Ethnic differences in DSM-classifications

Because cross-culturally validated screening instruments are hardly ever used for ethnic populations, there is a potential biasing effect in diagnostic procedures when working with Asian, Middle Eastern and African children and adolescents. International studies have found that non-ethnic minority youth more often receive specific psychiatric disorders and co-morbid diagnoses on Axis I, while ethnic minority children more often received V-codes only, indicating that there is insufficient information to determine a psychiatric disorder (de Haan et al., 2014). The findings that it is harder to recognise psychiatric disorders when ethnic minority clients are diagnosed may imply that refugee and migrant children and adolescents are not adequately treated for their disorders in Child and Adolescent Mental Health Services.

A number of studies show that psychiatric disorders are under-diagnosed with ethnic minority youth. A substantial part of this under-diagnosing can be attributed to the influence of ethnic stereotyping when professionals have to judge children from ethnic minority groups (Reijneveld et al., 2005; Zwirs et al., 2006). Other studies have indicated that diagnoses generated through the use of cross-culturally validated diagnostic instruments, conducted in accordance with standard rules for information gathering, are more valid than are clinician-generated diagnoses (Aklin & Turner, 2006; Basco et al., 2000). In addition, diagnostic accuracy (an agreement between diagnoses generated by the clinician or by validated instruments) predicts better therapy engagement and a decreased likelihood of therapy dropout (Jensen-Doss & Weisz, 2008).

de Haan et al, (2014) and others have found that when ethnic minority children are referred to CAMHS, mental health practitioners may identify their disorders differently from majority culture clients. Different ethnic groups express mental health problems in different ways to majority culture groups. Additionally, for ethnic minority clients the language used for expressing distress may differ from that of the host country, which hinders the diagnostic process (Nikapota & Rutter, 2008). As well, Asian and other ethnic minority parents may be less willing, or less capable of sharing information on their child’s development (Pels & Nijsten, 2003). Sharing information about the child’s early years is important, because it is hard to make correct diagnoses, for example with ADHD or autism, without it. In Dutch studies, minority children who present to CAMHS are mainly treated for relational problems and not for psychiatric disorders indicating that there is an ethnic bias in the diagnostic process (de Haan et al., 2014).

Currently, diagnostic instruments, if used at all, are often not specific and sensitive enough to diagnose correctly with non-native groups (de Haan, 2014). For assessing diagnoses with (non-native) children and adolescents, it would be best if this was done on the basis of deciding if diagnostic criteria are met, modelled on the gold standard for each disorder and alongside other clinical and cultural assessment tools. This can, for instance, be done with the Schedule for Affective Disorders and Schizophrenia for School-age Children (K-SADS), which is a semi-structured diagnostic interview designed to assess current and past episodes of psychopathology in children and adolescents according to DSM-V criteria (Kaufman, Birmaher, Brent, Rao, & Ryan, 1996; Puig-Antich & Chamber, 1978). The K-SADS is administered by interviewing the parent(s) and the child and, finally, achieving summary ratings that include all sources of information (parent, child, school, chart and other).

The DSM-V offers an adaptive interview technique (the Cultural Formulation of Diagnosis) (APA, 2013a; APA, 2016; Kirmayer et al., 2008) to compensate for the cultural insensitivity of diagnostic instruments. Cultural interviews provide additional information on the client’s life context and perceptual meanings and can ultimately facilitate comprehensive care (Marsella & Kaplan, 2002). Assessing a client’s cultural and religious perspectives; health beliefs and practices and perceptions of health and illness is important to make a comprehensive, culturally sensitive assessment (Lonner & Ibrahim, 2002).

The DSM-V specifies that in order to make a diagnosis of a mental disorder, the behaviour in question must not merely represent a culturally expectable and sanctioned response to a particular event, even though it may seem odd in the light of the examiner’s own cultural standards. The DSM-V also recognises that abnormal behaviours may take different forms in different cultures and that some abnormal behaviour patterns are culturally specific (see section on Cultural Presentations of Distress).

The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-V) includes an Outline for Cultural Formulation (CF) that identifies cultural information that can be used to modify diagnosis, clinical assessment and treatment plan. Cultural Formulation can be a useful tool for interdisciplinary collaboration and knowledge transfer by providing a framework to systematically introduce different disciplinary perspectives and levels of description that transcend the narrow frame of disorder-centred psychiatric diagnosis, assessment and care (Dinh et al., 2012).

The "Outline for Cultural Formulation" in DSM-V systematically calls attention to five distinct aspects of the cultural context of illness and their relevance to diagnosis and care. The clinician is encouraged to:

1. Inquire about patients' cultural identity to determine their ethnic or cultural reference group, language abilities, language use, and language preference.
2. Explore possible cultural explanations of the illness, including patients' idioms of distress, the meaning and perceived severity of their symptoms in relation to the norms of the patients' cultural reference group, and their current preferences for, as well as past experiences with, professional and popular sources of care.
3. Consider cultural factors related to the psychosocial environment and levels of functioning. This assessment includes culturally relevant interpretations of social stressors, available support, and levels of functioning, as well as patients' disability.
4. Critically examine cultural elements in the patient-clinician relationship to determine differences in culture and social status between them and how those differences affect the clinical encounter, ranging from communication to rapport and disclosure.
5. Render an overall cultural assessment for diagnosis and care, meaning that the clinician synthesises all of the information to determine a course of care.