The Mental Health of Minority and Marginalized Young People: An Opportunity for Action

In the next few years, my children will enter an important stage of their education and development, where they will learn how to build friendships, deal with problems, and lay the foundation of a personal values system. They and millions of their peers will start down the path to adulthood—each path different and filled with potential challenges. As a parent and as a physician, I am deeply concerned that some of the challenges and obstacles that this generation of young people face—the ubiquity of technology platforms, loneliness, economic inequality, and progress on issues such as racial injustice and climate change—are unprecedented and uniquely hard to navigate. The impact that these challenges are having on their mental health—their emotional, psychological, and social well-being—is devastating.

Mental health is an essential part of overall health. It not only affects the ability of young people to succeed in school, at work, and throughout life but is critical to their overall well-being and to the health of our nation. Even before the COVID-19 pandemic, mental health challenges were the leading cause of disability and poor life outcomes among young people, with up to 1 in 5 children and adolescents aged 3 to 17 years in the United States having a reported mental, emotional, developmental, or behavioral disorder. ¹ Many mental health challenges first emerge early in life, and studies suggest that the average delay between the onset of mental health symptoms and treatment is 11 years.^2,3

The last 2 years have dramatically changed young people’s experiences at home, at school, and in their communities. It is not just the unfathomable number of deaths or the instability of daily routines that has changed; it is also the pervasive uncertainty and the continual sense of fear. It is the isolation from loved ones, friends, and communities at a moment when human support systems are irreplaceable. As COVID-19 continues into its third year, the impact on children and young people’s mental health and well-being continues to weigh heavily.

The COVID-19 pandemic exposed the extent and severity of the mental health crisis on racial and ethnic minority, sexual and gender minority, and marginalized young people. ⁴ Marginalized young people are children, adolescents, and young adults who have experienced economic, social, political, and cultural marginalization because of factors beyond their control, including poverty, discrimination, violence, trauma, dislocation, and disenfranchisement. ⁵ Experiences of trauma and marginalization, among other factors, can place these young people at heightened risk for mental health difficulties later in life, too.

The pandemic has been a stressful period for everyone, but evidence from recent studies and surveys demonstrates that racial and ethnic minority and marginalized populations continue to be disproportionately affected. Across the world, children and adolescents aged <18 years from racial and ethnic minority groups have been more likely than their non-Hispanic White peers to experience grief and loss of family members during the pandemic, with risk of loss up to 4.5 times higher among racial and ethnic minority young people. ⁶ The disproportionate experiences of grief and loss of family members are in addition to the higher rates of COVID-19 transmission in communities that have been historically marginalized, such as racial and ethnic minority groups, compared with non-Hispanic White communities. ⁷ Moreover, a recent study found that social determinants of inequity worsened by the pandemic, including family structure, socioeconomic status, and the experience of racism, negatively affected the functioning of children, above and beyond other factors such as preexisting medical or mental conditions. ⁸

Young people who are marginalized can experience high levels of stress. Evidence points to high levels of stress and adverse childhood events that can negatively affect children’s brain development.^9,10 Exposure to high levels of social and familial stress (ie, food insecurity, housing instability) and adversity may have a lasting impact on the mental health and overall well-being of marginalized young people. ¹¹ Facing economic instability and hardships as a result of COVID-19 can contribute to the development of posttraumatic stress disorder and hinder healthy child development. ¹² From August through December 2020, Hispanic and non-Hispanic Black households with children experienced ≥3 hardships (ie, unemployment, food insecurity) at twice the rate of non-Hispanic Asian and non-Hispanic White households with children (29% Hispanic, 31% non-Hispanic Black, 13% Asian, 16% non-Hispanic White). ¹³

During the pandemic, many detention facilities for young people substantially reduced their mental health services, which limited access to counselors and treatment programs and enforced 23-hour periods of isolation to prevent the spread of coronavirus, halting family visitation. ¹⁴ These mitigation measures substantially affected young people’s mental health, which is concerning given that approximately 70% of young people in detention centers or correctional settings have a preexisting mental health disorder. ¹⁵

Young people who are marginalized experienced other challenges that may have affected their mental and emotional well-being, including the national reckoning regarding the deaths of Black Americans at the hands of police officers, the loss of affirming and supportive environments, and COVID-19–related violence against Asian American people. Lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) students experienced greater harassment than heterosexual and cisgender students, in school and online, and faced heightened risks for anxiety and stress because of loss of regular access to affirming organizations and supportive networks. ¹⁶ Recent data indicate that during the COVID-19 pandemic, 76% of LGBTQ+ high school students reported persistent feelings of sadness or hopelessness and 74% reported emotional abuse by a parent, compared with 37% and 50% of heterosexual students, respectively. ⁴ More than 80% of 10- to 18-year-old Asian American people experienced or witnessed COVID-19–related discrimination in person or online, and roughly 65% reported being worried that they would be blamed for COVID-19. ¹⁷

As devastating as these statistics are, the real tragedy is that we were failing to adequately respond to them. Even before the pandemic, we were not doing enough to provide adequate care and treatment options in every community, especially communities that have been historically marginalized, such as low-income and racial and ethnic minority communities, and COVID-19 has only worsened this disparity. We were not doing enough as a country to build and maintain a sufficient and diverse mental health care workforce. We were not doing enough to integrate the mental health care system with the rest of the health care system, and we were not doing enough to prevent, not just treat, this crisis.

