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Diagnostic Bias and Conduct Disorder:Improving Culturally Sensitive DiagnosisLauren Mizock a & Debra Harkins ba Center for Psychiatric Rehabilitation, Boston University , Boston,Massachusetts, USAb Department of Psychology , Suffolk University , Boston,Massachusetts, USAPublished online: 20 Sep 2011.

To cite this article: Lauren Mizock & Debra Harkins (2011) Diagnostic Bias and ConductDisorder: Improving Culturally Sensitive Diagnosis, Child & Youth Services, 32:3, 243-253, DOI:10.1080/0145935X.2011.605315

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Diagnostic Bias and Conduct Disorder:Improving Culturally Sensitive Diagnosis

LAUREN MIZOCKCenter for Psychiatric Rehabilitation, Boston University, Boston, Massachusetts, USA

DEBRA HARKINSDepartment of Psychology, Suffolk University, Boston, Massachusetts, USA

Disproportionately high rates of Conduct Disorder are diagnosed inAfrican American and Latino youth of color. Diagnostic biascontributes to overdiagnosis of ConductDisorder in these adolescentsof color. Following a diagnosis of Conduct Disorder, adolescents ofcolor face poorer outcomes than their White counterparts. Thesenegative outcomes occur within mental health and juvenile justicesettings. The aims of this article are to: (a) identify the factors thatcontribute to overdiagnosis of Conduct Disorder in adolescents ofcolor, (b) discuss the associated negative outcomes, and (c) providerecommendations for culturally sensitive diagnosis of adolescents ofcolor with conduct problems in order to reduce overdiagnosis.Clinical and research implications will also be presented.

KEYWORDS Conduct Disorder, diagnostic bias, ethnic minority,juvenile justice, race

Researchers have called for revision of the diagnosis of Conduct Disorder inthe next edition of the Diagnostic and Statistical Manual of Mental Disorders(DSM-V). Specifically, they have underscored the need to reduce overdiag-nosis 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 adolescentsof color experience more negative outcomes in juvenile justice and mental

Address correspondence to Lauren Mizock, Center for Psychiatric Rehabilitation, BostonUniversity, 940 Commonwealth Avenue West, Boston, MA 02215, USA. E-mail: Lauren.mizock@gmail.com

Child & Youth Services, 32:243–253, 2011Copyright # Taylor & Francis Group, LLCISSN: 0145-935X print=1545-2298 onlineDOI: 10.1080/0145935X.2011.605315

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health systems than do their White counterparts (Pottick, Kirk, Hsieh, & Tian,2007; Seagrave & Grisso, 2002), heightening the clinical importance of thistopic. The aims of this article are to: (a) identify the diagnostic biases thatcontribute to overdiagnosis of Conduct Disorder in adolescents of color,(b) discuss the associated negative outcomes, and (c) provide recommenda-tions for culturally sensitive diagnosis of adolescents of color with conductproblems in order to reduce overdiagnosis. Clinical and research implicationswill also be presented.

Conduct Disorder is defined in the current edition of the Diagnostic andStatistical Manual of Mental Disorders (DSM-IV-TR; American PsychiatricAssociation, 2000) as a recurring set of behaviors that are harmful to othersand must include 3 or more of the following criteria to be present withinthe past 12 months to qualify for the diagnosis: aggression to people andanimals, destruction of property, deceitfulness or theft, and serious rule-breaking or defiance. Symptoms must persistently interfere with functioningin academic, social, or occupational roles. The diagnosis of Conduct Disorderis characterized by antisocial behavior and is a prerequisite to the adultdiagnosis of Antisocial Personality Disorder.

DIAGNOSTIC BIAS

A number of studies have documented historic diagnostic bias with the useof the Diagnostic and Statistical Manual of Mental Disorders (AmericanPsychiatric Association, 2000). One study found overdiagnosis of schizo-phrenia in African Americans as compared to White Americans (Neighbors,Trierweiler, Ford, & Muroff, 2003). Another study found Latinos wereoverdiagnosed with depression in contrast to their White counterpartsand underdiagnosed with psychotic disorders (Minsky, Vega, Miskimen,Gara, & Escobar, 2003). A third study found that African Americans werediagnosed more frequently with severe behavior disturbance disorders,while White Americans were diagnosed more frequently with more mildadjustment disorders (Feisthamel & Schwartz, 2009). These are among thefew examples of a wide range of studies that have documented higher ratesof stigmatizing diagnoses assigned to populations of color (Lopez, 1989;Neighbors et al., 2003).

