Bridging Disciplinary Boundaries (January 11 - 14, 2007)

Purpose: Because diagnostic decisions shape treatment choices, bias or inconsistency in assessment pose a potentially serious problem for effective clinical practice and service delivery. The Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 1994) was predicated on the expectation that structured, behaviorally-oriented criteria to judge diagnoses would minimize bias and promote consistency among clinicians with different theoretical orientations and professional affiliations. But does it? Do clinicians make distinctions between disordered and non-disordered behaviors as specified in DSM clinical guidelines? Given identical DSM clinical criteria, do clinicians reach the same judgments regardless of the race-ethnicity of their clients or their own professional and social characteristics? Our study answered these questions. Method: We used a between-subject design with the use of mailed, experimentally manipulated case vignettes of Black, White, and Hispanic youths to a national sample of experienced social workers, psychologists, and psychiatrists to investigate how the youth's race-ethnicity and clinicians' characteristics (age, race, gender, professional group, theoretical orientation, and mental health experience) affect their judgment of mental disorder among antisocial behaving youth. Vignettes describe problematic behaviors meeting the DSM-IV criteria for conduct disorder, but contain contextual information suggesting either internal dysfunction (i.e., disorder) or a normal response to a difficult environment (i.e., non-disorder), following DSM inclusionary and exclusionary guidelines. Respondents were asked to judge whether the youth had a psychiatric or mental disorder. Simultaneous logistic regression was applied for analysis. We obtained a sample of 1,401 clinicians, representing a 48.6% response rate. Comparisons with known national characteristics of these occupational groups yielded few differences. Results: The social context of behavior is the best predictor of whether clinicians judged mental disorder versus no disorder; clinicians appropriately distinguish between disordered and non-disordered behaviors as specified in DSM guidelines. Other factors associated with the likelihood of making mental disorder judgments were professional group (social work < psychology < psychiatry), youths' race-ethnicity (minority < White), theoretical orientation (cognitive/behavioral/ family/systems or eclectic < psychodynamic/psychoanalytic), and clinicians' age, with older respondents less likely to judge disorder than younger ones. There were no variations in mental disorder judgments by clinicians' gender, race-ethnicity or mental health experience. Implications for Practice: Our study provides new information about how clinicians' judgment of mental disorder is influenced by youth's race-ethnicity, clinicians' characteristics, and the social context of behavioral symptoms. Results contribute to our current understanding of race-ethnic disparities in diagnostic prevalence rates, including the troubling possibility that clinicians may be biased-- viewing White youths as having a mental disorder (and retaining them in the mental health system) and minority youths as delinquent (and directing them to the juvenile justice system). Findings suggest that professional socialization processes may generate variations in clinical decision-making regarding the presence or absence of disorder, demonstrating how profoundly difficult it is to develop classification criteria that are applied uniformly across professional groups, and among clinicians with different theoretical orientations. Together, these results have important implications for clinical training to improve equity of services, and for future research to improve the accuracy of clinical assessment.