Spotting Depression in Your Child: What Parents of Color Should Know

Depression is rarely ever visible to the naked eye, and even less visible in communities where mental health stigma is more prevalent than in others. Further, living with an invisible illness like depression as a person of color adds another layer of loneliness to an already isolating condition.

We’re talking about the communities where “pushing forward” is a survival tactic rather than a coping mechanism; communities that question if something is “wrong” with us for considering we should seek professional help for ourselves, let alone for our children.

But with mental health now at the forefront of the national consciousness, more communities are paying attention—and Verywell Mind medical review board member and psychiatrist Akeem Marsh, MD, has been at the helm of such conversations all along the way. As a psychiatrist at a community-based clinic in New York City, he advocates for early diagnosis in kids of color and helps to mitigate access to treatment for marginalized families across the board.

The following interview has been edited for clarity.

VWM: Dr. Marsh, thank you so much for chatting with us. Aside from being a review board member, you’ve dedicated your career to working with children and families in underserved communities. Can you talk a little bit more about the focus of your work?

Marsh: Right now I work in an outpatient mental health program. It’s a community-based clinic, which means that we see people regardless of insurance status. I run the psychiatry service here, and a unique thing about the clinic is that a lot of treatment is provided short-term, but it’s primarily different types of family-based therapy, which is an important thing that a lot of programs don’t offer.

So even though treatment is short-term, you get highly specialized family therapy from psychiatry support and there’s also short-term individual therapy as well. The main focus of that is addressing trauma. And then there's also a version of CBT for older teens and young adults called cognitive processing therapy.

Outside of my main clinical focus, I’m really interested in trauma, but specifically as it pertains to youth that have disruptive behavior disorders. That would be things like ADHD but more so what they call oppositional defiance conduct disorder—that came to me from my past experience working in the juvenile detention system. That led to a book that I co-edited, which was published earlier this year called “Not Just Bad Kids: The Adversity and Disruptive Behavior Link.”

I'm still interested in trying to understand more and still working clinically, still working with some justice-involved youth too because some family therapy programs are designed for that population. I’m all-around interested in trying to address all those kinds of things to the extent I can.

VWM: There has been a lot of coverage of how the pandemic has affected children during the pandemic but we're now seeing the specific impacts to children of color. What are the unique ways in which these three years have impacted the mental health of kids in marginalized communities?

Marsh: Oh, that's a great question. It’s so, so layered. I think of it like it was a major collective trauma for the entire world, honestly. For the youth and families of color, we have more of a burden of morbidity, people getting sick and people dying. So there’s a lot of having to deal with that. And then there was being away from peers, being away from environments that we’re used to, so a very limited sense of “normalcy.”

VWM: Some people may not be aware of how depression and mental illness can present differently in kids versus adults. What are some of the early warning signs or symptoms of depression parents should be aware of and how can they discern them from the usual ups and downs that kids might go through?

Marsh: I would say that for kids, they start to cycle into it. Usually, a parent’s intuition can pick up things like, this person doesn't quite seem like themselves. It starts with something soft, maybe you can't quite put your finger on it. And then as it progresses, other things will happen like trouble sleeping, they might not be eating as well, they might seem like they're tired or less playful, and things like that.

And then issues in school—behavioral concerns. That could be anything like having trouble focusing in class or being more disruptive, or even getting into physical altercations. Those could all be different signs or presentations for depression. You've got to know what's really underlying to pinpoint it.

VWM: What are the social stigmas around mental health and Black and Brown communities that prevent young adults, let alone children, from seeking help? What are some ways that parents can better show up for their kids despite these stigmas?

Marsh: I feel like oftentimes we'll take it as a personal failing. People don't usually say it but that's the feeling I get. If there's something going on or they need extra support, extra help, that'll be a barrier. Along with the major barriers like insurance status, availability of providers, and then trying to navigate the system. It's very easy to get frustrated.

