Editorial: The Relationship Between Internalized Racism and Mental Health Symptoms in Black Adolescents.

Since the 1890s, scholars such as W.E.B. DuBois have understood that Black people living under conditions of pervasive White supremacist oppression are subjected to constant assaults on their self-image.1 In the intervening years, Fanon,2 Morrison,3 and many others have described the complex psychological consequences of Black Americans attempting to live and adapt to the dominant culture, which devalues Black lives and Black cultural traditions, and how these devaluing messages reaffirm their inferior status in society. The pioneering doll studies conducted by psychologists Kenneth and Mamie Clark in the 1940s4-in which Black (and White) child participants expressed a preference for White dolls over Black dolls-demonstrated to a broad audience that Black children, by the age of 5 years, understand that being Black is a marker of inferior status. The Clarks' groundbreaking work brought attention to racism's impact on childhood identity development, opening the door for further explorations. The term internalized racism (IR) is widely used today in mental health research to describe how members of racially subordinated groups (eg, Black Americans and people of color) can consciously and unconsciously accept the dominant culture's view of their inferior status and hold associated negative self-evaluations (eg, less beautiful, less intelligent, etc), beginning in the earliest years of life.5.

How Should We Approach Faculty Who Create Hostile Learning Environments for Underrepresented Students and Trainees?

Faculty members who demonstrate resistance to or lack of skill in addressing negative bias in practice and learning environments can erode safety, especially among underrepresented students. This commentary on a case suggests how educators and leaders should respond to problematic behaviors of unwilling or unskilled faculty, prevent mistreatment of students and colleagues, and facilitate continuous faculty development. This commentary also considers strategies for motivating equity and building health care cultures of accountability.

Editorial: Cash Transfers to Families Living in Poverty: Can Benefits for Children Extend to the Next Generation?

Childhood poverty is the most widespread and important modifiable risk factor for the development of a range of health outcomes, including childhood-onset mental health problems.1 In the United States, 30 million children are growing up impoverished, which ranks among the highest per capita rates of child poverty among high-income countries.2 As a nation, the United States does less to support its poor children and their families than any other wealthy country, despite scientific evidence that growing up in poverty significantly increases lifetime risk of physical and mental health problems, reduces likelihood of academic and vocational success, and leads to poorer social outcomes for children.1 Meanwhile, 2 decades of research in low- and middle-income countries has demonstrated that directly providing poor families with financial support (commonly referred to as cash transfer programs)-delivered as one-time lump sum or smaller payments over time-produces reliably positive effects on a range of outcomes, including improved parental mental health, food security, housing security, educational and vocational attainment, female empowerment within families, as well as family savings and ownership of durable goods.3-6 Critics of cash transfer programs, who argue that poor families will exhibit temptation spending patterns (ie, alcohol, entertainment, etc), are increasingly being proven wrong by this literature, as studies have shown that recipient families tend to invest in the supports their children need to thrive.7.

Editorial: Mindfulness in Schools: Promises, Challenges, and Future Directions.

Amid rising national rates of childhood depression and anxiety,1,2 the development and accessibility of therapeutic psychosocial interventions for children have taken on paramount importance. Given the limited bandwidth of the existing clinical mental health services nationally, there is also an imperative to integrate therapeutic interventions within nonclinical, community-based settings (eg, schools) that can address emergent symptoms before crises manifest. Mindfulness-based interventions are a promising therapeutic modality for such preventive community-based strategies. While the literature on the therapeutic potential of mindfulness in adults is well established,3 the evidence for mindfulness in children is more precarious, with one meta-analysis demonstrating unconvincing results.4 Especially in school-based mindfulness training (SBMT) for children, there is a dearth of literature showing intervention effectiveness,5 and researchers have cited many implementation challenges,6 which spotlights SBMT as a burgeoning, promising, and multifaceted intervention deserving of more inquiry.

Re-examining the utility and validity of benign ethnic neutropenia: A narrative literature review.

