Racial Bias

Understanding and dealing with implicit bias

and discipline in early care and education
By Diana Westerberg, Ph.D.

Published in cooperation with Bradley Hospital The term “implicit bias” is now com-
monly used in mainstream media as
October 2016 the public tries to make sense of recent,
widely publicized shootings of unarmed
Vol. 32, No. 10 • ISSN 1058-1073 black men. Although most public atten-
Online ISSN 1556-7575 tion currently focuses on implicit bias
within police departments, the effects of
race, repeatedly finding that people across
multiple demographic backgrounds tend
to hold stronger associations between
positive valence/attributes with white
adults and children compared to black
adults and children, and stronger associa-
tions between negative valence/attributes

Highlights… implicit bias are pervasive, potentially

affecting some of the youngest in our
Our page one stories this month look at society, children who have yet to enter
racial bias in people working with young kindergarten.
children, and at how EDs should respond to Implicit bias has been defined as auto-
pediatric mental health emergencies. matic associations that people develop
between social objects (e.g., people) and
✦✦✦ valence/attribute (e.g., good/bad, calm/
Keep Your Eye On… See page 2 violent) (Rudman, 2004). Much of the
•  The risk of pain in the development research on implicit bias has examined
of prescription opioid use disorders
•  Changing diagnostic criteria for fetal Emergency Care
alcohol spectrum disorders
What’s New in Research… See pages 3–5
•  Bipolar disorder increases risk
AAP issues guidance to EDs on acute pediatric
for substance use disorder in teens
•  NSDUH shows increase in some SUDs
mental health conditions
and depression, especially among youth
By Alison Knopf
The American Academy of Pediatrics
Editor’s Commentary (AAP) last month issued a call for emergency
•  Integrated care promotes professional department (ED) clinicians to pay attention
communication to pediatric patients with acute mental health
— By Gregory K. Fritz, M.D. or behavioral problems. The report came
See page 8 in two parts, one devoted to common clini-
✦✦✦ cal challenges and the other to side effects
of psychiatric medications that may not be
Free Parent Handout…
known to ED clinicians, as well as problems
Officials discourage with diagnosis of somatic conditions.
preschool suspensions, Children and adolescents are seeking
mental health care in emergency depart-
encourage mental ments and primary care in increasing
health consultations numbers, but there are no guidelines or
resources for clinicians who treat pediatric
with black adults and children compared
to white adults and children (Nosek et al.,
2007). Critical to the definition of implicit
bias, associations can occur without
intention or conscious awareness (Rud-
man, 2004).
In contrast to explicit biases, which
reflect people’s self-report or how they
believe they view others, implicit bias is
See Racial Bias, page 4…
mental health emergencies, according to
the AAP. These two clinical reports support
a joint policy statement issued 10 years ago
by the AAP and the American College of
Emergency Physicians, which had the goal
of addressing knowledge gaps. The reports
are mainly for emergency department clini-
cians but are “intended for all clinicians who
care for children and adolescents with acute
mental health and behavioral problems.”
Medical clearance
Emergency department clinicians
must perform “medical clearance” of
See Emergency Care, page 6…

Monthly reports on the problems of children and adolescents growing up View this newsletter online at wileyonlinelibrary.com • DOI: 10.1002/cbl

