Spencer C. Evans

Vignette methodologies for studying clinicians’ decision-making: Validity, utility, and application in ICD-11 field studies ☆

Vignette-based methodologies are frequently used to examine judgments and decision-making processes, including clinical judgments made by health professionals. Concerns are sometimes raised that vignettes do not accurately reflect “real world” phenomena, and that this affects the validity of results and conclusions of these studies. This article provides an overview of the defining features, design variations, strengths, and weaknesses of vignette studies as a way of examining how health professionals form clinical judgments (e.g., assigning diagnoses, selecting treatments). As a “hybrid” of traditional survey and experimental methods, vignette studies can offer aspects of both the high internal validity of experiments and the high external validity of survey research in order to disentangle multiple predictors of clinician behavior. When vignette studies are well designed to test specific questions about judgments and decision-making, they can be highly generalizable to “real life” behavior, while overcoming the ethical, practical, and scientific limitations associated with alternative methods (e.g., observation, self-report, standardized patients, archival analysis). We conclude with methodological recommendations and a description of how vignette methodologies are being used to investigate clinicians’ diagnostic decisions in case-controlled field studies for the ICD-11 classification of mental and behavioural disorders, and how these studies illustrate the preceding concepts and recommendations

Psychologists’ perspectives on the diagnostic classification of mental disorders: Results from the WHO-IUPsyS Global Survey

This study examined psychologists’ views and practices regarding diagnostic classification systems for mental and behavioral disorders so as to inform the development of the ICD-11 by the World Health Organization (WHO). WHO and the International Union of Psychological Science (IUPsyS) conducted a multilingual survey of 2155 psychologists from 23 countries, recruited through their national psychological associations. Sixty percent of global psychologists routinely used a formal classification system, with ICD-10 used most frequently by 51% and DSM-IV by 44%. Psychologists viewed informing treatment decisions and facilitating communication as the most important purposes of classification, and preferred flexible diagnostic guidelines to strict criteria. Clinicians favorably evaluated most diagnostic categories, but identified a number of problematic diagnoses. Substantial percentages reported problems with crosscultural applicability and cultural bias, especially among psychologists outside the USA and Europe. Findings underscore the priority of clinical utility and professional and cultural differences in international psychology. Implications for ICD-11 development and dissemination are discussed.

Disorders specifically associated with stress: A case-controlled field study for ICD-11 mental and behavioural disorders

As part of the development of the Eleventh Revision of International Classification of Diseases and Related Health Problems (ICD-11), the World Health Organization Department of Mental Health and Substance Abuse is conducting a series of case-controlled field studies using a new and powerful method to test the application by clinicians of the proposed ICD-11 diagnostic guidelines for mental and behavioural disorders. This article describes the case-controlled field study for Disorders Specifically Associated with Stress. Using a vignette-based experimental methodology, 1,738 international mental health professionals diagnosed standardized cases designed to test key differences between the proposed diagnostic guidelines for ICD-11 and corresponding guidelines for ICD-10. Across eight comparisons, several proposed changes for ICD-11, including the addition of Complex PTSD and Prolonged Grief Disorder, produced significantly improved diagnostic decisions and clearer application of diagnostic guidelines compared to ICD-10. However, several key areas were also identified, such as the description of the diagnostic requirement of re-experiencing in PTSD, in which the guidelines were not consistently applied as intended. These results informed specific revisions to improve the clarity of the proposed ICD-11 diagnostic guidelines. The next step will be to further test these guidelines in clinic-based studies using real patients in relevant settings.

An empirically based alternative to DSM-5's disruptive mood dysregulation disorder for ICD-11

The World Health Organization (WHO)s priorities for the development of the classification of mental and behavioural disorders in the ICD-11 include increasing its clinical utility in global mental health settings (1) and improving the identification and diagnosis of mental disorders among children and adolescents (2). An issue that has been hotly debated in the area of childhood psychopathology is the assessment, diagnosis and treatment of children with severe irritability and anger (3,4). Although virtually all children display irritable and angry behaviours at times, some children exhibit them more frequently and more intensely, to the extent that they become an impairing form of emotional dysregulation. Recent findings indicate that these children with chronic and severe irritability/anger have not been adequately identified through existing classification systems, are at an increased risk for particular negative outcomes, and have not received appropriate treatment. To the extent that ICD-11 can help clarify the clinical picture of irritability/anger, children and families will benefit from more accurate diagnoses, more useful prognoses, and more effective interventions. This paper provides a brief overview of the issue, followed by several possible options and the current proposal for the classification of childhood irritability/anger in ICD-11. This proposal represents a markedly different – but we believe more scientifically justifiable – solution to the problems in this area than that selected for DSM-5 (5).

Searching the scientific literature: Implications for quantitative and qualitative reviews

Literature reviews are an essential step in the research process and are included in all empirical and review articles. Electronic databases are commonly used to gather this literature. However, several factors can affect the extent to which relevant articles are retrieved, influencing future research and conclusions drawn. The current project examined articles obtained by comparable search strategies in two electronic archives using an exemplar search to illustrate factors that authors should consider when designing their own search strategies. Specifically, literature searches were conducted in PsycINFO and PubMed targeting review articles on two exemplar disorders (bipolar disorder and attention deficit/hyperactivity disorder) and issues of classification and/or differential diagnosis. Articles were coded for relevance and characteristics of article content. The two search engines yielded significantly different proportions of relevant articles overall and by disorder. Keywords differed across search engines for the relevant articles identified. Based on these results, it is recommended that when gathering literature for review papers, multiple search engines should be used, and search syntax and strategies be tailored to the unique capabilities of particular engines. For meta-analyses and systematic reviews, authors may consider reporting the extent to which different archives or sources yielded relevant articles for their particular review.

