Treating the Child or Syndrome: Does Context Matter for Treatment Decisions for Antisocially Behaving Youth?

Background and Purpose:  Selecting an appropriate treatment strategy for clients with mental health problems is central to clinical practice.  The treatment decision-making process generally involves judgments about the nature of the individual's problems, and a judgment about what treatment may be most effective. The treatment literature generally describes best practices based on research on diagnostic syndromes described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013). However, clinicians often engage clients with complex life circumstances, in addition to their diagnostic profiles. This study asks: Do clinicians alter their judgments about treatment based on contextual information? Given identical DSM criteria, do clinicians reach the same judgments regardless of the race or ethnicity of their clients or their own occupational group?

Methods: We used a between-subject design with 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 social context, youth's race/ethnicity, and clinicians' occupational  group affect their judgment of the effectiveness of 14 practices for treating antisocially behaving youth. Vignettes describe problematic behaviors meeting DSM-5 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 rated each treatment's level of effectiveness, and whether the youth had a mental disorder.  Frequency, median and mean of these effectiveness scores were compared for each treatment in a series of bivariate analyses, stratifying context, youth's race/ethnicity, and occupational group. 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: Clinicians make distinctions about effective treatments based on the social context of the behavior, judging three different treatments as effective (median scores ≥ 7 of 9) in the disorder and non-disorder conditions, respectively (Disorder: Anger management training, Parent-management training, Behavior modification; Non-disorder: Prosocial peer groups, Social problem-solving skills training, and Community mobilization and planning). In the DSM symptom-only condition, they judge all six as effective, adding also systems-oriented family therapy.  This pattern remained when we restricted the sample exclusively to clinicians who judged also that the youth had a mental disorder. Social context was associated with differences in effectiveness judgments of youth in 13 out 14 treatments. Youth race or ethnicity and occupational group were associated with different judgments of effectiveness.

Conclusions and Implications: Our study provides new information about clinicians' treatment decision-making, demonstrating that clinicians use social context information to distinguish the best treatments to use with antisocially behaving youth. Given identical contextual information, clinicians make different judgments about what treatment is effective for youths of different races and ethnicities, suggesting the troubling possibility of treatment decision bias based on race or ethnicity. Findings also suggest that professional socialization processes may generate variations in judgments. Together, results have important implications for clinical training to improve delivery of services, and for future research to improve the evidence-base.