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Graduate Student Journal of Psychology (GSJP), Volume 18, Special Issue 2022 

Effects of Child and Parent Race on Reported Externalizing 
and Internalizing Symptoms: Findings from the PACCT 

Study 

Shira Mattuck 
Teachers College, Columbia University 

A substantial body of research has demonstrated that Black children are more likely to be 
diagnosed with Disruptive Behavior Disorders (DBD) compared with non-Hispanic 
white children and less likely to be diagnosed with affective disorders. Several 
explanations for this phenomenon have been explored in the literature, including the 
effects of stereotypes, clinician bias, and measurement bias. There is also evidence to 
suggest that Black and non-Hispanic white caregivers may report symptoms differently 
and have different thresholds for determining a behaviour as problematic. The current 
study aimed to assess whether caregiver race impacted the level of parent-reported 
externalizing and internalizing symptoms for Black and non-Black children in a sample 
of 324 children and adolescents with same and different-raced parents recruited from an 
ongoing longitudinal study of early childhood adversity. Results indicate that non-Black 
caregivers reported significantly higher rates of internalizing symptoms in non-Black 
children. However, there were no significant differences in the reported rate of 
internalizing or externalizing symptoms in Black children, regardless of reporter race. 
There were also no significant differences between Black and non-Black children in terms 
of symptoms overall.  These results suggest that there may be meaningful differences in 
the manner in which Black and non-Black caregivers report externalizing and 
internalizing symptoms. These findings are a preliminary analysis and future research 
should further investigate the role of caregiver race in the determination of childhood 
diagnoses for Black and non-Black children.  

Keywords: externalizing, internalizing, child race, parent race 

Previous research has demonstrated that Black individuals are diagnosed with certain 
psychiatric disorders at higher rates than non-Hispanic white individuals (Garb, 1997). In 
adults and adolescents, studies have shown that Black individuals receive diagnoses of 
schizophrenia at higher rates than non-Hispanic white patients (Garb, 1997; Kilgus et al., 
1995; Strakowski et al., 1993; Strakowski et al., 1995; Olbert et al., 2018). In children and 
youth, researchers have documented higher rates of externalizing disorders among Black 
children (Delbello et al., 2001; Lau et al., 2004; Nguyen et al., 2007). Specifically, Black 
youth are more likely to receive a diagnosis of Conduct Disorder (CD) than non-Hispanic 
white youth, and less likely to receive a diagnosis of Attention Deficit Hyperactivity 
Disorder (ADHD; Cameron & Guterman, 2007; Coker et al., 2016; Fadus et al., 2020; 
Feisthamel & Schwartz, 2009; Flores & Lin, 2013; Mandell et al., 2007; Morgan et al., 2013). 
However, Black children appear to experience similar or greater rates of ADHD 
symptomatology compared to non-Hispanic white children (Miller et al., 2009). There is 
some evidence to suggest that the higher rate of CD diagnoses in Black youth may be 
reflective of stereotypes of Black children as more aggressive, older, and more culpable 
for their actions than non-Hispanic white children (Goff et al., 2014). There is also research 
that indicates Black caregivers may report symptoms differently than white caregivers, 
and clinicians may receive reports differently as a function of race (Bax et al., 2019; 
Cooper-Patrick et al., 1999; Lau et al., 2004; Leslie et al., 2007; Mandell et al., 2007; Mandell 
& Novack, 2005; Vázquez & Villodas, 2019). The current study aims to assess 
whether 

© 2022, Graduate Student Journal of Psychology, Teachers College, Columbia University. ALL 
RIGHTS RESERVED. Graduate Journal of Psychology 18, pp-pp. 



Mattuck 

Graduate Student Journal of Psychology 

there are differences in the magnitude of externalizing and internalizing symptoms for 
Black and non-Black children as a function of caregiver race. This study is unique in that 
it utilizes data from the ongoing Parents and Children Coming Together (PACCT) 
longitudinal study on adverse childhood experiences and includes a large proportion of 
child and caregiver dyads who are not matched on race. This study represents a first step 
in disambiguating the effects of child and reporter race on reported externalizing and 
internalizing symptoms.

