Pivoting: Responding to the Mental Health Needs of Youth of Color With Technology

Abstract

Mental health treatments currently available to address racial discrimination for 21 million youth of color are inadequate. Given the nascent but promising mechanisms found within behavioral health interventions via racial socialization, or the process through which children acquire knowledge about race, developing effective and scalable therapeutic strategies to contend with the stress from racism and discrimination is possible. We outline the active ingredients that facilitate behavioral change for youth psychosocial outcomes impacted by racial discrimination and describe how technology is being utilized for current and future implementation efforts. We argue that technological advancement, in addition to ecological considerations, is crucial for the reduction of structural and interpersonal risk factors negatively influencing the psychological wellness of youth of color. Technology integration across implementation and assessment will be critical, particularly given the potential for technology to further exacerbate mental health disparities.

Keywords

racial socialization racial discrimination youth of color intervention digital health

Seventeen years marks an unofficial maturing across sectors. For some adolescents, it can be the age at which they graduate high school, culminating their completion with a sigh of relief. For others, it may be the age at which they take their last breath, having experienced a traumatic or fatal encounter with racial discrimination (RD; e.g., Jordan Davis, Brayla Stone, Trayvon Martin). The 17-year “bench-to-bedside” problem within clinical trials research (Morris et al., 2011) becomes that much more troublesome in the latter case; promising research without fast-acting implementation may be a matter of life or death—or suboptimal living at least—for 21 million adolescents of color in America. The vast majority of youth of color (YoC) indicate experiencing daily encounters with racism (English et al., 2020), a socially structured action based on race that is unfair or unjustified and harms individuals and groups (National Institute of Mental Health, 2021). Youth experiencing greater incidences of racially discriminatory harm have consistently reported higher depression, anxiety, and suicidal ideation in studies of psychological outcomes (Priest et al., 2013). Despite this increase in racial stress, YoC are less likely to receive traditional mental health services for psychological problems. Given that only 9% of YoC receive services annually relative to 17% of their White peers (Center for Behavioral Health Statistics and Quality, 2021)—a disparity often attributed to mental health stigma, service costs, and clinician shortages (Mongelli et al., 2020)—families, peers, and other trusted adults often provide YoC with coping strategies to combat the mental health impacts of RD, a practice referred to as racial socialization (RS). In light of this discrepancy in need and service provision, it is a clinical and public health priority to identify accessible, scalable, culturally relevant, and evidence-based strategies that meet the needs of YoC, their families, and other socializing agents.

Aided by widespread and growing smartphone ownership (91% to 96%) and frequent daily internet use (97%) among U.S. adults and teens, the potential for technology-enabled approaches to address unmet mental health needs has received increasing attention in the past decade (Vogels et al., 2022). Although it is important to acknowledge challenges within technology (e.g., bias) and the cautionary missteps of moving research to practice too soon (Onken et al., 2014), it is also critical to adapt and translate long-standing behavioral strategies into formats that meet the evolving needs of YoC. Thus, the goal of this article is to highlight current behavioral health interventions (BHIs) that utilize culturally relevant strategies for YoC experiencing mental health challenges due to RD, with a focus on the promise of digital and virtual formats to improve scale and uptake.

Behavioral Health Interventions

The behaviors of youth and those close to them (e.g., parents, teachers) play a critical role in their health and well-being, and mitigating the deleterious effects of RD is no exception. Though multifarious, BHIs typically target specific health behaviors at the individual level (e.g., increasing the frequency of use of a coping skill in response to stress) and are grounded in behavior change theories (see Glanz & Bishop, 2010, for a review). Importantly, BHI outcomes are variable and sensitive to individual and contextual factors, which underscores the importance of considering the theoretical mechanisms that facilitate desired behavior change in BHIs to identify the appropriate and synergistic “active ingredients” to increase their efficacy, effectiveness, and efficiency (Kazdin, 2007).

