Researching the Classification of Adolescent Antisocial Behavior

Background and Purpose: Clinical social workers are the primary mental health care providers for the estimated 20% of adolescents struggling with mental disorders in the United States.  Social workers use the behavioral indicators specified in Diagnostic and Statistical Manual of Mental Disorders (DSM) to formulate diagnoses, but it remains unclear how indicators guide the determination of mental disorder. Moreover, there is little existing research that examines how factors other than behavioral indicators may influence mental disorder judgments. To formally diagnose conduct disorder, social workers must discriminate between antisocial behavior that meets diagnostic criteria for conduct disorder and that which indicates delinquency, not mental disorder.  This analogue study examined the influence of moral development and course of antisocial behavior on mental disorder judgments of social work clinicians and students presented with clinically realistic vignettes meeting criteria for conduct disorder according to the DSM-IV-TR (American Psychiatric Association, 2000). The study was guided by the following questions: (a) Do social workers and social work students accurately discriminate between adolescent antisocial behavior that is a result of mental illness and that which denotes delinquency?, and (b) Which variables impact social workers and social work students assessment of adolescent antisocial behavior?

Method: We recruited social workers (n = 200) and social work students (n = 41) in a Northeastern state. Vignette packets were mailed to practicing social workers, and distributed to social work students in first-year MSW classes. In a quasi-experimental 3x3 design vignettes examined whether low moral development and life-course persistent antisocial behavior were interpreted as internal dysfunction, required by DSM–IV–TR to make mental disorder judgments.  Respondents rated the question “this youth has a mental disorder” on a six point scale. Vignettes were separated into three independent groups for logistic regression analyses in which neutral vignettes were used as reference categories.

Results:  Low moral development did not affect mental disorder judgments among social work practitioners and students. The presence of life-course persistent antisocial behavior significantly increased the odds of a mental disorder judgment across three groups (OR=5.351, p<.001; OR=7.180, p<.001; OR=4.085, p<.001). The presence of adolescent-limited antisocial behavior significantly decreased the odds of a mental disorder judgment, (OR=.250, p= .006; OR=.345, p=.012; OR=.226, p=.001). Prior training in the use of DSM was significantly associated with disorder judgments (OR=3.145, p = .028). There was no interaction effect between level of moral development and the course of antisocial behavior.

Conclusions:  Social workers accurately identified the presence of mental disorder according to diagnostic criterion in DSM.  Results indicate that social work respondents may view life-course persistent antisocial behavior as evidence of internal dysfunction when making mental disorder judgments. Further, accurate clinical disorder judgments were associated with prior training in the DSM. A challenge for social work research and practice is identifying factors that produce accurate assessments and facilitate effective treatment. This study demonstrates that professional training can improve diagnostic judgments.