Emotion Regulation Attenuates the Prospective Links from Peer Victimization to Internalizing Symptoms during Middle Childhood.

Objective: Peer victimization has been shown to be a robust predictor of depressive and anxiety symptoms over time. Relatively little is known, however, regarding what protective factors may attenuate these associations and render youth more resilient to this interpersonal stressor. Therefore, the current study examined sadness and worry regulation as moderators of the prospective links from peer victimization to internalizing symptoms over a 1-year period.Method: Participants included 464 predominantly Caucasian children (54.7% boys; ages 7-10), as well as their homeroom teachers, from an elementary school located in the Midwestern United States. Child and teacher reports of peer victimization and child reports of sadness and worry regulation were assessed at Time 1. Children also provided ratings of depressive and anxiety symptoms at Time 1, approximately 6 months later (Time 2), and again approximately 1 year later (Time 3). Moderating effects were evaluated using a series of multivariate latent growth curve models.Results: Consistent with expectations, sadness regulation attenuated the prospective links from both child- and teacher-reported peer victimization to internalizing symptoms. Worry regulation also attenuated the prospective links from teacher-reported peer victimization to internalizing symptoms. The moderating effects of emotion regulation did not differ according to gender.Conclusions: Findings suggest that the ability to effectively manage feelings of sadness and worry may serve as a buffer against the internalizing symptoms associated with peer victimization. Additional research is needed to determine whether interventions focused on enhancing victims' emotion regulation skills reduce their subsequent risk for depressive and anxiety symptoms.

Examining ODD/ADHD Symptom Dimensions as Predictors of Social, Emotional, and Academic Trajectories in Middle Childhood.

The goal of this article is to investigate the symptom dimensions of oppositional defiant disorder (ODD; irritability, defiance) and attention deficit/hyperactivity disorder (ADHD; inattention, hyperactivity-impulsivity) as predictors of academic performance, depressive symptoms, and peer functioning in middle childhood. Children (N = 346; 51% female) were assessed via teacher-report on measures of ODD/ADHD symptoms at baseline (Grades K-2) and academic performance, depressive symptoms, peer rejection, and victimization on 7 occasions over 4 school years (K-2 through 3-5). Self-report and grade point average data collected in Grades 3-5 served as converging outcome measures. Latent growth curve and multiple regression models were estimated using a hierarchical/sensitivity approach to assess robustness and specificity of effects. Irritability predicted higher baseline depressive symptoms, peer rejection, and victimization, whereas defiance predicted higher baseline peer rejection; however, none of these ODD-related effects persisted 3 years later to Grades 3-5. In contrast, inattention predicted persistently poorer academic performance, persistently higher depressive symptoms, and higher baseline victimization; hyperactivity-impulsivity predicted subsequent peer rejection and victimization in Grades 3-5. In converging models, only inattention emerged as a robust predictor of 3-year outcomes (viz., grade point average, depressive symptoms, peer rejection, and relational victimization). Broadly, ODD dimensions-particularly irritability-may be linked to acute disturbances in social-emotional functioning in school-age children, whereas ADHD dimensions may predict more persistent patterns of peer, affective, and academic problems. By examining all 4 ODD/ADHD symptom dimensions simultaneously, the present analyses offer clarity and specificity regarding which dimensions affect what outcomes, and when. Findings underscore the importance of multidimensional approaches to research, assessment, and intervention.

Forms and Functions of Aggression in Early Childhood.

Evidence supports the distinctions between forms (relational vs. physical) and functions (proactive vs. reactive) of aggression; however, little research has investigated these two subtype frameworks simultaneously or by teacher-report in early childhood. We examined the factor structures, interrelations, and longitudinal associations of teacher-reported forms and functions of aggression in young children. Preschool and kindergarten students (N = 133; ages 3-6 years; 58.6% male) were rated by their teachers during the spring semester and on two subsequent occasions over the following school year (a three-wave cross-sequential design). Bayesian confirmatory factor analyses and path models were estimated, controlling for covariates and cross-classification of students within classrooms. Correlated two-factor models showed acceptable measurement characteristics for both aggression frameworks. Within and between frameworks, aggression subtypes were highly correlated with one another. Physical aggression showed greater stability than, and was a precursor to, relational aggression, whereas both proactive and reactive aggression were stable and bidirectional. All subtypes-especially reactive and physical aggression-were robustly associated with peer rejection but not with academic performance or depressive symptoms. Results suggest that brief, teacher-reported rating scales can be used to measure forms and functions of aggression during early childhood. However, examination of one framework should elicit questions regarding the other (e.g., to what extent are measures of proactive and reactive aggression capturing physical aggression?), and research following a form-by-function approach may be particularly useful. Given their stability and outcomes, physical, reactive, and proactive aggression may be important targets for screening and intervention in early childhood settings.

