The DSM-IV criteria for CD abstracted from the medical record included 15 behaviors, falling into four main groupings: aggressive, non-aggressive, deceitfulness or theft, and serious rule violations. Three or more of these behaviors must have been present in the past 12 months, with at least one behavior in the past six months. The behavior must have caused clinically significant impairment in social, academic or occupational functioning. Results from an extensive analysis of symptom, history and treatment differences by gender and ethnicity indicated that males were not more likely to have the target symptoms of CD documented in their medical charts, but they were four times more likely than females to have co-occurring ADHD. Females were more likely to have run away in the past six months. Furthermore, there were no significant gender differences for documentation of symptom development history and medical history, medication monitoring, ratings of functional impairment, onset criteria prior to age 10, severity ratings, whether DSM- IV criteria were met, use of a standard diagnostic instrument for assessment, drug-use history, or arrests or detention.
There was no greater likelihood for African-Americans to be diagnosed with CD or have co-occurring ADHD, based on the chart documentation. However, African-Americans were less likely to have documentation of the target symptoms of CD present in their chart. There were no ethnic differences in symptom development history, medical history, medication monitoring or for the major symptoms of CD. However, African-Americans were less likely to have lying or conning noted as one of their behavior problems. There also were no ethnic differences noted in ratings of functional impairment, onset criteria prior to age 10, meeting DSM-IV criteria for CD, use of a standard diagnostic instrument in assessment, or arrests or detention. African-Americans were more likely to have a mild/moderate severity rating and were also less likely to have a drug use history. Males and African-Americans were less likely to be prescribed a mood stabilizer or antidepressant in this sample.
The nine criteria for inattention and nine criteria for hyperactivity-impulsivity were abstracted from the medical records in the study of ADHD. At least six of the nine criteria in each category must have been documented as present and persisting for at least six months in order for a subject to meet the first part of the diagnostic criteria for this disorder. Some inattention and/or hyperactivity-impulsivity must have been present before the age of 7, impairment must have been present in more than one setting and interfered with developmentally appropriate functioning, and the symptoms must not have been better accounted for by another mental disorder.
No gender or ethnic differences were detected for meeting the DSM-IV diagnostic criteria for ADHD or presence of information regarding the target symptoms of ADHD or for symptom development history and medical history in the medical record. There also were no gender or ethnic differences in whether a rating of serious functional impairment was present in the chart, whether symptoms present prior to age 7 were noted in the chart or whether a standard diagnostic instrument was used. Likewise, there were no gender or ethnic differences in those prescribed medication, in whether medication monitoring was occurring, or in whether a physical exam was given and the results noted in the chart. Finally, there were no gender or ethnic differences in the prescription of medications by type (stimulants, a-blockers or mood/anxiety medications).
Bipolar I disorder criteria entail either an elated or irritable mood and three or more other symptoms of mania that necessitate hospitalization or significantly impair functioning. This is usually accompanied by a depressed mood or a loss of all interest in pleasurable activities and four or more other symptoms of depression, plus clinically significant distress or functional impairment. In our sample, there was no difference in the likelihood of males or African-Americans to meet the criteria for any affective disorder or be prescribed any antipsychotic, mood stabilizer or antidepressant medication.
Overall, these results are encouraging because they suggest that clinicians are not assessing and treating males or African-American patients differently across diagnostic subgroups, despite the challenges faced in most mental health care systems, including the rapidly increasing numbers of children being seen, especially for ADHD and CD; the complexity of assessing and treating these disorders; and the relative lack of knowledge about "best" or most effective clinical practices for these disorders.
There are, however, some noteworthy findings, especially from the CD study. Males were four times more likely to have a co-occurring diagnosis of ADHD. This may be another indicator of severity or difficulty in diagnosis, because this comorbidity is associated with a worse and more persistent course of the illnesses (Wozniak et al., 1995). Furthermore, there has been other evidence in the literature that an early diagnosis of CD or ADHD may be a marker for the development of BD, which also has a persistent and severe clinical course (Faraone et al., 1997; Kovacs and Pollock, 1995).
The other striking finding is that African-American youths with a CD diagnosis were less likely to have their symptoms documented and less likely to have lying, conning or substance abuse documented for their diagnosis. We cannot tell from these results whether these symptoms were simply not present and the child should not have been diagnosed with CD, or whether the pre-sentation was for ADHD symptoms with added behavioral disturbance features.