Diagnosing Conduct Problems of Children and Adolescents in Residential Treatment

Abstract This naturalistic study of diagnostic practice in residential treatmentagencies for children investigated the use of the DSM-IVconduct disorder diagnosisand its association with residents’ externalizing behaviors. The conduct disorder(CD) diagnosis was a poor predictor of participants’ externalizing behaviors duringtheir first few months in residence. Additionally, the assignment of the diagnosis wasassociated with the gender and race of study participants. Decisions of admissionspersonnel and practitioners in residential treatment facilities regarding their exter-nalizing clients may not be well-served by use of DSM diagnoses. Assessments ofcaregivers may prove a useful adjunct to DSM diagnoses.

Keywords Diagnosis Æ Children Æ Adolescents Æ Conduct disorder ÆResidential treatment; DSM-IV validity

Diagnosing emotional and behavioral problems has long been identified as aninexact science. Studies conducted over the last half of the 20th century have shownthat the practice of diagnosing is susceptible to the influences of irrelevant factorsthat may sway diagnostic decision-making (Ash, 1949; Bishop & Richards, 1984;Borreson, 1965; Eells & Guppy, 1963; Franklin, 1985; Houts, 1984; Temerlin, 1968).Further, the establishment of the reliability and validity of the use of diagnoses ofthe Diagnostic and Statistical Manual remains only partially achieved (Kirk &Kutchins, 1992; Widiger, Frances, Pincus, Davis, & First, 1991). Due to these factors,it is likely that the accuracy and the usefulness of DSM diagnoses used by practi-tioners may be limited.

At this time, the study of the diagnostic practices of clinicians working in the fieldis not yet well-advanced (e.g., Lipkowitz & Idupugnati, 1983, 1985; Lipton & Simon,

M. Cameron (&)Department of Social Work, Southern Connecticut State University, 101 Farnham Avenue,New Haven, CT 06515, USAe-mail: [email protected]

N. B. GutermanSchool of Social Service Administration, University of Chicago, Chicago, IL, USA

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Child Youth Care Forum (2007) 36:1–10DOI 10.1007/s10566-006-9027-6

ORI GI N A L P A PE R

Diagnosing Conduct Problems of Children andAdolescents in Residential Treatment

Mark Cameron Æ Neil B. Guterman

Published online: 8 January 2007� Springer Science+Business Media, LLC 2007

1985; Vitiello, Malone, Buschle, Delaney, & Behar, 1990). An abundant experi-mental literature, primarily produced by researchers testing revisions of the DSM,has produced much of what is known about diagnostic reliability and validity (e.g.,Spitzer, Davies, & Barkley, 1990). Given findings related to the impact of envi-ronmental variables on diagnostic practices (for reviews see Berlin & Marsh, 1993;Garb, 1998), it is likely that this literature derived from experimental settings maynot adequately capture the ways in which the actual diagnoses of working practi-tioners reflect conditions related to day-to-day working conditions. As a result, littleis known about how these diagnoses are made, how well they conform to theexperiences and behaviors of clients, and the extent, to which and the ways in whichthey may support effective intervention.

DSM diagnoses perform key functions in determining the eligibility of clients forservices and the nature of services provided to clients and likely influence the ways inwhich practitioners view clients (Martin, Peters, & Glisson, 1998). This lack ofknowledge regarding diagnostic practice is particularly a concern when children andadolescents are the clients of services. Failure to validate emotional and behavioralproblems in youths could allow treatable concerns to worsen and possibly developinto more serious difficulties and disrupted development. Additionally, inappropri-ate diagnostic labels can stigmatize children or create self-fulfilling prophecies, iat-rogenically complicating their difficulties (Martin et al., 1998). This may beespecially true for those with conduct problems. Aggressive and delinquent youthsnegatively labeled by parents and teachers may even attract the attention of lawenforcement agencies. For these young clients, accurate diagnoses seem especiallycrucial for their improved functioning and healthy development.

