Consistency in diagnoses for a sample of adolescents at a private psychiatric hospital

Adolescence, Fall, 1996 by Nancy Hickin, John R. Slate, David A. Saarnio

An estimated 18 to 20% of children and adolescents are affected by emotional and behavioral disorders (Canning, Hanser, Shade, & Boyce, 1992). Although psychiatric diagnoses are infrequently assigned to children, such diagnoses become more frequent for adolescents (Smeeton, Wilkinson, Skuse, & Fry, 1992). Moreover, the frequency of adult diagnoses is quite high given a diagnosis in adolescence. For example, Smeeton et al. (1992) found that of the adolescents they sampled who had received a psychiatric diagnosis (approximately one in 19), 38% received a psychiatric diagnosis as young adults. This percentage is higher than that of others (e.g., Graham & Rutter (1985) found that about 17% of adolescents with emotional problems do not show improvement as they enter adulthood), but still indicates that many adolescents will have problems into adulthood. In light of these findings, a clear need exists for the proper identification and diagnosis of adolescents with problems in order for treatment to be as effective as possible before the problems become long term.

The Diagnostic and Statistical Manual of Mental Disorders, Third Edition (American Psychiatric Association, 1987) is widely used for diagnoses, and is considered to be a reliable classification system for mental health disorders (Skre, Onstad, Torgersen, Kringlen, 1991). Although several studies have found interrater agreement of the DSM-IIIR to be high, especially with regard to Axis I diagnoses (Skre et al., 1991), the available studies have examined broad categories of mental health disorders (e.g., mood disorders) rather than specific diagnoses (e.g., depression). As a result, the interrater agreement reported in studies may not accurately represent the interrater agreement for specific diagnostic categories (Skre et al., 1991) or, for that matter, the interrater agreement for combinations of DSM-IIIR diagnoses.

Whereas the DSM-IIIR itself has been found to be a reliable classification system, much less information is available regarding clinicians' precision in using it. In fact, inferences from several studies (e.g., First et al., 1993; Spitzer, Forman, & Nee, 1979; Webb, Gold, Johnstone, & Diclementa, 1981) can be drawn that the diagnostic criteria delineated in the DSM-IIIR are not used correctly. This can create a problem if adolescents are misdiagnosed, especially if medications are involved.

In this study, admission psychiatric, psychological, and discharge Axis I diagnoses were examined in order to determine the relationships between admission and discharge diagnosis. Also investigated was whether interrater agreement varied as a result of diagnostic label and as a function of the particular evaluation. The specific research questions in this study were: (1) To what extent are the primary and secondary AXIS I diagnoses on the initial psychiatric evaluation, the psychological evaluation (when conducted), and the discharge evaluation related? (2) To what extent are sex differences present in the interrater agreement of the primary and secondary AXIS I discharge evaluations? (3) To what extent are differences present in interrater reliability as a result of the initial primary AXIS I diagnosis, for the initial psychiatric, psychological, and discharge evaluations? and (4) Does interrater agreement differ across evaluations for primary vs. secondary diagnoses?

METHOD

Data were collected from 291 medical records of adolescent inpatients at a private psychiatric and substance abuse hospital in the Mid-South. a random sample of every third medical record of adolescent inpatients was examined for the following information: (a) AXIS I primary and secondary diagnoses on the initial psychiatric evaluation, (b) AXIS I primary and secondary diagnoses on the psychological evaluation conducted during the adolescent's stay at the facility, and (c) AXIS I primary and secondary diagnoses on the discharge summary. For all adolescents admitted to this particular facility, admit and discharge evaluations are conducted. The psychological evaluations were conducted only when the physician specifically requested them in order to obtain additional information. Demographic information regarding the adolescent's age, sex, and ethnicity was also recorded.

The sample consisted of 97 adolescents (53 males, 44 females); 85 were Caucasians, 11 African-Americans, and 1 Native-American. Their ages ranged from 12 to 18 years, with a mean age of 14.7 years (SD = 1.6). Of the AXIS I primary diagnoses on the initial psychiatric disorder, 10 were polysubstance abuse, 9 were conduct disorder, and 8 were adjustment disorder. For the remaining 27 adolescents, no other diagnosis occurred more than 4 times. Of the AXIS I secondary diagnoses on the initial psychiatric evaluation, 11 were polysubstance abuse, 6 were alcohol abuse/dependence, and 4 were conduct disorder. For the remaining 76 adolescents, no other secondary diagnosis occurred more than 4 times.

An examination of AXIS I primary diagnoses for males revealed that 13 (25.5%) were that of depression, 8 (15.7%) were polysubstance abuse, 6 (11.8%) were conduct disorder, and 6 (11.8%) were oppositional-defiant disorder. No other diagnosis was assigned more than 4 times. An analysis of AXIS I primary diagnoses for females indicated that 21 (47.7%) were that of depression. No other diagnosis label was assigned more than 4 times. Unless otherwise specified, statistical data analyses utilized all diagnostic labels.