Mechanisms linking racial discrimination to youth of color mental health

Determining the active ingredients, or theoretically derived individual components that facilitate positive behavior change in an intervention, is a critical step to effectively develop BHIs for YoC experiencing racism-related mental health challenges. Toward this aim, recent theoretical models (e.g., RECAST; Anderson & Stevenson, 2019 ) have advanced our understanding of the pathways linking exposure to RD to adverse outcomes for youth. RECAST posits that RD experiences are associated with stress-related neural and psychophysiological mechanisms (e.g., racial stress; Muscatell et al., 2022), which are followed by effective or ineffective racial coping. Although some coping processes can be automatic or unconscious for individuals, racial coping is effortful health behavior that often requires the transference of explicit and implicit knowledge, awareness, and skill strategies, chief among them RS. Over four decades of research have established RS as a primary moderator of racial distress and coping strategies in YoC and one of the foremost protective factors against adverse short- and long-term health outcomes associated with RD (Hughes et al., 2006), including psychosocial, physiological, academic, and identity-related outcomes. Specific RS behaviors include sharing messages about customs and practices about race and racism, which vary in their frequency, content (e.g., cultural socialization, preparation for bias), mode of transmission (e.g., verbal or nonverbal), intent (e.g., proactive or reactive), and competency (e.g., skills, confidence, stress) and are each influenced by individual and contextual factors (Hughes et al., 2006). Ultimately, within the context of RECAST, the goal of RS is to improve youth racial coping self-efficacy and provide skills that improve racial coping behaviors directly (e.g., practicing words, behaviors, or strategies that reduce distress) or indirectly (e.g., increasing parental RS competency).

Racial socialization interventions as BHIs

Pioneering clinical interventions developed in the past 20 years primarily target parents’ RS behaviors and, increasingly, youth’s racial coping behaviors directly. These RS interventions include stand-alone programs (e.g., EMBRace; Anderson et al., 2019) and adaptations of evidence-based treatments that explicitly target racial stress in youth (e.g., trauma-focused cognitive behavioral therapy; Metzger et al., 2023). Active ingredients in RS interventions include psychoeducation, skills practice, role-playing, and self-monitoring and feedback (Bo et al., 2023), which are common across other BHIs targeting youth and family health behaviors (MacDonell & Prinz, 2017). Accordingly, though adapted interventions have limited empirical support and the vast majority of stand-alone RS interventions are within pilot stages, Bo and colleagues (2023) observed promising effects on RS efficacy and behaviors and racial coping behaviors among parents and youth in a scoping review of eight stand-alone interventions. Further, preliminary evidence from the EMBRace pilot demonstrated that parents reported a decrease in their child’s internalizing outcomes from baseline (M = 0.46, SD = 0.39) to posttest (M = 0.33, SD = 0.31) of the BHI, supported in qualitative feedback from an 11-year-old boy who noted that participating “felt good cuz like, we can talk about, like, what we seen. So like, we won’t have anger built up inside of us” (Anderson et al., 2017).

Current Directions in Digital RS Interventions: Opportunities and Challenges

Despite their promise, BHIs, like RS interventions, typically face challenges in research and practice, including variable outcomes, short-lasting effects, and poor scalability (Kwasnicka et al., 2016). To address these issues, digital BHIs have been developed that leverage technology to disseminate the active ingredients in BHIs, which range from entirely person delivered (e.g., telehealth) to adjunct (e.g., some person-delivered and some automated components) to fully automated (e.g., standalone apps; Mohr et al., 2014). Similarly, common active ingredients in RS interventions can be integrated into digital RS interventions for a range of socializing agents to improve the effectiveness, efficiency, and accessibility of culturally responsive, evidence-based care for youth experiencing racial stress.