This study presents an exploratory, naturalistic investigation of the assignment ofthe DSM conduct disorder diagnosis given to youths in three types of residentialtreatment settings and the relationship of diagnoses with the externalizing behaviorsof those youths during their first three months of residence. The conduct disorderdiagnosis is used to identify children and adolescents with ‘‘a repetitive and persistentpattern of behavior in which the basic rights of others or major age-appropriatesocietal norms are violated’’ which ‘‘causes clinically significant impairment in social,academic, or occupational functioning’’ (American Psychiatric Association, 1994, p.85). Behaviors included in this diagnosis include aggression toward people and ani-mals, destruction of property, deceitfulness or theft, and serious violations of rules.This study will assess the extent to which those youths given the CD diagnosis conformto this profile of behaviors, as determined by the ratings of child care workers andguardians working very closely with them on a daily basis. Additionally, the study willattempt to identify biases in the use of the DSM diagnosis of conduct disorder withyoung residential treatment clients. This type of study offers a glimpse of the natureand quality of diagnostic practices in non-experimental, real world settings. A greaterunderstanding of the relationship of diagnoses made by clinicians in the field and theirclients’ behaviors may benefit the decision-making of admissions personnel and directservice practitioners working with children and youths in residential facilities.

Methods

Because methods used in studies of diagnostic reliability and validity using the DSMhave been criticized (see Kirk & Kutchins, 1992), and also because these studies

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employ statistics not often used in other kinds of social science research, discussionregarding the data collection and statistical analytic procedures used in this study isprovided below.

Sample

This investigation is part of the largest study of children and adolescents in residentialtreatment conducted in the United States, the Odyssey Project, sponsored by theChild Welfare League of America and its member agencies. The aims and methods ofthis study are described elsewhere (Curtis, Alexander, & Lunghofer, 2001). TheOdyssey Project sample is a convenience sample of those children and adolescentsadmitted to participating study agencies who agreed to participate in the study and,among the youths under 18 years of age, for whom the informed assent and informedconsent of a caretaker or legal guardian was obtained. The sampling frame is drawnfrom 2,487 boys and girls receiving care in one of the three types of CWLA-affiliatedresidential settings: residential group care, group homes, and therapeutic foster care.The present study sample (N = 1,173) includes participants from this larger samplewith complete data collected on all on study variables. The present study sample wascomposed of 775 boys (66.1%) and 398 girls (33.9%). The mean age was 13.3, themedian was 14.0, and the modal age was 15 (19.7%); the age range was 3–20.

Participants were predominantly white (N = 557, 47.5%), followed by African–Americans (N = 337, 28.7), and Hispanic (N = 134, 11.4%). Seventy–five youthsdescribed themselves as biracial (6.4%), while 58 Native Americans constituted4.9% of the sample. Information regarding participants’ social class or family incomewas not available. This sample is highly similar to the larger Odyssey Project samplein regard to gender (boys 64.7%, girls 35.3%), age (mean 13.15, median 14, mode 15,range 3–20), and race (White 49.2%, African–American 30.3%, Hispanic 9.6%,biracial 6.1%, Native American 3.6%). The twenty-four CWLA member agenciesthat participated in the Odyssey Project were located in a number of regions in theUnited States, including the Northeast (Maine, New York State, Massachusetts,New Jersey, Pennsylvania), the Midwest (Ohio, Indiana, Illinois, North Dakota,Missouri, and Kentucky), the Pacific Northwest (Washington and Oregon), theSouthwest (Arizona), and the MidAtlantic (Maryland).

Diagnoses

Diagnoses were given to study participants following routine agency diagnosticinterviews held during the first month of the youths’ residence. Diagnostic interviewsincluded the diagnosing practitioner, the youth and, in some cases, the youth’sparent(s) or guardian(s). DSM-IV Axis I diagnoses given to study participants wereabstracted from participants’ files. Interviewers included psychiatrists, psychologists,social workers, and practitioners with other master’s and bachelor’s degrees.