NSDUH shows increase in some
SUDs and depression, especially
among youth
By Alison Knopf
The National Survey on Drug Use and
Health (NSDUH) for 2015 shows a steady
continued increase in substance use disor-
ders (SUDs) and mental illness, especially
depression, among some age groups. The
annual report is issued by the Substance
Abuse and Mental Health Services Admin-
istration (SAMHSA) and has been con-
ducted since 1979 by survey. This year, a
second NSDUH focuses on abusable pre-
scription drugs only.
Key findings of the report, released Sept.
8, include a leveling off of marijuana and
heroin use by youth and young adults, and
a reduction in use of alcohol and tobacco
by youth. SAMHSA has chosen to feature
mental illness in recent years’ issues of the
NSDUH, and this year found that mental
illness has leveled off among adults 26 and
older, but there has been a slight rise in
major depressive episodes among adoles-
cents and young adults.
The rate of current (past-month) ciga-
rette smoking dropped from 26% for all
people aged 12 and older in 2002 to 19.4%
in 2015. Among young adults, the rate
is down from 40.8% in 2002 to 26.7% in
2015. The rate of daily cigarette smok-
ing by adolescents and young adults also
decreased significantly, from 31.8% of ado-
lescent smokers in 2002 to 20% in 2015,
and from 51.8% of young adult smokers in
2002 to 42% in 2015. However, vaping and
e-cigarettes are not included in NSDUH
survey questions, so some of the decline
may reflect nicotine delivery by e-cigarette
use, according to SAMHSA.
The level of current alcohol use by ado-
lescents dropped from 17.6% in 2002 to
Racial Bias
From page 1
not subject to the forces of social desir-
ability, the desire to avoid appearing
biased (Rudman, 2004). These uncon-
scious biases can contribute to a host of
The Brown University Child and Adolescent Behavior Letter October 2016
4
9.6% in 2015. Alcohol use disorder rates
also dropped among adolescents, from
5.9% in 2002 to 2.5% in 2015. Rates of
alcohol use and alcohol use disorder also
dropped among young adults, from 60.5%
in 2002 to 58.3% in 2015 for alcohol use,
and from 17.7% in 2002 to 10.9% in 2015 for
alcohol use disorder.
Marijuana is still the most commonly
used illicit drug, with 8.3% of people aged
12 or over using it at least once a month —
comparable to 2014, but higher than 2002
(6.2%). The percentage of adolescents who
were current marijuana users remained
steady over the past year — 7% in 2015
versus 7.4% in 2014 — and is similar to
recent years.
Heroin use levels remain about the
same as last year. Cocaine use levels are
similar to most previous years, although
slightly higher than in 2014. However,
there is an increase in past-month cocaine
use for young adults to 1.7% in 2015, com-
pared to 1.1% in 2012 and 2013.
“These findings offer hope that mar-
ijuana and heroin use may be slowing
down,” said SAMHSA Principal Deputy
Administrator Kana Enomoto. “And more
American youth are rejecting alcohol and
tobacco. This is great progress.” However,
one in five Americans has a substance
use disorder or a mental illness, and 39%
aren’t receiving treatment. The percentage
not receiving treatment for SUDs is much
higher than it is for mental illness, a treat-
ment gap that parity laws and regulations
have not closed.
“We know that evidence-based pre-
vention efforts are the most effective way
to reduce drug use and to support the
roughly 90% of American youth who do
not use illicit drugs,” said Michael Bot-
ticelli, director of the Office of National
Drug Control Policy. Botticelli did not
miss the opportunity to call for Congress
to fund $1.1 billion that was requested
unintentional negative outcomes, rang-
ing from microaggressions in day-to-day
interactions to police shootings. Mod-
eled after much of the work identifying
implicit bias experimentally, this article
will use the terms “black” and “white”
to contrast racial groups, acknowledging
these terms are overly simplified.
last February by President Obama in the
2017 budget.
Prescription drugs
SAMHSA also released a new, second
NSDUH report focusing on misuse of
prescription drugs. This report includes
tranquilizers, stimulants, sedatives, and
pain relievers (including those containing
opioids). This report contains informa-
tion on the total number of people using
these medications based on questions
on any use and misuse. It also provides
insight into several important issues, such
as why people misuse these medications
and how misuse may be associated with
other forms of substance use and/or men-
tal issues.
This report shows that among people
aged 12 and older, 6.4 million people
currently (in the past month) misuse psy-
chotherapeutic medications. About three-
fifths (59.3%) of this current misuse con-
sists of the 3.8 million people currently
misusing prescription pain relievers. The
report also shows that most people who
used prescription drugs in the past year
did not misuse them. In fact, 84.1% of
them did not misuse prescription drugs
even once in the past year.
Changes in survey methodology for
seven of the 10 illicit drug categories —
hallucinogens, inhalants, methamphet-
amine, and the misuse of prescription
pain relievers, tranquilizers, stimulants,
and sedatives — prevent direct compari-
sons of measurements involving those
illicit drugs between 2015 and prior years.
✦✦✦
For the reports, go to http://www.samhsa
.gov/data/sites/default/files/NSDUH-FFR1-2015/
NSDUH-FFR1-2015/NSDUH-FFR1-2015.htm and
http://www.samhsa.gov/data/sites/default/files/
NSDUH-FFR2-2015/NSDUH-FFR2-2015.htm.
The strikingly high rates of expul-
sion from child care, preschool/pre-
kindergarten, and other early learning
environments (cumulatively referred to
throughout this article as early care and
education [ECE] settings) for black males
may in part be an effect of implicit bias.
The national rate of expulsion for pre-

