Conduct disorder (CD) is a serious mental health

Conduct disorder (CD) is a serious mental health concern
that is associated with repetitive patterns of behavior including violating
others, aggression towards people and animals, deceitfulness, criminal
behavior, and violation of rules (Frick, 2016). Conduct disorder affects youth
of many races and ages. CD can be detrimental for an adolescent’s development
and it can be even worse if a child is mistakenly diagnosed with CD. An
adolescents cultural background has a large impact on the expression and
interpretation of CD symptoms and the DSM-IV has not yet formally incorporated these
factors into the criteria of CD, making it extremely difficult for a clinician
to differentiate the behaviors caused by negative environments and those
behaviors that are caused by internal dysfunction (Canino, Polanczyk,
Bauermeister, Rohde & Frick, 2010). Minorities and individuals in poor
countries often have many environmental disadvantages such as, poorer prenatal
care and infantile nutrition, higher rates of exposure to toxins, and tend to
live in impoverished neighborhoods with high rates of crime, exposing youth to
other stressful situations (Canino et al., 2010).

Prevalence rates of CD across cultures might be affected by
cultural factors. Canino et al. (2010) suggest that CD symptoms and what is
considered dysfunctional, are tolerated very differently across many cultures. Aggression,
anger, and strong emotions are viewed and interpreted differently and even
manifest itself in many different ways across many cultures, so these
differences may lead parents to have a lower a threshold for these behaviors
while those in different cultures are more accepting of these behaviors (Canino
et al., 2010). This indicates that while the prevalence of CD is low in other
cultures, the expression of CD manifests itself so differently from Western
Cultures that it becomes difficult to diagnose CD in other cultures when the
diagnostic criteria for CD so imbedded in Western cultural ideals. Canino et
al. (2010) claims that these cultural differences in the expression of CD come
from differences in how individuals internalize or externalize syndromes, like
how people in Asian cultures tend to internalize syndromes compared to Western
countries where many individuals tend externalize syndromes. While many
cultures express CD symptoms differently, the DSM doesn’t capture these
differences adequately and therefore leads to lower prevalence rates in non-Western
cultures (Canino et al., 2010). The DSM should offer different contexts of CD
expression and include how the meaning of symptom expression changes across
cultures, ethnicity, and developmental stages (Canino et al., 2010).

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There are many factors that protect youth from expressing CD
symptoms. Protective factors of CD include positive family environments that
help prevent disruptive disorders (Canino et al., 2010) and religion which
helps foster conventional behavior (Pearce, Jones, Schwab-Stone
& Ruchkin, 2003). These protective factors can be helpful cross-culturally,
one study found that close family attachments and family monitoring in Puerto
Rico led to lower rates of CD symptoms in youth (Canino et al, 2010). Researchers
have not been able to detangle how the prevalence rates of CD in poor/minority
backgrounds are affected by the environmental disadvantages or whether the
differences in culture are due to these protective factors (Canino et al.,
2010).  Engagement in private religious
practices were associated with a decrease in CD problems, while church
attendance had no effect on CD problems (Pearce et al., 2003), this could be
due to the internalization of private religious practices. Pearce et al. (2003)
claim that religion moderates the negative effects of environmental exposure to
violence due to either the social learning theory that claims that behavior is
taught through social influences or parental involvement in which parental
attachment is the initial experience that leads to acceptance of conventional beliefs
which in turn leads to conventional behavior.

There are many issues that
play a role in the biases in the diagnosis of CD. One of the many is that there
are disproportionately high rates of CD diagnoses in youth of color, specifically
urban, low-income adolescents of Latino or African American backgrounds (Mizok
& Harkins, 2011). Mizok & Harkins (2011) found that African American
children were 2.4 times more likely to be diagnosed with CD and the racial
proportions of adolescents diagnosed are 43.3% Latino, 34.4% African American,
and 24.4% White American. These statistics clearly indicate that there are
biases playing a role in the diagnoses of CD. Historically diagnostic biases
have influenced the over diagnoses of many disorders: African Americans have
been over diagnosed with Schizophrenia, and have been diagnosed more frequently
with severe behavior disturbance disorders, while their White counterparts have
been diagnosed with more mild adjustment disorders (Mizok & Harkins, 2011).
Latinos have also been over diagnosed with depression (Mizok & Harkins,
2011). But, Mizok and Harkins (2011) also found that CD specifically has been particularly
over diagnosed among individuals of color.

Mizok & Harkins explore possible
biases that could be responsible for the disproportionate over diagnoses of CD.
First, they describe that therapists may be interpreting disruptive and
aggressive symptoms of African American children differently than they
interpret the same symptoms in White Americans, affecting the diagnoses and
treatment given because these clinicians may have stereotypes towards people of
color (Mizok & Harkins, 2011). Clark (2003) describes how African American
youth are often misunderstood which leads to misdiagnosis of behavior. Clinicians
often label African Americans as aggressive based on their communication styles
and how they dress and walk, which leads to misdiagnosis of CD (Clark, 2003). African
American families also emphasize the use of physical punishment over
psychological punishment, also parental values and practices in African
American families tend to focus on interdependence, security, group effort, and
perseverance which in turn impacts how African American youth respond to
treatment (Clark, 2003).