The Influence of Internalizing Symptoms and Emotion Dysregulation on the Association Between Witnessed Community Violence and Aggression Among Urban Adolescents.

The current cross-sectional study examined whether internalizing (i.e. anxiety and depressive) symptoms and/or emotion dysregulation moderated the association between witnessed community violence and aggressive behavior. Participants were 180 predominantly African American adolescents (62% girls; M age = 15.87 years, SD = 1.19 years) from a high school located in an urban community in the United States. Approximately 95% of adolescents reported having witnessed at least one violent act during their lifetimes, with many endorsing repeated exposure to severe acts of community violence. Results indicated that emotion dysregulation exacerbated the association between witnessed community violence and aggression. A quadratic effect of anxiety symptoms also moderated this association, such that witnessed community violence was linked to aggression at low and high, but not moderate, levels of anxiety symptoms. In contrast, a quadratic effect of depressive symptoms was uniquely related to aggression, regardless of witnessed community violence. Directions for future research and implications for practice are reviewed.

Advancing the Scientific Foundation for Evidence-Based Practice in Clinical Child and Adolescent Psychology.

Evidence-based practice (EBP) has become a central focus in clinical child and adolescent psychology. As originally defined, EBP in psychology is the integration of the best available research evidence, patient characteristics, and clinical expertise. Although evidence-based perspectives have garnered widespread acceptance in recent years, there has also been some confusion and disagreement about the 3-part definition of EBP, particularly the role of research. In this article, we first provide a brief review of the development of EBP in clinical child and adolescent psychology. Next, we outline the following 4 points to help clarify the understanding of EBP: (a) knowledge should not be confused with epistemic processes, (b) research on clinician and client factors is needed for EBP, (c) research on assessment is needed for EBP, and (d) the 3-part conceptualization of EBP can serve as a useful framework to guide research. Based on these principles, we put forth a slightly revised conceptualization of EBP, in which the role of research is expanded and more clearly operationalized. Finally, based on our review of the literature, we offer illustrative examples of specific directions for future research to advance the evidence base for EBP in clinical child and adolescent psychology.

Treatment for Anxiety Disorders in the Pediatric Primary Care Setting.

Anxiety disorders are among the most diagnosed mental health problems in children and adolescents. Without intervention, anxiety disorders in youth are chronic, debilitating, and amplify risk of negative sequelae. Youth with anxiety present to primary care frequently and often families choose to first discuss mental health concerns with their pediatricians. Both behavioral and pharmacologic interventions can be effectively implemented in primary care, and research demonstrates the effectiveness of both approaches.

Collaborative Assessment and Management of Suicidality for Teens: A Promising Frontline Intervention for Addressing Adolescent Suicidality.

This pilot open trial examined the feasibility, acceptability, and preliminary outcomes of the Collaborative Assessment and Management of Suicidality for teens (CAMS-4Teens) who presented to outpatient care with suicidal thoughts and behaviors. Participants were 22 adolescents (13-17; 59% identified as female) with clinical elevations (≥7) on the Suicidal Behaviors Questionnaire-Revised (SBQ-R). Primary outcomes were feasibility and acceptability. We also explored outcomes of suicidal thoughts and behaviors, as well as mixed effects modeling for weekly assessments of the Suicide Status Form (SSF) Core Assessment constructs. Our main implementation outcomes suggest that the intervention is acceptable, appropriate, and feasible to deliver. Clinicians were adherent to the model with high ratings of adherence. In addition, preliminary evaluation of suicidal thoughts and behaviors found a large effect size for reduction in suicidal thoughts. Benchmarking to other adolescent suicide specific interventions and the Collaborative Assessment of Management of Suicidality with adult populations provide promise that suicidal adolescent responses may be on par with established interventions. Findings from the study are preliminary in nature and intended to inform if CAMS with adolescents is a promising approach to engage and treat patient-defined "drivers" of suicide. The results suggest that a future investigation with power to detect significant change over another active intervention is warranted.

Developmental Variation in the Associations of Attention Bias to Emotion with Internalizing and Externalizing Psychopathology.