Assessment of Behaviors

Ratings of externalizing behavior levels are derived from the Aggressive Behaviorand Delinquent Behavior subscales of the Achenbach Child Behavior Checklist(Achenbach, 1991), a survey of the most common problem behavior syndromes ofchildren and adolescents. The CBCL has excellent psychometric properties includ-

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ing test-retest reliability, inter-rater agreement between mothers and fathers of bothclinical and general populations, long-term stability of scores, and content, construct,and criterion-related validity. Cross-cultural validation has also been established(Achenbach, 1991). The Aggressive and Delinquent subscales are used as thebehavioral criteria against which the diagnoses were assessed. Experimental vali-dation studies have shown good convergence between the CD diagnosis and theCBCL Aggressive and Delinquent subscales (Beiderman et al., 1993; Bird et al.,1987; Bird, Gould, Rubio-Stipec, Stagezza, & Canino, 1991; Edelbrock & Costello,1988; Jensen, Salzberg, Richters, & Watanabe 1993; Kazdin & Heidish, 1984).Respondents on the CBCL were child care workers for children in residentialtreatment and guardians for children in foster care who were with them on a dailybasis and were very familiar with the behaviors of the study participants.

Data Analysis

Kraemer’s (1992) model for evaluating the accuracy of diagnoses was employed inthis study. Descriptive statistics used include prevalence (P)–the proportion of studyparticipants given the conduct disorder diagnosis, level (Q)–the proportion of studyparticipants reaching the clinical level of aggressive and delinquent behaviors on theCBCL, sensitivity (SE)–the proportion of those study participants given the CDdiagnosis who are also at the clinical level on the CBCL, and specificity (SP)–theproportion of those study participants who were not given the CD diagnosis who alsodid not reach the clinical level on the CBCL. Sensitivity and specificity scores havebeen used for many years in studies of diagnostic accuracy. However, both sensitivityand specificity scores are modified by behavior level (Q) scores, and so comparisongroups with unequal Q scores cannot be validly compared using these measures(Kraemer, 1992). To remedy this, kappa coefficients, j (1,0) for sensitivity and j (0,0)for specificity, are used to enable comparisons between subgroups with dissimilarlevels of externalizing behaviors (Kraemer, 1992), and this approach was employedin this study. Benchmark standards for evaluating kappa values developed andadopted by psychometric researchers were used to nominally categorize and com-pare scores: above 80% representing ‘‘almost perfect’’ agreement, 60–80% ‘‘sub-stantial’’ agreement, 40–60% ‘‘moderate,’’ 20–40% ‘‘fair,’’ and below 20% ‘‘slight’’or ‘‘poor’’ (Landis & Koch, 1977). T scores from the Aggressive Behavior andDelinquent Behavior subscales of the CBCL were used to allow comparison be-tween the subscales. The ‘‘borderline clinical’’ cut point, a T score of 67 on theCBCL, was used to differentiate study participants with problematic aggressive anddelinquent behaviors from those without these behavior patterns. Statistical differ-ences among subgroup rates were tested using the z statistic (Moore & McCabe,1998), using .05 p as the threshold value for significance.

To determine the extent to which the conduct disorder diagnosis correspondedwith youths’externalizing behaviors, and to identify possible biases in the assignationof the CD diagnosis, the following analyses were performed:

1. Correspondence of the diagnosis of conduct disorder and aggressive, delinquent,and externalizing problem behavior syndromes. Sensitivity levels and kappaswere calculated to assess the strength of the association of a CD diagnosis andstudy participants’ scores on CBCL aggressive, delinquent, and externalizingscales. A z test was used to test for significant differences between proportions.

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2. Correspondence of the diagnosis of conduct disorder and aggressive, delinquent,and externalizing problem behavior syndromes by youths’ gender and race. Studyparticipants were categorized by gender and by self-identified race. Sensitivity,specificity, and kappas were calculated to assess the strength of the association ofthe CD diagnosis and aggressive, delinquent, and externalizing subscales. A z testwas used to test for significant differences between proportions.