Psychoeducation and skills modeling

Psychoeducation and skills modeling are hallmark features of RS interventions (Bo et al., 2023). Many RS interventions with parents and youth include psychoeducation on how to identify racial stressors and techniques to effectively cope with these stressors, and parent RS interventions also teach techniques to improve parent RS messages and problem-solving skills when discussing racism and RD with their children (Bo et al., 2023). Although typically facilitated in person by a clinician or community leader with RS training, technologies with audio/video capabilities are well suited to disseminate RS psychoeducation. Indeed, asynchronous, video-based RS psychoeducation and skills modeling have recently been incorporated into multiple digital RS interventions or resources, including web (e.g., Stein et al., 2021) and mobile apps (e.g., Teens Navigating the Talk; RACE Space Inc., 2023). However, given the early stage of this work, parent and youth engagement in digital RS psychoeducation, its impact on outcomes, and its performance relative to in-person and synchronous psychoeducation (e.g., teletherapy) is unclear. Further, to our knowledge, RS interventions have yet to leverage existing, widely used social media platforms (e.g., YouTube) or virtual reality (VR) for psychoeducation, despite its potential to increase access and engagement, respectively (Bell et al., 2020; Kruzan et al., 2022).

Skills practice and role-playing

Role-playing in RS interventions involves youth and parents practicing specific skills using prompts, vignettes, or scenarios (see Anderson et al., 2019, for an example). Although these are typically facilitated by a clinician or trained facilitator, advancements in VR and artificial intelligence (AI; e.g., chatbots) may allow youth and socializing agents to experience more realistic and immersive scenarios. VR is a computer-generated, three-dimensional simulation of a real-life situation aided by a robust combination of sensory stimuli that a user can interact with using VR systems (often, headsets with a head-mounted display). To our knowledge, only one VR narrative game (Passage Home VR) has been used to simulate RD encounters for YoC and, although not a BHI in and of itself, has benefited RS BHIs via collaboration between computer and social sciences to assess behaviors through technology (see Olson et al., 2023). Passage Home prompts the user to role-play an encounter of RD in a classroom setting and iteratively select their character’s verbal and gestural responses to the teacher throughout the scenario (Olson et al., 2023). Similarly, chatbots, which are conversational agents that use text and speech recognition to simulate human conversation, have yet to be implemented to target racial coping behaviors in youth or RS behaviors in socializing agents, despite being a feature in many publicly available web and mobile mental health apps for youth (Haque & Rubya, 2023).

While VR and chatbots are underinvestigated in the RS literature to date, some evidence suggests they may support skill acquisition for parents (e.g., practice conveying specific RS messages, problem-solving, and using coping skills to manage RS stress) and youth (e.g., practice using various coping skills in response to RD), especially when simulations are culturally relevant, appropriate, and responsive to behavioral and psychophysiological feedback (Bell et al., 2020; Haque & Rubya, 2023). Thus, because the use of VR and chatbots for role-playing in RS interventions is nascent, significant future research is needed to establish the effective, safe, and ethical use of these technologies in digital RS interventions, especially fully or primarily automated BHIs.

Self-monitoring and feedback

A particular benefit of digital BHIs is the ability to automate the self-monitoring and feedback loop by tailoring how and for whom active ingredients are disseminated based on repeated measurements of individual and environmental characteristics. Importantly, self-monitoring can focus on the specific behavioral targets of a digital RS intervention (e.g., increasing youth use of effective racial coping skills), upstream determinants (e.g., youth racial stress), or downstream effects (e.g., parent RS competency, youth mental health symptoms). Although measures have been limited to self-reported RS or coping behaviors in previous digital RS interventions, advancements in momentary assessment methods, biosensor technologies, and machine learning and AI techniques provide opportunities for more robust integration of self-monitoring into digital RS interventions. For example, parents’ automatic verbal RS behaviors, which are difficult to capture on self-report measures, may be quantified and categorized using a combination of speech and text recognition and natural language processing, thus informing a more robust measure of RS frequency for monitoring parent behavior change (Yasui, 2015).

