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Examining Racial Differences in Internalizing and Externalizing Diagnoses for Children Exposed to Adverse Childhood Experiences


A substantial evidence base has established both that adverse childhood experiences (ACEs) deleteriously impact youth mental health outcomes and that racial biases in diagnosing youth are common among mental health professionals. However, the literature to date has hardly examined the relationship between ACEs and diagnostic disparities based on race. This study examines how racial disparities and ACEs contribute to childhood diagnoses of internalizing and externalizing disorders. Using data from the 2017 National Survey of Children’s Health, racial disparities in internalizing (i.e., depression, anxiety) and externalizing (i.e., behavioral/conduct problems) mental health diagnoses were analyzed using logistic regression. ACE score was a significant predictor of all three diagnoses and presented a dose–response relationship. Race was also found to be a significant predictor of diagnoses, as Black children were less likely to be diagnosed with anxiety or depression and more likely to be diagnosed with behavioral problems. Moreover, when examining racial disparities in mental health diagnoses by ACE score, the present study found that the severity of these disparities increased at higher ACE scores. Our study demonstrates that while ACEs are harmful for all children, providers’ identification of internalizing and externalizing disorders appears to occur differentially based on the race of the child they diagnose. These findings yield important insights about potential bias among healthcare providers, educators, and clinical social workers and warrant further research, training for professionals, and culturally responsive interventions. As such, we call on clinical social workers to lead the effort to address racial disparities within mental health services.

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No funding was received for conducting this study.

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Correspondence to Christopher T. Thyberg.

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Thyberg, C.T., Lombardi, B.M. Examining Racial Differences in Internalizing and Externalizing Diagnoses for Children Exposed to Adverse Childhood Experiences. Clin Soc Work J (2022).

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  • Adverse childhood experience
  • Racial disparity
  • Diagnosis
  • Anxiety
  • Depression
  • Behavior and conduct disorder