Diagnostic Differences Based on Race 
Differences in the rate of diagnosis of certain disorders based on race was first identified 
in the research literature in the 1980’s (Adebimpe, 1981; Adebimpe, 1982; Bell & Mehta, 
1980; Bell & Mehta, 1981). Specifically, Adebimpe (1981) reviewed available literature on 
misdiagnosis of black patients and highlighted the need for clinicians and diagnostic 
criteria to be sensitive to the symptomatology of Black patients. Several scholars have 
demonstrated that Black adults and adolescents, especially Black men, are more likely to 
be diagnosed with schizophrenia than non-Hispanic white adults (Kilgus et al., 1995; 
Olbert et al., 2018; Strakowski et al., 1993; Strakowski et al., 1995). Strakowski et al. (1993) 
retrospectively analyzed the charts of 173 patients with psychotic disorders discharged 
from a state psychiatric hospital during a 7-month period. Results indicated that Black 
patients were more likely to be diagnosed with schizophrenia than white patients (odds 
ratio (OR) = 5.1), and men were more likely to be diagnosed with schizophrenia than 
women (OR = 1.9).  

Strakowski et al. (1995) further conducted a retrospective chart review of 490 patients 
randomly selected from 9500 visits to a psychiatric emergency service during a period of 
one year. The authors found Black patients were more likely to be diagnosed with 
schizophrenia and substance use disorder and less likely to be diagnosed with a 
personality disorder than similar white patients. Black patients were also more likely to 
be hospitalized. More recently, Olbert et al. (2018) conducted a meta-analysis of 
schizophrenia diagnosis rates in the United States. The authors included 14 studies that 
used structured diagnostic instruments and 41 studies using unstructured instruments. 
Results indicated that Black individuals were diagnosed with schizophrenia at higher 
rates than white individuals across all studies (OR = 2.42), including studies using 
unstructured interviews (OR = 2.43) and in studies using structured interviews (OR = 
1.77). Importantly, studies that used structured interviews did not seem to significantly 
attenuate the odds ratio as compared to studies that used unstructured interviews. Thus, 
there appears to be a consistent trend in which Black adults are diagnosed with 
schizophrenia at higher rates than non-Hispanic white adults.  

In children, several studies have documented higher rates of diagnosed disruptive 
behaviour disorders among Black children and lower rates of affective disorders as 
compared to non-Hispanic white children (DelBello et al., 2001; Lau et al., 2004; Nguyen 
et al., 2007). In a retrospective chart review of all adolescents aged 12 to 18 admitted to the 
Adolescent Psychiatry Unit at Cincinnati Children's Hospital Medical Center between 
July 1995 and June 1998 (N = 1001), DelBello et al. (2001) found that Black males were 
diagnosed with schizophrenic spectrum disorders at higher rates than Black females, or 
Caucasian adolescents overall. Black patients were diagnosed with conduct disorder (CD) 
at significantly higher rates than Caucasian adolescents, who were diagnosed more often 
with alcohol use disorders and major depression.  

Nguyen et al. (2007) examined the impact of race and ethnicity on psychiatric diagnoses 
for 1189 children and adolescents who participated in a federally funded community 



Effects of Child and Parent Race on Reported Externalizing and Internalizing Symptoms 

Graduate Student Journal of Psychology 

mental health program. The authors found that after controlling for age, gender, 
functional impairment, and socioeconomic status (SES), Black and Native Hawaiian youth 
were at higher risk of being diagnosed with a disruptive behaviour disorder (DBD). Black, 
Asian American, and Native Hawaiian youth were also rated as having fewer 
internalizing symptoms than white youth. This study demonstrates that the higher rates 
of externalizing disorders in Black youth are not accompanied by higher rates of 
functional impairment and cannot be attributed to other demographic factors such as SES. 

Among the DBDs (ADHD, CD, Oppositional Defiant Disorder [ODD]), research suggests 
that Black children and youth are diagnosed with CD more often than non-Hispanic white 
children and diagnosed with ADHD at lower rates (Cameron & Guterman, 2007; Coker et 
al., 2016; Fadus et al., 2020; Feisthamel & Schwartz, 2009; Flores & Lin, 2013; Mandell et 
al., 2007; Morgan et al., 2013). Mandell et al. (2007) analyzed the diagnoses received prior 
to the diagnosis of Autism Spectrum Disorder (ASD) in a sample of 406 Medicaid-eligible 
children. ADHD was the most common diagnosis among children who did not receive an 
ASD diagnosis on their first specialty care visit. However, African American children 
were 2.4 times more likely than white children to receive a diagnosis of CD than ADHD. 
As a possible explanation for these results, the authors suggest that Black parents may be 
more likely to describe their child’s behaviours in a way that emphasizes externalizing 
symptoms (Mandell et al., 2007). In a longitudinal study of 4297 children and caregivers, 
Coker et al. (2016) found that African American children had significantly lower odds of 
receiving an ADHD diagnosis in both fifth grade (OR = .40) and tenth grade (OR = .42) as 
compared to non-Hispanic white children.  

