Assessing Feedback From Multiple Sources
The Carlat Child Psychiatry Report, Volume 13, Number 1&2, January 2022
Andres De Los Reyes, PhD
Editor-in-Chief, Journal of Child and Adolescent Clinical Psychology. Professor of Psychology and Director of the Comprehensive Assessment and Intervention Program, University of Maryland, College Park, MD.
Dr. De Los Reyes has disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity
CCPR: Welcome, Dr. De Los Reyes. You’ve spent much of your career researching collateral clashes—how reports of kids’ symptoms may vary depending on who is reporting those symptoms, eg, parents, kids, teachers, and others.
Dr. De Los Reyes: Yes, for the past 20 years I’ve been thinking about how different people in kids’ lives have fundamentally different perspectives on their mental health functioning, and how these different perspectives represent a strength of our assessment processes rather than a barrier to making good decisions.
CCPR: Where do we usually first see this situation come up?
Dr. De Los Reyes: Parents tend to report disruptive symptoms, such as overactivity, and kids independently tend to report internalizing ones, such as depression and anxiety. It’s a ubiquitous phenomenon. Back in the 1950s, Lapouse and Monk created an interview to assess the base rates of psychiatric symptoms with parallel items for parents and children to complete. Both groups showed very different reports about children’s psychiatric symptoms (Lapouse R and Monk MA, Am J Public Health 1958:48(9):1134–1144). It’s also true when you compare child reporting with teachers, clinical staff, trained observers, and even peers. In 1987, Achenbach and colleagues found a 0.28 correlation between informants like parents and kids and teachers, which is pretty low (Achenbach TM et al, Psychological Bulletin 1987;101(2):213–232). In 2015, we conducted the same meta-analysis with other studies and found the same 0.28 correlation (De Los Reyes A et al, Psychological Bulletin 2015;141(4):858–900).
CCPR: How widespread is this finding?
Dr. De Los Reyes: It’s global. In a recent meta-analysis we found that it manifests in every assessment in 30 countries on seven continents, in every language tested. The consistency of this discrepancy effect rivals the placebo effect (De Los Reyes A et al, Review of General Psychology 2019;23(3):293–319; Ashar YK et al, Annu Rev Clin Psychol 2017;13(1):73–98).
CCPR: What are the implications of these discrepancies for clinical care?
Dr. De Los Reyes: Clinicians tend to suppress or discount discrepant reports and think about what the data have in common. People do this in the clinic, in the laboratory, everywhere. But when you focus only on the commonalities, you leave out unique information that could impact clinical decision making.
CCPR: I’ve heard that these variations can occur even when people use supposedly objective rating scales. For example, the Autism Diagnostic Observation Scale (ADOS) may report more or fewer symptoms depending on how restrained or engaging the tester is.
Dr. De Los Reyes: Yes, you see these discrepancies regardless of how well established an instrument is. We’ve seen discrepancies when informants are distressed or depressed, or when they do not understand what we are assessing. The care we’ve taken in developing these instruments cannot remove these discrepancies, including the sensitivity to the characteristics of the person reporting.
CCPR: Since these discrepancies are a fact of clinical practice, how do you suggest we manage them?
Dr. De Los Reyes: Think about how phones track our locations. They’re linked to satellites that triangulate on us. That’s how we need to think about information sources. You don’t get an accurate read on a patient’s mental health status by getting all your data from one source. The trick is to triangulate—to get data from many sources, including your ongoing clinical exploration, and think about why those sources are saying different things. Only then can you make better decisions as the treatment unfolds.
CCPR: What kind of informants do you look for as you conduct an assessment for most kids?
Dr. De Los Reyes: It’s important to get informants from a variety of contexts, like home and school. We try to get good observers from familial and non-familial authority figures as well as peers. Think about reasons why informants might disagree, clinically relevant reasons such as observing behavior in different contexts. Select informants who will reliably produce these discrepancies, including young children. And we want self-reports from patients as well.
CCPR: How do we get this from our young patients?
Dr. De Los Reyes: You can try the Berkeley Puppet Interview, which does not require kids to verbalize responses and can be integrated with reports from parents and teachers (Kraemer HC et al, Am J Psychiatry 2003;160(9):1566–1577).
CCPR: How do you explain this phenomenon to parents?
Dr. De Los Reyes: Normalize the process. I tell them it’s like asking people to estimate how many marbles are in a jar—there’s an objective answer, but each person will estimate differently. And different people rating behavior can have even more divergent views. For instance, the same child with the same strengths and challenges can get along great with one teacher and not at all with another. That might have to do with the teacher or the situation or both.
CCPR: What do we do when parents and teachers are more or less discrepant in their reports?