OBJECTIVE: To conduct a narrative literature review of published evidence documenting racial differences in white blood cells (WBCs) resulting in the legitimization of benign ethnic neutropenia (BEN) as a diagnosis. METHOD: A search of English-language U.S.-based articles was undertaken using the following electronic databases: Medline (1860 to 1990); PsycINFO (1860 to 1990); and EMBASE (1860 to 1990), which resulted in a total of eight studies. A narrative literature review of the eight studies was conducted to assess how race was utilized in the study methods. RESULTS: Of the eight studies, several themes emerged within the scientific literature that demonstrate imprecise, problematic use of race in research practice. 1) Researchers embedded flawed notions of biological differences between racial groups (mostly focused on Black people compared to white people) within the research hypotheses, methods, and conclusions, 2) studies were unclear on how racial group membership was defined and identified within the study samples, 3) studies did not adequately account for structural or historical determinants of health that may drive racial differences in immune status (i.e., neutropenia). CONCLUSIONS: Given the limitations in this U.S.-based scientific literature, BEN is a diagnosis of limited construct validity that reinforces false notions of biological race, warrants renaming to remove "ethnic" language (to include "familial" or "hereditary"), and suggests a need for global expansion of the existing absolute neutrophil count reference ranges in the clozapine monitoring guidelines.

Widening Racial Disparities During COVID-19 Telemedicine Transition: A Study of Child Mental Health Services at Two Large Children's Hospitals.

OBJECTIVE: To examine whether racial disparities in access to pediatric mental health care were affected during the COVID-19 telemedicine transition at both The Children's Hospital of Philadelphia (CHOP) and Boston Children's Hospital (BCH). METHOD: Electronic health records were queried for all unique outpatient visits from a pre-pandemic period in 2019 and a within-pandemic period in 2020. Changes in the proportion of patients were compared based on insurance status, clinic location, and racial identification. Hypotheses were tested via logistic regression analyses. RESULTS: At CHOP, from 2019 to 2020, the proportion of racially minoritized patients significantly declined within a 1-month period from 62% to 51%, whereas the proportion of White-identifying patients increased from 38% to 49% (ß = 0.47; z = 3.60; p =.0003), after controlling for insurance status and clinic location. At BCH, the proportion of racially minoritized patients significantly declined within a longer 6-month period between 2019 and 2020, from 62% to 59%, whereas the proportion of White-identifying patients increased from 38% to 41% (ß = 0.13; z = 2.8; p = .006), after controlling for insurance status. CONCLUSION: At CHOP and BCH, the COVID-19 telemedicine transition exacerbated pre-existing racial disparities in pediatric mental health services. Our findings suggest that racially minoritized patients receiving services in urban areas may be particularly at risk for losing access when telemedicine is implemented. Although there are limitations to this racial dichotomization, examining differences between White and racially minoritized patients can highlight ways in which White-identifying individuals have disproportionately received enhanced access to healthcare resources.

Editorial: Racial Battle Fatigue: The Toll of Policing Black Students.

The current pediatric mental health crisis, recently named by AACAP and the American Academy of Pediatrics (AAP),1 is inextricably linked to school-based policies and practices. Fueled by public fears of crime and violence, "tough on crime" approaches took root in the United States during the 1980s, when school systems became an extension of a national-scale punitive apparatus. Punitive policies (eg, zero-tolerance policies) became a reflex response to disruptive behaviors at school, and police presence within schools increased. Envisioned to deter crime and violence, these policies instead too often criminalized routine, nonviolent misbehaviors, producing an intimate connection between school discipline and incarceration systems,2 often referred to as the "school-to-prison pipeline" disproportionately affecting Black students. In the contemporary context of calls for racial justice, local and state officials are re-examining the impacts of school-based police and strict discipline policies to better understand the potential academic and psychological consequences.

Advancing Antiracism in Community-Based Research Practices in Early Childhood and Family Mental Health.

