems with their physician or medical assistant, whereas those parents who lived in the United States for more than 10 years or who were born in the United States were more likely to discuss behavioral problems with their child (Lê
). Shared decision-making between Latino and African American parents of two- to seven-year-olds and health care providers was increased with externalizing behavioral problems along with lowered mental health stigma (
). However, Hispanic and African American adolescents and young adults (aged 13–21 years) reported preferring to talk to a mental health professional instead of their primary care provider for mental health concerns (
). In addition, African American and Latino teens (ages 13–17 years old) who experienced depressive symptoms were less likely to share their feelings with their health care provider, particularly when they felt that they would be judged. Teens within the same sample who were fearful of an intense reaction from their parents were less likely to disclose their mental health symptoms to their health care provider as well (
). Finally, one study identified a program that increased trust among Hispanic mothers and adolescents through an Internet, and family-based preventative intervention called the eHealth Families Unidas program (
Thirteen articles examined treating racial and ethnic minority youth in primary care within this system. These treatments included parenting interventions (
Effectiveness of a psychoeducational parenting group on child, parent, and family behavior: A pilot study in a family practice clinic with an underserved population.
). Inclusive parenting interventions included the effective implementation of the Love, Limits, and Latitude: A Thousand Small Moments of Parenting program for behavioral problem reduction within a predominately African American, an urban sample of parents of 5- to 10-year-old children (
Effectiveness of a psychoeducational parenting group on child, parent, and family behavior: A pilot study in a family practice clinic with an underserved population.
). Depressive symptoms decreased for urban, low-income Latino adolescents engaged in a brief version of Interpersonal Psychotherapy for Depressed Adolescents (
). African American and Latino parents of teens were significantly less likely to have knowledge of antidepressants and counseling than White parents (
Several studies identified the benefits of inclusive treatments that incorporated others present in the youth's environment or as a part of the health care team. One study addressing substance use for adolescents, specifically an intervention that incorporates the influence of an adolescent's peers, was found to decrease cannabis for African American teens (
) parents of kindergarten to sixth-graders were more likely to follow through for behavioral health treatment when there was a collaborative effort among health care professionals (
). In addition, two studies examined physician prejudice using case vignettes, one finding no racial difference in diagnosing and treating childhood disruptive disorders (
). Finally, one study identified the benefit of seeking mental health treatment for African American (45%) and Latino (55%) male adolescents in school-based health centers (
Substantiating the need for primary care-based sexual health promotion interventions for ethnic minority adolescent women experiencing health disparities.
Journal of the American Association of Nurse Practitioners.2016; 28: 487-492
Peterson, B. L., Lewandowski, L. A., & Chiodo, L. M. (2011). Relationships among trauma, nightmares, and quality of life in urban, African American adolescents. Western Journal of Nursing Research, 33, 1104–1105.
). By race, African American teens were found to have a higher prevalence of meeting the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (
Peterson, B. L., Lewandowski, L. A., & Chiodo, L. M. (2011). Relationships among trauma, nightmares, and quality of life in urban, African American adolescents. Western Journal of Nursing Research, 33, 1104–1105.
). A sample of predominately African American (91%) urban youth between the ages of 8 to 17 years were screened and surpassed the cutoff criteria indicating emotional and/or behavioral problems (
Substantiating the need for primary care-based sexual health promotion interventions for ethnic minority adolescent women experiencing health disparities.
Journal of the American Association of Nurse Practitioners.2016; 28: 487-492
Substantiating the need for primary care-based sexual health promotion interventions for ethnic minority adolescent women experiencing health disparities.
Journal of the American Association of Nurse Practitioners.2016; 28: 487-492
Several articles addressed environmental factors that may be contributing to mental health needs among racial and ethnic minority youth. In examining youth, the parental report was one of the main sources of behavioral health needs. More socioemotional and behavioral concerns were reported by African American and Latino parents of infants (aged 12–48 months) who had lower education levels, were teenage parents, had low social support, significant medical problems, and parental depression (
Mental health services embedded in inclusive school-based health centers were found to be used by racial and ethnic minority students with mental health concerns. A mixed sample of African American (14%), Hispanic (25%), and Asian American (34%) were more likely to seek mental health services in their school-based health centers when they reported suicide ideation, depressive symptoms, parental divorce/separation, and losing a close friend (
). A sample of predominately Hispanic (60.9%) high-school students reported that among their unmet health needs, coping with stress was one of the most prevalent (
). Finally, a sample of school counselors and school nurses identified 23 mental health disparities among Latino/a youth which included adjustment concerns, poor interpersonal skills, anxiety, depression, substance use, grief/loss, and physical and sexual abuse (
The purpose of applying EST to the results of this systematic review was to emphasize the multiple levels of care highlighted in the literature regarding the assessment and treatment of behavioral health concerns of racial and ethnic minority youth in primary health care settings.
