The process of diagnosis delivery (DD), often involving the breaking of bad news to patients (1), includes stressful elements as physicians struggle with finding the best way to inform patients and relatives of a diagnosis that is perceived as having negative implications on various life domains (2). The physicians' perceptions of the effect of the diagnosis on the patient's life, and their attitudes specifically toward DD, were found to affect the nature of the disclosure of a diagnosis (3–5). A physician's lack of communication skills, which are essential in DD, may also increase the likelihood of the physician's experience of associated stress (2).

A few studies on physicians' experience with DD were conducted among samples that included participants from diverse medical fields. For example, Ptacek et al. (6) showed that ~18% of a mixed sample of physicians experienced stress in the process of DD, and 42% of them reported that it lasted from several hours to several days. However, the majority of the reviews, commentaries, and reports of empirical studies on DD are focused upon medical settings that are perceived as most challenging, such as oncology, pediatric, emergency settings, and neurology [e.g., (2, 5, 7–9)]. Those reports describe the struggle, distress, and often the actual avoidance of DD among physicians.

Studies on DD in psychiatry in general and specifically in child psychiatry are relatively rare. They describe unique characteristics due to two factors: the uncertainty of the accuracy of diagnosis due to the absence of objective tests and, even more so, the social stigma of mental illness (10), which may be present among professionals as well (11). For example, professionals working in psychiatry reportedly perceive psychiatric illness in a stigmatic way, viewing it as dangerous and as possessing extensive negative implications on potential career and/or social isolation (12). In addition, professionals working in psychiatry who do not hold stigmatic attitudes may nevertheless be sensitive to the potentially harmful implications of labeling and stigma on patients and their families and may therefore experience distress accompanying DD (13). While the internalization of stigma toward mental illness is evident not only among patients but also among their family members (14), child psychiatrists may struggle with the fear that parents will view the diagnosis in a stigmatic way.

The few studies, reviews, and commentaries that have addressed DD in psychiatry assessed it mainly from the perspective of the patients and families, the majority of whom learned about the diagnosis in the hospital discharge form or in an incidental encounter with a professional staff member (15). Others adopted a comprehensive approach and assessed patients, caregivers, and professionals' perspectives and focused on the experience of DD mostly among patients [e.g., (16)]. There is only one study that did explore adult psychiatrists' experiences of DD in the setting of schizophrenia and found that, overall, psychiatrists perceived disclosure as problematic, unproductive, and harmful (13). Data on DD in child psychiatry is even more sparse, and the limited studies that do exist focus mainly on parents' attitude to the delivery of an ASD diagnosis (17–19). To the best of our knowledge, there are no studies on the perceptions of DD among child psychiatrists. The goal of our study, therefore, was to better understand the perspectives of child psychiatrists in the process of DD. Our specific aims were two-fold. First, we wanted to explore factors that are related to the attitudes of child psychiatrists toward three different disorders and toward their DD. Specifically, we hypothesized that child psychiatrists will perceive schizophrenia as the most severe mental disorder, its treatment as relatively ineffective, express negative perceptions toward its DD, and experience its DD as distressing. Conversely, we hypothesized that they will perceive ADHD as the least severe disorder, its treatment as relatively effective, will have positive perceptions toward its DD, and will experience its DD as comparatively less distressing. As for ASD, we hypothesized that psychiatrists will perceive its level of severity as moderate, its treatment as ineffective, that they will have both positive and negative perceptions toward its DD, and that that they will experience its DD as moderately distressing. Secondly, we sought to identify factors associated with the distress of child psychiatrists associated with the DD process. We hypothesized that they would include lack of professional experience, negative perceptions of DD, and the perception of parents as being in opposition of the diagnosis. To further explore additional potential factors, a qualitative exploratory component was added.

The study included 80 participants, 51 of whom completed the questionnaire during the conference (72.8% participation rate) and 29 who completed the online survey (72.5%). The participants were child and adolescent psychiatrists with a mean age of 48.7 (SD = 10.7) years, and a mean of 18.6 (SD = 10.6) years of professional experience. There were 47 females (58.7%), and 21 (26.3%) of the 89 responders reported having mental illness in the family. The demographics of the study group are presented in Table 1.

This study explored attitudes toward DD and possible stressful factors in the process of DD among child psychiatrists. The findings suggest that attitudes varied according to diagnosis and that there are multiple stressful factors while delivering a diagnosis in general, as well as unique factors that are related to a specific diagnosis. The facts that the diagnosis of schizophrenia was perceived as severe and that there is no effective treatment were found to be associated with negative attitudes toward DD. This was supported by both quantitative and qualitative data. The qualitative data revealed the challenges and dilemmas and suggested additional factors that affect child psychiatrists' attitudes toward DD: their perception concerning the legal obligation to deliver a diagnosis, their identification either with the child or with the parent, their perceptions of the parents' willingness and ability to cope with the news, and the level of devastation expected to be experienced.