As for parents supporting their children, as always, if there's any concern about what's going on, parents can have an evaluation done in school. It wouldn't be the same as a comprehensive mental health evaluation by the community, but it could be a good place to start because then they can see, 'OK, well, this child probably needs more than what we can provide so I’m going to refer out.' And if it’s the child’s doctor, then hopefully they will be connected to or affiliated with a program where they can have them seen as an outpatient.

VWM: Accommodations are also an option, and people often don't really know what those can entail unless it’s for a physical disability. What are those accommodations that are available for students with depression? And are there challenges in achieving equal access to these accommodations?

Marsh: Yeah, there are definitely challenges because a lot of times systems will be resistant. It starts with them often actually not recognizing that something may be going on. There may be a focus towards disciplinary action, which seems to be a reflex, and that kind of puts the blame and onus on the child. When in reality, I think people should be thinking more open-mindedly, like 'Maybe something's going on with this child!'

For accommodations, some of the things that one could get would be extra time on tests, maybe give them some time to take a break at certain intervals, or more intensive things like counseling or have 1-to-1 staff. All of those things are potentially accessible. It's just a matter of what that individual’s need is and then actually being able to get it. I’ve seen schools—when they do their evaluation—may input less services than what actually meets the child’s needs.

For a situation like that, an independent evaluation could be helpful, which is something that families can also ask for from the school. If they're not satisfied with what the school says that they can always request having an independent evaluation, and that might be helpful to their cause.

VWM: I came across a report from Mental Health America that shows that White children with depression are more likely to receive mental health counseling than their Black, Hispanic, and Asian counterparts. Can you talk more about the disparities in therapy for marginalized youth?

Marsh: I think it starts with access, because they’re more likely to be insured; that's number one. And then number two, there's more or likely to be access to providers wherever they're living. There’s still a shortage, but you have a higher likelihood of getting access to a provider. And the other thing to consider as part of all this, too, is in mental health treatment, there's inadequate representation of people of different backgrounds. The majority of providers are White. It doesn't exactly match up with the demographics of the communities. So, that can add a layer to complicate things.

VWM: What’s the solution for equal access to affordable, high-quality medications?

Marsh: The medication thing is part of a broader general healthcare issue because of the way things are set up over here in the US. Each insurance company has its own deals with certain pharmaceutical companies, which limits the options of what could be used. That's actually what tends to guide us in trying to make a decision on what medication to use—what's actually covered by your insurance. That information is not easy to find, so that complicates it further. I think if that system of insurance was simplified, it would make it easier for families, along with increased access.

VWM: In communities of color, seeking therapy is still seen as very taboo and there is something “wrong” if you decide to seek therapy for yourself, let alone your child. Have you seen these conversations shift, if at all?

Marsh: Honestly, I think so, thankfully. It's unfortunate that it has to come to this but a lot more celebrities have been talking about it more. And it's been an increasingly normalized part of pop culture. I think that helps, along with efforts to raise awareness.

I've seen it not just in pop culture but also professional organizations. The AACAP (the American Academy of Child and Adolescent Psychiatry) made a joint statement declaring a state of emergency in children’s mental health. All of that helps to have most people recognize the importance and think we need to do something about it, and also helps to reduce stigma a little bit.

VWM: Speaking of stigma, what common misconceptions about therapy come up in your line of work?

Marsh: A lot of times people don’t see it as important or they don't see a potential benefit for them. And a lot of families have this culture where things that happen at home stay at home, and therapy brings privacy concerns. People might think if they talk about things that happen, Child Protective Services could get involved. And that is a possibility, obviously, but it's not our main focus or what we’re hoping to do.

VWM: The privacy layer is interesting.

Marsh: Yeah, that's pretty big. It's kind of like...don't tell the family’s business, we don't want our business out there. For some people, it's nice that we have telehealth but some people are not willing to do that because, 'This technology thing, I don't know about it.' We think it’s secure, that’s what we’re told, but there’s a possibility that something could go awry.

