Authored by Lamisa Nubayaat
Art by Joyce Wang
William was always considered a problem. As a toddler, he couldn’t sit still. In school, he refused to listen to teachers, bit his classmates, and stole whatever he could. He didn’t have friends, could never control his emotions, and was eventually suspended for being a “danger to his classmates”. In her desperation, his mother turned to the medical system, seeing it as the only hope to improve his condition. However, instead of receiving comfort, she was given a list of a dozen potential diagnoses. After being consistently blamed for his behavior, his mother could do nothing but watch as her son was handcuffed and feared by those who were supposed to help him [1].
William’s distressing journey is sadly just one example of the endless challenges faced by children battling behavioral issues. The ignorance, misdiagnoses, and prejudice he encountered sheds light on a larger societal problem: the stigma surrounding mental illness. The general public propagates this stigma by spreading negative, discriminatory and inaccurate stereotypes about those with mental health problems [2]. People consider them to be dangerous, lazy, or faking it for attention. Unfortunately, children with these conditions are not immune to this, as they often face immense judgment and isolation from their peers, and even adults [3].
Despite notable progress, as society has gradually shown more empathy towards individuals with mental illness [4], this shift has not been universal. Every condition is perceived differently and thus, receives varying degrees of stigma. One study found that self-reported stigma was lowest for depression, Generalized Anxiety Disorder, and Obsessive Compulsive Disorder, as most participants felt pity for those suffering from these conditions. Conversely, stigma was highest for schizophrenia, followed by Borderline Personality Disorder and Antisocial Personality Disorder (ASPD) because these conditions caused participants to feel fearful and angry [5]. These findings illustrate how people with more complex and less understood mental health conditions are disproportionately impacted by stigma and maltreatment.
Conduct disorder (CD), one of William’s proposed diagnoses, is often found at the severe end of this ‘stigma hierarchy’ [5]. CD is a childhood and adolescent behavioral disorder that is characterized by aggressive, defiant and antisocial behavior. Those with CD struggle to adhere to social rules and show empathy [6]. CD is considered a precursor or risk factor to the development of ASPD [7], and in some cases schizophrenia [8], later in life. Based on its relation to other disorders and its diagnostic characteristics, it is clear that children with CD are victims of this dangerous stigma. Similarly to ASPD and schizophrenia, society often labels kids with CD as “bad kids” or “delinquents” [9] due to the fear and discomfort caused by their behavior. Rather than being given sympathy and understanding for being ill, they are blamed for their condition.
When combined with pre-existing racial biases, these misconceptions result in the perpetual overdiagnosis of CD in children of color. Studies have shown that, despite presenting similar symptoms, black and hispanic children are more likely to receive a diagnosis of conduct disorder compared to their white peers [10, 11]. Given two children with identical symptoms, the white child is likely to be diagnosed with ADHD, whereas a racial minority is likely to be diagnosed with a behavioral disorder [11, 12]. Rooted in unconscious racial biases, adults, such as teachers, counselors, and doctors, often perceive children of color as more aggressive, dangerous, and disobedient, resulting in increased misdiagnosis of behavioral disorders such as CD. These errors have extreme outcomes, as it prevents these children from receiving treatment for the issues they do have, hindering their progress.
Ultimately, the weight of this stigma and discrimination has tangible consequences, far beyond just societal judgment. Negative perceptions of children with CD create significant barriers to receiving appropriate care, resulting in increased isolation, worsening symptoms, and delayed treatment [5]. Furthermore, it is often difficult for CD patients to find doctors to treat their condition or schools willing to accept them. Due to being labeled as “dangerous”, organizations are hesitant to work with these kids, fearing potential disruptions or harm to fellow students [13]. The pervasive stigma may eventually enter a child's mind, leading them to internalize these negative labels and blame themselves, resulting in lower self esteem and an escalation of their challenges [14].