Attention biases to emotion are associated with symptoms of internalizing and externalizing psychopathology in children and adolescents. It is unknown whether attention biases to emotion and their associations with different symptoms of psychopathology vary across development from early childhood through young adulthood. We examine this age-related variation in the current study. Participants (N = 190; ages: 4-25) completed survey-based psychopathology symptom measures and a dot-probe task to assess attention bias to happy, sad, and angry relative to neutral faces. We tested whether linear or non-linear (e.g., spline-based models) associations best characterized age-related variation in attention to emotion. We additionally examined whether attention biases were associated with depression, anxiety, and externalizing symptoms and whether these associations varied by age. No age-related differences in attention biases were found for any of the emotional faces. Attention biases were associated with psychopathology symptoms, but only when examining moderation by age. Biased attention to angry faces was associated with greater symptoms of anxiety and depression in adolescents and young adults, but not children. Similarly, biased attention to happy faces was associated with externalizing symptoms in adolescents and young adults, but not in children. In contrast, biased attention to happy faces was associated with greater anxiety symptoms in children, but not in adolescents or young adults. Biased attention toward social threat and reward becomes more strongly coupled with internalizing and externalizing symptoms, respectively, during the transition to adolescence. These findings could inform when interventions such as attention bias modification training may be most effective.

Exploring Longitudinal Mechanisms of Irritability in Children: Implications for Cognitive-Behavioral Intervention.

Severe irritability is a common and clinically important problem longitudinally associated with internalizing and externalizing problems in children. To better understand these mechanisms and to inform treatment research, we tested cognitive-behavioral processes as candidate mediators in the paths from irritability to later problems. Methods: A school sample (N = 238, 48% female, ages 8-10) was assessed at ~6-month intervals in fall (T1) and spring (T2) of third to fourth grade, and again the following fall (T3). Measures assessed irritability (T1/predictor); anger and sadness coping, intolerance of uncertainty, and rumination; (T1-T2/mediators); and anxiety, depressive symptoms, reactive aggression, and oppositionality (T1-T3/outcomes). Focused cross-lagged panel models, controlling for gender and grade, were specified to examine full (XT1 ➔ MT2 ➔ YT3) and half (XT1 ➔ MT2; MT1 ➔ YT2) longitudinal mediation. Across one or more intervals, irritability predicted higher depressive symptoms, anxiety, reactive aggression, oppositionality, intolerance of uncertainty, and poor emotion coping. From T1 irritability to T2/T3 outcomes, mediation was found for poor sadness coping leading to reactive aggression and oppositionality; poor anger coping to anxiety, depressive symptoms, and oppositionality; and intolerance of uncertainty to anxiety. Results offer further evidence for internalizing and externalizing outcomes of youth irritability and new evidence suggesting underlying mechanisms. Irritability may confer risk for externalizing problems via poor sadness/anger coping, and for internalizing problems via poor anger coping and intolerance of uncertainty. Theoretical models and psychosocial treatment should consider addressing regulation of various unpleasant emotions as well as psychological flexibility and tolerating uncertainty.

Mechanisms of Change in the Prevention of Depression: An Indicated School-Based Prevention Trial at the Transition to High School.

OBJECTIVE: Depression represents a major public health concern, and prevalence increases significantly during adolescence. The high school transition may exacerbate the risk of depression for youth with pre-existing vulnerability. The High School Transition Program (HSTP) is a brief, skills-based intervention that has demonstrated efficacy in preventing depression in adolescents. The current study aimed to evaluate the theorized mechanisms of change of the HSTP intervention by testing a multiple mediation model including school attachment (SA) and self-esteem (SE) as two mediators of treatment outcomes. METHOD: Students (N= 497; 61.5% girls) with elevated depressive symptoms, identified for the intervention program via an eighth-grade screening, were randomized to a brief intervention (n = 247) or the HSTP (n = 233) from 2003 to 2008. Participants completed measures at five time points. The first assessment occurred at the start of the second semester of eighth grade and the last assessment occurred at the end of ninth grade. A multiple mediation model tested whether SA and SE contributed to changes in depression for youth in the HSTP. RESULTS: The mediation model, including contemporaneously assessed SE and SA, was not supported. There was evidence of sequential mediation, such that students who participated in the HSTP intervention reported higher SA, which in turn predicted improved SE, and in turn contributed to amelioration of depressive symptoms. CONCLUSION: The HSTP intervention ameliorated depressive symptoms by targeting factors specific to the school transition (ie, SA). Results suggest youth at risk for depression may benefit from prevention efforts that enhance students' capacity to effectively manage identified environmental stressors, such as school transitions. CLINICAL TRIAL REGISTRATION INFORMATION: Middle School to High School Transition Project: Depression and Substance Abuse Prevention; https://clinicaltrials.gov/; NCT00071513.