Similarly, Morgan et al. (2013) analyzed rates of ADHD diagnosis in a nationally 
representative sample of 17,100 children involved in a longitudinal study. The authors 
found African American children were 69% less likely to be diagnosed with ADHD than 
non-Hispanic white children. These disparities were already present in kindergarten and 
extended to at least eighth grade. Another study found that among 1173 youth living in 
residential treatment facilities, only 24.4% of non-Hispanic white youth were diagnosed 
with CD while 34.4% of African American youth had received a CD diagnosis (Cameron 
& Guterman, 2007). Feisthamel and Schwartz (2009) conducted a study of diagnostic rates 
in a sample of 899 community mental health agency clients ranging from 4 to 85 years of 
age. Clients were assessed by master’s and doctoral level mental health counsellors blind 
to the research question using the Structured Clinical Interview for DSM-IV (SCID; First, 
Spitzer, Gibbon, & Williams, 1995). European American clients were significantly more 
likely than their African American counterparts to receive a diagnosis of adjustment 
disorder (15% vs 7%), while African American clients were significantly more likely to 
receive a childhood disorder diagnosis, including DBDs (20% vs. 12%). In this study, none 
of the diagnosticians identified as African American. This study demonstrates that the use 
of a structured clinical interview may not be sufficient to prevent discrepancies in clinical 
diagnoses based on race.  

Importantly, Miller et al. (2009) have demonstrated that lower rates of ADHD diagnosis 
among Black children are not attributable to lower rates of ADHD symptomatology in 
this group. The authors conducted a review and meta-analysis of 5 studies on ADHD 
diagnosis and 5 studies of ADHD symptoms. Results suggest that African American 
children actually had more ADHD symptoms but were diagnosed with ADHD only two-
thirds as often as Caucasian children (OR = .66), even after controlling for SES.  Other 
studies in adult populations have also shown differences in diagnosis based on race when 
structured or semi-structured clinical interviews were used (Neighbors et al., 2003; Olbert 
et al., 2018). Neighbors et al. (2003) analyzed data from 665 African American and white 



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 Graduate Student Journal of Psychology 
 

psychiatric inpatients interviewed by psychiatric residents using a shortened version of 
the DSM-III-R Symptom Checklist (Hudziak et al., 1993). African American patients were 
significantly more likely to be diagnosed with schizophrenia, and clinicians used a 
different process to link client symptoms to diagnostic constructs for African Americans, 
especially for schizophrenia. Taken together, these studies suggest that CD may be over-
diagnosed in Black children while ADHD may be under-diagnosed. These discrepancies 
appear to persist even when structured diagnostic instruments are used.  
 
Implications and Causes of CD Overdiagnosis 
Overdiagnosis of CD in Black children may reflect stereotypes of Black children as 
aggressive, violent, and older than non-Hispanic white children (Goff et al., 2014). In a 
series of studies using mixed methodologies with university students and police officers, 
Goff et al. (2014) demonstrated that Black male children are perceived as less innocent and 
childlike than white children and elicit a less essential conception of childhood. Results 
also demonstrated that Black youth were perceived as older and more culpable for their 
actions than white youth. The authors further demonstrated that dehumanization of Black 
children through implicit associations between Black children and apes predicted actual 
racial disparities in police officer use of force. Rattan et al. (2012) further demonstrated 
that Black adolescent offenders are viewed as more deserving of adult sentencing than 
identical white offenders.  
 
The conception of Black youth as older and more responsible for their actions is reflected 
in the rate of Black youth who are sentenced as adults within the criminal justice system. 
Research has demonstrated that Black youth are 18 times more likely than white youth to 
be sentenced as adults and make up 58% of those youth sentenced to adult facilities (Poe-
Yamagata & Jones, 2007). These findings reflect more general trends in the 
overcriminalization of Black individuals. According to the US Department of Justice 
Bureau of Justice Statistics, in 2018 Black males were incarcerated at a rate 5.8 times higher 
than white males. While Black people make up approximately only 13% of the US 
population, they comprised 33% of the sentenced prison population in 2017 (Gramlich, 
2019). According to the most recently available data from the US Department of Justice 
Office of Juvenile Justice and Delinquency Prevention, in 2017 Black juveniles were 
incarcerated at a rate of 151 for every 100,000 whereas non-Hispanic white juveniles were 
incarcerated at a rate of 26 for every 100,000.  
 
Stereotypes of Black children as aggressive may perpetuate and bolster the reciprocally 
reinforcing relationship between diagnoses of CD and criminal justice system 
involvement. CD is one of the most frequent diagnoses given to youth in the criminal 
justice system (Drerup et al., 2008; Teplin et al., 2002). Teplin et al. (2002) assessed the rate 
of psychiatric diagnoses amongst a randomly selected, stratified sample of 1829 detained 
juveniles in Cook County, Illinois using the Diagnostic Interview Schedule for Children 
version 2.3 (DISC; Schaffer et al., 1996). The authors found that 37.8% of male detainees 
met criteria for CD. Interestingly, compared with African American juveniles, non-
Hispanic white juveniles had significantly higher rates of any disorder, any DBD, and CD 
specifically.  
 