VWM: Cultural competence/safety is something that’s especially important for people of color. Can you explain the importance of having culturally competent treatment?

Marsh: Yes, absolutely. I would say that’s actually a cornerstone of mental healthcare. There have been studies looking at the rate of effectiveness of therapy—you’ll see differences in that. And why is that, what's going on here?

I know from anecdotes of people who I've worked with, patients I've seen, plus anecdotes of other people, hearing stories that people have experienced microaggressions or felt dismissed or invalidated in treatment.

And when stuff like that happens, it can have an impact; a potential to cause somebody to just say, “OK, I don't want to do this, I don't want to try to deal with this,” and just be gone for years, or maybe even never come back.

VWM: That sounds like what we've heard of as ‘medical gaslighting’ where symptoms are completely dismissed just because they don't have that research or the research is limited to White cis males, so the condition is something that they can't really validate.

Marsh: Unfortunately, that is very true that medical gaslighting happens all the time. You would expect that going through medical training that you'd get to a point where we're scientific or objective, but you know, we're human. We're subject to our own biases.

Cultural competence isn't good enough. It should be more like cultural humility, and being curious and trying to understand and recognize your own biases, and really trying to address them as best you can, and know your own limits. Maybe you're not the best person to see this patient. Everyone has something like that. It’s not a good fit, or you don't want to cause this person harm or give them a bad experience. You can say, "There's another provider who might be better for you,” which a lot of times there is.

VWM: Aside from cultural competence, what are some tips for finding the right therapist for your child?

Marsh: It’s funny, the first thing that comes to mind is, it’s really hard to find someone! Good places to start would be the primary doctor's office and insurance company. Ideally between those two, you should be able to identify somebody, but sometimes that's also not enough. I think if somebody identifies as a child therapist, you have a pretty decent chance of that being a good fit, but if not, hopefully that person can then refer you to someone else.

VWM: We also have to acknowledge that not everyone, like you mentioned, has the access or the means to afford therapy for their children. What other options or resources would you suggest?

Marsh: So the programs I’m in, in the city, work basically like a mental health clinic. A lot of times, programs like that won’t charge, so they see people regardless of insurance status, or some practices will have a sliding scale where families would have to pay a nominal fee.

One program that works with people across the country, The AAKOMA Project, is run by Dr. Alfiee Breland-Noble. They offer five therapy sessions, free of charge, so that would be worth looking into as well, at least to start with. I know that there are a bunch of programs like that; they will offer some kind of free therapy for people who either have difficulty accessing or can't afford it. Then maybe they're connected with another provider who can assist with ongoing treatment.

VWM: How can parents model healthy behaviors for their kids? Is there anything they can do to ensure their kids feel supported at home when they're tackling childhood stressors like school or friendships?

Marsh: Prepare to be honest with the children because a lot of times, you might think 'I'm really struggling, but I don't want my child to know that. So I'm not gonna say anything.' But the child knows something’s going on. They know something, so if you don't talk about it openly, it’s left to their imagination and wherever it takes them. Be open and vulnerable. Just let them know they're going through something as well. We're human, and part of being a human is going through things and having certain struggles.

I'd also say to the extent possible, you can model by taking care of yourself. Besides [therapy], taking days off when you need to or making sure that you go to the doctor. Try to do things as a family, if you can manage that. Because that would really have a meaningful impact on the child. They may be more inclined to go [to therapy] if they see Mom or Dad or caregivers going to therapy as opposed to posing it in a way like something’s wrong with the kid.

And trust your instincts. If you feel like something’s off, it doesn't necessarily mean there's a major mental illness going on. It’s just one of those things where you want to try to get early help if you can. On the flip side, the child may be in too many activities, over-scheduled, and that can be a problem. Let's prioritize what we feel is more important, because they also still have to be a child and live life.