Conduct Disorder is one disorder in particular that has been found to beoverdiagnosed among populations of color (Cameron & Guterman, 2007;Cuffe et al., 1996; Fabrega, Ulrich, & Mezzich, 1993; Kilgus et al., 1995; Wuet al., 1999). Specifically, Conduct Disorder has been overdiagnosed inurban, low-income, adolescents of Latino and African American backgrounds(Mandell et al., 2007; Mota-Castillo, 2004). In one study of adolescents in alarge U.S. residential treatment facility (N¼ 1,173), racial proportions of thosewho were diagnosed with Conduct Disorder were 43.3% Latino, 34.4%

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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 tobe diagnosed with mood, anxiety, or developmental disorders (Mandell et al.,2007). A study of 406 children found African American children were 2.4times more likely than White American children to receive what is consideredto be the more stigmatizing diagnosis of Conduct Disorder than AttentionDeficit-Hyperactivity Disorder (ADHD; Mandell et al., 2007).

Statistical discrimination may be contributing to clinicians’ assumptionsabout the differing rates of diagnoses like Conduct Disorder among ethnicgroups (Balsa & McGuire, 2001). In addition, clinicians may be interpretingdisruptive and aggressive symptoms of African American children differentlythan White American children, leading to differences in diagnosis and appro-priate treatment (Mandell et al., 2007). Many of these clinicians may holdstereotyped views toward clients of color resulting in differential treatmentand assessment (Vasquez, 2007).

Is Conduct Disorder being diagnosed while problems with mood oranxiety are overlooked? Research findings suggest Conduct Disorderdiagnoses are often accompanied by depression, separation anxiety, andadjustment disorders (Drerup, Croysdale, & Hoffman, 2008; Kazdin &Whitley, 2006). This data suggests the possibility that many youth may expressconduct problems in response to underlying mood or anxiety disorders. Forexample, research has found depression to be a precursor to conductproblems (Beyers & Loeber, 2003; Renouf, Kovacs, & Mukerji, 1997). Youthwith 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 (Drerupet al., 2008). Hence, conduct problems may in fact be a behavioral responseto depression, anxiety, or substance abuse as opposed to a sign of underlyingantisocial pathology implied in the diagnosis of Conduct Disorder.

Mota-Castillo (2004) described the tendency for clinicians to misper-ceive Conduct Disorder in adolescents of color who present with behavioralsymptoms of other psychological disorders. Adolescents with Obsessive-Compulsive Disorder may exhibit strong opposition to rigid rules in theclassroom and at home. Children with Bipolar Disorder as well as ADHDmay engage in destructive behavior. Those with Social Anxiety Disorderoften refuse to attend school and express defiance toward teachers in theschool setting. Mota-Castillo described working with an adolescent of colorwith schizophrenia who was misdiagnosed with Conduct Disorder. Theauthor believed diagnostic bias had occurred in this case, mislabeling theadolescent’s behavioral symptoms as conduct problems as opposed topsychosis, and resulting in incorrect medication. In this case and in manyothers, clinical misperception may interfere with detecting true etiology inadolescents of color and lead to inappropriate treatment.

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OUTCOMES OF CONDUCT DISORDER

Mental Health Outcomes

Adolescents of color frequently experience more harmful outcomes followingoverdiagnosis of Conduct Disorder than White American adolescents (Potticket al., 2007). African American adolescents diagnosed with Conduct Disorderare more likely to be hospitalized (Lapointe, Garcia, Taubert, & Sleet, 2010;Pavkov & George, 1997; U.S. Department of Health & Human Services,2001). Both African Americans and Latino Americans have limited access tomental health care in general and on the outpatient basis, which contributesto poorer mental health care service delivery once diagnosed (Alegrı́a et al.,2002; Classen et al., 2000; Merritt-Davis & Keshavan, 2006). Therefore, adoles-cents of color diagnosed with Conduct Disorder are less likely to receiveappropriate mental health treatment following diagnosis.

In addition, adolescents with Conduct Disorder diagnoses are oftenstigmatized, affecting outcome of treatment quality and appropriateness ofservices provided. For example, clinicians may label adolescents of colorwith conduct problems and make more pessimistic predictions toward theirrecovery (Salekin, 2002). Also suggestive of therapeutic pessimism was astudy of 109 juvenile justice clinicians that found clinicians gave higherratings of risk for future criminality to adolescents with Conduct Disorderdiagnoses (Rockett, Murrie, & Boccaccini, 2007). These pessimistic predic-tions for the mental health outcomes of adolescents of color may lead to lesseffective treatment from mental health providers (Salekin, 2002).

