No. 1872

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.

DIAGNOSTIC BIAS
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

REFERENCES
Alegria, M., Canino, G., Rios, R., Vera, M., Calderon, J., Rusch, D., & Ortega, A. N. (2002). Mental health care for Latinos: Inequalities in use of specialty mental health services among Latinos, African Americans, and non-Latino Whites. Psychiatric Services, 53(12), 1547-1555.
American Academy of Pediatrics. (2001). Health care for children and adolescents in the juvenile correctional care system. Pediatrics, 107(4), 799-803.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
Balsa, A., & McGuire, T. (2001). Statistical discrimination in health care. Journal of Health Economics, 20(6), 881-907.
Beyers, J. M., & Loeber, R. (2003). Gender differences in juvenile violence: A report from Ad Health. Journal of Adolescent Health, 32(3), 234-240.
Cameron, M., & Guterman, N. B. (2007). Diagnosing conduct problems of children and adolescents in residential treatment. Child Youth Care Forum, 36(1), 1-10.
Cuffe, S., Waller,]., Cuccaro, M., Pumariega, A., & Garrison, C. (1996). Race and gen­der differences in the treatment of psychiatric disorders in young adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 34(11), 1536-1543.
Deykin, E. Y., Levy, J. c., & Wells, V. (1987). Adolescent depression and alcohol and drug abuse. American Journal of Public Health, 7(2), 178-182.
Drerup, 1. C., Croysdale, A., & Hoffman, N. G. (2008). Patterns of behavioral health con­ditions among adolescents in a juvenile justice system. Professional Psychology: Research and Practice, 39(2), 122-128.
Fabrega, H., Ulrich, R., & Mezzich, J. E. (1993). Do caucasian and black adolescents differ at psychiatric intake? Journal of the American Academy of Child & Adolescent Psychiatry, 32(2), 407-413.
Feisthamel, K. P., & Schwartz, R. C. (2009). Differences in mental health counselors' diagnoses based on client race: an investigation of adjustment, childhood, and substance-related disorders. Journal of Mental Health Counseling, 31(1), 47-59.
Kazdin, A. E., & Whitley, M. K. (2006). Comorbidity, case complexity, and effects of evidence-based treatment for children referred for disruptive behavior. Journal of Consulting and Clinical Psychology, 74(3), 455-467.
Kilgus, M., Pumariega, A., & Cuffe, S. (1995). Influence of race on diagnosis in adolescent psychiatric inpatients. Journal of the American Academy of Child & Adolescent Psychiatry, 34(1), 67-72.
Lopez, S. (1989). Patient variable biases in clinical judgment: Conceptual overview and methodological considerations. Psychological Bulletin, 106(2), 184-203.
Mandell, D. S., Ittenbach, R F., Levy, S. E., & Pinto-Martin,]. A (2007). Disparities in diagnoses received prior to a diagnosis of Autism Spectrum Disorder. Journal of Autism Developmental Disorders, 37(9), 1795-1802.
Merritt-Davis, O. B., & Keshavan, M. S. (2006). Pathways to care for African Americans with early psychosis. Psychiatric Seroices, 57(7), 1043-1044.
Minsky, S., Vega, W., Miskimen, T., Gara, M., & Escobar, ]. (2003). Diagnostic patterns in Latino, African American, and European American psychiatric patients. Archives of General Psychiatry, 60(6), 637-644.
Moffitt, T. E., Arseneault, L., Jaffee, S. R, Kim-Cohen,]., Koenen, K. C., Odgers, C. L., et al. (2008). DSM- V conduct disorder: Research needs for an evidence base. Journal of Child Psychology and Psychiatry, 49(1), 3-33.
Mota-Castillo, M. (2004). Eliminate conduct disorders and ODD ... this is the right time! Psychiatric Times, 4, 3-5.
Neighbors, H. W., Trierweiler, S.]., Ford, B. C., & Muroff,]. R. (2003). Racial differ­ences in DSM diagnosis using a semi-structured instrument: The importance of clinical judgment in the diagnosis of African Americans. Journal of Health and Social Behavior, 44(3), 237-256.
Pottick, K, Kirk, S. A, Hsieh, D. K, & Tian, K. (2007). Judging mental disorder in youths: Effects of client, clinician, and contextual differences. Journal of Consulting and Clinical Psychology, 75(1), 1-8.
Renouf, A. G., Kovacs, M., & Mukerji, P. (1997). Relationship of depressive, conduct, and comorbid disorders and social functioning in childhood. Journal of the American Academy of Child & Adolescent Psychiatry, 36(7), 998-1004.
Seagrave, D., & Grisso, T. (2002). Adolescent development and the measurement of juvenile psychopathy. Law and Human Behavior, 26(2), 219-239.
Vasquez, M.]. T. (2007). Cultural difference and the therapeutic alliance: An evidence­based analysis. American Psychologist, 62(8), 878-885.
Wells, K, Klap, R, Koike, A., & Sherbourne, C. (2001). Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care. American Journal of Psychiatry, 158, 2027-2032.
Wu, P., Hoven, C., Bird, H., Moore, R, Cohen, P., Alegria, M., ... Roper, M. T. (1999). Depressive and disruptive disorders and mental health service utilization in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 38(9), 1081-1090.