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Anxiety Disorders 19 (2005) 193–210 Making sense of informant disagreement for overanxious disorder Debra L. Foleya,*, M. Rutterb, A. Angoldc, A. Picklesd, H.M. Maesa, J.L. Silberga, L.J. Eavesa a Department of Human Genetics, Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, P.O. Box 980003, Richmond, VA 23298-0003, USA b Social, Genetic and Developmental Psychiatry Research Center, Institute of Psychiatry, London, UK c Department of Psychiatry, Duke Medical Center, Duke University, Durham, NC, USA d School of Epidemiology and Health Science and Center for Census and Survey Research, University of Manchester, Manchester, UK Received 29 September 2003; received in revised form 15 January 2004; accepted 25 January 2004 Abstract A community sample of 2798 8–17-year-old twins and their parents completed a personal interview about the child’s current psychiatric history on two occasions separated by an average of 18 months. Parents also completed a personal interview about their own lifetime psychiatric history at entry to the study. Results indicate that informant agreement for overanxious disorder (OAD) was no better than chance, and most cases of OAD were based on only one informant’s ratings. Disagreement about level of OAD symptoms or presence of another disorder (mostly phobias or depression) accounted for most cases of informant disagreement: 60% of cases based only on child interview, 67% of cases based only on maternal interview, and 100% of cases based only on paternal interview. OAD diagnosed only by maternal interview was also distinguished by an association with maternal alcoholism and increasingly discrepant parental reports of marital difficulties. Given the substantial overlap in case assignments for DSM-III-R OAD and DSM-IV GAD, these findings may identify sources of informant disagreement that generalize to juvenile GAD. # 2004 Published by Elsevier Inc. Keywords: Parent report; Child report; Child anxiety; Anxiety disorders; Anxiety * Corresponding author. Tel.: þ1-804-828-8755; fax: þ1-804-828-1471. E-mail address: [email protected] (D.L. Foley). 0887-6185/$ – see front matter # 2004 Published by Elsevier Inc. doi:10.1016/j.janxdis.2004.01.006 194 D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 1. 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. 2. Method Subjects were participants in The Virginia Twin Study for Adolescent Behavioral Development (VTSABD) (Eaves et al., 1997). Recruitment and assessment D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 195 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 of children, and appropriate adjustment for the correlation between co-twins was made in the data analyses. Juvenile twin subjects were eligible for the current study if the twin, mother or father was interviewed about the twin’s history of OAD at Time 1. The eligible sample comprised 2798 twin children: 1291 boys and 1507 girls. Juvenile subjects at Time 1 were 8–17 years of age (mean ¼ 11:57, S:D: ¼ 2:98), 54% female; 100% Caucasian and 54% lived within an urban area. Using census tract data to estimate regional socioeconomic characteristics, subjects resided in areas where, on average, 26% of adults were college educated, and the mean (median) family income was $45,520. Trained field workers interviewed twins and their parents in the family home. Interviewers held a Master’s degree in Social Work or an equivalent professional degree, or had extensive experience in psychiatric interviewing. Interviewer training consisted of three weeks of residential instruction, and all field interviews were audio taped and reviewed by senior monitors. Regular meetings were conducted to avoid drift in use of the interview or other aspects of the protocol. A residential meeting was held annually to ensure that the assessment protocol was being implemented in a standardized manner (Hewitt et al., 1997). Twin subjects were personally interviewed about their psychiatric history using the Child and Adolescent Psychiatric Assessment-Children’s version (CAPA-C; Angold & Costello, 2000; Angold et al., 1995) on two occasions separated by an average of 18 months. These two occasions of measurement are referred to as Time 1 and Time 2. On each occasion twins were randomly assigned to different interviewers, and each twin was interviewed simultaneously in separate areas of the family home. Immediately following the interviews with the twins, each parent was subsequently interviewed about each twin’s psychiatric history during the past 3 months using the Child and