Further, some nonverbal RS behaviors (e.g., eye contact, facial expressions) can be captured using various technologies with video/audio recording capabilities (e.g., smartphones, wearable eye-tracking glasses) and subsequently analyzed and categorized using machine learning algorithms. This is complementary to the observational work being conducted within emotion socialization studies for younger YoC (see Dunbar et al., 2022). Finally, coupling momentary assessment methods and wearable technologies may capture a more dynamic, in-the-moment assessment of youth’s racial stress, use of specific racial coping strategies, and strategy effectiveness via self-report and psychophysiological measures (e.g., heart rate variability, galvanic skin response) as well as contextual information (e.g., geolocation data). In turn, these data can be used to identify intervention goals, reinforce desired behaviors (e.g., gamification), and tailor active ingredients (e.g., psychoeducation; Stein et al., 2021) based on treatment adaptation frameworks specific to RS (e.g., REACH UP; DeLapp & Gallo, 2022).

Considerations for designing digital racial socialization interventions

Despite the promise of digital interventions to improve scale and uptake, their proposed benefits can be hampered by low engagement or adherence (Gan et al., 2021). However, appropriate design features, which are a by-product of intentional and person-centered design processes, have been shown to mitigate these barriers. Although several digital BHI design theories, models, and frameworks have been proposed in the past decade, a recent scoping review distilled their common elements into a five-stage process model (i.e., behavioral design thinking approach; Voorheis et al., 2022). Importantly, efforts to improve engagement in and uptake of BHIs, like digital RS interventions, also require careful attention to cultural responsiveness at each stage of the design process, which has received comparatively less attention in the literature to date, in part, because of the underrepresentation of people of color as decision-makers and participants in these processes (Schueller et al., 2019; Willis et al., 2022). Thus, we propose recommendations for developing digital RS interventions using the behavioral design thinking approach with particular emphasis on cultural adaptation and responsiveness (see Table 1).

Table 1.

Considerations for Designing Digital Racial Socialization Interventions

Design phase	Guiding questions
Step 1: Empathize with users and their behavior change needs	Are investigators prepared to engage with youth and/or socializing agents with empathy and cultural humility? What culturally sensitive, trauma-informed approaches and measures can be employed to explore behavioral domains of interest, such as racial coping or socialization behaviors (e.g., Racial Socialization Competency Scale)? What experiences, perceptions, motivations, beliefs, and needs are associated with these domains? What are the relevant behavioral and behavior change theories (e.g., RECAST)? What individual and community values and strengths empower youth and/or socializing agents (e.g., REACH Up model)? What other developmental processes (e.g., racial identity development, youth adjustment) theoretically relevant to behavioral domains of interest should be considered? Are only the minimum necessary data being collected?
Step 2: Define user and behavior change requirements	Are design aids (e.g., user personas, profiles, scenarios, or journeys) based on Step 1 data representative of the target group and their experiences? Are the criteria used to evaluate and refine target behaviors and behavior change requirements considerate of the values and priorities of youth and/or socializing agents? Are the selected target behaviors and behavior change requirements acceptable to the target group?
Step 3: Ideate user-centered features and behavior change content	Is a digital approach optimal given the behavior change requirements? Have the potential benefits, risks, and harms of a digital approach been thoroughly considered? How might a digital approach alleviate or exacerbate existing health disparities? What are the potential barriers to engagement in the intervention (e.g., mistrust due to medicalized racism) and what are ethical strategies to address these barriers? How might potential adverse effects, such as worsening outcomes, data misuse, or privacy infringements, be prevented, addressed, and reported to impacted communities? How might the intervention facilitate synergies across levels of a youth’s ecological system toward increased engagement and sustained behavior change for youth and/or socializing agents?
Content	What “active ingredients” (e.g., psychoeducation, biofeedback) are most relevant to the intervention based on research with the target group(s) and the behavior change requirements? These may include features that target theoretically relevant perceptions, motivations, and beliefs (e.g., racial coping self-efficacy). If the intervention has existing content, was the need for cultural adaptation assessed and pursued if indicated? How might verbal and nonverbal racial socialization content be embedded within various content types in a digital interface (e.g., text, decorative images, videos)? How might these content types be designed to reinforce behavior change?
Delivery	What digital interface optimizes fit between the user and behavior change requirements and technology feasibility (e.g., technical capabilities and accessibility within the target group)? Is it appropriate for the environment in which it will be used (e.g., home or school)? How might changes in mental state associated with target behaviors (e.g., racial socialization and racial stress) influence appropriate design features (e.g., strategies to reduce cognitive load)? What theoretically relevant variables could be used to tailor the delivery of “active ingredients” to youth and/or socializing agents (e.g., timing, frequency, messaging)? How could those variables be collected?
Step 4: Prototype a user-centered solution that supports behavior change	How might youth and/or socializing agents engage in prototyping and evaluation processes early and iteratively?
Step 5: Test the solution against users’ needs and for its behavior change potential	Are the outcome variables assessed culturally relevant and meaningful? Are the measures used to assess outcome variables culturally valid? How might the limitations of these measures (e.g., underrepresentation of diverse people of color in development) influence the interpretability of the data? How might the impact of intersecting systems of oppression on intervention outcomes be assessed (see Framework for Digital Health Equity; Richardson et al., 2022)? What are the barriers and facilitators to intervention use and implementation? How might the intervention be implemented and reinforced across multiple levels of a youth’s ecological system (e.g., social media)?