Structural racism-the ways that institutional policies, practices, and other norms operate to create and sustain race-based inequities1-has historically been foundational to the operations of academic medical centers and research institutions. Since its inception, academic medicine has depended on the exploitation of vulnerable communities to achieve medical, educational, and research goals.2 Research practices have long ignored or taken advantage of the individuals purportedly benefiting from the research, a dynamic most manifestly true for Black, Indigenous, and People of Color (BIPOC) communities in the United States. Reflecting current practices in racial justice work, we intentionally use the term "BIPOC" to highlight shared experiences within racially and ethnically minoritized communities, given the history of White supremacy in the United States. We acknowledge limitations of this term, which collapses myriad unique communities and histories into one construct. Specifically, child and adolescent psychiatry has historically been driven by Eurocentric approaches, paradigms, and methodology. These nonparticipatory dominant research practices have contributed to a lack of culturally responsive interventions for BIPOC communities, a paucity of evidence-based practices with demonstrated effectiveness within BIPOC communities, and disparities in access and quality of care.3 Mental health research involving BIPOC communities has been replete with exploitation and inequality.2.

Assessment of Perceptions of Professionalism Among Faculty, Trainees, Staff, and Students in a Large University-Based Health System.

Importance: With a renewed focus on medical professionalism, an opportunity exists to better define its standards and application to meet the needs of an increasingly diverse workforce given the important association between interprofessional behavior and patient care. Objective: To examine the context of how professionalism is operationalized and perceived in diverse health care work and learning environments. Design, Setting, and Participants: A qualitative mixed-methods analysis of survey data collected from February to April 2015, was conducted followed by analysis of narrative data collected in June 2017. The setting was 2 health systems and 4 health professional and graduate schools. Participants were faculty, trainees, staff, and students (3506 survey respondents and 52 narratives) affiliated with the University of Pennsylvania and the University of Pennsylvania Health System. Data analysis was conducted in 2018 and 2019. Exposures: Independent variables included the following respondent characteristics: gender identity, sexual orientation, race/ethnicity, position, generational age group, length of employment at institution, disability status, belief system or religion, and primary site of work or study. Main Outcomes and Measures: Survey questions were used to assess participants' perception and experiences of professionalism in the workplace as measured by a 5-point Likert-type scale. Results: For the survey, there were 3506 respondents from a pool of 18 550 potential respondents (18.9% response rate). Of 3506 survey respondents, 2082 of 3231 (64.4%) were women, 331 of 3164 (10.5%) identified as gender or sexual minority groups, and 360 of 3178 (11.3%) were non-Hispanic Black individuals. In adjusted analyses, women compared with men (adjusted odds ratio [aOR], 1.8; 95% CI, 1.4-2.3) and Asian individuals (aOR, 2.0; 95% CI, 1.7-2.3) and Hispanic individuals (aOR, 2.0; 95% CI, 1.4-2.7) compared with non-Hispanic White individuals were more likely to value institutional professionalism. In addition, gender identity and sexual minority groups compared with heterosexual respondents (aOR, 1.5; 95% CI, 1.2-1.8) and non-Hispanic Black individuals compared with non-Hispanic White individuals (aOR, 1.3; 95% CI, 1.2-1.4) were statistically significantly more likely to consider changing jobs because of unprofessional behavior at work. The qualitative analysis of narratives revealed that marginalized populations (including but not limited to women, gender and sexual minority groups, racial/ethnic minority groups, those who identify as having a disability, and religious minority groups) reported (1) greater infringements on their professional boundaries, as well as increased scrutiny over their professional actions, and (2) a tension between inclusion vs assimilation. Conclusions and Relevance: The findings of this study highlight the need for health care organizations to revisit how they define and operationalize professionalism to improve inclusivity.

Systematic review of racial disparities in clozapine prescribing.