Adolescent Psychiatric Assessment-Parent’s version (CAPA-P) at Time 1 and Time 2. Different field workers interviewed each parent, and the twin about whom the parent was first interviewed was randomly assigned. Agoraphobia (fear of open spaces, going out in crowded spaces or using public transportation), attention deficit hyperactivity disorder (ADHD, surveyed only by the CAPA-P), conduct disorder (CD), depression [minor (DSM-IV) or major], overanxious disorder (OAD), oppositional-defiant disorder (ODD), and separation anxiety disorder (SAD) were assessed following the DSM-III-R (APA, 1987). Any phobia referred to a composite phobia diagnosis (any simple or specific phobia). The 1–11-day testretest reliability of the total number of rated CAPA symptoms was .60 for conduct disorder, .88 for major depression, .50 for oppositional-defiant disorder, .80 for overanxious disorder, and .63 for separation anxiety disorder (Angold & Costello, 1995). 196 D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 The symptomatic criteria for OAD required at least four of the following symptoms: (1) excessive or unrealistic worry about future events; (2) excessive or unrealistic concern about the appropriateness of past behavior; (3) excessive or unrealistic concern about competence in one or more areas, e.g., athletic, academic, social; (4) somatic complaints, such as headaches or stomach aches, for which no physical basis can be established; (5) marked self-consciousness (6) excessive need for reassurance about a variety of concerns (7) marked feelings of tension or inability to relax. The CAPA assessed 15 areas of psychosocial impairment associated with specific symptom clusters (Angold et al., 1995; Pickles et al., 2001). Each area of disability was rated on a three-point scale (for no, partial or severe impairment), and ratings are summed to estimate overall level of associated impairment. An impairment score of 1 or higher was used here to define OAD with at least minimal associated impairment. Four CAPA-C items were used to assess pubertal status. Body hair, skin changes, voice breaking and facial hair were used to estimate puberty in boys, and body hair, skin changes, breast development and menstruation were used to estimate puberty in girls. Items ratings (0: no; 1: yes, barely; 2: yes, definitely; and 3: development complete) were summed to estimate current level of pubertal development. The mean puberty score was 2.92 (S:D: ¼ 2:89, range 0–11) in boys and 3.78 (S:D: ¼ 3:13, range 0–10) in girls. The Pearson correlation coefficient between age in years and puberty score was r ¼ :82 (P ¼ :0001) for boys and r ¼ :85 (P ¼ :0001) for girls. Parents were interviewed about their own lifetime psychiatric history after they completed the CAPA-P at Time 1. The following parental disorders were diagnosed following the DSM-III-R: alcoholism, anti-social personality disorder (ASPD), generalized anxiety disorder, major depressive disorder, panic disorder, social phobia and simple phobia. The parental interview was a modified version of the SCID, described in detail elsewhere (Foley et al., 2001). Parents completed a questionnaire that included the Dyadic Adjustment Scale (DAS) immediately following the child and parent interviews. Dyadic satisfaction during the previous year was surveyed and scored as outlined by Spanier (1976), with higher scores reflecting a relatively higher level of satisfaction. The dyadic satisfaction items in the DAS survey the frequency of regret associated with the marriage, thoughts of separation/divorce, leaving the house after a fight, quarrelling or irritation with spouse, positive interactions with spouse, degree of happiness with the marital relationship and feelings about the future of the relationship. The mean level of dyadic satisfaction rated by mothers and fathers in the VTSABD was 33.79 (S:D: ¼ 3:95, range ¼ 3–42, N ¼ 1165) and 34.19 (S:D: ¼ 3:52, range ¼ 17–45, N ¼ 965), respectively (Wilcoxon 2-sided Test, P ¼ :06). Maternal ratings, paternal ratings and the absolute difference between maternal and paternal ratings of dyadic satisfaction were used to characterize the association between parental perceptions of marital harmony and informant disagreement for OAD. D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 197 2.1. Data analysis Variation in prevalence between groups was evaluated using a two-tailed Chi-square test. Fisher’s exact test was used when the expected number of participants in any cell of the contingency table was <5. Logistic regression was used to estimate age effects, and pubertal effects minus age effects to test if pubertal developmental that was atypical for (or independent of) chronological age was associated with risk for OAD. Logistic regression was also used to estimate the association between OAD and other diagnoses or characteristics, and informant effects were evaluated following the method described by Fitzmaurice, Laird, Zahner, and Daskalakis (1995). Regression analyses were performed within PROC GENMOD in SAS version 6.12 to adjust for the correlation between twins (SAS Institute Inc., 1995). 