Self-reported emotion reactivity among early-adolescent girls: evidence for convergent and discriminant validity in an urban community sample

Emotion reactivity, measured via the self-report Emotion Reactivity Scale (ERS), has shown unique associations with different forms of psychopathology and suicidal thoughts and behaviors; however, this limited body of research has been conducted among adults and older adolescents of predominantly White/European ethnic backgrounds. The present study investigated the validity of ERS scores for measuring emotion reactivity among an urban community sample of middle-school-age girls. Participants (N = 93, ages 11-15, 76% African-American, 18% Latina) completed the ERS and measures of emotion coping, internalizing problems, proactive and reactive aggression, negative life events, and lifetime suicidal ideation and substance use. As hypothesized, ERS scores were significantly associated with internalizing problems, poor emotion coping, negative life events, reactive aggression, and suicidal ideation (evidence for convergent validity), but showed little to no association with proactive aggression or lifetime substance use (evidence for discriminant validity). A series of logistic regressions were conducted to further explore the associations among internalizing problems, emotion reactivity, and suicidal ideation. With depressive symptoms included in the model, emotion reactivity was no longer uniquely predictive of lifetime suicidal ideation, nor did it serve as a moderator of other associations. In conjunction with previous research, these findings offer further support for the construct validity and research utility of the ERS as a self-report measure of emotion reactivity in adolescents.

Advancing the Scientific Foundation for Evidence-Based Practice in Clinical Child and Adolescent Psychology

Evidence-based practice (EBP) has become a central focus in clinical child and adolescent psychology. As originally defined, EBP in psychology is the integration of the best available research evidence, patient characteristics, and clinical expertise. Although evidence-based perspectives have garnered widespread acceptance in recent years, there has also been some confusion and disagreement about the 3-part definition of EBP, particularly the role of research. In this article, we first provide a brief review of the development of EBP in clinical child and adolescent psychology. Next, we outline the following 4 points to help clarify the understanding of EBP: (a) knowledge should not be confused with epistemic processes, (b) research on clinician and client factors is needed for EBP, (c) research on assessment is needed for EBP, and (d) the 3-part conceptualization of EBP can serve as a useful framework to guide research. Based on these principles, we put forth a slightly revised conceptualization of EBP, in which the role of research is expanded and more clearly operationalized. Finally, based on our review of the literature, we offer illustrative examples of specific directions for future research to advance the evidence base for EBP in clinical child and adolescent psychology.

Associations Between Proactive and Reactive Subtypes of Aggression and Lifetime Substance Use in a Sample of Predominantly Hispanic Adolescents

The current study evaluated the link between proactive (goal-oriented) and reactive (behavior in response to a perceived threat) aggression and lifetime alcohol, tobacco, and marijuana use in a sample of 152 predominantly Hispanic (94.7%) high school students. Furthermore, the impact of neighborhood violence and gender invariance on these associations were examined. Findings suggested unique associations between proactive, not reactive, aggression and use of all three substances. No significant interactions between the aggression subtypes and neighborhood violence were evident, and no gender differences emerged. Findings suggest targeting proactive aggression for the prevention of substance use for both males and females.

Parental Depressive Symptoms as a Predictor of Outcome in the Treatment of Child Internalizing and Externalizing Problems

Child internalizing and externalizing problems have been identified as high priority intervention targets by the World Health Organization. Parental depression is a risk factor for development of these childhood problems and may negatively influence intervention outcomes; however, studies have rarely assessed its influence on these outcomes. The present study assessed whether baseline parental depressive symptoms predicted psychotherapy outcomes among children treated for clinically significant internalizing and externalizing problems. The sample included 142 children (79 with primary internalizing problems, 63 with primary externalizing problems). Children were aged 7–13, 67.6% boys, and race included Caucasian (46.5%), African-American (9.9%), Latino (5.6%), Asian (1.4%), and multi-racial (32.4%). Analyses focused on child- and parent-reported weekly trajectories of change and post-treatment symptoms among children treated for internalizing and externalizing problems whose parents did (N = 28 and 25) and did not (N = 51 and 38) have elevated depressive symptoms. For children with internalizing problems, growth curve analyses showed markedly different trajectories, by child- and parent-report: children with less depressed parents showed significantly steeper symptom declines than did children with more depressed parents, who showed an increase in symptoms. ANCOVAs showed marginally lower post-treatment symptoms for children of less depressed versus more depressed parents (p = 0.064 by child-report). For children with externalizing problems, growth curve analyses showed trajectories in the opposite direction, by child- and parent-report; however, ANCOVAs showed no group differences at post-treatment. These findings suggest that it may be important to consider the impact of parental depressive symptoms when treating child internalizing and externalizing problems.

International education and training for clinical child and adolescent psychology

Psychological problems in youth and adequate mental health service delivery to children, adolescents, and families are critical public health dilemmas around the world. Central to effectively addressing the mental health needs of youth and families is focusing attention on the evaluation and development of specialized training programs in clinical child and adolescent psychology. All countries to more or less degree face challenges, but lower-income countries have additional limitations (e.g., scarce resources for training, high demand for services, cultural barriers) to establishing clinical psychology programs and specialized services for children and adolescents. This article discusses the status of efforts in the United States to define clinical child and adolescent psychology and develop standard training recommendations for mental health providers who work with youth and families, international considerations for intervention implementation and training, and future directions in the field of clinical child and adolescent psychology.