Making sense of informant disagreement for overanxious disorder
Introduction
Disagreement among parents and children about presence of juvenile emotional disorders in community settings is common (Achenbach, McConaughy, & Howell, 1987; Choudhury, Pimentel, & Kendall, 2003; Foley et al., 2004; Grills & Ollendick, 2003; Jensen et al., 1999, Klein, 1991) and routinely dealt with by combining different informants ratings using an or-rule at either a symptom or a diagnostic level (Bird, Gould, & Staghezza, 1992).
The utility of an or-rule is predicated on the assumption that all positive reports are valid, and the or-rule represents an attempt to mimic clinical decision making by integrating all known sources of information. Using an or-rule increases the estimated prevalence of juvenile disorders, and by implication likely service needs in the community, but an uncritical use of an or-rule sheds no light on the relevance of informant disagreement or the accuracy of case identification in community settings.
There are several possible explanations for informant disagreement. Each informant may contribute largely unique but equally valid information about the subject’s psychiatric status. If so, the application of an or-rule is justified. Adult informants may, however, provide biased ratings in association with their own psychiatric histories or other characteristics (Chapman, Mannuzza, Klein, & Fyer, 1994; Kendler et al., 1991) and this may yield juvenile diagnoses that are unrelated to the child’s true status. Multiple informants may also conceptualize a child’s behavior differently because they apply variable thresholds, standards or time frames for identifying a deviation from normal functioning. Discrepant reporting may also occur if a child’s behavior is only expressed in certain situations (Achenbach et al., 1987), or if parents are not equally exposed to their child’s behavior.
This study examined the basis for informant disagreement for overanxious disorder (OAD) of childhood in a community setting. Anxiety, especially generalized worry, is a phenotype which is largely internally experienced, but which can be observable if children confide in others about their worries or if their worries impact on their functioning. The utility of the or-rule was evaluated using data collected by personal interview with children and parents enrolled with a population-based, twin-family study to characterize: (1) variation in the 3-month prevalence of OAD by sex, age and pubertal status, based on interview with each informant and using a symptom and diagnosis-based or-rule, (2) agreement between informants about the presence of OAD, and (3) the correlates, outcomes and distinguishing characteristics of OAD diagnosed by interview with only one informant.
Section snippets
Method
Subjects were participants in The Virginia Twin Study for Adolescent Behavioral Development (VTSABD) (Eaves et al., 1997). Recruitment and assessment of the 1412 twin-families who comprised Time 1 of the VTSABD was described in detail elsewhere (Hewitt et al., 1997, Meyer et al., 1996). The VTSABD was conceived as an epidemiological study of children and as an epidemiological study of twins for genetically informative analysis. In this study VTSABD twins are treated as an epidemiological sample
The 3-month prevalence of over anxious disorder
The estimated 3-month prevalence of OAD ranged from 0.25 and 8.40% depending on the handling of multiple informant data (Table 1). Interviews with children or mothers identified more cases of OAD than interviews with fathers. Using an or-rule increased the prevalence of OAD, but cases diagnosed by child interview and confirmed by parent interview were very rare. The prevalence of OAD dropped by approximately 25% when at least minimal impairment in one area of functioning was required for a
Discussion
OAD was replaced by the revised criteria for generalized anxiety disorder (GAD) in the transition from DSM-III-R (APA, 1987) to DSM-IV (APA, 1994) and DSM-IV-TR (APA, 2000). Like OAD, GAD is characterized by pervasive and uncontrollable worries that may include concerns about performance, personal relationships, physical health, or ruminations about future or past behavior (APA, 2000). In addition to excessive worries, only one of the six symptomatic (somatic) criteria for DSM-IV GAD is
Limitations
Results presented here should be interpreted in light of the following limitations. First, results are based on the CAPA and may not generalize to other assessment instruments. Clinician-related inter-rater reliability is not currently available for the CAPA, and we therefore cannot compare clinician and parental agreement. Second, the study participants were all Caucasian and results may not generalize to other ethnic or racial groups. Third, the study participants were all twins and it is
Acknowledgements
This work was supported by grants MH-60324 (Dr. Foley), MH-45268 (Dr. Angold) and MH-57761 (Dr. Eaves) from the U.S. National Institute of Mental Health, Bethesda, MD and by the Carman Trust for Scientific Research, Richmond, VA (Dr. Silberg). We acknowledge the contribution of the Virginia Twin Study for Adolescent Behavioral Development, now part of the Mid-Atlantic Twin Registry (MATR), to ascertainment of subjects for this study. The MATR (PI Dr. Linda Corey) has received support from the
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