William is not a bad kid; he is a young man facing internal struggles beyond his control. He deserves compassion as he navigates a world that misunderstands his condition. Children with behavioral disorders deserve to live in a society dedicated to guiding them towards growth and healing, without judgment and harmful labels. By increasing mental health education, fostering open discussion, and correcting our internal biases, we can create a world where children with mental health challenges are supported and empowered, free from prejudice.
Works Cited
Weissman, M. M. (2001). Stigma. JAMA, 285(3), 261-262. https://doi.org/10.1001/jama.285.3.261.
Zolezzi, M., Alamri, M., Shaar, S., & Rainkie, D. (2018). Stigma associated with mental illness and its treatment in the Arab culture: A systematic review. The International Journal of Social Psychiatry, 64(6), 597-609. https://doi.org/10.1177/0020764018789200.
Mukolo, A., Heflinger, C. A., & Wallston, K. A. (2010). The stigma of childhood mental disorders: a conceptual framework. Journal of the American Academy of Child and Adolescent Psychiatry, 49(2), 92-198. https://doi.org/10.1097/00004583-201002000-00003.
Pescosolido, B. A., Halpern-Manners, A., Luo, L., & Perry, B. (2021). Trends in Public Stigma of Mental Illness in the US, 1996-2018. JAMA Network Open, 4(12), e2140202. https://doi.org/10.1001/jamanetworkopen.2021.40202.
Hazell, C. M., Berry, C., Bogen-Johnston, L., & Banerjee, M. (2022). Creating a hierarchy of mental health stigma: testing the effect of psychiatric diagnosis on stigma. BJPsych open, 8(5), e174. https://doi.org/10.1192/bjo.2022.578.
Kerekes, N., Zouini, B., Karlsson, E., Cederholm, E., Lichtenstein, P., Anckarsäter, H., & Råstam, M. (2020). Conduct disorder and somatic health in children: a nationwide genetically sensitive study. BMC Psychiatry, 20, 595. https://doi.org/10.1186/s12888-020-03003-2.
Antisocial behaviour and conduct disorders in children and young people: recognition and management. (2017). National Institute for Health and Care Excellence (NICE).
Schiffer, B., Leygraf, N., Müller, B. W., Scherbaum, N., Forsting, M., Wiltfang, J., Gizewski, E. R., & Hodgins, S. (2012). Structural Brain Alterations Associated With Schizophrenia Preceded by Conduct Disorder: A Common and Distinct Subtype of Schizophrenia? Schizophrenia Bulletin, 39(5), 1115-1128. https://doi.org/10.1093/schbul/sbs115.
Conduct Disorder. (2018, June). American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Conduct-Disorder-033.aspx#:~:text=Children%20and%20adolescents%20with%20this,delinquent%2C%20rather%20than%20mentally%20ill.
Garb, H. N. (2021). Race bias and gender bias in the diagnosis of psychological disorders. Clinical Psychology Review, 90, 102087. https://doi.org/10.1016/j.cpr.2021.102087.
Fadus, M. C., Ginsburg, K. R., Sobowale, K., Halliday-Boykins, C. A., Bryant, B. E., Gray, K. M., & Squeglia, L. M. (2019). Unconscious Bias and the Diagnosis of Disruptive Behavior Disorders and ADHD in African American and Hispanic Youth. Academic Psychiatry, 44, 95-102. https://doi.org/10.1007/s40596-019-01127-6.
Ballentine, K. L. (2019). Understanding Racial Differences in Diagnosing ODD Versus ADHD Using Critical Race Theory. Families in Society: The Journal of Contemporary Social Services, 100(3), 282-292. https://doi.org/10.1177/1044389419842765.
Miller, G. & Lee, S. A. What Is Conduct Disorder? (2021, October 5). Child Mind Institute. https://childmind.org/article/what-is-conduct-disorder/.
Drapalski, A. L., Lucksted, A., Perrin, P. B., Aakre, J. M., Brown, C. H., DeForge, B. R., & Boyd, J. E. (2013). A Model of Internalized Stigma and Its Effects on People With Mental Illness. Psychiatric Services, 64(3), 264-269. https://doi.org/10.1176/appi.ps.001322012.