Results

Prevalence of the Conduct Disorder Diagnosis and Levels of Conduct Problems

The overall prevalence of the CD diagnosis was 29.2% among study participants.However, a significantly higher proportion of study participants were in the clinicalrange of the aggressive and delinquent scales of the CBCL (37.8% and 56.1%,respectively). A majority of the youths in the study were in the clinical range ofeither or both the aggressive and delinquent scales of the CBCL (62.1%). Most ofthese were in the clinical range for both aggression and delinquency (N = 373, 31.8%overall). About one-quarter of the sample were clinically delinquent only (N = 285,24.3%), and 6.0% were clinically aggressive only (N = 70) (see Table 1).

Association of CD and Levels of Aggression and Delinquency

About one-third of youths given the CD diagnosis were in the clinical range foraggression (SE = 33.9%). The kappa value for sensitivity was negative (–6.3%),indicating a very poor concordance of the diagnosis and clinical level aggression. Thekappa for specificity was negative (–4.2%), indicating that those youths without theCD diagnosis were often in the clinical range on the aggression scale. On thedelinquent scale, the kappa for sensitivity was 12.8% (poor) and for specificity it was4.1% (poor). The proportion of youths with diagnoses other than a CD diagnosiswho were in the clinical range of the delinquency scale was more than twice that ofyouths with the diagnosis who were clinically delinquent (38.1% vs. 18.0%).

Table 1 Overall prevalence of the conduct disorder diagnoses, levels of CBCL externalizingbehavior syndromes, and the correspondence of a CD diagnosis and externalizing behaviorsyndromes

P Q SE j (1,0) SP j (0,0)

Aggressive 29.2% 37.8% 33.9% –6.3% 60.6% –4.2%Delinquent 29.2% 56.1% 61.7% 12.8% 46.2% 4.1%

Aggressive P versus Q p < .0001

Delinquent P versus Q p < .0001

Aggressive Q versus Delinquent Q p < .0001

P = Prevalence (% diagnosed with CD)

Q = Level (% in the CBCL clinical range)

SE = Sensitivity (% diagnosed with CD in the CBCL clinical range)

j (1,0 ) = Kappa for sensitivity (improvement over chance given level of CBCL behavior)

SP = Specificity (% not diagnosed with CD below CBCL clinical range)

j (0,0) = Kappa for specificity (improvement over chance given level of CBCL behavior)

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CD and Clients’ Gender and Race

Participants’ gender and race were associated with clinicians’ use of the conductdisorder diagnosis. Boys more often were assigned the CD diagnosis (35.4% vs.17.1%, p < .0001). However, girls were significantly more often in the clinical rangefor both the aggressive (41.2% vs. 36.0%, p < .0002) and delinquent (58.0% vs.55.1%, p = .0262) scales. Whites least often were given the CD diagnosis (24.4%).Hispanics were most likely to be assigned the CD diagnosis (43.3%), and theprevalence of the diagnosis among African–American youths was between Whitesand Hispanics (34.4%). Differences among the three racial groups were statisticallysignificant (p < .0001 for each comparison) (see Table 2).

Among both boys and girls, White youths least often received the CD diagnosis.White girls were less often assigned the CD diagnosis than African–American girlsand were approximately three times less often diagnosed with CD compared toHispanic girls. The disparity in the prevalence of the CD diagnosis among the boysin the three racial groups was more modest, but White boys were significantly lessoften given the diagnosis (p < .0001), while virtually equal proportions of African–American and Hispanic boys were diagnosed with CD.