In December 2021, I released a Surgeon General’s Advisory on Youth Mental Health that outlines the policy, institutional, and individual changes it will take to address long-standing challenges, strengthen the resilience of young people, support their families and communities, and mitigate the pandemic’s mental health impacts. ¹⁸ I have seen firsthand the dedication and efforts that young people, parents, schools, community-based organizations, and other entities have taken to support the mental health of children, adolescents, and young adults. I remain hopeful and moved by those efforts and recent state and federal investments to address and improve the mental health of our nation’s young people. One promising effort at the state level is California’s Children and Youth Behavioral Health Initiative (CYBHI), ¹⁹ a $4.4-billion 5-year investment to enhance, expand, and redesign the systems that support behavioral health for children, adolescents, and young adults aged ≤25 years. The goal of the CYBHI is to reimagine mental health and emotional well-being for all children, adolescents, and young adults and their families in California by delivering equitable, appropriate, timely, and accessible behavioral health services and supports. The CYBHI’s 7 priorities parallel the top priorities I called out in the advisory:

• 1) Advance equity for all children, adolescents, young adults, and their families by providing access to linguistically, culturally, and developmentally appropriate services and supports.

• 2) Engage children and young people in the design and implementation of services and supports to ensure that programs address their needs.

• 3) Encourage the systems that support children, adolescents, young adults, and their families to act early by promoting positive mental health and reducing risk for mental health needs and challenges.

• 4) Form coordinated systems of care to deliver high-quality behavioral health programs responsive to the needs of young people and their families across agencies that serve them and all levels of government.

• 5) Empower families and communities by equipping them with information and tools to recognize signs of poor mental health or substance use and how to access supports.

• 6) Ensure that children, adolescents, and young adults can access high-quality care and information when and where they need it.

• 7) Create environments free of stigma that allow children, adolescents, young adults, and their families to talk about their mental health and well-being and seek help without feeling ashamed or fearing discrimination.

This statewide comprehensive approach provides an opportunity to build a system of care for all young people in California with a strong focus on equity, including supporting and developing strategies for communities of color, low-income families, LGBTQ+ individuals, and communities with elevated rates of adverse childhood experiences. Such efforts can change the arc of the lives of the next generation and create the potential to alter drivers of poor mental health. We need initiatives like this for all young people, wherever they are in the country, and we need to be sure not to leave anyone behind.

At the federal level, substantial investments have been made to improve access to and provision of mental health care among young people across the country amid and beyond the pandemic, including investments in community-based mental health and substance use care (eg, the Certified Community Behavioral Health Clinics expansion grant program ²⁰ ), investments to enhance access to behavioral health services and connect young people to care (eg, expanding access to telemental health and mental health supports in schools and colleges), investments to strengthen the health system capacity (eg, expanding the pipeline of behavioral health providers and training a diverse group of paraprofessionals), and investments to create healthy environments to support young people (eg, stronger online protections for young people).^21,22 As we emerge from the pandemic, we have an opportunity to build on these efforts and develop a national coordinated approach to addressing the mental health challenges that young people face, especially for our nation’s children, adolescents, and young adults who are excluded from social, economic, and educational opportunities as a result of factors beyond their control.

We must collectively come together to ensure that young people, particularly those who are marginalized, understand that struggling with their mental health does not mean that they are broken or that they did something wrong. We must actively engage young people and their families in conversations on mental health and reinforce that mental health challenges are real, common, and treatable.

In better serving young people who are marginalized, we must strengthen cross-sector collaborations at the local level, including community-based organizations, health systems, and schools. In addition, we must (1) create safe and supportive climates (ie, school and community) by implementing culturally responsive and trauma-informed policies and practices; (2) systematically and routinely screen children for mental health challenges and risk factors, including adverse childhood experiences; and (3) consider ways to identify and provide additional supports for young people at elevated risk for stress or trauma, such as those experiencing the loss of a loved one or food or financial insecurity.

Gaining better knowledge of how young people who are marginalized fare is complicated by the fact that the nature of their marginalization can change over time. Maximizing the use of administrative data to better understand marginalized populations ultimately will require collaboration and coordination across state and local governments. We should encourage systems and programs that serve young people who are marginalized to make better use of administrative data for describing the overlap of populations across service systems and young people’s trajectories into and out of these systems and for evaluating policies and programs affecting children, adolescents, and young adults.

When conducting research, we should actively involve young people who are marginalized and researchers and program managers familiar with the marginalized populations to ensure that study designs, including sampling and recruitment strategies and survey items, appropriately capture the experiences of these populations.

We all have the opportunity and the responsibility to make change happen now. Our obligation to act is not just medical; it is moral. It is not only about saving lives; it is about listening to young people, who are concerned about the state of the world they are set to inherit. It is about our opportunity to rebuild the world we want to give them—a world that fundamentally refocuses our priorities on people and community and builds a culture of kindness, inclusion, and respect. I believe that if we seize this moment, amplify marginalized voices, and step up for children and families in their moment of need, we can lay the foundation for a healthier, resilient, more connected future for our nation’s young people.