Disproportionality and Disparities
Abstract and Keywords
Racial disproportionality and disparities are problems affecting children and families of color in the child welfare, juvenile justice, education, mental-health, and health-care systems. The term “disproportionality” refers to the ratio between the percentage of persons in a particular racial or ethnic group at a particular decision point or experiencing an event (maltreatment, incarceration, school dropouts) compared to the percentage of the same racial or ethnic group in the overall population. This ratio could suggest underrepresentation, proportional representation, or overrepresentation of a population experiencing a particular phenomenon. The term “disparity” refers to “unequal treatment or outcomes for different groups in the same circumstance or at the same decision point.” A close examination of disproportionality and disparities brings attention to differences in outcomes, often by racial group, and by social service systems. It is necessary to examine the reasons for these differences in outcomes and to be sure that culturally competent practices are upheld.
Racial Disproportionality and Disparities
The term “disproportionality” refers to the ratio between the percentage of persons in a particular racial or ethnic group at a particular decision point or experiencing an event (such as maltreatment, incarceration, school dropouts) compared to the percentage of the same racial or ethnic group in the overall population (Alliance for Racial Equity, 2010; McRoy, 2005; Wells, 2011). This ratio could suggest underrepresentation, proportional representation, or overrepresentation of a population experiencing a particular phenomenon. A close examination of disproportionality brings attention to differences in outcomes, often by racial group, and it is necessary to examine the reasons for these differences.
Whereas disproportionality refers to the state of being out of proportion, “disparity” refers to a state of being unequal. In health and social service systems, disparity is typically used to describe unequal outcomes experienced by one racial or ethnic group when compared to another racial or ethnic group (in contrast, disproportionality compares the proportion of one racial or ethnic group to the same racial or ethnic group in the population). For example, an examination of disparities may look at differences by race or ethnicity at various points of entry into the child welfare or juvenile justice system, differences by county or region, or differences by age (for example, infants, adolescents) to better understand the dynamics of disparities present in a given system. In addition to disproportionality and disparities that can occur within systems, there may be overlapping challenges that can occur between systems.
In this entry, disproportionality and disparities will be examined by looking at various racial or ethnic population breakdowns in relation to the representation and outcomes for each of those groups in the following systems: child welfare, education, juvenile justice, mental health, and health. The causes as well as overlapping challenges and struggles between systems will be highlighted.
Review of Disproportionality and Disparities in Social Service Systems
Disproportionality and disparities manifest themselves differently across health and social service systems, yet they are present in each and share similar characteristics and causes, affecting outcomes, interventions, and policies.
Disproportionality and Disparities in Child Welfare
Within the context of the child welfare system, disproportionality occurs when the proportion of one racial or ethnic group in the child welfare population (for example, children in foster care) is proportionately larger than the proportion of the same group in the general child population. This phenomenon has most significantly affected African American children, with estimates from 2012 indicating that African American children represented 26% of children in foster care, although they represented only 14.5% of children in the general population (U.S. Census Bureau, 2012; U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, & Youth and Families, Children’s Bureau, 2013). Similarly, disproportionality has consistently been observed among American Indian or Alaska Native children. As of 2012, American Indian or Alaska Native children represented 2% of children in foster care, although they represented only 0.9% of children in the general population (U.S. Census Bureau; U.S. Department of Health and Human Services).
In contrast, Asian American and Pacific Islander children have consistently been underrepresented in foster care (Summers, Wood, & Russell, 2012). Similarly, Latino children have historically been underrepresented when examined at the national level. However, in recent years there has been growing awareness of the need to better understand disproportionality as it affects Latino children because of significant regional differences. As of 2012, Latino children represented 21% of children in foster care, whereas they represented 20.1% of children in the general population, suggesting nearly proportionate representation (U.S. Census Bureau, 2012; U.S. Department of Health and Human Services, 2013). However, significant statewide differences exist in which Latino children are overrepresented in some states whereas they are underrepresented in others.