Microsystem: Behavioral Health Screening and Assessment
One of the themes deduced from the articles collected was inclusive provider screenings. One major reason that behavioral health screener/assessment tools are supported in primary health care settings is because of the prevalence rates among youth (
). For youth in general, regardless of racial and/or ethnic background, researchers have advocated for the screening of social-emotional needs in primary health care (e.g.,
Evaluation of an early detection tool for social-emotional and behavioral problems in toddlers: The brief infant toddler social and emotional assessment - A cluster randomized trial.
). As another theme revealed, there were distinct prevalence rates among the racial and ethnic minority youth communities that would support the needed behavioral health screening in this population (e.g.,
Substantiating the need for primary care-based sexual health promotion interventions for ethnic minority adolescent women experiencing health disparities.
Journal of the American Association of Nurse Practitioners.2016; 28: 487-492
Does screening for and intervening with multiple health compromising behaviours and mental health disorders amongst young people attending primary care improve health outcomes? A systematic review.
), behavioral health screening and treatment were found to positively impact youth's overall health outcomes. However, implementing behavioral health screeners and assessments within primary health care may not necessarily lead to better health outcomes.
describe that the presence of behavioral health screeners is not enough; once screeners are administered, there is a need for regularly scheduled behavioral health follow-ups and consistent, effective treatment for positive screening to improve care. The authors encourage practitioners to make the behavioral health conversations and assessments common practice among all youth, but particularly racial and ethnic minority youth, given the disparity. The authors do not recommend a specific screener for these diverse populations because of the limited studies available validating these instruments with large racial and ethnic minority samples. There is a need for more studies that examine various inclusive behavioral health screening tools in these pediatric health care settings.
Mesosystem and Exosystem: What to Do with a Positive Screening?
For health care settings that are able to use and support integrated behavioral health care providers such as marriage and family therapists, psychologists, licensed social workers, licensed professional counselors, or licensed mental health counselors, behavioral health screening and treatment can be referred to these experts within primary health care settings. If this is an option, having integrated behavioral health care professionals such as these are recommended by the authors and supported by the literature as being effective in promoting comprehensive care within a collaborative care model (
). In other cases, when no integrated behavioral health care providers are available, the question then becomes, what to do in the event that an assessment is administered by a nonintegrated behavioral health provider and results are positive for behavioral health need. What are the next steps?
In the cases in which a youth is found to need behavioral health support, it may be most helpful for the patient and their family to be connected with outside behavioral health support and other community resources.
highlight how connecting patients with community resources can enhance clinical treatment. These authors do explain that it can be a challenge staying up to date with available resources as they may change over time and by area. Solidifying referral pathways and a method to continue to add and remove potential referrals for clinical treatment and nonclinical resources may be helpful in supporting youth and their families after a positive screening. In addition, sequential screenings (
) and consistent behavioral health follow-ups within traditional appointments are also suggested. Finally, the results revealed the identification of behavioral health needs within medical clinics within school settings (
). For youth, having a strong connection with schools may be helpful in using the resources that they have available and staying current with the available resources within the community. There is also a need for increased inclusive resources and services to help support racial and ethnic minority youth, particularly given the mental health disparity and stigma within these communities.
Macrosystem: Factors impacting Local Communities
In discussing the need for more community resources, each community across the United States has unique needs on the basis of multiple factors. As part of EST, there are various macrolevel influences that may contribute or create unique situations that require a strategic inclusivity plan in addressing behavioral health needs. Below are three examples of this across the United States that focus on areas that have relatively high racial and ethnic minority populations.
Flint, MI
With a population of roughly 98,000 and a median age of 35 years with 41.2% living below the poverty level, over half of Flint (53.4%) identifies as African American (
). In Flint, approximately 18% of the population is aged between 5 and 17 years. During the past few years, Flint came into the mainstream news because of the lead levels within the water that had a negative impact on the health of the community (
). As the health crisis persists, the state of Michigan has found that youth aged younger than 21 years have worsening behavioral health needs after the water crisis (
). Behavioral health needs have been found to be complex because of this environmental concern within this community, so there is a need for a specialized assessment, treatment, and resources needed to manage this unique health need.
North Carolina
The Latinx American population in North Carolina is growing faster now than it has in previous years. Since 2010, the Latinx American population has grown faster than White and African American populations in the state, increasing to approximately 1.26 million in the state (
). One of the major concerns relating to the rapid growth is that there may be limited resources than other states with larger Latinx communities that are far more established. Not having established Latinx communities can create a challenge for youth; thus, contributing to behavioral health and emotional needs (
). Many other states may be experiencing similar circumstances with the rapid growth of Latinx communities in recent years (South Dakota, Tennessee, South Carolina, Kentucky, etc.;
). In this case, community resources to support this population in a culturally sensitive way may be limited to reduce the mental health disparity.