In contrast with this finding, more recent research by Baglivio et al. (2017) found that 
among 8763 adolescent males involved with the Florida Department of Juvenile Justice, 
Black males were 40% more likely than non-Hispanic white males to have received a 
diagnosis of CD, and approximately 40% less likely to have received a diagnosis of 
ADHD. However, Black males were 32% less likely to receive psychiatric treatment. 
Similarly, Rawal et al. (2004) found that among a sample of 473 justice-involved youth, 



Effects of Child and Parent Race on Reported Externalizing and Internalizing Symptoms 

Graduate Student Journal of Psychology 
 

Black youth demonstrated greater mental health needs but received lower rates of 
services. Further, Teplin et al. (2005) found that white youth were twice as likely to be 
detected by the criminal justice system as needing mental health treatment than Black 
youth.  
 
Some research has suggested that white youth who demonstrate conduct problems are 
more likely to be steered towards mental health treatment while Black youth may be 
relegated to the criminal justice system (Atkins et al., 1999; Cohen et al., 1990; Lewis et al., 
1979). In a comparison of youth age 12-15 residing in a state psychiatric hospital or 
juvenile corrections facility, Cohen et al. (1990) found that Black youth in the correctional 
setting had similar scores on the Child Behavior Checklist (CBCL; Achenbach & 
Edelbrock, 1983) as white youth in the psychiatric hospital. Similarly, Westendorp et al. 
(1986) found that race, but not psychopathology, significantly predicted which youth 
would be treated in a psychiatric facility and which would be sent to a juvenile justice 
facility. Atkins et al. (1999) has reported similar findings. These findings suggest that the 
overdiagnosis of Black children and youth may be one expression of systemic racial biases 
in which clinicians and service providers view Black youth as inherently more delinquent 
and less treatable than non-Hispanic white youth.  
 
Mechanisms and Moderators of Bias 
Emerging evidence suggest that discrepancies in the rate of CD and ADHD diagnoses 
between Black and non-Hispanic white children may not be accompanied by concomitant 
symptom levels (Miller et al., 2009). There is evidence to suggest that racially based 
differences in the presentation, interpretation, and/or reporting of externalizing 
symptoms may contribute to the higher rate of externalizing disorder diagnoses among 
Black children. Specifically, clinicians are not immune to racial biases about Black patients. 
Studies have shown that health professionals hold both implicit and explicit biases that 
may affect delivery of care to Black patients (Fitzgerald & Hurst, 2017; Institute of 
Medicine, 2002; van Ryn et al., 2011). van Ryn et al. (2011) found that white health 
professionals most often have low explicit and high implicit bias towards Black patients, 
who perceive this combination as particularly aversive due to the mismatch between 
verbal and non-verbally communicated cues. Diagnostic bias may also occur as a result of 
statistical discrimination (Balsa & McGuire, 2001), in which clinicians use expectations 
about the rate of a disorder in a particular population to inform diagnostic decision 
making. In this way, clinicians who believe externalizing behaviours are more common 
in Black children and ADHD less common, may reinforce this discrepancy by conforming 
to this stereotype in their diagnostic decisions. Research has also demonstrated that 
clinicians who are under conditions of greater cognitive load may experience reduced 
capacity to regulate implicit biases and may rely more heavily on stereotypes (Dyrbye et 
al., 2019; Johnson et al., 2016).  
 
There is also evidence to suggest that clinical diagnostic measures used to assess 
psychopathology may be producing differential diagnoses for non-Hispanic white and 
Black children (Breslau et al., 2008; Eisen et al., 2006; Green et al., 2012; Johnson et al., 2007; 
Randolph & Koblinsky, 2003; Zink et al., 2015). Instruments designed to diagnose 
psychopathology are often validated on general population samples and thus may not be 
as sensitive or specific to psychopathology in minority populations (Breslau et al., 2008). 
As previously discussed, studies that assessed participants using structured or semi-
structured instruments have also found differences in the rate of diagnoses for certain 
disorders in Black individuals (Cohen et al., 1990; Neighbors et al., 1999; Neighbors et al., 
2003; Olbert et al., 2018). Given the evidence suggesting that Black children experience 
ADHD symptoms at similar or higher rates than non-Hispanic white children (Miller et 



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al., 2009), these results suggest that the race of children or reporters may be impacting the 
diagnostic process at some junction. 
 