Note: Adapted from the behavioral design thinking approach (Voorheis et al., 2022).

Importantly, from a culturally responsive lens, it is critical for investigators to examine potential sources of exclusion within their methods and translate these insights into strategies to reduce bias and other potential harms. For example, sociopolitical barriers that disproportionately impact people of color, such as transportation or Internet inequality, may differentially impact recruitment and engagement across research methods (e.g., in-person vs. virtual focus groups) and, by extension, influence data interpretability at each stage of the design process. Thus, investigators should consider using methods that minimize these barriers for their target users and employ analytical methods (e.g., missing data and intersectional analyses) to examine the impact of these barriers on data validity, interpretability, and generalizability. Ideally, these processes are iteratively shaped and actualized alongside YoC and/or socializing agents using community-centered, participatory approaches that promote trust, transparency, and accountability throughout the design process (see Olson et al., 2023, for an example).

Ecological considerations

Within the research on RS, the vast majority of scholars and practitioners focus on how parents and children share messages, behaviors, and beliefs with each other at the microsystem level, or the level including people and groups that play an immediate and direct role in a child’s life. However, exploring how digital RS interventions can be implemented and reinforced across multiple levels of a child’s ecological system is imperative for optimizing their long-term effectiveness and scalability and, thus, mental health outcomes for YoC. Our work demonstrating the prevalence of trusted adults (e.g., teachers, nonparental family members) and friends (Anderson et al., 2022) as well as the influence of therapists as microsystem socializing agents (Anderson et al., 2017) underscores how impactful “the village” is to the mental health of YoC experiencing RD. The mesosystem in which a child’s microsystems connect and interact, furthermore, considers the interaction of these socializing agents. Although research has not been conducted that demonstrates the cumulative effects of socializing agents across sectors, it stands to reason that consistent and competent socialization, particularly with respect to acute discriminatory distress, will be an important future direction for this work.

The chronosystem, which accounts for environmental shifts and transitions in a child’s life, including sociohistorical events, may be especially beneficial for this approach. If a digital platform existed that allowed youth to express when they are facing discriminatory distress and select with whom within their trusted networks they wish to share this information, there may be increased opportunities for agents to collaborate on a solution or at the very least provide support in their own domain. Taking advantage of the chronosystem—which has brought both opportunity and challenge to YoC’s mental health through social networking—may allow individuals within systems to support youth through burgeoning and rapidly developing technology. More importantly, not taking advantage of this technology opposes research on how youth currently communicate, how and where they spend their time, and how they desire mental health support (Willis et al., 2022). Although youth are turning to social media platforms to meet their mental health needs, YoC are encountering misinformation and experiencing distress as a result of biased algorithms or malicious content and exposed to greater incidents of RD online than their peers (Tao & Fisher, 2022), thus requiring ecologically and culturally mindful approaches.