Implementation Determinants and Outcomes of a Technology-Enabled Service Targeting Suicide Risk in High Schools: Mixed Methods Study.

BACKGROUND: Technology-enabled services (TESs), which integrate human service and digital components, are popular strategies to increase the reach and impact of mental health interventions, but large-scale implementation of TESs has lagged behind their potential. OBJECTIVE: This study applied a mixed qualitative and quantitative approach to gather input from multiple key user groups (students and educators) and to understand the factors that support successful implementation (implementation determinants) and implementation outcomes of a TES for universal screening, ongoing monitoring, and support for suicide risk management in the school setting. METHODS: A total of 111 students in the 9th to 12th grade completed measures regarding implementation outcomes (acceptability, feasibility, and appropriateness) via an open-ended survey. A total of 9 school personnel (school-based mental health clinicians, nurses, and administrators) completed laboratory-based usability testing of a dashboard tracking the suicide risk of students, quantitative measures, and qualitative interviews to understand key implementation outcomes and determinants. School personnel were presented with a series of scenarios and common tasks focused on the basic features and functions of the dashboard. Directed content analysis based on the Consolidated Framework for Implementation Research was used to extract multilevel determinants (ie, the barriers or facilitators at the levels of the outer setting, inner setting, individuals, intervention, and implementation process) related to positive implementation outcomes of the TES. RESULTS: Overarching themes related to implementation determinants and outcomes suggest that both student and school personnel users view TESs for suicide prevention as moderately feasible and acceptable based on the Acceptability of Intervention Measure and Feasibility of Intervention Measure and as needing improvements in usability based on the System Usability Scale. Qualitative results suggest that students and school personnel view passive data collection based on social media data as a relative advantage to the current system; however, the findings indicate that the TES and the school setting need to address issues of privacy, integration into existing workflows and communication patterns, and options for individualization for student-centered care. CONCLUSIONS: Innovative suicide prevention strategies that rely on passive data collection in the school context are a promising and appealing idea. Usability testing identified key issues for revision to facilitate widespread implementation.

Tailoring Individualized Evaluation of Pediatric Abdominal Pain Using Ecological Momentary Assessment (EMA): A Pilot Study Testing Feasibility and Acceptability.

OBJECTIVE: The current study aimed to determine if it was feasible and acceptable to use ecological momentary assessment to assess individual associations between biopsychosocial contributors to chronic abdominal pain with 2 objective sensors and a mobile application. Specifically, we aimed to determine if it was possible to identify individualized associations between idiopathic pain associations. The goal was to determine if idiographic profiles have clinical value while the field works torward consensus about nomothetic trends. MATERIALS AND METHODS: Participants included 30 pediatric chronic abdominal pain patients, aged 8 to 17, who wore a physiological monitor and accelerometer that measured sleep and physical activity and answered 4 surveys per day on an app over the course of a 14-day study period. RESULTS: Results indicated that participants were 96.2% and 95.5% compliant to the wrist-worn accelerometer measuring sleep and physical activity, respectively. Participants completed 76.3% of expected surveys and were least adherent to the physiological monitor (37.9%). In addition, it was possible to generate 24 (80%) personalized reports describing unique associations with pain for participants in the study. DISCUSSION: Findings provide initial support for the use of ecological momentary assessment over a 2-week period to inform and create personalized profiles for improved clinical care in this population.

"Are you gonna publish that?" Peer-reviewed publication outcomes of doctoral dissertations in psychology.