While clinician and measurement bias may contribute to the overdiagnosis of Black 
children with CD and underdiagnosis of ADHD, the description of externalizing 
symptoms may also vary by reporter race. Specifically, there is evidence to suggest that 
white parents may report externalizing symptoms differently than Black parents (Bax et 
al., 2019; Lau et al., 2004; Mandell et al., 2007; Vázquez & Villodas, 2019).  Further, research 
has also demonstrated that clinicians may receive and interpret reports of symptoms 
differently as a function of reporter race (Cooper-Patrick et al., 1999; Leslie et al., 2007; 
Mandell & Novack, 2005). For example, Mandell et al. (2007) found that African American 
parents were more likely to describe their children's behaviour in a way that emphasized 
externalizing symptoms. Bax et al. (2019) conducted a secondary analysis of children with 
and without ADHD according to teacher and parent symptom report. The authors found 
that among children with underlying ADHD, white children from two parent households 
were more likely to have received assessment and medication services.  Studies have also 
shown that Black parents may express greater concerns about the motivations of mental 
health care providers and the possibility of stigmatization (Mishra et al., 2009). 
Additionally, Bignall et al. (2015) have demonstrated that Black individuals are more 
likely to normalize psychopathology and make spiritual attributions for mental health 
issues.  
 
There is also evidence to suggest that non-Hispanic white and Black caregivers may have 
different thresholds for labelling behaviour as problematic. In an analysis of 4175 youths 
and their caregivers, Roberts et al. (2005) found that the rate of concordance between 
youth and caregiver report of youth emotional and behavioural problems varied by race. 
The authors found a higher rate of concordance among European American dyads 
compared to African Americans. European American caregivers appeared to have a lower 
threshold for labeling youth behaviours as problematic, despite similar rates of youth 
reported problems across groups. However, in a study of 741 caregivers, Vázquez and 
Villodas (2019) found that Black parents were more likely to indicate their child needed 
intervention programs when they reported clinically elevated externalizing problems. 
Thus, Black caregivers may have a higher threshold for identifying behaviours as 
clinically elevated yet may be more likely to endorse the need for intervention when 
problem behaviours are identified. However, research has demonstrated that clinicians 
may be more responsive to reports of problem behaviours from non-Hispanic white 
parents (Leslie et al., 2007), which may contribute to the discrepancy between Black and 
non-Hispanic white youth in service utilization and treatment receipt. 
  
Despite documented findings indicating that Black and non-Hispanic white caregivers 
may report symptoms differently, studies have not yet disambiguated the effects of parent 
and child race in the reporting of internalizing and externalizing symptoms. Elucidating 
the specific effects of parent race on reported symptoms is difficult as most studies use 
samples in which parent and child dyads are primarily biologically related, and thus 
matched on race. The current study is unique in that it utilizes a sample from an ongoing 
longitudinal study on adverse childhood experiences. Experimental groups in this study 
are characterized by a high proportion of children who were adopted. As such, many 
children and guardian pairs are not of the same race. This discrepancy will allow for an 
analysis of the effects of reporter race on the reported internalizing and externalizing 
symptoms in both Black and non-Black children.  
 



Effects of Child and Parent Race on Reported Externalizing and Internalizing Symptoms 

Graduate Student Journal of Psychology 

This study aims to examine whether differences exist in the magnitude of externalizing 
and internalizing symptoms for Black and non-Black children that are moderated by 
caregiver race. This study utilizes data from the longitudinal study on adverse childhood 
experiences and includes a large proportion of child and caregiver dyads who are not 
matched on race. This sample presents a unique opportunity to analyze the effects of 
caregiver race on reported symptoms for Black and non-Black children. This study 
represents an initial step in disambiguating the effects of child and reporter race on 
reported externalizing and internalizing symptoms.  

Hypotheses 
The hypotheses for this study are twofold. The first hypothesis is that there will be 
differences in the rate of internalizing and externalizing symptoms for Black and non-
Black children overall such that Black children will have higher parent-reported 
externalizing symptoms than will non-Black children. The second hypothesis is that 
parent race will moderate the level of internalizing and externalizing symptoms for both 
Black and non-Black children such that the level of symptoms for Black and non-Black 
children will be influenced by the race of the parent reporter.  

