Why Are Black Parents Concerned About Medication Treatment?

“I am deeply concerned that mental health services will rely too heavily on medication rather than seeking the root cause.”

This sentiment — expressed by a participant in a recent study that explores the views and experiences of Black families and young adults seeking mental health care — reflects a common concern within the Black community.

The study, conducted by the Child Mind Institute in partnership with The Steve Fund, included a nationally representative survey of 1,000 Black parents seeking mental health care for their children and 500 young adults seeking care for themselves. When asked about their concerns around mental health care, about half of the respondents (both parents and young adults) agreed that “mental health professionals are too quick to prescribe medication for mental health issues.”

This sense of mistrust around medication treatment is also reflected in other studies. For instance, a 2021 review of data on African American caregivers deciding whether or not to give children with ADHD medication, caregivers were less likely to trust the efficacy of the medication and were more concerned about side effects and addiction than white caregivers.

“I work in an integrated mental health system, which includes psychiatry. So, concerns about medication come up a lot,” says Rhonda Boyd, PhD, a mental health advisor for The Steve Fund, psychologist, and associate director of the Children’s Hospital of Philadelphia’s (CHOP) Child and Adolescent Mood Program. “Black families in particular want to start with therapy first and see how it works before considering medication if therapy is not working.”

One source of medication reluctance, Dr. Boyd says, is concern about side effects — will it stunt their child’s growth? But it also may come from feeling pressure from schools. “Schools oftentimes refer kids for treatment if the kid’s behavior is disruptive, which could be for a number of reasons. And that’s where the pressure comes in — you have to do this, or we can’t treat your child in a regular classroom. They may not even be able to be in this school.”

But concerns about medication run deeper, in no small part because of the historical use of psychiatric medication to silence and control Black people in the United States. 

Historically, the overmedication of Black patients in the mental health care system has been linked to their frequent misdiagnosis. The background of schizophrenia characterization and diagnosis is a clear example.

In the late 1950’s, as psychiatric hospital wards began to desegregate and the Civil Rights Movement gained momentum, the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) was published. Schizophrenia previously had been separated into subtypes, including “paranoid schizophrenia,” which was characterized by delusions and/or frequent auditory hallucinations. But in the DSM-II, researchers redefined characteristics of that subtype as a “masculinized belligerence” in which patients displayed violent delusions, hostility, and aggression. Based on racial bias, researchers and clinicians began to associate this type of schizophrenia with Black patients — specifically Black men. Schizophrenia diagnoses among Black individuals drastically increased, and by 1969, the National Institute of Mental Health found that Black patients had “a 65% higher rate of schizophrenia” than white patients.

As more Black people were diagnosed with schizophrenia, psychiatrists started to conflate civil unrest with the disorder’s “violent delusions” characteristic. Two prominent New York psychiatrists coined the term, “protest psychosis,” arguing that Black Liberation rhetoric and art caused hallucinations and acts of violence among Black men. In response, clinicians argued Black patients should be given higher doses of tranquilizing antipsychotic medication to quell these violent tendencies. For Black patients, medication transitioned from treatment to a form of control.

While the language in the DSM has since changed, recent studies have shown that Black Americans are still 2.4 times more likely to be diagnosed with schizophrenia than their white counterparts. Additionally, researchers have found that Black patients are more likely to receive higher doses of long-acting antipsychotic drugs — indicating a persistent belief among providers that Black patients not only need more medication than typically necessary but are also less likely to take it as prescribed.  

This idea that Black people are inherently more prone to violence and disruption continues to be perpetuated to this day. And in classrooms, Black children are much more likely to be viewed as disruptive or displaying behavioral challenges than their white counterparts.

“If Black and brown children display behavioral challenges like biting or hitting — things that you may see in the pre-K years or early childhood years where this type of behavior is developmentally appropriate — these children are seen as more aggressive, more forceful, and much more of a concern,” explains Robert Harris, an early childhood intervention supervisor for the D.C. Healthy Futures Program.