kindergarten settings (6.7 per 1,000) is
more than three times higher than the
rate for K–12 (2.1 per 1,000) (Gilliam,
2005). Moreover, black children are two
times as likely to be expelled compared
to white and Latino children, and five
times as likely to be expelled compared to
Asian American children (Gilliam, 2005).
Although factors such as behavior prob-
lems are a frequently cited reason for
such disciplinary actions, research with
older children shows that difficult behav-
ior alone does not account for racial dis-
parities (Okonofua & Eberhardt, 2015),
suggesting that implicit biases of educa-
tional institutions and teachers may also
play a role.
Why is this happening? Although the
data clearly demonstrate great disparities,
research explaining the underlying causes
of such disparities is limited, especially in
ECE settings. The current article will draw
upon the extant research to start to under-
stand potential links between teachers’
implicit bias and their understanding of
and interaction with students, as it relates
to disproportionate expulsion rates. Fur-
thermore, given the pervasive nature of
implicit bias in the United States, there
could be great benefit in providing staff
in ECE settings supports aimed at reduc-
ing bias.
Harsher punishments by teachers
Research has found that implicit racial
bias affects the way teachers in kinder-
garten through 12th grade see their stu-
dents. Teachers were shown to be more
likely to interpret multiple misbehaviors
of black students as “troublesome” and
to respond with harsher punishments,
compared to white students (Okonofua
& Eberhardt, 2015). Additionally, when
black students misbehaved two times,
teachers were more likely to label stu-
dents as “troublemakers,” consider the
misbehavior as a pattern, and can more
easily imagine using suspension as a dis-
ciplinary response, compared to white
students (Okonofua & Eberhardt, 2015).
Although the previous findings have
been in the context of elementary, mid-
dle, and high school, there is good reason
to expect the tendencies extend down
to ECE settings. As such, ECE teachers
have similarly shown differences in their
views of students’ behavior based upon
their racial background. Teachers tended
The Brown University Child and Adolescent Behavior Letter October 2016
5
to rate black students who showed more
imaginative play and negative affect in
play as less well-adjusted compared to
nonblack children who received simi-
lar imaginative play and negative affect
scores during the lab play task (Yates &
Marcelo, 2014). These results show that
the same behaviors in children from dif-
ferent racial backgrounds may carry dif-
ferent meaning to teachers. ECE teachers
have also been found to give more com-
mands to children who they perceived to
have more behavior problems (Dobbs &
Arnold, 2009).
The literature base examining
implicit bias in ECE settings is in
its infancy. More research with
stronger methodology is needed
to understand how this plays
out in student-teacher relation-
ships, parent engagement, and
disciplinary action.
More research needed
If teachers perceive behaviors in some
children as indicative of problems and
thus give more commands, this could
lead to a cycle of repeated negative inter-
actions between students and teachers.
Implicit bias may be particularly harmful
in the early years when student-teacher
relationships are of utmost importance,
setting the stage for a cascade of devel-
opmental outcomes, affecting children’s
socioemotional, academic, health, and
eventual career outcomes.
The literature base examining implicit
bias in ECE settings is in its infancy.
More research with stronger methodol-
ogy is needed to understand how this
plays out in student-teacher relation-
ships, parent engagement, and disciplin-
ary action. Given the consistent findings
that adults and children in the United
States develop implicit bias, and the lack
of conscious awareness of the bias, it
is likely that unequal treatment stems
from the way people have been socialized
over the course of their lives, rather than
unchangeable malicious intent (Nosek et
al., 2007; Rudman, 2004).
Thus, creating nonjudgmental struc-
tures, in which ECE personnel are able to
examine the nuances of children’s difficult-
to-manage behavior, can reduce the ten-
dency to rely on fast-acting implicit bias.
As adults have the opportunity to recog-
nize biases that were previously outside of
their awareness, they may be able to start
to lessen these negative judgments and
respond in fairer, more effective ways. Both
mental health consultation and ongoing
cultural competence training may help to
provide such opportunities.
Mental health consultation as a school
resource
Early childhood mental health consul-
tation (ECMHC) may be one resource to
provide this structure. ECMHC involves
a mental health professional working col-
laboratively with ECE staff, programs, and
families to improve their ability to pre-
vent, identify, and respond to concerns
about social emotional development and
mental health among children in their
care. ECMHC is emerging as an effective,
evidence-based strategy. For example,
research shows significant reductions in
preschool expulsion rates when teachers
have access to mental health profession-
als who can help support teachers in
managing difficult child behavior (Perry,
Dunne, McFadden, & Campbell, 2008).
Much of the work done by the mental
health consultant is in the context of his
or her relationship with the ECE profes-
sional. Over time, the consultant creates
a safe space in which the ECE profes-
sional develops a sense of trust and open-
ness, which allows for the exploration
of negative feelings he or she may hold
about a child and the child’s family. The
consultant works to understand the ECE
professional’s perspective with a careful
ear to any biases or misperceptions he
or she might hold, racial or otherwise.
It is within the context of a collabora-
tive, trusting relationship in which ECE
professionals will likely feel safe enough
to identify biases and work to change
them with the guidance and support from
the consultant; indeed, collaboration has
been found to reduce implicit bias in
other settings (Rudman, 2004).
Through ECMHC, the consultant works
to help the professional better understand
the child and create shared, collaborative
Continued on next page…