One factor that is often identified as leading to disproportionality in the child welfare system is that children of color tend to suffer disproportionately from poverty. For example, in 2010, only 12.4% of White children were poor compared to 39.1% of African American children, 35% of Hispanic children, and 14.4% of Asian children (Children’s Defense Fund [CDF], 2012). A related factor that may contribute to poverty is that fewer than 40% of African American children live with both of their parents (CDF, 2011). In fact, African American children are more than twice as likely as White children to live with neither parent, and African American children are more than seven times as likely as White children to have a parent in prison (CDF). Although poverty does not cause maltreatment, a large body of research has documented that maltreatment occurs disproportionately among poor families (see, for example, Drake, Lee, & Jonson-Reid, 2009; Drake & Pandey, 1996; Freisthler, Bruce, & Needell, 2007). This was confirmed in the most recent National Incidence Study of Child Abuse and Neglect, which found that children in low-socioeconomic-status households experienced some form of maltreatment at a rate more than five times the rate of other children (Sedlak et al., 2010b).
Once experiencing abuse and neglect, the availability of services can make a difference in outcomes for children. In 2009, about 40% of children who were abused and neglected received no services and many others received insufficient services to address their needs (CDF, 2011). Some have suggested individual bias on the part of child welfare workers and mandated reporters that may impact their decision making regarding the need for services. Others have identified cultural bias, cultural insensitivity, or failure to seek culturally responsive resources as impacting the likelihood of seeking and receiving appropriate services (Chibnall et.al, 2003; Dettlaff & Rycraft, 2008). For example, Rivaux et al. (2011) completed a study to better understand why African American children were placed in foster care at higher rates than White children. She and her co-investigators found that even when controlling for risk, poverty, and other relevant factors, race affected the decision to provide services and to remove children from their homes.
In 2007, the U.S. Government Accountability Office (GAO) issued the findings of a study that examined the multiple causes of the overrepresentation of African American children in care. According to this report, cultural misunderstandings, stereotypes, assumptions, and bias all lead to disparate decision making (U.S. GAO, 2007). In addition, Sedlak, McPherson, & Das (2010a) noted that high rates of poverty in African American communities can impact longer stays in the foster-care system. Given that many children come from single mothers who are poor, live in impoverished neighborhoods and communities with few resources, experience long waiting lists to receive needed services, and may experience discrimination, they have decreased likelihood of achieving family reunification and instead remain in foster care for longer periods of time.
In response to the growing problem of disproportionality and disparities, Simmel (2011) challenged child welfare workers to avoid taking a “one size fits all approach” to service delivery and to recognize that factors such as age, gender, and ethnicity of children should be taken into consideration, calling for the assessment of “parenting practices and family characteristics with cultural sensitivity” (p. 108). Culturally competent recruitment of child welfare staff, subcontracting with minority specializing agencies, increased use of kinship adoptions, and customary adoptions within tribal communities are all culturally relevant approaches to addressing the disproportionate number of children of color in the child welfare system. There is also growing awareness of the need for efforts to be directed toward the prevention of maltreatment and the reduction of maltreatment-related risk factors among children and families of color, as well as the need to address the underlying social problems that contribute to disproportionate need. These strategies call for increased efforts by child welfare agencies to collaborate with community stakeholders to address these issues and facilitate children being maintained in their homes and reducing disproportionality.
Disproportionality and Disparities in Juvenile Justice Outcomes
Not only are children of color overrepresented in the child welfare system, but also two thirds of youth in the juvenile justice system are youth of color (CDF, 2011). Data indicate that youth of color are significantly more likely than their White counterparts to be arrested, detained, prosecuted, incarcerated, given probation, or transferred to adult court (Models for Change, 2011). Within the juvenile justice system, this phenomenon is referred to as disproportionate minority contact (DMC). In 2009, among the 1.5 million youth seen in juvenile courts, 34% were African American, although they represented only 16% of youth ages 10 to 17 in the population (Puzzanchera & Kang, 2011). Similarly, Latino youth represented 25% of youth who were incarcerated, although they represented only 19% of youth ages 10 to 17 (Saavedra, 2010). Statistics appear to suggest that Asian American or Pacific Islander and American Indian youth are proportionally represented within this system. However, American Indian youth are largely seen in federal courts because crimes committed on tribal lands are considered federal offenses. These contacts are not included among those with the juvenile justice system and thus affect the interpretation of those data.
