Research report
Factors influencing mother–child reports of depressive symptoms and agreement among clinically referred depressedyoungsters in Hungary

https://doi.org/10.1016/j.jad.2006.10.008Get rights and content

Abstract

Background

Psychiatric assessments of children typically involve two informants, the child and the parent. Understanding discordance in their reports has been of interest to clinicians and researchers. We examine differences between mothers' and children's report of children's depressive symptom severity, and factors that may influence their reports and level of agreement. We hypothesized that agreement between mother and child would improve if (1) the mother is depressed, due to improved recall of mood congruent symptoms, (2) the child is older, due to better social-cognitive and communication skills, and (3) the child is a female.

Methods

Subjects were 354 children (158 girls; mean age 11.69 years, SD: 2.05 years) with Major Depressive Disorder. Depressive symptoms were evaluated by a semi-structured interview separately with the mother and the child. Agreement on symptom severity was based on concordance of the presence and extent of symptoms.

Results

Maternal reports were significantly higher than their son's but not daughters'. Girls, particularly with increasing age, reported higher levels of symptoms; however mothers' reports were not affected by child sex or age. Maternal depression predicted more severe symptom reports for both children and mothers. Agreement between the mother and the child increased as children got older.

Limitations

The same clinician interviewed the mother and the child, which might inflate rates of agreement. However, this method mirrors clinical evaluation.

Conclusion

During a clinical interview one must consider the age and sex of the child and the depressive state of the mother in assimilating information about the child.

Introduction

Psychiatric diagnoses for school age and older children typically are derived based on information from parents and direct interviews with the children themselves. However, given that agreement is generally low to moderate between the symptom reports of mothers and their children (Bennett et al., 1997, Breslau et al., 1987, Cole et al., 2002, Frick et al., 1994, Martin et al., 2004, Nguyen et al., 1994), factors that may influence individual reports and inter-informant agreement and how such factors should be weighted have been of interest (De Los Reyes and Kazdin, 2004, De Los Reyes and Kazdin, 2005). Three categories of variables have received considerable attention for their effects on parent–child symptom reports: maternal psychopathology, the type of symptom being reported, and child demographic characteristics. In the present study, one goal is to examine whether mother–child factors influencing symptom reports and trends in inter-rater agreement that have been reported mostly in US samples can be detected in a large European sample of clinically referred, depressed youths.

Maternal psychopathology has been shown to affect mothers' reports of their children's symptomatology (for reviews, see Grills and Ollendick, 2002, Richters, 1992). For example, in clinical and semi-structured interviews, depressed mothers report more depressive and behavioral symptoms in their children than the children report about themselves (Chilcoat and Breslau, 1997, Kroes et al., 2003, Renouf and Kovacs, 1994, Richters, 1992). Additionally, the more depressed the mothers are, the more serious they rate their children's symptoms (Youngstrom et al., 1999, Youngstrom et al., 2000). The literature is ambiguous about the effect of maternal depression on mother–child agreement, however. For example, it has been reported that maternal depression improves (Conrad and Hammen, 1989), worsens (Renouf and Kovacs, 1994, Youngstrom et al., 2000), or has no detectable effect (Breslau et al., 1987, Nguyen et al., 1994) on parent–child symptom agreement. Further, maternal psychopathology other than depression also appears to inflate the ratings of children's symptoms (Frick et al., 1994, Najman et al., 2001, Youngstrom et al., 2000).

Mother and child reports of symptoms and their agreement also appear to vary as a function of the type of symptom being assessed. Having grouped symptoms according to whether they are overt and externalizing (observable) or covert and internalizing (thoughts or feelings), Bennett et al. (1997) found higher mother–child agreement in a sample of girls on several behavioral observable symptoms but poor agreement on several internalizing symptoms. In a sample of boys, Youngstrom et al. (2000) similarly found higher parent–child concordance on externalizing than internalizing symptoms. Other symptom dimensions studied as possibly influencing reports include type of context, the social desirability of the symptoms (eg., school-based vs. family-based or socially acceptable vs. undesirable symptoms) (Comer and Kendall, 2004, Grills and Ollendick, 2002) and perceived distress over the presenting symptoms (De Los Reyes and Kazdin, 2005).