Minneapolis, MN
Minneapolis has seen an explosion of people who are refugees or those who have emigrated to the United States from Somalia in the past two decades. Recent census numbers indicated that the Minneapolis/St. Paul area boasts a Somali ancestry population of 52,333 (
) with specific objectives and benchmarks to ensure Somali refugees have access to health care. Despite the focus on health care, very little attention to mental health access has been rendered (
). Somali refugees have high incidence rates of trauma exposure because of high rates of violence in their native country and are often the victims of human trafficking on arrival in the United States (
). Although improvement in health care access is certainly an area to be celebrated, improvements in mental health care are desperately needed.
Macrosystem: Health Care Policy Development
Finally, at the macrosystem level, the results of this systematic review identified prevalent behavioral health concerns among racial and ethnic minority youth in primary health care. As literature continuously produces evidence on the prevalence of behavioral health needs of racial and ethnic minority youth, there is a need for inclusive health care policy that addresses the quality and consistency of care provided to racial and ethnic minority youth.
presented various recommendations on how health care policy could be catered to support the health needs of children of color, one of those included improvements in quality of care. For example, a potential policy change could be, given the high levels of behavioral health need among racial and ethnic minority youth, that all racial and ethnic minority youth should be screened during their visit using a validated behavioral health screener. Furthermore, as integrated behavioral health care in primary health care settings is increasing in its application, there could be requirements that specify the amount of behavioral health support needed within a respective primary care clinic on the basis of a certain percentage of behavioral health needs within the patient population. For example, if 20% of a patient population has been diagnosed with a behavioral health need, there could be a requirement of a certain amount of in-house behavioral health support. Future research could advocate for ways to support the care of racial and ethnic minority youth in primary care settings state by state.
LIMITATIONS AND FUTURE RESEARCH
There are several limitations to this study that should be considered. Articles only including samples of racial and ethnic minorities that are 50% or more were included, which limited the results discussed to predominately African American and Latinx American populations. These exclusion criteria highlighted the gap in representation of other racial and/or ethnic minority groups in the United States, such as Asian American, Middle Eastern American, and Native/Indigenous American. As the racial and ethnic minority population grows within the United States, there is a growing opportunity and need for more studies to include larger minority samples. Another significant limitation to this study was the exclusion of autism and/or developmental delays. There is limited literature addressing intellectual disabilities in racial and ethnic minority communities and addressing them in primary health care settings. Racial and ethnic minorities are underdiagnosed for autism spectrum disorders among pediatricians (
). Black caregivers of children with autism spectrum disorder reported inconsistent diagnosis of developmental delays in their children, racial bias in health care treatment, and stigma related to in the Black community (
). It seems that this presents an even greater disparity in addressing intellectual disabilities among racial and ethnic minorities in primary health care settings. Finally, the intersection between race and/or ethnicity alongside other social locations of concern such as gender, age, social class, and geographic location was not discussed or analyzed within this study. For example, many of the studies included reported high female, racial and/or ethnic minority youth samples (e.g., 60% female [
]). Highlighting these intersections among the studies analyzed may have presented useful information for those in clinical practice. Future research should address the behavioral health needs of other racial and ethnic minority youth in primary care, including—but not limited to—Asian Americans and Native/Indigenous Americans. In addition, the need for more inclusive resources to address intellectual disabilities in primary health care settings.
References
Alegria M.
Vallas M.
Pumariega A.J.
Racial and ethnic disparities in pediatric mental health.
Child and Adolescent Psychiatric Clinics of North America.2010; 19: 759-774
Effectiveness of a psychoeducational parenting group on child, parent, and family behavior: A pilot study in a family practice clinic with an underserved population.
Substantiating the need for primary care-based sexual health promotion interventions for ethnic minority adolescent women experiencing health disparities.
Journal of the American Association of Nurse Practitioners.2016; 28: 487-492
The concurrent validity of the Problem Oriented Screening Instrument for Teenagers (POSIT) substance use/abuse subscale in adolescent patients in an urban federally qualified health center.
Evaluation of an early detection tool for social-emotional and behavioral problems in toddlers: The brief infant toddler social and emotional assessment - A cluster randomized trial.
Peterson, B. L., Lewandowski, L. A., & Chiodo, L. M. (2011). Relationships among trauma, nightmares, and quality of life in urban, African American adolescents. Western Journal of Nursing Research, 33, 1104–1105.
Does screening for and intervening with multiple health compromising behaviours and mental health disorders amongst young people attending primary care improve health outcomes? A systematic review.
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