Several studies have noted that many of the youth in the juvenile system are “dually involved” or “crossover youth” who have experienced both juvenile justice and child welfare system involvement (Herz et al., 2012). Therefore, many may have complex needs because of prior abuse and neglect, frequent moves, unstable situations, and lack of services to address these issues (Ryan, Herz, Hernandez, & Marshall, 2007). All of these factors may increase the likelihood of these youth entering residential or group settings and sometimes juvenile facilities.
Similar to the child welfare system, the causes of DMC are complex and include racial bias within the system, differences in the types and levels of offending behavior, legislation and policies with disproportionate impact, and the presence of other risk factors, including family economic status, family structure, and neighborhood (Huizinga et al., 2007). Further, disproportionality that exists in other systems may contribute to disproportionality within the juvenile justice system. In addition to overrepresentation in the child welfare system, youth of color are more likely than their White counterparts to have unmet mental-health needs (Kataoka, Zhang, & Wells, 2002) and experience difficulties in school (National Council of La Raza, 2011)—each of which can contribute to involvement in the juvenile justice system.
The Office of Juvenile Justice and Delinquency Prevention (OJJDP) reports that as of 2008, 25 states were engaged in programs to provide alternatives to detention as a means of addressing DMC, whereas 15 states were providing cultural competency training as part of their efforts to address this problem (OJJDP, 2009). Other approaches include early intervention programs to prevent crime and delinquency, whereas systems change efforts focus on the use of structured decision-making models to reduce the impact of racial bias and legislative reforms to address laws and policies that may have differential impacts on youth of color (OJJDP, n.d.).
Disproportionality and Disparities in Educational Outcomes
In addition to the disproportionality that is evident in the juvenile justice and child welfare systems, it also exists in the educational system, where it can manifest in a number of different ways. These include underrepresentation in gifted and talented programs and overrepresentation in special education programs. For example, White and Asian American students comprise nearly three fourths of all students enrolled in gifted and talented programs, whereas African American, Latino, and American Indian students are disproportionately underrepresented in these opportunities (U.S. Department of Education [U.S. DOE], Office of Civil Rights, 2012). Conversely, African American children are disproportionately overrepresented among children identified with a learning disability or emotional disturbance. Further, African American students represent only 16% of sixth to eighth graders, yet comprise 42% of students in those grades who are held back one year (U.S. DOE, Office of Civil Rights).
Disproportionality can also involve overrepresentation among youth receiving disciplinary actions. For example, African American students are more than three times as likely as their White peers to be suspended or expelled (U.S. DOE, Office of Civil Rights, 2012). Additionally, Latino and African American students comprise 56% of students expelled from school under zero-tolerance policies, although they represent only 45% of the student body (U.S. DOE, Office of Civil Rights). The increasing use of zero-tolerance policies has resulted in growing awareness of what is often referred to as the “school-to-prison pipeline” because children who have been suspended are more likely to fall behind in school, be retained a grade, drop out of high school, commit crimes, and become incarcerated as adults (Advancement Project, 2000).
Root causes of disproportionality within the educational system are complex, but most discussions of these causes focus on the historical advantages that White children have benefitted from in the American educational system. Access to learning and full educational opportunities were not accessible to non-Whites for the majority of this nation’s history. Institutionalized racism that remains within educational systems exacerbates this White advantage (Singleton & Linton, 2006). Further, socioeconomic conditions are frequently cited as compounding the educational barriers that students of color encounter (Robinson, 2010).