Finally, investigators also have considered whether children's demographic characteristics such as age, sex, and socioeconomic status (SES) influence symptom reports and inter-informant agreement on them. Studies have found that parent–child agreement improves with increasing age among outpatients (Renouf and Kovacs, 1994), and to a lesser extent in community samples (Jensen et al., 1999). But other studies found no significant age effects on parent–child symptom agreement, possibly because of a restricted age range (Bennett et al., 1997) or dichotomization of age groups (Breslau et al., 1987, Nguyen et al., 1994). De Los Reyes and Kazdin (2005) note in their review that inconsistent findings about age effects on agreement could be due to different methods across studies, small sample sizes, or categorization of the children's ages. Likewise, child sex has been reported to affect parent–child concordance with regard to some symptoms but not others (for a review, see Grills and Ollendick, 2002). Jolly et al. (1994) found that girls' self-reported depressive symptoms were more comparable to observer ratings than boys'. Frank et al. (2000) found in an in-patient sample that discrepancies in the ratings of the emotional impairment of the child were greater in mother–son pairs. Family SES does not seem to have a significant impact on mother–child agreement on child's depressive symptoms (Bennett et al., 1997, Mick et al., 2000, Nguyen et al., 1994, Renouf and Kovacs, 1994, Youngstrom et al., 2000).

Given that multiple variables appear to affect mother–child agreement in symptom report, an important concern is the extent to which these factors interact in their effects. However, most studies of parent–child concordance have employed univariate statistics (e.g., Bennett et al., 1997, Nguyen et al., 1994) and thus did not model interactions among variables.

In the present study, we examined mother–child agreement about the severity of the child's depressive symptoms overall as well as by clinically meaningful depressive symptom clusters. We hypothesized that mother–child agreement on child's depressive symptoms would improve with maternal depression, because depressed mothers would be more accurate observers of their children's depression and have better recall of such mood congruent information (Blaney, 1986, Bower, 1981, Burt et al., 1995, Richters, 1992, Youngstrom et al., 1999). We tested this hypothesis using overall depressive symptom severity as well as depressive symptom clusters. We also hypothesized that: a) informant agreement on depressive symptoms will improve as a function of the child's age due to higher levels of social-cognitive development and better communication skills, and b) that mother–child concordance will be higher among mother–daughter than mother–son pairs (possibly due to greater degree of empathy in same sex pairs and higher self-consciousness in girls (Jolly et al., 1994)).

To use an index of mother–child agreement that is meaningful to clinicians, we gave the highest weight to instances where informants agreed on both the presence and intensity of a symptom, compared to instances where parent and child agreed on the presence only (but not intensity), or finally, to where they disagreed on the presence of the symptom. In modeling cross-informant agreement, we also considered as covariates: maternal anxiety (given that symptoms other than depression may have effects), household size (in so far as it may indirectly indicate the extent of time mother can dedicate to a particular offspring and hence influence her familiarity with and symptom report for the child, e.g., Treutler and Epkins, 2003) and highest educational grade that mothers completed as a proxy for SES. To better understand the potential effects of these factors, we examined their relations to maternal reports of children's depressive symptoms and children's own symptom reports, before modeling cross-informant agreement.

Section snippets

Participants

Subjects for the present article are 354 children (158 girls), aged 11.69 years on average (SD = 2.05, range = 7.31–15.35 years) at the time of the assessment, who were enrolled in a study of genetic and psychosocial risk factors in childhood-onset depression by December 31, 2003, met diagnostic criteria for Major Depressive Disorder (MDD), and had biological mothers as parental informants. Boys (M = 11.28, SD = 1.99) were significantly younger than girls (M = 12.19, SD = 2.03) by approximately one year, t

Statistical analyses

T-tests were performed to examine mean differences on CSS based on child sex and reporter identity (child or mother). We conducted preliminary univariate analyses to examine how each variable of interest was related to children's self-reports and maternal reports (separately) and to the agreement scores. Only variables that showed significant association to CSS or agreement scores in the preliminary analyses were included in the multivariate models. Because the results of the univariate models

Discussion

The aim of the present study was to investigate the influence of maternal and child factors on symptom reports and mother–child agreement regarding the child's depressive symptoms among 7 to15 year-old psychiatric patients. This study is unique because of its very large sample of clinically referred children whose depressive disorders were diagnosed in a rigorously standardized, multiphase process. The large sample made it possible to examine potential interactions among several variables which

Acknowledgements

Members of the International Consortium for Childhood-Onset Mood Disorders: István Benák, Emília Kaczvinszky M.D., Viola Kothencné Osváth, László Mayer M.D., University of Szeged, Department of Child and Adolescent Psychiatry, Szeged, Hungary. Márta Besnyő M.D., Júlia Gádoros M.D. and Ildikó Baji M.D. Vadaskert Hospital, Budapest, Hungary. Judit Székely M.D. Semmelweis University, I. Pediatric Department, Budapest, Hungary. Edit Dombovári M.D., Heim Pál Hospital for Sick Children, Outpatient

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