Methods 
Procedures 
Data were obtained from the first phase of the ongoing Parents and Children Coming 
Together (PACCT) longitudinal study led by Dr. Nim Tottenham (IRB-AAAR1888) on the 
effects of early adverse childhood experiences on psychosocial and neurobiological 
outcomes. All procedures were approved by the Columbia University Institutional 
Review Board. Caregivers gave written informed consent and assent was obtained from 
child participants. Trained research assistants with master’s level education in either 
psychology or social work collected self-report questionnaire data from reporters at in-
person visits. While the race of the research assistants may be an important variable in 
influencing symptom reports, this data was not available for the purpose of this study. 
Participants were compensated $175 USD for each child that participated in an in-person 
visit. Children also received 4 hours’ worth of community service and a video file with 
neuroimaging from their visit.  

Participants 
The current study included four experimental groups and one control group. 
Experimental groups consisted of children with prior histories of international 
institutional care (Previously Institutionalized; PI), domestically adopted children 
(Domestically Adopted; DA), children with disrupted caregiving (Disrupted Caregiving; 
DC), and children who have experienced international foster care but not 
institutionalization (International Foster Care; IFC). The control group was composed of 
children who had always been with the biological parent(s) and had never experienced 
prolonged separation from the primary caregiver.  
There were 324 participant dyads in this study, consisting of a unique child and a reporter. 
Data was available for 71.29% (n = 231) children and 67.59% (n = 219) reporters. Data on 
self-identified race was missing for 93 (28.7%) children and 105 (32.4%) reporters. Some 
reporters had multiple children enrolled in the study. Age at the time of data collection 
ranged from 6-12 years old (M = 8.84, SD = 2.03). Of the child participants, 52.6% (n = 169) 
were female and 28.7% children (n = 93) reported their race as African American or Black. 
Of the children in this study, 30.86% (n = 100) reported their race and ethnicity as non-
Hispanic white. Of the reporters in this study, 25.93% (n = 84) reported their race as 
African American or Black while 52.16% (n = 169) reported their race as non-Hispanic 
white. Participant dyads were matched on race between child and reporter in 54.01% (n = 



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Graduate Student Journal of Psychology 

175) cases. Reporters consisted of biological parents, adoptive parents, foster parents,
and/or legal guardians.

Measures 
Externalizing and Internalizing symptoms were measured using the Parent Report 
version of the Child Behavior Checklist for ages 4-18 (CBCL; Achenbach, 1991). The CBCL 
is a 113-item parent report questionnaire scored on a three-point Likert scale (0 = Not 
True, 1 = Somewhat or Sometimes True, 2 = Very True or Often True). Reporters were 
asked to choose the response that reflected their child’s behavior in the past six months. 
The CBCL has 8 subscales, grouped into three categories including the two categories of 
Internalizing Behaviors (Withdrawn, Somatic Complaints, and Anxious/Depression), 
and Externalizing Behaviors (Delinquent and Aggressive). The final three subscales are 
Social Problems, Thought Problems, and Attention Problems (Achenbach, 1991). The 
current study analyzed the computed T-scores for the Internalizing and Externalizing 
scales. The CBCL has good psychometric properties with high internal consistency within 
scales (Internalizing, a = .90 and Externalizing, a = .94), inter-rater reliability 
(Internalizing, r = .72, Externalizing, r = .85), and stability (Internalizing, r = .80, 
Externalizing, r = .82) and has normed comparison data (Achenbach, 1991). The CBCL has 
also demonstrated good content, criterion-related, and construct validity (Achenbach, 
1991).  

Data was analyzed using IBM SPSS v.27. Based on parent reported demographic data, 
children and reporters were coded as Black or non-Black. T-scores for the Externalizing 
and Internalizing subscales of the CBCL were computed using manualized protocols 
provided by the authors (Achenbach, 1999). 

Results 
Child and Reporter Race Effects 
First, a repeated measures ANOVA was used to assess whether dichotomized child and 
reporter race, and their interaction, were associated with the difference in T-scores on the 
Externalizing CBCL subscale from the Internalizing CBCL subscales. The repeated 
measures ANOVA was used to elucidate whether child or reporter race was significantly 
associated with differences in CBCL T-scores. There were no significant main effects of 
child race (F(1, 301) = 1.06, p = .304) or reporter race (F(2, 301) = 1.08, p = .340) on 
differences between Externalizing and Internalizing T-scores. There was a significant 
interaction of child race and reporter race on the difference between Externalizing and 
Internalizing T-scores (F(1,301) = 5.53, p = .019), such that non-black children who had 
non-Black reporters had higher internalizing scores than non-Black children with Black 
reporters (t = -2.48, p = .014), while we did not find a significant effect of reporter race on 
CBCL difference scores for Black children (t = .85, p = .397). 