Strategies to address disproportionality vary widely across educational systems, yet most begin with identification and awareness of disproportionality as a problem. Although some districts have implemented concerted efforts to address disproportionality in their state and local systems, others have lacked a coordinated response to this problem. Beyond identification and awareness, efforts have included an emphasis on culturally responsive teaching—a pedagogy that recognizes the importance of including students’ cultural references in the classroom—as well as raising awareness of the historical causes of differences in educational outcomes, efforts to create more supportive learning environments, and system-wide efforts to improve school climate, eliminate racial bias, and promote cultural competence.
Disproportionality and Disparities in Mental-Health Outcomes
Although mental-health disorders and the need for mental-health services are present across racial and ethinic groups, considerable disparities exist in the mental-health system. These disparities exist in access to mental-health services, the quality of services provided, and outcomes that result from services. Specifically, African Americans, Asian Americans, and Latinos in need of mental-health services are all significantly less likely to utilize mental-health services compared to Whites (Office of Minority Health and Health Disparities, 2007). For example, Garland et al. (2005) found that among youth receiving services in a large, publicly funded system of care in San Diego, 79% of non-Hispanic White youths received mental-health services compared to only 59% of Asian Americans or Pacific Islanders, 64% of African Americans, and 70% of Latino Americans. They also found that there were racial or ethnic differences by type of service used. Although outpatient mental-health services were used most frequently overall, African American and Asian American or Pacific Islander youth were less likely to use this type of service than non-Hispanic White youth.
Barriers to mental-health services include economic barriers (such as, cost, lack of insurance), lack of awareness of mental-health issues, and stigma associated with mental illness. Additional barriers include a lack of culturally competent mental-health providers and prior negative experiences with the mental-health system (Yeh, McCabe, Hough, Dupuis, & Hazen, 2003). For some racial or ethnic groups, an additional barrier may include a lack of services available in their native language. Further, immigration status can serve as a barrier to accessing services because undocumented immigrants may fear being deported or prohibited from becoming naturalized if they attempt to access certain resources.
Social conditions within predominantly racial or ethnic communities may also present barriers to accessing mental-health services. Geographical segregation can restrict employment opportunities, and thus insurance, as well as access to mental-health services (Alegría, Pescosolido, Williams, & Canino, 2011). Communities with high proportions of African American and Latino residents have been found to be four times as likely as those with predominantly White residents to have a shortage of providers, regardless of community income (Putsch & Pololi, 2004). As a result, those in need of care may be more likely to seek services in the primary-care sector, where their concerns will receive considerably less attention (Tai-Seale, McGuire, Colenda, Rosen, & Cook, 2007).
Strategies to address mental-health disparities within the mental-health system include insurance reforms, particularly as they affect Medicaid eligibility criteria, and efforts to improve the cultural competence of mental-health providers to ensure appropriate diagnosis and referrals. Additional strategies include addressing the organizational climate of agencies that may serve as barriers to care for racial or ethnic minorities. Within racial or ethnic communities, strategies to reduce disparities include general education and improved health literacy, as well as increased efforts to engage with community systems to reduce stigma and mistrust that may be associated with mental-health providers. This includes ensuring access to mental-health services within racial or ethnic communities.
Disproportionality and Disparities in Health Outcomes
Health disparities include health status; access to, and utilization of, health care; and social determinants of poorer health. In each of these areas, people of color fare worse than their White counterparts. Disparities in health status are numerous and include higher rates of disease and illness, higher rates of death from disease, higher rates of chronic illness, and higher rates of infant mortality (Robert Wood Johnson Foundation, n.d.). Racial or ethnic minorities receive lower quality care than Whites—regardless of where they live, their income, or their health insurance coverage. African Americans and Hispanics receive a lower quality of care across disease areas, including cancer, HIV/AIDS, diabetes, and other chronic illnesses. For example, African Americans with coronary artery disease or who have experienced heart attacks are less likely than Whites to receive appropriate procedures or therapies. Further, African Americans are more likely than Whites to receive less desirable services, such as amputation (Institute of Medicine, 2003). Social determinants of health include poverty, median household income, no high school diploma, unemployment, wage gap, and incarceration rate. In each of these indicators, people of color fare worse than their White counterparts (James, Salganicoff, Ranji, Goodwin, & Duckett, 2012).