The diagnosis of ASD was perceived by child psychiatrists as less severe than the diagnosis of schizophrenia, and they reported having less-negative attitudes toward DD of ASD and experiencing less stress accompanying the DD compared to that of schizophrenia. The finding that DD of ASD is perceived by child psychiatrists as less negative and stressful is interesting and may be explained by the following. In the past, both schizophrenia and ASD were considered a single clinical entity termed “childhood schizophrenia” (23). Even though the two diagnoses were subsequently separated in the DSM-III, both were considered severe disorders until the last two decades. We believe that ASD was gradually considered as a less severe disorder due to lowering the threshold of diagnosis. For example, currently the intelligence of most children that are diagnosed with ASD is within the normal range whereas in the past most of the children with the diagnosis of ASD were diagnosed also with intellectual disability (24). In addition, in Israel and in other western countries, the diagnosis of ASD enables families to receive considerable support, including treatments (e.g., applied behavioral analysis, occupational and speech therapy) and one-on-one school assistance. Thus, it can be assumed that while delivering the diagnosis of ASD, child psychiatrists perceive not only the negative implications of the diagnosis on various life domains but also the benefits of increased support that the DD of ASD will provide to the child and family.

The findings on attitudes toward DD emphasize the important effect of illness perception on the DD process. Extensive research has addressed the effects of psychiatric illness perception on patients and relatives (25, 26), showing that negative perception, mostly in the form of stigma against psychiatric disorders, interferes with an adaptive coping process [see review of (14), on parents' perceptions]. Psychiatric illness perception of professionals, however, is barely studied, probably assuming that their perception is relatively objective and less prone to biases or that, as professionals, they are less prone to be influenced by their biases. However, there is evidence that psychiatrists tend to perceive serious mental illness as schizophrenia as “bombastic” in its implications or as “being sick in mind,” and ASD in child psychiatry as devastating (27), which are perceptions that were identified as likely to create reluctance to DD to patients and families (13). The findings of the current study further support those conclusions by showing an association between the perception of a given mental illness as being severe, the diagnosis as being uncertain, and the treatment as being ineffective, with negative attitudes toward DD among child psychiatrists.

The distress psychiatrists experience while practicing DD and its correlates is an additional major finding in the current study. Less professional experience, negative attitudes toward DD, and the perception that the parents opposed the diagnosis were all associated with higher DD-related stress. In line with these questionnaire responses, the qualitative analysis also showed that psychiatrists experience various negative feelings, such as sadness, sorrow, grief, empathy, guilt, compassion, and frustration while delivering a diagnosis, and even long after. This led to their wish for support and for opportunities to share and reflect with colleagues on these challenges in preparation to and following these encounters.

Our finding that psychiatrists with fewer years of professional experience reported more stress accompanying DD may be explained by the fact that DD requires high communication skills that are usually achieved over time. In addition, younger psychiatrists reported feeling obligated to deliver the diagnosis for the benefit of the child more than older psychiatrists. This feeling of obligation may limit younger psychiatrists' freedom to choose whether to delay or soften the DD and, in turn, may also explain their experience of DD as more stressful.

As had been shown in previous studies in psychiatry [see review of (16)] as well as in the present one, the process of DD included psychosocial aspects that emerged from the connection with the family and the psychiatrist's perception of the way the parents cope with the verdict. Further exploration is needed to understand the source of these perceptions and their accuracy, and perhaps find ways to help psychiatrists enhance families' resilience and willingness to accept the disease.

There are several limitations to this study that bear mention. First, it focused on DD of three diagnoses, thereby limiting generalization of the findings to other psychiatric diagnoses. Second, the study design was cross-sectional and therefore it is not clear how perception and attitudes affect the experienced distress longitudinally. Lastly, the study was conducted from the perspectives of psychiatrists and did not address the perspectives of patients and relatives. Perkins et al. (16) recently recommended a triangular approach to the understating of DD in psychiatry, which includes psychiatrists, patients, and relatives, and future studies should combine them to better explore the more inclusive dynamics of DD.

The current study highlighted the importance of perceptions and attitudes of psychiatrists in the process of DD. The findings suggest that child psychiatrists are affected by their own perception of disorders and of DD as well as by additional factors that are operative in the interpersonal domain of communicating DD. We believe that these results can assist in tailoring interventions to assist psychiatrists in coping with DD of conditions that have far-reaching ramifications as well as with their own biases. This, in turn, may improve the way DD is practiced, leading to a better experience for the psychiatrist, the patient, and the family.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Tel Aviv University Institutional Review Board and Sheba Medical Center Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.

AB-G, DG, and OK-M: conceiving and designing the study. AB-G, and DB: data collection. NH-P: statistical analyses. AB-G, IH-O: qualitative analyses. AB-G, IH-O, NH-P, DG, and OK-M: data interpretation. AB-G, IH-O, NH-P, DG, and OK-M: writing of the final manuscript. All authors contributed to, reviewed, and approved the final manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.