Juvenile Justice Outcomes

Labels such as Conduct Disorder increase the likelihood that adolescents ofcolor who have been improperly diagnosed will be transferred to adultcourts or be ordered to serve longer sentences (Petrila & Skeem, 2003;Seagrave & Grisso, 2002). Moreover, youth with Conduct Disorder diagnosesare prevalent in the juvenile justice system. In a study of 597 court-involvedadolescents, Conduct Disorder was the most common diagnosis (Drerupet al., 2008). Another study estimated Conduct Disorder and OppositionalDefiant Disorder rates in juvenile justice system as high as 40% (Teplinet al., 2002). The American Academy of Pediatrics (AAP; 2001) found 20%–60% of juvenile detainees were diagnosed with Conduct Disorder, and manyof these juvenile detainees were adolescents of color who were more likelyto receive formal prosecution and harsher treatment than White Americandetainees.

Adolescents of color overdiagnosed with Conduct Disorder face racialdisparities of the juvenile justice system. Youth of color are overrepresentedin juvenile detention centers, incarcerated more than White youth who

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committed similar crimes, and are frequently arrested for minor statusoffenses that pose no serious safety risk to society (W. Haywood BurnsInstitute, 2011). In particular, they are more likely to be arrested and enterinto the juvenile justice system (Fite, Wynn, & Pardini, 2009; Hanson,Henggler, Haefele, & Roddick, 1984; Lahey, Waldman, & McBurnett, 1999).Subjective risk assessment procedures may contribute to these racial dispari-ties in juvenile justice decision making (Steinberg, 2008; Steinhart, 2006).

CULTURALLY SENSITIVE DIAGNOSIS

The DSM-IV-TR (American Psychiatric Association, 2000) description ofConduct Disorder indicates that clinicians should not assign the diagnosisif conduct problems are a response to a negative environment, as opposedto an internal psychological dysfunction (Wakefield, Pottick, & Kirk, 2002).However, adolescents of color often experience disparities in environmentalstressors due to higher rates of poverty and experiences of racial discrimi-nation (Gonzalez, 2005). Overdiagnosis among adolescents of color maydiminish with a more thorough assessment of environmental factors thatmay contribute to conduct problems (Beauchaine, Webster-Stratton, & Reid,2005; Fite et al., 2009; Jaffee, Belsky, Harrington, Caspi, & Moffitt, 2006; Tietet al., 2001). In this section, the environmental stressors that may accountfor conduct problems among adolescents of color are outlined in order tofacilitate thoughtful diagnosis of Conduct Disorder.

Socioeconomic Status

Socioeconomic status (SES) has been linked with expression of conductproblems among adolescents of color (Beiser, Hou, Kaspar, & Noh, 2000;Jaffee et al., 2006; Sampson & Groves, 1989; Tiet et al., 2001). One studyfound conduct problems were negatively correlated with income, with diag-nosis rates increasing as absolute income of immigrant families decreased(Beiser, Hou, Kaspar, & Noh, 2000). Children who are reared in neighbor-hoods that are impoverished and disorganized (i.e., disrupted socialnetworks) are at additional risk for conduct problems and being chargedwith criminal behaviors (Sampson & Groves, 1989; Tiet et al., 2001). A studyof 246 families in a 30 year cohort found children with parents with low SESin addition to a history of conduct problems and relationship violence weremore likely to have children with conduct problems (Jaffee et al., 2006).Additional diagnostic consideration is needed to assess the stressors of pov-erty and exposure to violence in a high crime environment. These stressorsmight contribute to acting out behaviors among adolescents living below thepoverty line that would rule out the diagnosis of Conduct Disorder.

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Violence

Violence exposure has been linked to the expression of conduct problemsamong adolescents of color in particular. In a study of urban AfricanAmerican adolescents, witnessing violence was a primary factor in predictingconduct problems (Durant, Cadenhead, Peendergrast, Slavens, & Linder,1994). In another study, witnessing of and victimization by communityviolence led to development of conduct problems over the course of a 1-yearperiod (Pearce, Jones, Schwab-Stone, & Ruchkin, 2003). An additional studyfound experiences of violence in school contributed to conduct problems forteens living in high crime communities (Flannery, Wester, & Singer, 2004).Violence exposure and victimization appear to be significant precursors tothe development of violent behavior. This tendency further highlights theneed to consider the environmental context of the adolescent of color withconduct problems prior to assigning Conduct Disorder.

