Diagnostic Bias and Conduct Disorder
Researchers have called for revision of the diagnosis of Conduct Disorder in the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Specifically, they have underscored the need to reduce overdiagnosis of Conduct Disorder among African American and Latino youth (Cuffe, Waller, Cuccaro, Pumariega, & Garrison, 1996; Kilgus, Pumariega, & Cuffe, 1995; Mandell, Ittenbach, Levy, & Pinto-Martin, 2007; Moffitt et al., 2008; Wu et al., 1999). Once diagnosed with Conduct Disorder, these adolescents of color experience more negative outcomes in juvenile justice and mental health systems than do their White counterparts (Pottick, Kirk, Hsieh, & Tian, 2007; Seagrave & Grisso, 2002), heightening the clinical importance of this topic. The aims of this article are to: (a) identify the diagnostic biases that contribute to overdiagnosis of Conduct Disorder in adolescents of color, (b) discuss the associated negative outcomes, and (c) provide recommendations for culturally sensitive diagnosis of adolescents of color with conduct problems in order to reduce overdiagnosis. Clinical and research implications will also be presented.
Conduct Disorder is defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) as a recurring set of behaviors that are harmful to others and must include 3 or more of the following criteria to be present within the past 12 months to qualify for the diagnosis: aggression to people and animals, destruction of property, deceitfulness or theft, and serious rulebreaking or defiance. Symptoms must persistently interfere with functioning in academic, social, or occupational roles. The diagnosis of Conduct Disorder is characterized by antisocial behavior and is a prerequisite to the adult diagnosis of Antisocial Personality Disorder.
A number of studies have documented historic diagnostic bias with the use of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000). One study found overdiagnosis of schizophrenia in African Americans as compared to White Americans (Neighbors, Trierweiler, Ford, & Muroff, 2003). Another study found Latinos were overdiagnosed with depression in contrast to their White counterparts and underdiagnosed with psychotic disorders (Minsky, Vega, Miskimen, Gara, & Escobar, 2003). A third study found that African Americans were diagnosed more frequently with severe behavior disturbance disorders, while White Americans were diagnosed more frequently with more mild adjustment disorders (Feisthamel & Schwartz, 2009). These are among the few examples of a wide range of studies that have documented higher rates of stigmatizing diagnoses assigned to populations of color (Lopez, 1989; Neighbors et aI., 2003).
Conduct Disorder is one disorder in particular that has been found to be overdiagnosed among populations of color (Cameron & Guterman, 2007; Cuffe et aI., 1996; Fabrega, Ulrich, & Mezzich, 1993; Kilgus et al., 1995; Wu et aI., 1999). Specifically, Conduct Disorder has been overdiagnosed in urban, low-income, adolescents of Latino and African American backgrounds (Mandell et aI., 2007; Mota-Castillo, 2004). In one study of adolescents in a large U.S. residential treatment facility (N = 1,173), racial proportions of those who were diagnosed with Conduct Disorder were 43.3% Latino, 34.4% African American, and 24.4% White American (Cameron & Guterman, 2007). Within this sample, African American youth were particularly overrepresented.
In contrast, White American children with comparable behaviors tend to be diagnosed with mood, anxiety, or developmental disorders (Mandell et a1., 2007). A study of 406 children found African American children were 2.4 times more likely than White American children to receive what is considered to be the more stigmatizing diagnosis of Conduct Disorder than Attention Deficit-Hyperactivity Disorder (ADHD; Mandell et a1., 2007).
Statistical discrimination may be contributing to clinicians' assumptions about the differing rates of diagnoses like Conduct Disorder among ethnic groups (Balsa & McGuire, 2001). In addition, clinicians may be interpreting disruptive and aggressive symptoms of African American children differently than White American children, leading to differences in diagnosis and appropriate treatment (Mandell et aI., 2007). Many of these clinicians may hold stereotyped views toward clients of color resulting in differential treatment and assessment (Vasquez, 2007).
Is Conduct Disorder being diagnosed while problems with mood or anxiety are overlooked? Research findings suggest Conduct Disorder diagnoses are often accompanied by depression, separation anxiety, and adjustment disorders (Drerup, Croysdale, & Hoffman, 2008; Kazdin & Whitley, 2006). This data suggests the possibility that many youth may express conduct problems in response to underlying mood or anxiety disorders. For example, research has found depression to be a precursor to conduct problems (Beyers & Loeber, 2003; Renouf, Kovacs, & Mukerji, 1997). Youth with depression or anxiety may also use substance abuse as a way to cope (Deykin, Levy, & Wells, 1987; Wells, Klap, Koike, & Sherbourne, 2001). Additionally, substance abuse may lead to behavioral misconduct (Drerup et aI., 2008). Hence, conduct problems may in fact be a behavioral response to depression, anxiety, or substance abuse as opposed to a sign of underlying antisocial pathology implied in the diagnosis of Conduct Disorder.
Mota-Castillo (2004) described the tendency for clinicians to misperceive Conduct Disorder in adolescents of color who present with behavioral symptoms of other psychological disorders. Adolescents with ObsessiveCompulsive Disorder may exhibit strong opposition to rigid rules in the classroom and at home. Children with Bipolar Disorder as well as ADHD may engage in destructive behavior. Those with Social Anxiety Disorder often refuse to attend school and express defiance toward teachers in the school setting. Mota-Castillo described working with an adolescent of color with schizophrenia who was misdiagnosed with Conduct Disorder. The author believed diagnostic bias had occurred in this case, mislabeling the adolescent's behavioral symptoms as conduct problems as opposed to psychosis, and resulting in incorrect medication. In this case and in many others, clinical misperception may interfere with detecting true etiology in adolescents of color and lead to inappropriate treatment.
LAUREN MIZOCK and DEBRA HARKINS
Extract from: Mizock, I.. and Harkins, D. Diagnostic Bias and Conduct Disorder: Improving Culturally Sensitive Diagnosis . Child & Youth Service, 32 (3), July - September 2011
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