Adverse effects

Although there is a great deal of promise for digital BHIs, caution should be exercised with respect to potential adverse effects. It is important to emphasize ethical considerations and the steps necessary to maximize benefits and minimize risks to YoC and their community. Concerns of autonomy, appropriate data use, and bias-aware data interpretability can be addressed by cocreating privacy policies, surveillance, and consent procedures with youth and socializing agents, enforcing aggregate-only data sharing with extensively vetted partners, and using intersectional statistical approaches to assess and report potential data biases. Additionally, because AI is becoming increasingly relied upon in technology-supported treatments (e.g., chatbots, diagnostic tools), great caution should be taken for treatments for YoC given the canon of evidence demonstrating algorithmic racial bias. Working intimately with coders and making decisions weighing the costs and benefits of AI use is critical in the uptake and acceptability of products for the mental health treatment of YoC.

Another primary concern for youth writ large is how much they are replacing face-to-face interactions with digital use. Although digital BHIs are attempting to meet youth “where they are,” this same technology could exacerbate the mental health costs associated with the reduction of human contact. As these tools are being built for youth consumers, the ability for the technology to be hybrid or primarily automated should be weighed against potential losses for fully automated products, which may contribute to other psychological problems, such as loneliness. Finally, although YoC maintain the largest share of smartphone users, structural barriers may impede the effectiveness and usability of technology platforms for this population. Although studies that provide equipment like a VR headset or the latest version of a phone or tablet may generate data in controlled settings, the wide scaling of these methodologies may be hampered by the effects of structural racism (e.g., limited familial liquid assets, reduced WiFi infrastructure, inequitable school budgets). This potential furthering of the problem that these BHIs are intending to solve is a primary challenge to many mental health-focused solutions that require additional resources for YoC to acquire. It is not enough just to develop the tools—there must be mindfulness toward the importance of targeting various determinants of mental health when conceptualizing and designing digital BHIs for YoC. As such, we encourage the prioritization of culturally responsive approaches to the development and evaluation of these tools to be accountable to the youth we intend to serve, ensuring that ideas and methods are iterated upon as necessary to refine our approach.

Conclusion

As adolescents navigate the challenges of RD, it is imperative that researchers, clinicians, and supporters of YoC understand and intervene against its contemporaneous and long-term mental health effects. There is a large body of research demonstrating the deleterious effect of racism on adolescent mental health outcomes, and although the intervention literature integrating RS is burgeoning—especially due to our current work on parent, child, clinician, and tech interventions—there are still strides to take to meet the current implementation and uptake needs of YoC. In particular, RS interventions have yet to leverage existing social media platforms and capitalize on applications, although adapted interventions (e.g., EMBRace) and newly released apps (e.g., Teens Navigating the Talk) are starting to do so. Despite the exponential growth of digital BHIs in the past decade and its potential benefits, attention to ethical, community-centered, and equity-centered approaches to creating, evaluating, and disseminating digital RS interventions will be critical given the risks for technology to further exacerbate health inequities (Richardson et al., 2022). This nascent area of work requires significant future research to establish the effective, safe, and ethical use of these technologies in digital RS interventions, especially fully or primarily automated BHIs. BHIs that focus across varying ecological levels for youth are also imperative, especially given the changing landscape of youth interactions throughout their typical day, particularly on digital devices. Knowing the gap between research and practice, we cannot afford to lose an entire generation of YoC to the harms of racism—we must act with all deliberate speed now and for the future.

Footnotes

Transparency

Action Editor: Robert L. Goldstone

Editor: Robert L. Goldstone

ORCID iD

Riana E. Anderson

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Pivoting: Responding to the Mental Health Needs of Youth of Color With Technology

Abstract

Keywords

Behavioral Health Interventions

Mechanisms linking racial discrimination to youth of color mental health

Racial socialization interventions as BHIs

Current Directions in Digital RS Interventions: Opportunities and Challenges

Psychoeducation and skills modeling

Skills practice and role-playing

Self-m﻿onitoring and feedback

Considerations for designing digital racial socialization interventions

Ecological considerations

Adverse effects

Conclusion

Recommended Reading

Footnotes

Transparency

ORCID iD

References

Self-monitoring and feedback