Racial Discrimination

Experiences with racism at individual and systemic levels may enhance riskfactors for conduct problems among youth of color (Piquero, Moffitt, &Lawton, 2005). In one study of African American adolescents, racial discrimi-nation among teachers and peers predicted conduct problems and low aca-demic performance (Wong, Eclles, & Sameroff, 2003). In fact, poor academicachievement is one of the most significant contributors to conduct problems(Fite et al., 2009). Adolescents of color may experience prejudice from theseadults whose roles are intended to mentor and support. Taking into accountenvironmental stressors such as academic discrimination is essential tounderstanding the context of the child with conduct problems more fully,prior to assigning a Conduct Disorder diagnosis. These considerations ofenvironmental stressors can help differentiate conduct problems from Con-duct Disorder, potentially reducing racial disparities in diagnosis.

CLINICAL AND RESEARCH IMPLICATIONS

Clinical Training

How can clinicians become more aware of these problems in the diagnosis ofConduct Disorder for youth with conduct problems? Various barriers mayprevent culturally sensitive diagnosis from occurring. These barriers includethe lack of availability of and training in culturally sensitive diagnostictools, lack of cultural competence training of clinicians, and tendencies topathologize communities of color in mental health institutions (Park-Turner,Ventura, & Ng, 2010). Offering providers with didactic and experientialtraining to better understand the intersections of race, SES, gender, and other

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variables of social identity may improve culturally sensitive diagnosis withadolescents of color (Kress, Eriksen, Rayle, & Ford, 2005; Neighbors et al.,2003; Roysircar, 2005).

In general, more psychoeducation is needed for clinicians in training aswell as continuing education in conducting culturally sensitive diagnosis andtreatment of conduct problems (Pottick et al., 2007). Roysircar (2005) recom-mended culturally sensitive diagnosis to be improved with: (a) examinationof a clinician’s own cultural biases, (b) gathering information about clients’cultural backgrounds, (c) awareness of the cultural biases of any diagnosticassessment measures being used, and (d) careful differentiating of the client’sculture from mental disorder. These skills can help clinicians to avoid partici-pation in the overuse of Conduct Disorder as a label for adolescents of color.

In a social context of racial bias, youth of color who act out are oftenperceived as dangerous and disobedient (Mandell et al., 2007; Mota-Castillo,2004). Mental health providers can enhance their awareness of the larger sys-temic issues that contribute to conduct problems among adolescents of color.Increasing culturally sensitive diagnosis among clinicians is likely to enhanceeffectiveness of treatment for clients of color (Roysircar, 2005). Diagnosti-cians can improve their efforts to assess the experience of the adolescentof color with conduct problems to enhance culturally sensitive treatment.

Diagnostic Revisions

Revision of the Conduct Disorder diagnosis in DSM-V may assist clinicians intaking into account environmental stressors more consistently when workingwith adolescents of color (Moffitt et al., 2008). Clinicians often overlook thetextual commentary at the end of the criteria list for Conduct Disorder relatedto environmental stressors (Wakefield, Pottick, & Kirk, 2002). This commen-tary indicates exclusion of the diagnosis if conduct problems are a responseto environmental stressors. Clinicians may consider this diagnostic guidelinemore consistently if it were included in the core criteria list in order to avoidoverlooking this critical aspect of differential diagnosis.

Future Research

Additional research is needed to further explore the incidence of conductproblems in association with exposure to community violence (Weaver,Borkowski, & Whitman, 2008). Investigation is also needed to assess differ-ences in diagnosis of Conduct Disorder resulting from clinical bias (Potticket al., 2007). More field-based research is required to further delineate theoutcomes following diagnosis of conduct problems of adolescents of color(Cameron & Guterman, 2007; Mandell et al., 2007). Finally, further researchis needed to provide empirical evidence of the impact of cultural sensitivitytraining on diagnostic practices.

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CONCLUSION

Conduct Disorder is overdiagnosed among adolescents of color. Diagnosticbias that occurs among clinicians contributes to racial disparities in diagnosis.Diagnostic bias may occur due to statistical assumptions about rates of diag-nosis among populations of color, lack of cultural sensitivity training, and lackof consideration of environmental stressors that may differentially affect ado-lescents of color. Following diagnosis of Conduct Disorder, adolescents ofcolor often face poorer outcomes in mental health and juvenile justice settings.Culturally sensitive diagnostic skills can assist clinicians in making more accu-rate assessments of conduct problems among adolescents of color, potentiallyreducing overdiagnosis rates. Research can help clarify successful strategiesfor improving diagnostic assessment of clinicians working with adolescentsof color to ensure culturally appropriate and effective mental health treatment.

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