If a doctoral dissertation represents an original investigation that makes a contribution to one's field, then dissertation research could, and arguably should, be disseminated into the scientific literature. However, the extent and nature of dissertation publication remains largely unknown within psychology. The present study investigated the peer-reviewed publication outcomes of psychology dissertation research in the United States. Additionally, we examined publication lag, scientific impact, and variations across subfields. To investigate these questions, we first drew a stratified random cohort sample of 910 psychology Ph.D. dissertations from ProQuest Dissertations & Theses. Next, we conducted comprehensive literature searches for peer-reviewed journal articles derived from these dissertations published 0-7 years thereafter. Published dissertation articles were coded for their bibliographic details, citation rates, and journal impact metrics. Results showed that only one-quarter (25.6% [95% CI: 23.0, 28.4]) of dissertations were ultimately published in peer-reviewed journals, with significant variations across subfields (range: 10.1 to 59.4%). Rates of dissertation publication were lower in professional/applied subfields (e.g., clinical, counseling) compared to research/academic subfields (e.g., experimental, cognitive). When dissertations were published, however, they often appeared in influential journals (e.g., Thomson Reuters Impact Factor M = 2.84 [2.45, 3.23], 5-year Impact Factor M = 3.49 [3.07, 3.90]) and were cited numerous times (Web of Science citations per year M = 3.65 [2.88, 4.42]). Publication typically occurred within 2-3 years after the dissertation year. Overall, these results indicate that the large majority of Ph.D. dissertation research in psychology does not get disseminated into the peer-reviewed literature. The non-publication of dissertation research appears to be a systemic problem affecting both research and training in psychology. Efforts to improve the quality and "publishability" of doctoral dissertation research could benefit psychological science on multiple fronts.

Self-Reported Emotion Reactivity Among Early-Adolescent Girls: Evidence for Convergent and Discriminant Validity in an Urban Community Sample.

Emotion reactivity, measured via the self-report Emotion Reactivity Scale (ERS), has shown unique associations with different forms of psychopathology and suicidal thoughts and behaviors; however, this limited body of research has been conducted among adults and older adolescents of predominantly White/European ethnic backgrounds. The present study investigated the validity of ERS scores for measuring emotion reactivity among an urban community sample of middle-school-age girls. Participants (N = 93, ages 11-15, 76% African-American, 18% Latina) completed the ERS and measures of emotion coping, internalizing problems, proactive and reactive aggression, negative life events, and lifetime suicidal ideation and substance use. As hypothesized, ERS scores were significantly associated with internalizing problems, poor emotion coping, negative life events, reactive aggression, and suicidal ideation (evidence for convergent validity), but showed little to no association with proactive aggression or lifetime substance use (evidence for discriminant validity). A series of logistic regressions were conducted to further explore the associations among internalizing problems, emotion reactivity, and suicidal ideation. With depressive symptoms included in the model, emotion reactivity was no longer uniquely predictive of lifetime suicidal ideation, nor did it serve as a moderator of other associations. In conjunction with previous research, these findings offer further support for the construct validity and research utility of the ERS as a self-report measure of emotion reactivity in adolescents.

Vignette methodologies for studying clinicians' decision-making: Validity, utility, and application in ICD-11 field studies.

Vignette-based methodologies are frequently used to examine judgments and decision-making processes, including clinical judgments made by health professionals. Concerns are sometimes raised that vignettes do not accurately reflect "real world" phenomena, and that this affects the validity of results and conclusions of these studies. This article provides an overview of the defining features, design variations, strengths, and weaknesses of vignette studies as a way of examining how health professionals form clinical judgments (e.g., assigning diagnoses, selecting treatments). As a "hybrid" of traditional survey and experimental methods, vignette studies can offer aspects of both the high internal validity of experiments and the high external validity of survey research in order to disentangle multiple predictors of clinician behavior. When vignette studies are well designed to test specific questions about judgments and decision-making, they can be highly generalizable to "real life" behavior, while overcoming the ethical, practical, and scientific limitations associated with alternative methods (e.g., observation, self-report, standardized patients, archival analysis). We conclude with methodological recommendations and a description of how vignette methodologies are being used to investigate clinicians' diagnostic decisions in case-controlled field studies for the ICD-11 classification of mental and behavioural disorders, and how these studies illustrate the preceding concepts and recommendations.