3. Results 3.1. 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 diagnosis, irrespective of informant. All cases diagnosed by child interview, and confirmed by parent interview, had associated impairment. Girls were more likely to be diagnosed with OAD than boys, but the female to male ratio was highest for cases diagnosed by child interview. Prevalence of OAD increased with age, but age trends were only significant in boys. Pubertal development that was advanced for chronological age was more strongly associated with risk for OAD in girls than age in years. 3.2. Informant agreement Informant agreement for OAD was no better than chance (Table 2). Agreement was not improved when OAD diagnoses were associated with impairment, and, with few exceptions, agreement for individual symptoms was generally no better than agreement about the presence of disorder. 3.3. Making sense of informant disagreement Informant disagreement was investigated using children for whom three informants completed the OAD module from the CAPA at Time 1 (Table 3). 198 Table 1 Three-month prevalence of overanxious disorder Diagnosis Source Total Boys Girls Age (OR) Puberty (OR) Prevalence (%) Age (OR) Puberty (OR) Prevalence (%) Age (OR) Puberty (OR) OAD Symptom or-rule Diagnostic or-rule Child Mother Father Child and parent 8.40 7.18 3.69b 3.47c 1.43 0.25 1.08 1.08 1.12 1.08 1.04 1.08 1.15a 1.15a 1.20a 1.08 1.20b 1.25 5.96 4.80 2.03 2.62c 1.15 0.15 1.17a 1.20a 1.37a 1.10 1.12 1.54 1.07 1.03 1.05 1.05 1.03 1.19 10.48 9.22 5.10b 4.21c 1.68 0.33 1.09 1.09 1.10 1.13 1.01 1.04 1.14a 1.14a 1.19a 1.04 1.29 1.20 1.75a 1.92a 2.51a 1.60a 1.46 2.20 OAD with impairment Symptom or-rule Diagnostic or-rule Child Mother Father Child and parent 6.02 4.86 2.54b 2.30c 0.94 0.25 1.08 1.09 1.06 1.14 1.15 1.08 1.15a 1.14a 1.31a 1.00 1.09 1.25 4.04 3.25 1.38 1.86 0.84 0.15 1.24a 1.23a 1.24 1.21 1.35 1.54 1.05 1.05 1.26 0.98 0.92 1.19 7.71 6.24 3.51b 2.68c 1.03 0.33 1.08 1.08 1.08 1.15 1.01 1.04 1.14a 1.13a 1.24a 0.97 1.24 1.20 1.90a 1.92a 2.54a 1.44 1.22 2.20 OR: Odds ratios estimated using a type 1 (sequential) logistic regression analysis with age entered before pubertal status; OAD: subject met criteria for DSM-III-R OAD, with or without associated impairment in functioning; OAD with impairment: subject met criteria for DSM-III-R OAD and had at least partial disability in at least one area of psychosocial functioning. a Significant sex difference or age or pubertal effect at P ¼ :05. b Prevalence of OAD is significantly higher based on child report versus paternal report. c Prevalence of OAD is significantly higher at P :05 based on interview with mother versus father. D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 Prevalence (%) Girl:boy ratio Table 2 Informant agreement for individual symptoms and a diagnosis of overanxious disorder Child’s sex Child and father Mother and father Kappa 95% CI Kappa 95% CI Kappa 95% CI 0.07 0.01 0.05 0.02 0.10 0.06 0.002 0.05 0.09 0.01, 0.02, 0.03, 0.05, 0.03, 0.04, 0.06, 0.05, 0.04, 0.02 0.008 0.05 0.02 0.05 0.11 0.11 0.07 0.13 0.06, 0.01, 0.04, 0.06, 0.02, 0.04, 0.01, 0.08, 0.11, 0.08 0.21 0.09 0.11 0.09 0.007 0.13 0.14 0.20 0.03, 0.18 0.04, 0.47 0.02, 0.20 0.01, 0.23 0.01, 0.17 0.01, 0.003 0.006, 0.26 0.04, 0.32 0.04, 0.45 0.08 0.01 0.03 0.19 0.11 0.10 0.03 0.07 0.07 0.0008, 0.16 0.015, 0.004 0.04, 0.10 0.07, 0.31 0.04, 0.18 0.02, 0.22 0.04, 0.10 0.03, 0.16 0.04, 0.18 0.06 0.009 0.05 0.13 0.15 0.04 0.002 0.05 0.04 0.02, 0.14 0.01, 0.004 0.02, 0.13 0.03, 0.23 0.07, 0.22 0.06, 0.14 0.06, 0.06 0.04, 0.14 0.06, 0.14 0.15 0.009 0.12 0.09 0.17 0.17 0.05 0.15 0.22 0.10 0.004 0.14 0.11 0.13 0.25 0.24 0.22 0.36 Female Worry about future Worry about past Worry about competence Self-consciousness Excessive need for reassurance Physical symptoms Nervous tension Overanxious disorder Overanxious disorder with impairment 0.13 0.07 0.07 0.06 0.11 0.05 0.16 0.07 0.04 0.06, 0.21 0.04, 0.18 0.004, 0.15 0.01, 0.13 0.05, 0.17 0.03, 0.14 0.08, 0.25 0.001, 0.16 0.03, 0.12 D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 Male Worry