Similar to other systems, the factors contributing to these disparities are complex and at cross-system levels. Aspects of health systems—including financing, organization, and access to services—likely pose significant barriers for people of color. Shifts brought about by cost-control efforts and the movement to managed care may more negatively impact people of color as community-based care is decreased. People of color are less likely to have health insurance, which affects access to services. Even for those with insurance coverage, people of color are more likely to be enrolled in lower tiered plans and have fewer choices for health products and services (Institute of Medicine, 2003). Among providers, those who are unfamiliar with the racial or ethnic backgrounds of their patients may be vulnerable to uncertainty and misdiagnosis. Differences may also be present in the health-seeking behaviors of people of color because they may be more likely to refuse recommended services or delay seeking treatment. However, this may be the result of distrust or negative prior interactions with health-care systems.
Among children and youth, those of color are disproportionately uninsured and tend to experience more “preventable and treatable health conditions from birth through adulthood. In fact, one in five American Indian children, one in six Hispanic children, and one in eight Black children are uninsured compared to one in 14 White children” (CDF, 2011, p. E-2). This lack of insurance, coupled with disproportionate poverty, may be partly responsible for the finding that Black and Hispanic children are almost three times as likely to be in poor or fair health and more likely to have an unmet medical need than White children. Also, Hispanic children are 76% more likely and Black children are 50% more likely than White children to have an unmet health need because of cost (CDF, p. E-8).
Strategies to address health disparities begin with raising awareness of these disparities among key stakeholders, including providers, health plan purchasers, and the broader society. Health systems can make efforts to improve access to care, including ensuring interpreter services are available and expanding the use of community health workers. Systems also must take steps to ensure that financial incentives do not disproportionately impact people and communities of color. Similar to the mental-health system, efforts to improve health literacy among people and communities of color may play a role in reducing health disparities. Further, cross-cultural training and education for providers are necessary to ensure that unconscious biases or stereotypes do not interfere with the quality of patient interactions.
Challenges in Overlapping Systems
There are clearly overlapping challenges in the education, health, mental-health, child welfare, and juvenile justice systems. As these systems overlap and disproportionately impact children and families of color, policies and culturally appropriate interventions that take into account these interrelated systems are needed to address and prevent these disproportionate outcomes. Further, it is important for these overlapping social systems to provide services that address ethnically diverse contexts and are meaningful and relevant to the populations being served, resulting in increasing calls for cultural competence in all aspects of assessment, intervention, and evaluation. Services that are embedded with ideas from the majority culture can be limited by a number of factors—conceptual mismatches, language barriers, differing values, or differences in the meaning and manifestation of emotions—each of which can lead to poor outcomes.
Thus, effective assessment, intervention, and evaluation of services designed for diverse cultures require not only cultural competence, but also an increased awareness and understanding of the populations being served. Systems must understand how diverse groups perceive the services being provided, communicate their views and experiences, and respond to interventions. Further, systems working with diverse cultures must understand a number of different variables within those cultures, including diversity within an ethnic minority group or cultural contexts in help-seeking behaviors. As a result, cultural competency is not only an essential component of overlapping service systems, but also a necessary skill for service providers in those systems.
Yet the notion of cultural competence is sometimes misinterpreted to imply that service providers must know everything there is to know about a particular culture to be competent in that culture. This interpretation of cultural competence may not be practical because it is not possible to be perfectly competent in every culture for which one might provide services. Rather, service providers must have skills working cross-culturally that allow them to have an open mind, avoid making assumptions, and gather the appropriate information to make accurate assessments and intervention plans. To do this, providers must invest time learning about the history and culture of the population to understand what questions must be asked and what interventions are culturally appropriate. For overlapping systems, this will involve significant input from and collaboration with community-based stakeholders and others with expertise in the social, cultural, and historical contexts in which the social service system is based.
