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

Abstract

Using a between-subject 3 × 3 design of an experimentally manipulated realistic case vignette of Black, White, and Hispanic youth in a survey mailed to 1540 experienced psychologists, psychiatrists, and social workers, the authors examined if clinicians alter their judgments about treatment for antisocially behaving youth based on the symptom's social context (e.g., life circumstances) and the youth's race or ethnicity, even among youth who are otherwise identical in terms of behavioral symptoms. Vignettes describe behaviors meeting DSM-IV criteria for conduct disorder, but contain contextual information suggesting either internal dysfunction (ID) or a normal response to a difficult environment [i.e., environmental-reaction (ER)]. Comparison was symptomonly (SO). Judgments of effectiveness of 14 treatments for youth exhibiting antisocial behavior were examined. Frequencies and median scores of perceived effectiveness level (1-9, Likert) were compared in bivariate analyses, stratifying context and youth's race or ethnicity. The context of the behavior was associated significantly with differences in effectiveness judgments in 13 of 14 treatments. Within ID and ER contexts, clinicians judged three different treatments as effective (median ≥ 7 of 9). In the SO condition, clinicians were less selective, judging six as effective. In the ID context, psychiatric medications, systems oriented family therapy, and residential care were judged more effective for White than for Black or Hispanic youth. Evidence-based practice research may be hampered by inattention to the social context of behavioral symptoms. Context may activate implicit racial assumptions about treatment effectiveness. Implications are for clinical training to improve service delivery, and future clinical research.

Clients in context: Environment, class, race, and therapists' perceptions of generalized anxiety disorder

“…Therapists were more likely to diagnose clients when their anxiety symptoms were consistent with an internal factors (i.e., out of proportion for the situation, occurring without precipitants, and including a wide range of worries) than when symptoms were consistent with an environmental reaction (i.e., proportionate to the situation, with an onset associated with the stressor, and worries specific to the stressor). Although previous studies reported mixed findings on whether client context influences diagnosis (de Los Reyes & Marsh, 2011; Pottick et al, 2017), the current results indicate therapists do alter their diagnoses of anxiety based on client context. Thus, contextual information appears to be a significant element of therapists' decisions to diagnose an anxiety disorder.…”

“…We developed vignettes describing hypothetical clients using the methodology reported by Pottick et al (2017). There were two context conditions (internal factors and environmental reaction) for each of the three different hypothetical clients, yielding a 2 × 3 design for a total of six vignettes.…”

“…We also set out to test how environmental context influences therapists' clinical decisions. Similar vignettes studies have demonstrated mixed evidence as to whether contextual information increases or decreases therapists' determination of diagnosis (de Los Reyes & Marsh, 2011; Pottick et al, 2017). Subsequently, we examined the directionality of contextual information on diagnosis of anxiety symptoms and on therapist confidence in the diagnosis.…”

“…One way to clarify how therapists incorporate client context is to assess the ways they use information about the client's environment to inform diagnosis and treatment. Vignette studies have examined how therapists use contextual information describing symptoms as either normal reactions to environmental stressors or consistent with internal factors (de Los Reyes & Marsh, 2011; Pottick et al, 2017; Wakefield et al, 2002, 2006). Using this method, Pottick et al (2017) found evidence that client context and race interact, leading therapists to view certain therapies as less effective for Black and Hispanic clients with conduct symptoms.…”

“…Vignette studies have examined how therapists use contextual information describing symptoms as either normal reactions to environmental stressors or consistent with internal factors (de Los Reyes & Marsh, 2011; Pottick et al, 2017; Wakefield et al, 2002, 2006). Using this method, Pottick et al (2017) found evidence that client context and race interact, leading therapists to view certain therapies as less effective for Black and Hispanic clients with conduct symptoms. The authors suggested that implicit biases may be activated by contextual information.…”