about future Worry about past Worry about competence Self-consciousness Excessive need for reassurance Physical symptoms Nervous tension Overanxious disorder Overanxious disorder with impairment Child and mother 199 200 Informant per child Child, mother, father Child, mother Child, father Mother, father Child Mother Father N 1835 622 124 54 101 52 10 Overanxious disorder diagnosed by interview with Child only Mother only Father only Child þ mother Child þ father Mother þ father Child þ mother þ father Symptom or-rule only N % N % N % N % N % N % N % N % 52 25 3 – 7 – – 2.83 4.02 2.42 – 6.93 – – 51 24 – 1 – 1 – 2.78 3.86 – 1.85 – 1.92 – 18 – 3 1 – – 0 0.98 – 2.42 1.85 – – 0.00 4 4 – – – – – 0.22 0.65 – – – – – 2 – 1 – – – – 0.11 – 0.81 – – – – 2 – – 1 – – – 0.11 – – 1.85 – – – 1 – – – – – – 0.05 – – – – – – 27 7 0 0 – – – 1.58 1.23 0.00 0.00 – – – D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 Table 3 Three-month prevalence of overanxious disorder by the number of informants available per child D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 201 Table 4 Sub-threshold symptoms rated by other informants in association with one-informant only OAD Informant for OAD N Informant who didn’t confirm diagnosis % children with sub-threshold symptoms rated by other informant 0 symptoms 1 symptom 2 symptoms 3 symptoms Child 52 Mother Father 55.77 73.08 30.77 17.31 1.92 5.77 11.54 3.85 Mother 51 Child Father 78.43 70.59 13.73 13.73 5.88 9.80 1.96 5.88 Father 18 Child Mother 61.11 72.22 22.22 11.11 0.00 5.56 16.67 11.11 This sub-sample (66% of the total) was used to characterize OAD diagnosed by interview with only one informant (77% of all OAD cases in this sub-sample), and, where applicable, only by a symptom or-rule (17% of all OAD cases in this sub-sample). Unless otherwise indicated, the reference group in the analyses reported below were children without a diagnosis of OAD (by child, maternal or paternal interview, or by a symptom or-rule). 3.4. Disagreement about the number of symptoms versus disagreement about the presence of any symptoms Between 56 and 78% of children diagnosed with OAD by interview with only one informant had no symptoms of OAD according to the other two informants (Table 4). OAD diagnosed only by interview with mothers was less likely to be associated with a sub-threshold level of symptoms rated by the other two informants than OAD diagnosed only by interview with children or fathers. 3.5. Disagreement about the type of disorder versus disagreement about the presence of any disorder Cross-informant cross-disorder odds, adjusted for agreement about the presence of a second disorder, were estimated to distinguish diagnostic disagreement from agreement about the presence of a second disorder. For example, when the odds of OAD diagnosed only by child interview and depression diagnosed by maternal interview were estimated, depression cases diagnosed by maternal but not by child interview were coded 1 (1 ¼ disagreement ¼ mother rated depression as present, child rated depression as absent), and depression cases diagnosed by both child and maternal interview, or by neither child and maternal interview, were coded 0 (0 ¼ agreement ¼ mother and child agreed depression was absent or mother and child agreed depression was present), and so on. These analyses therefore estimated the odds of diagnostic disagreement associated with OAD diagnosed by interview with only one informant. 202 D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 OAD diagnosed only by child interview was associated with a significantly increased odds of mother-rated depression and father-rated agoraphobia that was not confirmed by the child (Table 5). Mother–child and father–child disagreement about presence of OAD versus any other disorder accounted for 11.54% (6/52) and 7.69% (4/52), respectively, of OAD cases diagnosed only by child interview. This was not significantly different from the level of parent–child disagreement found among children without a diagnosis of OAD (11.74%, P ¼ 1:00 and 8.10%, P ¼ 1:00, respectively). OAD diagnosed only by maternal interview was associated with a significantly increased odds of child-rated conduct disorder, child-rated depression and father-rated (any) phobia that was not confirmed by mothers (Table 5). Mother–child and mother–father disagreement about the presence of OAD versus any other disorder accounted for 29.41% (15/51) and 13.73% (7/51) of OAD cases diagnosed only by maternal interview. This was significantly different from the level of mother–child disagreement found among children without