Continued from previous page...
goals that will support the child’s optimal
development and reduce the likelihood of
expulsion. Given the widespread nature
of implicit bias, it is of utmost importance
for consultants to similarly be aware of
their own potential biases in working with
ECE staff.
In addition to addressing implicit
bias through mental health consultation,
trainings on cultural competence can
help individuals develop self-awareness
of their own cultural values and biases,
as well as awareness and acceptance for
other cultural values. Such programs have
shown effectiveness for reducing antiblack
implicit bias in college students (Rud-
man, 2004). Incorporating such trainings
at pre-service and regular in-service train-
ings can help to foster an environment
in which diversity of students, families,
and staff is often discussed and appreci-
ated. Developing a culture within ECE
programs of openness to difference and
being curious to learn more about one
another in a respectful way can reduce
implicit bias for staff and children. Learn-
ing ways to appropriately integrate stu-
dents’ backgrounds into the classroom
Emergency Care
From page 1
pediatric psychiatric parents, which is the
process of excluding potential medical
conditions causing the symptoms, as well
as evaluating the patient for diseases or
injuries that require intervention in the
ED. Some clinicians use the term “medi-
cally stable,” because the ED visit is not
expected to exclude all possible medical
etiologies, but rather to rule out acute
medical conditions. In the case of unex-
plained vital sign abnormalities or physi-
cal examination findings with new onset
or acute changes, it may be important to
conduct a careful evaluation for underly-
ing medical conditions.
Although many medical conditions can
present with mental health symptoms, the
utility of routine laboratory or radiologic
testing for these patients is questionable,
recent research has found. “This literature
supports the position of the American Col-
lege of Emergency Physicians for focused
The Brown University Child and Adolescent Behavior Letter October 2016
6
curriculum and environment can create
a welcome space and a sense of pride in
children instead of difference or, worse
yet, deficiency.
Moreover, the consultant may be in a
unique position to provide such program-
level training given his or her knowledge
of the pre-existing ECE program culture
and staff, as well as his or her ongoing
relationships with the ECE staff. Given the
widespread, pervasive nature of implicit
racial bias in our society, systematic mea-
sures should be in place to create open
dialogue that allows people to address
their biases in a supportive way. Such
opportunities provided through ECMHC
can mitigate the harmful effects of implicit
bias in ECE settings, better preparing
children for success through elementary
school to high school and beyond.
✦✦✦
Diana Westerberg, Ph.D., is a postdoctoral fellow
at the Warren Alpert Medical School of Brown
University.
References
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preschool teachers’ reports of children’s behav-
medical assessments and judicious test-
ing of these ED patients,” the AAP report
states. In many cases, mental health con-
sultants request pregnancy, toxicology,
and sexually transmitted infection testing
for adolescents. “Whether to obtain these
or other medical tests or evaluations can
usually be decided with a direct conversa-
tion between the ED and mental health
clinicians,” according to the report.
Suicide
One of the leading causes of death in
adolescents, suicide attempts are also one
of the most common ED mental presen-
tations. Sixteen percent of teenagers seri-
ously considered suicide, and almost 8%
attempted it in the past year. Females are
more likely to consider and attempt suicide,
while males are more likely to die because
they tend to use lethal methods such as guns
or hanging. Risk factors include previous
attempts, depression, irritable mood, bipo-
lar disorder, mood swings, impulsivity, dis-
ruptive behavior disorders, substance use
disorders, recent psychiatric hospitaliza-
ior and their behavior toward those children.
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Gilliam WS. Pre-kindergarteners left behind:
Expulsion rates in state pre-kindergarten sys-
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Okonofua JA, Eberhardt JL. Two strikes: Race
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Perry DF, Dunne MC, McFadden L, Campbell
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tion, family history of suicide, interpersonal
violence, homelessness, runaway behavior,
self-identification as LGBT, hopelessness,
history of aggressive or impulsive behavior,
recent loss or stress, physical illness, social
isolation, and barriers or unwillingness to
seek mental health care.
Because suicide attempts are often
triggered by psychosocial stressors, the
pediatric emergency patients should be
asked about the current situation, with
the patient and caregivers interviewed.
In the ED, patients who have attempted
suicide or are considering it should be
evaluated for their current mental health
state. Many children and adolescents mis-
judge the effect of an attempt — it may
have had low medical lethality, but the
wish to die may still be significant.
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