Child/Reporter Race Match Effects 
Next, a repeated measures ANOVA was used to assess whether dichotomized child race, 
child/reporter race match, and their interaction, were associated with the difference in T-
scores on the Externalizing CBCL subscale from the Internalizing CBCL subscales. 
Child/reporter race match was established by scoring whether the self-reported race for 
the child and caregiver dyad was congruent. There was no significant main effect of child 
race on the difference between Externalizing and Internalizing scores (F(1, 302) = .26, p = 
.606). There was a trend level main effect of child/reporter race match on the difference 
between Externalizing and Internalizing CBCL subscale T-scores (F(1, 302) = 3.75, p = 
.053). The interaction of child race and child/reporter race match was not significant (F(1, 
302) = .02, p = .902).



Effects of Child and Parent Race on Reported Externalizing and Internalizing Symptoms 

Graduate Student Journal of Psychology 
 

 
Discussion 
The present study aimed to assess whether there were differences between externalizing 
and internalizing symptoms for Black and non-Black children that varied as a function of 
reporter race. We anticipated that Black children would have higher reported 
externalizing symptoms than non-Black children and that this finding would be 
moderated by reporter race. Results support the hypothesis that there are differences in 
the manner in which Black and non-Black parents report internalizing and externalizing 
symptoms for non-Black children. However, the current study did not find significant 
differences between Black and non-Black children on the level of reported externalizing 
and internalizing symptoms overall.  
 
The hypothesis that there would be differences in reported externalizing and internalizing 
symptomatology between Black and non-Black children was not supported by the results 
of this study. Results indicated that there was a significant interaction of child race and 
reporter race on the difference between externalizing and internalizing symptom reports. 
Results indicated that non-Black caregivers with non-Black children reported significantly 
higher internalizing symptoms than Black caregivers with non-Black children. We did not 
find a significant difference between internalizing and externalizing symptoms for Black 
children as a function of caregiver race.  
 
Further, we analyzed whether congruency in child and caregiver race was associated with 
differences in the rate of internalizing and externalizing symptoms. We did find a trend 
level effect of child/reporter race match on the rate of internalizing and externalizing 
symptoms. The interaction of child race and child/reporter race match was not significant. 
Given the resources often necessary to adopt or foster children, there may be systematic 
socioeconomic or demographic differences between the groups in which children were 
not matched with their caregivers on race and the control group in which reporters were 
biological parents. This difference may be driving the trend level effect of child/reporter 
race match that was observed in this study.  
 
These results add to the body of literature suggesting that reporters of different races may 
have higher or lower thresholds for labelling youth behaviour as clinically significant 
(Roberts et al., 2005). However, non-Black caregivers of non-Black children only reported 
elevated levels of internalizing symptoms and not externalizing symptoms. Results are 
partially in accordance with findings from Roberts et al. (2005) who found that European 
American caregivers had lower thresholds for labelling their child as having emotional 
and behavioural problems. While the authors of that study described their measures as 
intending to capture “emotional and behavioural problems”, the five-item tool they used 
may have more effectively captured internalizing symptoms as compared with 
externalizing symptoms. The measure utilized by Roberts et al. (2005) probed overall 
mental health, life satisfaction, happiness, and role strain, which may be more closely 
associated with typical internalizing symptoms. This may explain why we did not find 
elevated rates of externalizing symptoms reported by non-Black caregivers of non-Black 
children.  
 
Results did not indicate differences in the rate of externalizing or internalizing symptoms 
for Black children depending on reporter race. Given the differences in sample size 
between Black (93 children, 84 reporters) and non-Black (138 children, 135 reporters) 
groups in this study, analyses may have been underpowered to detect differences 
between reporter ratings for Black children. The majority of research in this area has 
focused on differences in the rate of diagnosis and not symptomatology. As previous 



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Graduate Student Journal of Psychology 

research has described, Black children appear to have similar rates of externalizing 
symptoms as non-Hispanic white youth, yet are diagnosed at different rates (Cohen et al., 
1990; Miller et al., 2009). Thus, the finding that Black and non-Black children did not have 
different levels of reported symptoms may reflect findings from this literature.  

The current study compared the magnitude of caregiver-reported externalizing and 
internalizing symptoms for Black and non-Black children. However, most studies that 
have assessed differences in the rate of diagnosis have compared Black children with non-
Hispanic white children. Several studies have demonstrated that diagnostic trends in the 
underdiagnosis of ADHD and overdiagnosis of DBDs may also occur in Hispanic and 
Native Hawaiian youth (Baglivio et al., 2017; Cameron & Guterman, 2007; Fadus et al., 
2020; Garb, 1997; Nguyen et al., 2007). However, this trend appears to be inconsistent 
across studies. For example, Nguyen et al. (2007) found that both Black (OR = 2.76) and 
Native Hawaiian (OR = 2.05) youth involved in a community-based treatment program 
were more likely than non-Hispanic white youth to be diagnosed with a DBD. Hispanic 
youth in this study were not more likely to receive a DBD diagnosis than non-Hispanic 
white youth. Similarly, Baglivio et al (2017) found that among youth in a juvenile justice 
residential placement, Black male youth were significantly more likely than white youth 
to receive a diagnosis of CD. However, both Black and Hispanic male youth were less 
likely than non-Hispanic white youth to receive an ADHD diagnosis.  