Conduct disorders may be
diagnosed while problems with anxiety or mood are overlooked; CD is often accompanied
by several of these problems which leads to the suggestion that youth may be
expressing conduct problems as a behavioral response to these underlying
problems as opposed to these behaviors being a sign of underlying antisocial behavior
implied by CD diagnoses (Mizok & Harkins, 2011). African Americans are more
often diagnosed with CD while their White peers are more often diagnosed with
ADHD for the same symptoms (Clark, 2007). There needs to be consistency between
clinicians diagnosing CD, including cultural specific strategies in the
classroom because schools often fail to help children with CD, especially those
of color (Clark, 2007).

These biases that cause the
over diagnosis in youth of color have a long-lasting negative impact on these
individuals. These individuals are more likely to be hospitalized, less likely
to receive appropriate treatment, and face stigmas that are associated with CD
(Mizok & Harkins, 2011). Also, in treatment, the therapists tend to make
pessimistic predictions towards the recovery of minorities with CD, which may
lead to less effective treatment from these mental health providers (Mizok
& Harkins, 2011).

In the juvenile justice
system, adolescents of color diagnosed with CD are more likely to be
transferred to adult court and tend to receive longer sentences than their
White American peers (Mizok & Harkins, 2011). Youth that are diagnosed with
CD represent about 40% of those involved in the juvenile justice system and
many of these individuals of color are more likely to receive harsher treatment
(Mizok & Harkins, 2011). Once in the juvenile justice system, youth of
color face many racial disparities and are greatly overrepresented in detention
centers and are more frequently arrested for minor offenses than white youth
who commit the same offenses (Mizok & Harkins, 2011). Mizok and Harkins
(2011) believe that the subjective risk assessment procedures are responsible
for these racial disparities in the juvenile justice system.

Mizok
& Harkins (2011) suggest that clinicians shouldn’t give a CD diagnosis if
the conduct problems are a response to a negative environment, which youth of
color are more likely to experience disparities in environmental stressors due
to higher rates of poverty and racial discrimination. These negative
environmental factors may contribute to conduct problems but, a possible way to
prevent these factors from influencing CD diagnosis is to encourage clinicians
to include a more thorough assessment of these environmental factors (Mizok
& Harkins, 2011). Another factor that may be influencing the over diagnosis
of CD is socioeconomic status (SES), because low SES has been linked with to
the expression of CD problems in youth of color (Mizok & Harkins, 2011).
Diagnostic consideration to assess the stressors associated with poverty and exposure
to violence in the environment should be implemented, because these factors along
with a lower SES can decrease the amount of children experiencing these problems
to be diagnosed with CD when environmental factors are taken into consideration
(Mizok & Harkins, 2011). Exposure to violence is also highly associated
with the expression of CD and are precursors in the development of violent
behavior among youth of color particularly, and further highlights the need for
clinicians to consider the environmental context of the youth’s life before
diagnosing with them CD (Mizok & Harkins).

Having
experiences with racism also may lead to expression of CD problems in youth of
color: racial discrimination among teachers and peers influences academic
performance which in turn contributes to CD problems and is actually one of the
most significant contributors to CD symptom expression (Mizok & Harkins,
2011). Therefore, consideration of academic discrimination may help the clinician
to differentiate CD problems from a CD disorder and may therefore reduce racial
disparities in CD diagnoses (Mizok & Harkins, 2011).

Mizok
and Harkins (2011) give a few ideas on how to reduce the over diagnosis of CD
and the negative outcomes associated with it. Clinicians should undergo further
training to reduce the various barriers influencing over diagnosis of CD and to
improve the effectiveness of treatment such as, implementation of and availability
of culturally sensitive diagnostic tools, clinician training on cultural
competence, and clinician training to better understand how
race, SES and environmental factors influence the diagnosis of CD (Mizok &
Harkins, 2011). Mizok and Harkins (2011) also believe that diagnostic revisions
are needed in order to reduce the biases in diagnosing CD by helping the clinician
consider environmental stressors. In the DSM-V, clinicians may be overlooking
the information following the criteria for CD that described the environmental
factors associated with CD symptoms and also describes that CD shouldn’t be
diagnosed if CD symptoms are a response to those environmental factors (Mizok
& Harkins, 2011). Future research is needed to have a deeper understanding
of how CD is associated with environmental stressors and the impact that these
biases from clinicians leave on youth of color, and to develop strategies to
improve the diagnostic assessment of CD (Mizok & Harkins, 2011). Frick
(2016) describes the benefit of Parent Management Training (PMT) for families experiencing
CD, and suggests that the development of structured contingency management
programs that alter the child’s behavior at home along with improvement of parent-child
interactions with effective discipline strategies are important treatments for
youth with CD. Family interventions at an early stage is important in
preventing possible later aggression and antisocial behaviors, however the
youth must already be expressing serious conduct problems for treatment to be
as effective as possible (Frick, 2016).

In
conclusion, CD has been disproportionally over diagnosed in youth of color due
to several cultural and racial biases such as, a clinician’s lack of cultural
competency, a clinicians misunderstanding of how CD symptoms express themselves
in different cultures, and stereotypes that affect the diagnosis and treatment
of CD. Clinicians may mislabel youth of color with a CD diagnosis which leaves
long-lasting negative impacts on those youth. Once diagnosed with CD, youth of
color further experience many forms of stigmas in many different systems,
especially the juvenile justice system. There are many different ideas on how
to combat these biases such as, improving DSM-IV to include cultural expressions
of symptoms, to reiterate that CD shouldn’t be diagnosed when environmental
factors are at play, and implementing further cultural competency training for
clinicians who frequently diagnose CD.