OBJECTIVE: To conduct a systematic review of published evidence on clozapine prescribing disparities across racial and ethnic categories, estimate the size of these disparities, and assess possible causes to inform future monitoring and intervention. METHODS: Electronic databases (MEDLINE, Embase, PsycINFO, Web of Science) were searched for directly relevant studies. Three independent reviewers selected studies: (1) of US samples; (2) directly addressed ethnic and/or racial disparities in prescribing of antipsychotic medications; (3) identified specific ethnic and/or racial groups (e.g. White, Blacks, Hispanics, non-Hispanic etc.); (4) reported clozapine prescription rates and (5) reported relevant covariates (i.e. gender, age, co-morbidities etc.). FINDINGS: 16 studies met our eligibility criteria. All studies reported clozapine underutilization in ethnic and racial minority patients when compared to their white counterparts. These findings remained consistent despite different time periods, designs, data set types, and after controlling for relevant covariates such as: length of hospital stay, institutional setting, and disease severity. CONCLUSION: The reasons for underutilization of clozapine in minority patients remain unclear. Various contributors can be categorized as: clinician-related factors (e.g. prescriber lack of experience), patient-related factors (e.g. distrust or suspicion of clinician), and institution-related factors (e.g. state operated facilities). Direct examination of these factors can help inform efforts to reduce clozapine prescription disparities.

Colorblind Algorithms: Racism in the Era of COVID-19.

This commentary offers a critique of the recent policy document issued by White et al. (2020) to guide critical care resource (e.g. ventilators) allocation during public health emergencies such as COVID-19. We argue that, if disseminated widely, this criteria would result in a racially inequitable resource distribution in the current COVID-19 crisis. We link the White et al. (2020) resource distribution protocol to other "colorblind" healthcare algorithms that have relied on seemingly objective but fundamentally biased data, thereby reinforcing and exacerbating pre-existing racial health disparities. We suggest a health equity framework to ensure unbiased distribution of critical care resources during COVID-19 and in general practice.

Comparing the Effectiveness of a Guide Booklet to Simulation-Based Training for Management of Acute Agitation.

Simulation-based training may be an effective teaching modality for psychiatry residents; however, simulation-based training is an unstudied and underutilized aspect of psychiatry resident training. The objective of this study was to compare the teaching effectiveness of a simulation-based training to reading a resident on-call psychiatry guide booklet in improving the self-confidence and knowledge of residents that is necessary for managing acutely agitated patients. Pre-intervention self-confidence and knowledge were measured for all residents using a Likert scale questionnaire and a clinical vignette questionnaire, respectively. Residents (n = 23) were randomly assigned to either the simulation group (n = 12) or the guide booklet group (n = 11). Residents in the simulation group completed the simulation-based training, and residents in the guide booklet group were instructed to read the corresponding pages of the booklet regarding management of acute agitation. The comparative teaching effectiveness of the guide booklet and simulation-based training was measured with a post-intervention self-confidence questionnaire and a clinical vignette questionnaire. The study spanned approximately one academic year (July 2016- Sept 2017). Residents who participated in the simulation-based training showed significantly greater improvement in self-confidence (simulation median improvement = 1.458 vs. guide median improvement = 0.033, p = 0.002) and knowledge (simulation median improvement = 0.135 vs. guide median improvement = 0.021, p = 0.0124). Simulation-based training was more effective at improving residents' self-confidence and knowledge compared to the on-call psychiatry booklet for the management of acutely agitated patients. Though simulation is being used in other specialties, it is a very underutilized tool in the field of psychiatry. This finding underscores the potential for simulation-based training in residency programs to improve resident learning.

Confronting Racial Violence: Resident, Unit, and Institutional Responses.

By describing an instance of racial violence by a patient against a resident physician, the authors hope to stimulate further discussion by addressing three specific questions about managing racist patients: (1) How should the resident (or any level of trainee) respond to the immediate situation? (2) How should the unit respond to the event as a community? and (3) How should the institution (hospital and/or academic institution) respond to the event? The authors argue that responses to such incidents should acknowledge the history of structural racism in U.S. society and in medicine. The authors recommend an approach that names the racism directly while addressing the safety of the patient and the providers in the moment, supports those affected in the aftermath, and considers appropriate consequences for the perpetrators of violence.