In contrast, Cameron and Guterman (2007) found that among youth in residential 
treatment facilities, both Hispanic and African American youth received CD diagnoses at 
higher rates (43.3% and 34.4%) than non-Hispanic white youth (24.4%). Given these 
findings, the inclusion of Hispanic white children, Asian American children, Native 
Hawaiian/Pacific Islander children, American Indian and Alaska Native children, and 
children of more than one race in the “non-Black” group may have obscured differences 
in symptom magnitude between Black children and non-Hispanic white children in this 
study. The inclusion of these children may explain why differences were not observed 
between Black and non-Black children on the measure of externalizing and internalizing 
symptoms overall.   

Limitations 
There are several limitations to this study. First, data on self-identified race was missing 
for 93 (28.7%) children and 105 (32.4%) reporters. It is possible that the exclusion of these 
missing data points may have impacted the results of the current study. Many of the 
missing data points were associated with participants who had study visits at the 
beginning stages of this longitudinal study. This trend is likely due to initial issues in the 
implementation of study procedures at the start of data collection, rather than participant 
factors. However, there may be systematic differences between participants with missing 
data and those who have data available. Thus, results of this analysis should be 
interpreted with caution. 

Second, there were differences in the number of Black and non-Black participants both for 
children and reporters. These differences in sample size may have contributed to 
underpowered analyses that were unable to detect differences in reporter ratings for Black 
children. 

Finally, children and caregivers in the experimental groups in this study may not be 
representative of the general population in regard to socioeconomic variables. As 
previously discussed, the adoption process requires significant financial and personal 
resources. Thus, participant dyads who were not matched on race in this study may be 



Graduate Student Journal of Psychology 

Effects of Child and Parent Race on Reported Externalizing and Internalizing Symptoms 

systematically more socioeconomically advantaged than children and youth involved in 
other studies on parent-reported symptomatology. A systematic analysis of these factors 
was beyond the scope of the current study but deserves consideration.  
Future Directions 

Future projects could compare the rate of externalizing and internalizing symptoms for 
Black children compared only to non-Hispanic white children. While the current analysis 
used parent-report measures and did not include clinician assessed measures, the ongoing 
longitudinal project from which data for this study was derived used trained master’s-
level research assistants to diagnose participants using the Kiddie Schedule for Affective 
Disorders and Schizophrenia (KSADS) semi-structured interview. Future research could 
investigate whether there were differences in the rate of CD diagnosis compared to ADHD 
in this sample and whether this is associated with differences in symptom frequency, 
duration, and severity as reflected in clinician note-keeping during the interview. These 
findings may aid researchers in identifying whether differential rates of diagnosis are 
moderated by parent race.  

Additionally, there is some research to suggest that diagnostic discrepancies may affect 
Black youth differently depending on gender (Baglivio et al., 2017; DelBello et al., 2001; 
Goff et al., 2014). Given these findings, future research may benefit from analyzing 
whether there are differences in reported internalizing and externalizing symptoms as 
well as differences in the rate of CD and ADHD diagnosis for this sample depending on 
both race and gender.  
Conclusion 

This study represents a unique investigation into moderating effect of caregiver race on 
reported externalizing and internalizing symptomatology in Black and non-Black 
children. While the majority of research on this topic has utilized samples in which child 
and caregiver race was matched, this study utilized data from an ongoing longitudinal 
study in which a large portion of the child and reporter dyads were not biologically 
related and differed on self-reported race. Findings suggest that there are differences in 
the ways in which Black and non-Black caregivers report child symptoms that are 
dependent on race such that non-Black reporters may indicate higher rates of internalizing 
symptoms in non-Black children. These results represent an important first step in 
identifying the processes and junctures through which discrepancies in the rate of 
externalizing disorders in Black children are produced. This research is integral to the 
equitable and appropriate treatment of both Black and non-Black children and youth in 
health care and criminal justice settings, and the critical awareness that clinicians and 
researchers must have of the potential impact of caregiver race on reported 
symptomology. Further research is necessary to elucidate the mechanisms through which 
diagnostic discrepancies between Black and non-Black children are created.  

Acknowledgements 
The authors declare no conflict of interest associated with the publication, and no 
significant financial support for this work that could have influenced its outcome. 

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