Purpose: Clinical decision making concepts are present in “evidence based treatment” (EBT) definitions; decision making includes utilizing empirical information to provide best clinical care. Naturalistic decision making theory postulates that “experts” in a given field make decisions significantly differently than do “novice” individuals and experts are more accurate and efficient. Experts use specific cognitive tools (i.e. forward reasoning, heuristics) in their decision making that lead to successful conclusions. This study examines the decision making strategies of pediatric mental health clinicians in usual care community practice who have and have not been trained in an EBT.
Methods: Forty-nine clinicians (EBT=14, Non-EBT=35) participated. Samples were comparable on clinicians’ years of experience, demographics, and discipline (psychology, LCSW & MFT). A think aloud protocol was used where clinicians read clinical vignettes and verbalized case conceptualization and treatment planning thoughts out-loud without theorizing about their cognitive processes. Responses were coded according to decision-making process models.
Results: Results revealed that there is a lot of variation on what clinicians attend to and how they make clinical decisions. The presence of significant parent and family factors (e.g., clinical or demographic details) in the case impacted clinicians’ responses such that responses to vignettes describing more complex families resulted in more biases and cognitive errors, especially for non-EBT clinicians. Overall, EBT clinicians used cognitive decision making strategies more similar to “expert” decision-making processes and there were statistically significantly differences compared to non-EBT clinicians. EBT clinicians used forward reasoning (asked fewer assessment questions), organized information (sequential movement from case conceptualization to treatment), made less cognitive errors (attended to correct/relevant parent, family and child factors), generated a small number of accurate hypotheses (diagnoses), found solutions quickly (discussed treatment plan earlier), spent more time discussing treatment (percent of total response time), and provided extensive, detailed treatment plans. Non-EBT clinicians asked significantly more questions in total, made significantly more diagnoses per case (including significant number of inaccurate diagnoses) and spent significantly less time discussing treatment.
Conclusions: Results imply that clinical decision making practices are related to clinician training. Targeting mental health clinicians’ cognitions and decision-making regarding case conceptualization and treatment planning, may be an important avenue towards dissemination-implementation efforts within community pediatric mental health services, rather then the current focus on EBT content.
Candidate for the Lee B. Lusted Student Prize Competition