While White boys and girls were given the CD diagnosis least often, they wereequally as often or more often in the clinical range on the CBCL aggressive scalecompared with their same gender African-American and Hispanic peers. Approxi-mately equal proportions of White boys (38.5%) and Hispanic boys (36.8%) wereclinically aggressive, and White boys were proportionately more clinically aggressivethan African–American boys (34.1%, p < .0001). Levels of clinically aggressivebehavior were equal for White girls (45.1%) and African–American girls (45.5%),while proportionately fewer Hispanic girls were in the clinical range for aggressivebehaviors (20.5%). Among boys, Hispanic youths were most often in the clinicalrange of the delinquency scale (61.1%). Equal proportions of White boys andAfrican–American boys were in the clinical range. Among girls, African–Americanyouths were most often clinically delinquent. Hispanic girls were least often clini-cally delinquent, and the level of delinquent behaviors for white girls was betweenthat of African–American girls and Hispanic girls.

All sensitivity and specificity kappas were below 20% with two exceptions: thesensitivity kappas for white and African–American girls for delinquency (50.0%[moderate concordance] and 28.7% [fair concordance], respectively). All otherassociations between the given conduct disorder diagnosis and clinical levelaggressive and delinquent behaviors were in the poor range or negative.

Discussion

These analyses reveal a number of findings regarding the relationship of theassignment of the DSM-IV conduct disorder diagnosis to youths in these residentialtreatment settings and the externalizing behaviors of youths during the first threemonths of their residence in these facilities. Almost 30% of study participants weregiven the CD diagnosis, suggesting the extent to which diagnosing practitionersviewed these residents as having persistent patterns of serious and potentially dis-ruptive and harmful behaviors. However, many fewer youths were diagnosed withCD than were determined by their caretakers to have clinical level aggressive, and inparticular, delinquent problems.

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The conduct disorder diagnosis was not strongly correlated with the level ofconduct problems exhibited by youths in this study. The correspondence of theassignment of the CD diagnosis and youths’ externalizing behaviors in residence wasgenerally poor (kappa values under 20%) or in the negative range. Many of youths

Table 2 Prevalence of the DSM-IV conduct problem diagnoses and level, sensitivity, specificity, andquality indices for CD and CBCL aggressive and delinquent scales by race and gender of studyparticipants

P (%) Q (%) SE (%) j (1,0)(%) SP (%) j (0,0)(%)

Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls

AggressiveWhite 29.6 13.1 38.5 45.1 30.1 47.8 13.7 4.9 58.0 55.3 –9.1 0.89Af-Am 43.5 18.7 34.1 45.5 36.6 39.1 4.0 –11.7 67.8 53.0 5.6 –3.3Hispanic 45.3 38.5 36.8 20.5 34.9 26.7 –3.0 7.8 61.5 83.3 –4.6 18.5

BoysWhite P versus African–American P p < .0001White P versus Hispanic P p < .0001White P versus White Q p < .0001African–American P versus African–American Q p < .0001Hispanic P versus Hispanic Q p = .0084White Q versus African-American Q p < .0143

GirlsWhite P versus African-American P p < .0001White P versus Hispanic P p < .0001African–American P versus Hispanic P p < .0001White P versus Q p < .0001African–American P versus Q p < .0001Hispanic P versus Q p < .0001White Q versus Hispanic Q p < .0001African–American Q versus Hispanic Q p < .0001

DelinquentWhite 29.6 13.1 55.0 56.6 58.4 78.3 7.4 50.0 46.5 46.7 0.90 5.8Af-Am 43.5 18.7 56.1 63.4 60.2 73.9 9.3 28.7 47.1 39.0 5.7 3.8Hispanic 45.3 38.5 61.1 51.3 65.1 53.3 10.3 4.1 42.3 50.0 5.6 2.5

BoysWhite P versus Q p < .0001African–American P versus Q p < .0001Hispanic P versus Q p < .0001White Q versus African–American Q nsWhite Q versus Hispanic Q p = .0158African American Q versus Hispanic Q p = .0495

GirlsWhite P versus White Q p < .0001African–American P versus Q p < .0001Hispanic P versus Q p < .0113White Q versus African–American Q p = .0082White Q versus Hispanic Q p = .0158African–American Q versus Hispanic Q p = .0029