a diagnosis of OAD (16.21%, P ¼ :02 and 7.75%, P ¼ :12, respectively). OAD diagnosed only by paternal interview was associated with a significantly increased odds of child-rated agoraphobia, child-rated depression and motherrated depression that was not confirmed by fathers (Table 5). Father–child and father–mother disagreement about the presence of OAD versus any other disorder accounted for 38.89% (7/18) and 22.22% (4/18) of OAD cases diagnosed only by paternal interview. This was significantly different from the level of father–child disagreement found among children without a diagnosis of OAD (17.10%, P ¼ :02 and 12.51%, P ¼ :27, respectively). The pattern of informant disagreement therefore distinguished OAD diagnosed only by child interview, whereas both the pattern and the prevalence of informant disagreement distinguished OAD diagnosed only by parent interview. 3.6. Parental characteristics associated with informant disagreement Only two parental characteristics were significantly associated with informant disagreement for OAD (Table 6). Maternal alcoholism and increasingly discrepant parental reports of marital satisfaction were both more strongly associated with OAD diagnosed only by interview with mothers than OAD diagnosed only by interview with children. 3.7. Implications for comorbidty Examination of the pattern of comorbidity estimated for OAD diagnosed by interview with only one informant, within and across time, indicated that fathers were more likely than children to rate SAD or social phobia at Time 1 in association with OAD at Time 1 (Table 7). Fathers were also more likely than children to rate agoraphobia at Time 2 in association with OAD at Time 1. Table 5 Diagnostic disagreement associated with informant disagreement for overanxious disorder Diagnosis Time OAD diagnosed only by maternal interview OAD diagnosed only by paternal interview Informant for other diagnosis that is not confirmed by child Informant for other diagnosis that is not confirmed by mother Informant for other diagnosis that is not confirmed by father Mother (OR) Child (OR) Child (OR) Agoraphobia 1 2 0.00 0.00 Attention deficit hyperactivity disorder 1 2 0.00 2.07 Conduct disorder 1 2 Minor or major depression Father (OR) * 10.95 0.00 Father (OR) * 17.35 0.00 Mother (OR) 2.78 5.57 0.00 0.00 0.00 0.00 1.35 6.17* – – 0.00 0.00 – – 0.00 0.00 1.91 0.00 2.04 6.56 4.96* 1.44 2.22 0.00 2.41 0.00 0.00 0.00 1 2 3.89* 0.00 0.00 5.46 3.68* 2.49 0.00 4.77 6.64* 4.23 7.64* 0.00 Oppositional defiant disorder 1 2 1.71 2.72 0.00 0.00 0.00 7.57* 0.00 4.77 0.00 0.00 0.00 0.00 Separation anxiety disorder 1 2 0.00 0.00 0.00 0.00 1.27 0.00 5.57 11.16* 1.59 0.00 5.42 0.00 Any specific or social phobia 1 2 0.26 0.78 0.43 2.38 1.86 1.55 2.81* 1.92 2.41 2.53 1.54 1.06 203 Odds are adjusted for informant agreement about the presence of a second disorder, see text for details; reference group is children with no diagnosis of OAD using a symptom or-rule or child or parent CAPA. * P :05. D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 OAD diagnosed only by child interview 204 Table 6 Bivariate odds of OAD in association with parental history of psychiatric disorder Parental disorder Parent Odds of OAD diagnosed by interview with Mother only (N ¼ 51) (OR) Father only (N ¼ 18) (OR) Symptom or-rule only (N ¼ 27) (OR) Informant differences Mother > child P ¼ .04 Alcoholism Mother Father 0.92 0.64 4.52* 0.53 0.00 1.01 3.68* 0.95 Anti-social personality disorder Mother Father 0.00 0.52 8.53* 0.00 0.00 0.00 0.00 0.00 Generalized anxiety disorder Mother Father 0.96 1.38 1.77 1.31 1.01 3.42* 0.80 3.23* Major depression Mother Father 2.07* 1.73 1.54 1.74 3.07* 3.27* 2.17* 1.65 Panic disorder Mother Father 2.08 1.37 1.21 0.00 0.00 0.00 1.85 0.00 Simple phobia Mother Father 0.56 1.04 0.97 0.16 0.78 0.40 0.86 1.98 Social phobia Mother Father 0.32 0.89 1.30 1.68 0.00 1.27 0.96 1.47 Marital dissatisfaction Mother Father [M F] 0.97 0.99 0.93 0.91* 0.95 1.15* 0.98 0.90 0.99 0.90* 0.91* 1.25* [M F] ¼ the absolute difference between mother’s and father’s ratings of marital satisfaction. * P :05. Mother > child P ¼ .04 D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 Child only (N ¼ 52) (OR) D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 205 Table 7 Bivariate odds of comorbidity associated with one-informant only OAD—within-informant effects Diagnosis Time Informant for OAD and other diagnoses Child Agoraphobia Attention deficit hyperactivity disorder Conduct disorder Minor or major depression Oppositional defiant disorder Separation anxiety disorder Any specific or social phobia Overanxious disorder * 1 2 1 2 1 2 1 2 1 2 1 2 1 2 2 Mother * 6.56 14.57* – – 2.25* 0.00 10.30* 5.35* 4.37* 0.00 6.47* 5.25* 5.22* 2.75* 5.19* * 11.36 7.91 1.94 0.00 2.64 4.59* 11.24* 6.37* 8.79* 5.86* 8.60* 4.31* 5.21* 2.07* 9.37* Informant differences Father 0.00 37.69* 0.00 0.00 3.17 4.44 17.27* 6.67* 19.02* 5.46 25.75* 0.00 2.78* 6.94* 15.49* Father > child P ¼ .09 Father > child P ¼ .04 P :05. 