Overlapping challenges in the child welfare system have largely focused on the African American population. However, concerns are increasing regarding disparities that affect other children of color. Understanding how disparities and disproportionality manifest themselves for Native American and Latino children is important and strategies that address these disparities must be implemented and evaluated. Additionally, although there is a large body of research that focuses on understanding the factors that contribute to disproportionality and disparities, there is much less research on how to address or reduce them. The evidence base of strategies designed to address and reduce disproportionality and disparities must be strengthened and improved, not only through additional research, but also by ensuring that rigorous evaluation methods are employed.
Further, increased collaboration is needed across systems to more effectively meet the needs of youth involved across systems. This collaboration is necessary both to increase the understanding of the complex needs of cross-over youth and to improve service delivery. For example, youth involved in the juvenile justice system often have cross-system involvement with both the child welfare and the mental-health systems. Enhanced efforts also must be made to better understand and address the school-to-prison pipeline, whereby large disparities among youth of color in suspensions, expulsions, and school-based arrests contribute to the disparities that exist in the juvenile justice system.
In addition to collaboration among systems, increased collaboration and involvement are necessary with youth and the families involved in the juvenile justice system to ensure that their voices are heard and integrated into system improvement efforts. Efforts are also needed to improve the evidence base of interventions designed to reduce disproportionality in this system. Although promising practices have been identified, much further research is needed to strengthen the evidence base of these interventions. Further, more attention must be given to the evaluation of cross-systems efforts to reduce disproportionality and disparities, such as those that involve collaborations with the child welfare, mental-health, and educational systems.
Efforts are needed to transform the culture within schools to one that is responsive to changing demographics. Although the populations of schools reflect these changing demographics, the practices, procedures, protocols, and structures have remained the same. As part of these efforts, attention should be given to workforce development that ensures that educators are not only reflective of the populations whom they serve, but also understand the historical foundations of race and racism in the United States and how the existing structures within schools may perpetuate the inequalities that exist.
Educational systems must be equipped with culturally relevant curricula materials and resources as part of the overall process of system improvement. This is necessary not only to engage diverse students, but also to ensure that educational systems respect and value the histories, experiences, and value systems of culturally diverse groups. Increased efforts must be made to address the disparities that result from zero-tolerance policies within educational systems. These disparities contribute not only to poor educational outcomes for youth of color, but also to their involvement in other systems, particularly involvement in the juvenile justice system. Increased collaboration with the juvenile justice system is needed as part of these efforts to better understand and address the school-to-prison pipeline.
Efforts are needed that emphasize the development of a workforce of racial and ethnic minority professionals who are well trained in evidence-based mental-health and behavioral-health treatments that address the diverse needs of youth and families of color. This is important to facilitate not only culturally competent service provision, but also engagement of children and families of color in the health and mental-health systems.
Implications for Practice and Policy
At the systems level, strategies are needed to address the institutional issues that contribute to bias and inequities in social services offered in child welfare, juvenile justice, education, mental-health, and health systems. These efforts include examining and addressing the ways in which funding streams, payment methods, insurance coverage, and other institutional policies limit access to services or otherwise perpetuate existing inequities. Efforts are needed to ensure that the voices of children and families of color are included and valued in the development and delivery of mental-health services. This can be addressed through multiple methods, including enhanced community engagement with communities of color, increased use of community-based paraprofessionals, and increased involvement of service recipients in policy development and service decisions.
Because disparities in child welfare, juvenile justice, education, mental-health, and health systems are closely tied to the factors that affect the well-being of children and families of color, such as limited income and lack of health-care benefits, addressing the financial and structural barriers to social services is essential as children and families of color are disproportionately represented among the poor, the near poor, and those with insufficient services and benefits. Initiatives are needed to improve cultural competency and linguistic appropriateness within social service systems to enhance and increase engagement of people of color in preventative services. These must be extended to the engagement of communities of color through direct interaction and access to services within those communities. More attention is needed to develop strategies to improve public awareness of child welfare, juvenile justice, education, mental-health, and health disparities and to improve knowledge and literacy among racial and ethnic minorities to increase engagement in health services. These approaches must include considerable outreach to and engagement with communities of color that are most vulnerable to these disparities.
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