SubsamplesBoys Girls

Whites 382 175African–American 214 123Hispanic 95 39

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labeled with CD were neither clinically aggressive nor clinically delinquent. Addi-tionally, many youths without the CD diagnosis were rated as clinically aggressiveand delinquent. With the exception of the clinical level delinquent behaviors ofWhite and African–American girls, the CD diagnosis was not useful in identifyingthose youths who were behaviorally problematic, and for those girls the diagnosiswas at best only moderately associated. Further, the CD diagnosis failed to screenout many youths who were not given the diagnosis but were clinically aggressive and/or delinquent in residence.

The finding of a generally weak relationship between the assignment of CD andthe behaviors of the diagnosed was reinforced by the analysis of relationship of theuse of the CD diagnosis and youths’ gender. Boys were significantly more oftengiven the diagnosis than girls, while girls were more clinically aggressive anddelinquent. While the level of conduct problems is thought to be higher among boysthan girls in the general population (American Psychological Association, 1994),research has suggested that among clinical populations this difference may be muchsmaller or nonexistent (Zoccolillo, Tremblay, & Vitaro, 1996). The current findingssuggest that the levels of conduct problems among girls in residential treatment aregreater than estimated by previous research.

Analysis of diagnosis and client race also exposed problems with the use of theCD label. Whites of both genders were given the diagnosis substantially less oftenwhile they were most often clinically aggressive. Hispanic girls, most often diagnosedwith CD among girls, were least often aggressive and delinquent compared withother girls. The generally poor or negative sensitivity and specificity kappa valuesfound here suggest that in many cases of youths without externalizing behaviorproblems, the assigned CD diagnosis may not have been warranted.

This exploratory study was designed to identify the strength of association be-tween diagnosis and behavior among these study residents. This study was not de-signed to ascertain the decision-making processes of these diagnosticians, andinferences about their judgment cannot be drawn from these data. However, thedifferences in the assignment of the CD based on the gender and race of studyparticipants, and the discrepancies between the prevalence of the CD diagnosis andthe levels of conduct disorder among boys and girls and Whites and youths of colorsuggest that these client characteristics may have played some role in diagnosisassignment. Additional studies, using qualitative and protocol analytic approaches,are needed to develop more complex understandings of practitioners’ decision-making processes used when assigning diagnoses to diverse clients.

While these findings can be generalized only in a limited way, they suggest thatdiagnoses may not serve as useful predictors of incoming clients’ behaviors whilethey are in their first few months of residence. The findings are consistent with recentstudies that indicate that diagnoses made without information regarding youths’social contexts have limited reliability and validity (Hsieh & Kirk, 2003; Kirk &Hsieh, 2004; also see Wakefield, Pottick, & Kirk, 2002). Diagnoses may be morevalid if they include information such as that provided by dimensional behavioralinstruments such as the CBCL and other dimensional behavior measures (Rubio-Stipec, Walker, Murphy, & Fitzmaurice, 2002). This kind of information may beprovided by child care workers, caregivers, parents/guardians, and foster parentswho interact with clients intensively and have nuanced knowledge of their behaviorpatterns and the social contexts in which they occur. More field-based research ondiagnostic practices may help to establish the extent to which DSM diagnoses may

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be relied upon for admissions and other program-level and clinical decisions as wellas the ways in which these diagnoses adequately serve as foundations for sensitiveand effective interventions and care.

Acknowledgments The authors wish to thank the Child Welfare League of America for theirsupport of this project and their technical assistance, especially Alicia Drais-Parillo; and the Centerfor the Study of Social Work Practice, a joint program of the Jewish Board of Family and Children’sServices and Columbia University School of Social Work. The authors also wish to acknowledge EdMullen, Stuart Kirk, Peg Hess, and Christina Hoven for their thoughtful comments on an earlierversion of this study.

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Diagnosing Conduct Problems of Children and Adolescents in Residential Treatment

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