4. 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 required to diagnose GAD in children. Any four of seven symptomatic criteria were required to diagnose DSM-III-R OAD, but three symptoms related to worries and one symptom was somatic complaints. The criteria for childhood OAD and GAD are therefore similar, and a comparison of case assignments in a clinical study showed no significant difference using DSM-III-R OAD and DSM-IV GAD (Kendall & Warman, 1996). Agreement between DSM-III-R and DSM-IV for parent diagnostic interviews was 98% and agreement for child diagnostic interviews was 93%, supporting generalizations from OAD research to juvenile GAD defined by the DSM-IV (Kendall & Pimentel, 2003). Overlap between GAD and OAD was lower, however, in an epidemiological study that examined comorbidity across time in a large sample of youth aged between 9 and 16 years (Costello, Egger and Angold, 2003). In that study, 34% of children with GAD did not meet criteria for OAD. Given the low level of informant agreement for individual symptoms of GAD (Kendall & Pimentel, 2003), and the similarity of case assignments using criteria for each 206 D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 disorder, the findings of the present study may identify sources of informant disagreement for OAD that generalize to juvenile GAD. Most informant disagreement for OAD in the VTSABD reflected disagreement about whether the child had sufficient symptoms to meet the diagnostic threshold for OAD or disagreement about whether the child had OAD or another disorder. These two sources of disagreement accounted for 60% of OAD cases diagnosed only by child interview, 67% of OAD cases diagnosed only by maternal interview, and 100% of OAD cases diagnosed only by paternal interview. Informants mostly disagreed about the presence of OAD versus depression or phobia, especially agoraphobia. Disagreement about presence of generalized worry versus fear of one or more phobic stimuli is consistent with limited parental exposure to a child’s anxiety, or ignorance about the source or breadth of the child’s anxiety (generalized worry versus fear in response to a specific stimulus). Situational specificity has often been used to defend the validity of parent-, teacher- and child-based diagnoses, even when informant agreement is very low (Achenbach et al., 1987). Apparent situational specificity may, however, reflect ignorance of the generalized nature of some children’s anxiety. Awareness of a child’s anxiety in one setting, but not other situations in which anxiety also occurred, may logically lead to a misdiagnosis of phobia. It is therefore important to distinguish valid symptom ratings from invalid diagnoses because the former may reflect relatively accurate but limited knowledge whereas the latter may reflect inaccurate diagnostic inferences based on limited knowledge. Although OAD and depression were defined by different symptoms, it is conceivable that worry and nervous tension may be mistaken for sadness or irritability. This is likely to be especially important to consider in future studies of GAD because of overlap between the criteria for DSM-IV GAD and depression (e.g., difficulty concentrating, see Joormann & Stober, 1999). Some forms of informant disagreement could not, of course, be interpreted by considering the difficulty of distinguishing one emotion from another or the impact of having only partial knowledge about the circumstances under which a child felt anxious. For example, OAD diagnosed only by maternal interview was associated with CD and ODD based on child interview and future CD based on maternal interviews. Further investigation of the relationship between generalized anxiety based only on maternal report and risk for externalizing disorders in twins might clarify the impact on children of a maternal perception that is unconfirmed by other informants. Twins can be used to test the effects on children of maternal perceptions unshared by others because of predictions that can be made about the sources of twin similarity. Twin discordance reflects the impact of unshared environmental risk factors that make twins different from each