Misdiagnosis of Mood Disorders in Black Teenagers

The adolescent years can be tough, especially for teens dealing with mental health challenges, who often struggle to be heard and to feel like themselves. Mood disorders usually begin in the teenage years, but their symptoms can be hard to interpret, and kids may be overlooked or misdiagnosed. This is especially true for children of color, who research suggests are less likely to get an accurate diagnosis when they show signs of a mood disorder.

Mood disorders are a category of mental health disorder that includes depression, bipolar disorder and other disorders with similar symptoms. The National Institute of Mental Health estimates that about 14.3% of teens have a mood disorder, and girls are almost twice as likely to develop them as boys. Many factors influence the development of a mood disorder. These can be genetic, but they can also be environmental, with trauma being a significant trigger. This trauma can come from sources including strife at home, a significant death, bullying and even neighborhood violence.

Symptoms of mood disorders can be difficult to recognize. While people usually think of sadness as the main characteristic of depression, anger, irritability and behavior problems can also be signs of underlying mood disorders. For example, when a kid who acts out a lot in school doesn’t get a careful evaluation, they might be written off as just misbehaving or seeking attention when they’re really dealing with depression.

If they do get mental health care, they may get the wrong diagnosis. In particular, if a child with a mood disorder shows a lot of disruptive behavior or anger, a clinician who misses the signs of the underlying disorder might misdiagnose them with conduct disorder. Conduct disorder is a pattern of behavior in which a child intentionally hurts other people and acts out in extreme ways. Being diagnosed with conduct disorder can have serious consequences, including challenges finding clinicians who will work with the child and increased risk of incarceration. And when kids get the wrong diagnosis, they miss out on appropriate treatment for the disorder they do have, which leads to worse outcomes in the long term.

While kids of any race can receive the wrong diagnosis, research suggests that people of color and particularly Black people are less likely to be diagnosed with mood disorders than white people, even when their symptoms are the same.

One study found that Black male teenagers receiving psychiatric care were more likely to be diagnosed with schizophrenia than any other group, while white adolescents were more likely to be diagnosed with depression. Black teenagers of any gender were also more likely to be diagnosed with conduct disorder than white teenagers. Studies of Black adults have found that they are much more likely than white adults to be diagnosed with psychotic disorders including schizophrenia, even when they show clear signs of severe depression. Another study suggests a similar pattern of misdiagnosis for Black people with bipolar disorder.

More research is needed to clarify these apparent patterns and their causes. But in the meantime, it’s helpful for clinicians and parents alike to be aware of these trends and take care to ensure that teenagers of color get the correct diagnoses they need to thrive.

While there can be many causes of a misdiagnosis, one important factor may be unconscious bias on the part of clinicians.

Even when patients’ issues are the same, there can be a disparity in how youth of color are diagnosed when compared to white youth. “Research shows that when clinicians are given descriptions of the same symptoms labeled with different racial groups, there tends to be a bias to provide certain groups with certain diagnoses and other groups with other diagnoses,” says Heather Bernstein, PsyD, a clinical psychologist at the Child Mind Institute. For example, she explains, clinicians may unconsciously assume that a Black child who won’t participate in class is being defiant, while they might diagnose a white child with the same symptoms with depression.

Psychotherapist Jaynay C. Johnson, LMFT, runs a practice focused on helping Black teenagers navigate depression and suicidal ideation, and she explains exactly how that bias can be insidious. In addition to facing more scrutiny for apparent misbehavior, she explains, children of color face the added challenge of dealing with stresses that the white people often diagnosing them don’t understand. For example, a Black girl who gets into a fight may be labeled a behavior problem when really her actions stem in part from the stress of dealing with racism. Johnson explains that “a lot of people aren’t understanding systemic racism and microaggressions and how that can make a Black child frustrated. Instead, they may label it as anger.” She notes that in her Philadelphia practice, she’s often seen Black children be diagnosed with conduct disorder when they’re instead battling depression and anxiety.

Johnson adds that different cultural norms can also contribute to misunderstandings of children’s behavior. “The adults interacting with kids at school often don’t understand their culture,” she says. “So when children are acting within their culture, a lot of people will say that they’re behaving abnormally.” This behavior could include preferring to speak a language other than English, using certain verbal expressions, or even laughing at times that seem inappropriate. In cases like these, even kids with signs of possible mood disorders may be written off as just misbehaving, instead of getting the mental health support they need.

Language barriers are another factor that can contribute to misdiagnosis. Lack of trust in clinicians or medical systems can also lead to misunderstanding when, for instance, parents or children of color might withhold pertinent information out of fear of being judged or persecuted.

Despite the risk of misdiagnosis, it’s still very important for kids of color to get care when they’re dealing with a mental health challenge. If you think that depression or another mood disorder might be troubling your child or be behind behavior that’s getting them in trouble, the best thing you can do for them is seek an accurate diagnosis and appropriate treatment. And if you think your child has been misdiagnosed or written off by an authority figure, getting a second opinion can help.

You can learn more here about what mood disorders often look like in teenagers, and you can read more here about ways to tell if your child’s anger might be due to depression.

When you do seek help or a second opinion, working with the right clinician can make a big difference. Finding a clinician of color can help with the issues of bias and cultural awareness discussed above, but it’s not the only way to get an accurate diagnosis and quality care. Less than 15 percent of psychologists are people of color, so finding a non-white clinician can be a challenge. White clinicians can also be well-equipped to help your child, especially if they have experience working with other kids with similar symptoms and cultural backgrounds. It’s appropriate to discuss potential clinicians’ experience and training before choosing to work with them.

“Asking about the clinician’s level of cultural competence is a fair question, and it’s important for both the child and the caregiver,” says Dr. Bernstein. “You want to feel comfortable with the individual that they are seeing, and to know that that person has sufficient training and understands how intersecting identities are going to affect both who your child is and the type of treatment that’s going to be the most effective.” For instance, you could ask about the clinician’s understanding of the struggles faced by youth who share your child’s racial identity, or about their experience working with people from communities similar to your own.

Here are a few more ways to tell whether the clinician you’re working with is likely to give your child an accurate diagnosis:

• They consider systemic stressors. Research shows that experiencing racism leads to increased stress levels and adverse health outcomes. Clinicians should be aware of the way that this kind of stress impacts kids and their behaviors, as well as the way that systemic racism can create obstacles in kids’ lives. “We should be looking at what else could be going on in their lives,” says Johnson. “I think that sometimes we aren’t acknowledging that there may be systemic or poverty issues contributing to their symptoms.”
• They look at the whole picture. Medical issues like diabetes or chronic pain — which could both impact mood — should also be taken into account, as well as the social determinants of health. For example, a grumpy, argumentative child may be hungry, and Black children are more likely to live in food deserts than their white peers. Also, in high crime areas, trauma is more likely to be a cause of a child’s symptoms.
• They listen to your child without jumping to conclusions. An accurate diagnosis relies on getting information directly from the child as well, not just from teachers or other authority figures, who may misinterpret their behavior.
• They take their time. “Make sure that you’re working with a clinician who is open to not just putting a stamp on the diagnosis,” says. Dr. Bernstein. “The clinician should be willing to continue gathering information before making that diagnosis, and to really understand the child’s experience and take a more holistic view.”
• They use evidence-based methods based on up-to-date research. Dr. Bernstein notes that clinicians whose practice is based on well-researched tools will be better equipped to give appropriate diagnoses to kids of any race.