A new study published in the journal Clinical Psychological Science examines the biasing effect of irrelevant contextual information on judgments about a person’s mental health. The researchers found that if the context provided was negative—even if that context appeared unrelated to the mental health symptom—then participants were more likely to rate a child as having a “disorder.”
The researchers go on to note that this use of context is actually the opposite of how the DSM recommends context be used. In the DSM, context is to be considered as providing alternative explanations for distress—that is, diagnoses should be ruled out if a negative context could explain the symptoms.
However, the participants in this study did the opposite. They tended to rule out the diagnosis more often if there was a positive context for the child—that is, if context did not seem to “fit” the participant’s idea of what a mental health concern looks like.
The research was conducted by Jessecae K. Marsh at Lehigh University and Andres De Los Reyes at the University of Maryland at College Park. The same authors have previously conducted several studies on this effect.
According to Marsh and De Los Reyes, “When people encounter individual symptoms of a disorder, they are not interpreted independently of the surrounding context but rather will be seen in the light of that context.”
That is, “symptoms” of ‘mental illness’ are interpreted based on negative, neutral, or positive information about a person—information that may have nothing to do with the mental health concern being diagnosed.
The authors write that “In a real-world setting, these easily observable elements of a child’s life are profoundly influencing the way symptoms of disorder are interpreted.”
The previous studies examined conduct disorder and ADHD, which are known as “externalizing” disorders because they depend on acting-out behaviors. A study they conducted in 2011 found that mental health clinicians were more likely to diagnose conduct disorder in children if given negative contextual information about that child.
The current study consisted of two experiments. The researchers were interested in examining whether their previous conclusions about the biasing effects of context were limited to “externalizing” disorders like ADHD and conduct disorder, or whether contextual information would bias the diagnosis for “internalizing” disorders like panic disorder as well.
In the first experiment, 120 participants read a list that included three pieces of contextual information as well as a single symptom of panic disorder. In all cases, the contextual information was not relevant to the diagnosis. For half the participants, the contextual information about the child was negative, while the contextual information provided for the other half was neutral.
The authors provided the following example of the contextual information:
- “His parents have had a difficult time finding him a regular babysitter because his parents need a sitter at inconvenient times during the day.” (neutral)
- ““His parents have had a difficult time finding him a regular babysitter because people often refuse to babysit him more than once.” (negative)
The researchers found that the participants were more likely to overlook the symptom when given neutral information. When given negative contextual information, the participants were more likely to diagnose the child with a disorder.
It is important to note that in both cases, the actual symptom was the same. Only contextual information, designed to be unrelated to the diagnosis, was changed.
In the second experiment, Marsh and De Los Reyes attempted to determine if the contextual influence on ADHD diagnosis was greater than the contextual influence on panic disorder diagnosis. 149 participants were randomly assigned to one of three groups. Each group read lists with contextual information. Group 1 also had a symptom of panic disorder; group 2 had a symptom of ADHD, and group 3 had a symptom of both panic disorder and ADHD.
The researchers found that participants were more likely to use negative context to diagnose ADHD than panic disorder. The authors write that this was as expected—as an externalizing disorder, ADHD involves interaction with the environment/context, so it was to be expected that participants would use contextual information to inform this diagnosis.
However, it is still important to note that this contextual information was not pertinent to the actual symptoms of ADHD—meaning that participants were much more likely to conclude that the child had ADHD if the child was described as difficult or unlikeable than if the child was described neutrally.
The researchers again found that context influenced the diagnosis of panic disorder, as well—but not to the extent found with ADHD. A limitation of the current study is that the participants were not mental health clinicians. However, previous studies indicate that this effect is present for clinicians as well.
Additionally, Marsh and De Los Reyes suggest that much of the evidence used by clinicians to evaluate a child for ADHD and conduct disorder is based on the reports of parents and teachers (in the current study, about half the participants were parents, and about a third were teachers). If parents and teachers tend to base their reports on contextual information that is not relevant to the criteria for the disorder, clinicians will likewise be biased toward diagnosis based on this information.
The authors call for further research, because “Understanding more about the influence of contextual factors brings us closer to understanding the real world demands of seeing patients and decoding what mental health issues they are experiencing.” They add that the issue of diagnosis is complex, and it is yet unclear how context should be used in the process.
Marsh, J. K., & De Los Reyes, A. (2017). Explaining away disorder: The influence of context on impressions of mental health symptoms. Clinical Psychological Science, 1–14. https://doi.org/10.1177/2167702617709812