Las metodologías basadas en viñetas se utilizan frecuentemente para examinar los procesos de toma de decisiones, incluyendo los de profesionales sanitarios. No obstante, existen dudas sobre si las viñetas reflejan adecuadamente los fenómenos del "mundo real" permitiendo resultados y conclusiones válidas. Ofrecemos una visión de las características, variaciones de diseño, fortalezas y debilidades de estos estudios para examinar cómo los profesionales forman juicios clínicos (como el diagnóstico y tratamiento). Siendo "híbridos" de las encuestas tradicionales y los métodos experimentales, estos estudios pueden ofrecer la alta validez interna de los experimentos y la alta validez externa de las encuestas, para aislar múltiples factores predictivos del comportamiento de los clínicos. Un diseño adecuado para poner a prueba preguntas específicas acerca de los juicios y la toma de decisiones permite resultados altamente generalizables a la "vida real", sin las limitaciones éticas, prácticas y científicas de los métodos alternativos (observación, auto-informe, pacientes estandarizados, análisis de archivos clínicos). Concluimos con recomendaciones metodológicas que se ilustran tras una descripción del uso de las metodologías de viñetas para investigar las decisiones diagnósticas de los clínicos en los estudios de campo de casos y controles para la clasificación de los trastornos mentales y del comportamiento en la CIE-11.

Parental and Family Factors as Predictors of Threat Bias in Anxious Youth.

The present study examined the relative predictive value of parental anxiety, parents' expectation of child threat bias, and family dysfunction on child's threat bias in a clinical sample of anxious youth. Participants (N = 488) were part of the Child/Adolescent Anxiety Multi-modal study (CAMS), ages 7-17 years (M = 10.69; SD = 2.80). Children met diagnostic criteria for generalized anxiety disorder, separation anxiety and/or social phobia. Children and caregivers completed questionnaires assessing child threat bias, child anxiety, parent anxiety and family functioning. Child age, child anxiety, parental anxiety, parents' expectation of child's threat bias and child-reported family dysfunction were significantly associated with child threat bias. Controlling for child's age and anxiety, regression analyses indicated that parents' expectation of child's threat bias and child-reported family dysfunction were significant positive predictors of child's self-reported threat bias. Findings build on previous literature by clarifying parent and family factors that appear to play a role in the development or maintenance of threat bias and may inform etiological models of child anxiety.

Vignette methodologies for studying clinicians’ decision-making: validity, utility, and application in ICD-11 field studies / Metodología basada en viñetas para el estudio de toma de decisiones clínicas: validez, utilidad y aplicación en los estudios de campo de la CIE-11

Vignette-based methodologies are frequently used to examine judgments and decision-making processes, including clinical judgments made by health professionals. Concerns are sometimes raised that vignettes do not accurately reflect “real world” phenomena, and that this affects the validity of results and conclusions of these studies. This article provides an overview of the defining features, design variations, strengths, and weaknesses of vignette studies as a way of examining how health professionals form clinical judgments (e.g., assigning diagnoses, selecting treatments). As a “hybrid” of traditional survey and experimental methods, vignette studies can offer aspects of both the high internal validity of experiments and the high external validity of survey research in order to disentangle multiple predictors of clinician behavior. When vignette studies are well designed to test specific questions about judgments and decision-making, they can be highly generalizable to “real life” behavior, while overcoming the ethical, practical, and scientific limitations associated with alternative methods (e.g., observation, self-report, standardized patients, archival analysis). We conclude with methodological recommendations and a description of how vignette methodologies are being used to investigate clinicians’ diagnostic decisions in case-controlled field studies for the ICD-11 classification of mental and behavioural disorders, and how these studies illustrate the preceding concepts and recommendations (AU)

Las metodologías basadas en viñetas se utilizan frecuentemente para examinar los procesos de toma de decisiones, incluyendo los de profesionales sanitarios. No obstante, existen dudas sobre si las viñetas reflejan adecuadamente los fenómenos del “mundo real” permitiendo resultados y conclusiones válidas. Ofrecemos una visión de las características, variaciones de diseño, fortalezas y debilidades de estos estudios para examinar cómo los profesionales forman juicios clínicos (como el diagnóstico y tratamiento). Siendo “híbridos” de las encuestas tradicionales y los métodos experimentales, estos estudios pueden ofrecer la alta validez interna de los experimentos y la alta validez externa de las encuestas, para aislar múltiples factores predictivos del comportamiento de los clínicos. Un diseño adecuado para poner a prueba preguntas específicas acerca de los juicios y la toma de decisiones permite resultados altamente generalizables a la “vida real”, sin las limitaciones éticas, prácticas y científicas de los métodos alternativos (observación, auto-informe, pacientes estandarizados, análisis de archivos clínicos). Concluimos con recomendaciones metodológicas que se ilustran tras una descripción del uso de las metodologías de viñetas para investigar las decisiones diagnósticas de los clínicos en los estudios de campo de casos y controles para la clasificación de los trastornos mentales y del comportamiento en la CIE-11 (AU)