Disorder attribution and clinical judgment in the assessment of adolescent antisocial behavior

Abstract

When social workers judge that an antisocially behaving adolescent has a mental disorder, what are the implications of that attribution for other clinical judgments about the youth? Clinical case vignettes that satisfied DSM-IV diagnostic criteria for conduct were presented to 250 MSW students. Based on DSM-IV guidelines and on the harmful analysis of the concept of mental disorder, the of the symptoms presented in the vignettes was manipulated experimentally to suggest either internal dysfunction or a normal response to a difficult environment as the cause of the youth's behavior. Students were asked to judge whether the youth had a psychiatric and to assess prognosis, need for professional help, and appropriateness of medication. Key words: adolescence; behavior; assessment; conduct disorder; diagnosis; mental Diagnosing whether a condition is a psychiatric or a normal reaction to a problematic environment is central to social work assessment. This attribution of or nondisorder is often one of the first assessment decisions a clinician makes because of the widespread use of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994) for diagnostic and reimbursement purposes. DSM-IV emphasizes the distinction between and nondisorder: Axes I and II contain categories of mental disorders; a section containing codes is reserved for conditions that are not mental disorders (for example, delinquency, marital distress, identity crisis), although these conditions may exhibit overt manifestations similar to mental disorders. This DSM-IV distinction reflects a broader consensus among taxonomic theorists that sheer symptomatic similarity does not necessarily imply that two conditions fill under the same diagnostic category and that deeper etiological properties are involved in making diagnostic distinctions (Millon, 1991). In addition to diagnostic attribution, clinical assessment requires many other judgments. For example, a clinician must determine whether the problem is likely to continue (prognosis), whether professional mental health help is needed to solve the problem (need for professional mental health help), and whether the use of medication is indicated (appropriateness of medication). One might suspect that such clinical judgments depend to some extent on the initial distinction between and nondisorder. For this study, we tested whether such judgments regarding adolescent behavior are indeed related to attributions. distinction between and other problems in living is especially relevant to adolescent behavior, because such behavior can be caused by a variety of factors other than a psychiatric disorder. Indeed, some adolescent behavior is considered normal in certain developmental stages or environmental circumstances (Kazdin, 1995; Moffitt, 1993). DSM-IV (1994) protocol requires that in making a differential diagnosis the clinician distinguish conduct disorder--the axis I diagnosis of mental generally applied to adolescent behavior--from the V code of antisocial behavior in a child or adolescent that is not due to a mental disorder (p. 684), which may involve similar behaviors. This distinction is highlighted in DSM-IV's text by a unique cautionary statement: The diagnosis should be applied only when the behavior in question is symptomatic of an underlying dysfunction within the individual and not simply a reaction to the immediate social context (p. 88). DSM-IV's emphasis on the need to distinguish adolescent behavior resulting from an internal dysfunction and similar behavior resulting from a normal reaction to problematic circumstances raises two questions about social workers' clinical judgments: (1) Do social workers distinguish correctly from nondisorder when the facts of a case indicate that one or the other attribution is most appropriate? …