Worried about the disruption in learning, educators are quick to find a solution — and this most likely involves referring the child to a mental health professional. But according to Harris, “Even in the referral process and the description of the challenge, they tend to lean towards or hint at the use of medication to mitigate this issue that may exist. This is before parents have even spoken to a mental health professional.”

So, by the time parents are consulting a provider, they may already have their guard up, especially if that provider goes on to prescribe medication for their child’s mental health issues.

Clinicians worry that in some cases, reluctance towards medication treatment runs the risk of impeding a child’s quality of life. “Negative perceptions about medication can delay treatment longer than you want,” says Dr. Boyd. “If someone has severe depression, for instance, what is recommended is both therapy and medication at the same time to get the kid out of that episode. I understand exactly why parents have concerns, but it can be frustrating.”

To find the best solution for the child’s mental health challenges, the first critical step is to create a comfortable and collaborative environment, according to Jonathan Shepherd, MD, a child, adolescent, and adult psychiatrist who is chief clinical officer at DC Department of Behavioral Health. “For those initial appointments, I do my best to develop a form of trust where they feel comfortable enough with me,” he says.

And to do so, Dr. Shepherd suggests the following:   

• Be patient and meet them where they’re at. After explaining why he’s prescribing the medication, describes the side effects, and answers every question, Dr. Shepherd says that he still might face some resistance from a parent — and that’s okay. Instead of pushing, he schedules a follow-up appointment to continue the conversation at a different time. He also provides them with some helpful resources to gain more information about different treatment options. “You have to be very careful about the websites that people are going to, to seek out information. So, steer them in the right direction.”

• Educate yourself. Dr. Shepherd points out that when a mental health professional isn’t Black, it’s hard for Black patients to feel like the provider will understand where they’re coming from. Given the history of mistreatment of Black patients, there’s a hesitancy to even reach out to a provider. “You have to understand what that person may be going through or what environment they live in. It’s very difficult for people who don’t understand Black culture to be able to say, ‘I understand what it took for you to even come see the doctor.’” So, it’s important for non-Black providers, especially, to take that extra step and educate themselves on the history of mental health in the Black community.

• Listen to their concerns and answer every question. When encountering parents who are wary of treating their child with medication, Dr. Shepherd starts the conversation by saying, “You have every right to be skeptical and hesitant regarding care for your children. I get it. It is scary to think about providing a medication for your child, or your child having to take a pill and you don’t know what that pill may do. But that’s where the experts come in. Now, what I will not do is force my help on you, but I will work alongside you to guide you through the process.

When a school is pushing for a quick solution to a child’s disruptive behavior, such as medication treatment, parents may feel backed into a corner. Harris wants them to know that there’s still a choice. And if you feel uncomfortable with what you’re being told, you can say, “Yeah, when you said this, it really made me feel like I needed to go for medication.” This way, says Harris, educators might take a step back and re-evaluate how they approach the situation.

He also reiterates the importance of parents arming themselves with the knowledge of early signs to look for in their child, whether it’s a behavioral issue, mental health disorder, or learning challenge. “I think that’s why mental health consultation, particularly for infant and early childhood is paramount, because through education, we provide families as well as professionals with an understanding of what’s appropriate, what’s typical, what’s developmentally acceptable, and what you should expect.” For instance, it can be helpful for parents to know that there are several alternatives to medication treatment for disruptive behavior in a classroom, such as therapy, parent training,  specialized programs, and a change in classroom structure.

And in a clinical setting, Dr. Shepherd says, if you’re feeling skeptical about what your provider has prescribed for your child, you can start by making it clear to them that you don’t feel like they’re hearing you. “You can say, ‘I’m not sure if we’re hearing one another. I’m not sure that we are on the same page regarding what I’m saying I see in my child or what I think is necessary for my child at this point in time.’”

And that’s when it’s important to pay attention to the provider’s reaction, says Dr. Shepherd. Are they receptive to what you have to say? Are they open to answering questions or engaging in a dialogue about different treatment options? “Someone who does not allow you to ask questions or glosses over your questions, that’s a physician that you should run from.”

When parents and providers are able to have the tools and language they need to enter these types of conversations, it can make finding the solution to a child’s mental health challenges much easier.