Harvard Mental Health Letter

In Brief: Uncovering diagnostic biases

In Brief

Uncovering diagnostic biases

Mental health professionals presented with a realistic, brief, fictional case history describing a troubled young man provided diagnoses that varied with the age and theoretical orientation of the clinician, the race of the client or patient, and the social context in which the case history was presented.

Nearly 1,400 psychiatrists, psychologists, and social workers, a representative professional sample, participated in the study. Researchers mailed each of them one of three case vignettes describing a boy with typical symptoms of conduct disorder: persistent behavior violating social norms and the rights of others, including deceit, theft, aggression, and rule violations like truancy and running away from home. Conduct disorder was chosen because it is the most common reason for referring adolescents for treatment.

In some case histories the young man was described as white, in others as black or Hispanic. The vignettes took one of three forms, depending on whether the symptoms were described as an internal problem or a reaction to a destructive environment. In a basic, neutral version, the researchers supplied only a description of the symptoms and information on the age, sex, and ethnic background of the patient. An "internal dysfunction" version included an added paragraph stating that the behavior appeared irrational, was indiscriminate, persisted when the environment changed, and suggested a lack of empathy or concern for the consequences. An "environmental reaction" version included a different paragraph suggesting that the young man lived in a dangerous neighborhood pervaded with gang violence and that his behavior changed when he left that neighborhood.

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