other. Twin concordance reflects the impact of shared (familial) risk factors that makes twins resemble one another. OAD diagnosed only by maternal report was associated with an increased odds of child-rated CD. If OAD diagnosed only by maternal report predicted discordance for child-rated CD then maternal perceptions D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 207 unshared by others may act as an individual-specific environmental risk factor (e.g., due to differential maternal treatment of twins). If OAD diagnosed only by maternal report predicted concordance for child-rated CD then maternal perceptions unshared by others may act as a shared (familial) risk factors (e.g., because OAD diagnosed only by maternal report was strongly associated with maternal alcoholism and marital difficulties). Two maternal characteristics were differentially associated with OAD diagnosed only by maternal report and OAD diagnosed only by child report: maternal alcoholism and increasingly discrepant parental reports of marital satisfaction. These two characteristics did not differentiate OAD diagnosed only by paternal report and OAD diagnosed only by child report. Mothers with a history of alcoholism, and mothers who rate their marital satisfaction differently from their spouses, may be more sensitive to their child’s true anxiety than either the child or the father or they may over rate their child’s anxiety as a function of their own personal or marital difficulties. It is not clear why mothers would be more sensitive or biased raters in association with a personal history of alcoholism or marital difficulties, but previously reported associations between parental alcoholism and OAD diagnosed by combining child and parent (usually maternal) ratings should be interpreted cautiously (e.g., Kuperman, Schlosser, Lidral, & Reich, 1999). Future efforts to identify putative cases of juvenile anxiety disorder, including DSM-IV GAD, based only on maternal screening instruments should also be interpreted cautiously, and special care should be taken with the differential diagnosis of generalized anxiety, depression and agoraphobia. The findings of this study suggest that the low level of informant agreement in many community surveys may often reflect: (1) a hierarchy of informant knowledge (e.g., agreement that a child was anxious but disagreement about how many anxiety symptoms were present or disagreement about whether the anxiety was best attributed to a generalized source of worries or to specific phobic triggers); (2) reasonable misinterpretation of diagnostic status (e.g., mistaking anxiety for depression); (3) diagnostic error (e.g., mistakenly rating OAD rather than CD); or (4) variable maternal sensitivity or rating bias (e.g., due to maternal psychiatric history or marital difficulties). Unscrutinised informant disagreement and an uncritical application or an or-rule will, however, continue to impact on the accuracy of case identification in community settings. This, in turn, will impact on the accuracy of estimated prevalence rates, sex differences, age trends, pubertal effects, patterns and causes of comorbidity, and patterns and causes of parent– offspring associations. Finally, and contrary to popular wisdom, mothers may be more biased raters than fathers. 5. 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 208 D.L. Foley et al. / Anxiety Disorders 19 (2005) 193–210 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 always important to replicate findings based on twins with findings based on singletons or siblings of different ages. Our findings are nonetheless relevant for other Caucasian twin studies that use parent and/or child ratings of twins to estimate genetic and environmental contributions to juvenile anxiety and associated patterns of comorbidity. Fourth, sex and age effects on informant agreement were not examined in an effort to maximize statistical power. Fifth, analyses focussed on parent-based characteristics that may have been associated with a parental rating bias but child-based characteristics may have also contributed to rating errors and systematic patterns of informant disagreement. Seventh, it is important to consider the possibility that the statistically significant findings reported here may reflect chance associations (for a discussion of the interpretation of P values in the context of multiple statistical tests see Brown & Russell, 1997; Cohen, 1982; Feild & Armenakis, 1974; Goodman, 1998, 1999; Rothman, 1990; Savitz & Olshan, 1995; Thompson, 1998). 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