Dr. De Los Reyes: Tracking these discrepancies can track treatment response. Look at whether the discrepancies change. For example, we found that you tend to get more agreement between parents and teachers in autistic children when the challenges are more severe (Lerner MD et al, J Child Psychol Psychiatry 2017;58(7):829–839). But successive reports can change over time, with one or the other informant seeing lessening severity of symptoms. We have yet to study this, but one thought might be that growing disagreement between informants over the course of treatment signals that the child’s functioning is improving.
CCPR: So if you see somebody doing worse in one circumstance and better in another, you can learn from that and duplicate it?
Dr. De Los Reyes: Exactly. The notion that context may vary by contingencies is embedded in texts by Skinner. We expect certain behaviors to be present in some contexts and absent, or present to a lesser degree, in others (Skinner BF. Science and Human Behavior. New York, NY: MacMillan; 1953). If it looks like most of the action is present in one particular context, you might focus on that for a while.
CCPR: How do we know if a discrepancy is truly meaningful?
Dr. De Los Reyes: Well, some might be junk. An informant may have had a bad day or an instrument may not have performed the way you were hoping. I tell my team to trust but verify. Find independent assessments, numbers apart from these sources, to help corroborate whether the discrepancies feel real or whether you’re getting noise. (Editor’s note: Informant reports can be impacted by additional factors such as denial of mental health conditions, over-identification with the child, implicit bias, and structural inequities such as limited categories for individual educational planning.)
CCPR: Can you give an example?
Dr. De Los Reyes: Let’s say you have a mother who brings her 3rd grader to you because the teacher says he won’t follow instructions in class, that he’s defiant. The parents don’t see any problem. It’s common for us to agree more with whomever brings the child, so your tendency may be to go with the parents’ impression. You need to look at the whole picture. Gather grades, school records, and an observation of the family interacting at home. Talk with the teacher—is this report true oppositionality or a mismatch involving a teacher who expects more organization than the child can muster? Behavior varies across contexts, and no one information source provides a complete picture of how the patient behaves across circumstances.
CCPR: This can be tricky. With ADHD, we don’t diagnose unless there are symptoms across two or more settings.
Dr. De Los Reyes: ADHD really trips people up. Say a child has trouble concentrating in class and completes only half of her schoolwork. Her grades are terrible, and her parents bring her in asking about ADHD. The criteria for ADHD require that you see the symptoms in more than one setting, and the parents aren’t seeing any problems at home. You can’t formally diagnose ADHD, and it throws into question whether you are likely to succeed with any ADHD-specific treatment.
CCPR: Right. So how important is it that the child has symptoms across settings?
Dr. De Los Reyes: It’s a glaring hole in our evidence base. We need studies to see whether the cross-contextual criterion is necessary for an ADHD diagnosis, looking at differences using objective, independent markers of impairment between patients for whom parents and teachers agree and disagree on ADHD symptoms. Studies like these have been done in disruptive behavior and autism, but not ADHD (De Los Reyes A, J Abnorm Child Psychol 2009;37(5):637–652).
CCPR: What do we do to sort it out?
Dr. De Los Reyes: Look at independent assessments like grades or observations of peer relations. Computerized performance testing is not diagnostic per se, but it can give additional data about the child’s cognitive attention and impulsivity. If the outside evidence weighs toward ADHD, then the child may benefit from treatment. Otherwise we’re missing out on kids who would benefit from care because they don’t have symptoms in two settings so they don’t meet the diagnostic threshold.
CCPR: What about kids with depression who might appear OK when they are in the company of people but suicidal when they are alone?
Dr. De Los Reyes: For a long time, we’ve said that getting kids active with other people doesn’t bring much change in depression. But in the meta-analyses there’s a discrepancy—the children report positive effect sizes that are several times larger than what the parents report (Weisz JR et al, Psychological Bulletin 2006;132(1):132–149). We tend to think, “Well, if parents aren’t seeing a big change, then how much stock can we put into the kids’ reports?” I think these kids are telling us that cognitive behavioral therapy does help them with some problems, like when they’re with their peers, but not necessarily at home when they’re with their parents. However, to truly sort this out we need carefully conducted studies with independent assessments of how children behave with peers over the course of treatment.
CCPR: That reminds me of kids who are passive and anxious when I see them with their parents but less anxious when I see them alone.
Dr. De Los Reyes: Sure. Say you have a child referred for assessment of anxiety. The parents report that the child is avoiding social situations. He won’t go to birthday parties, refuses most playdates, and fusses when he’s supposed to go to soccer practice. Then you see the child, who says he’s fine with other kids and has no problem engaging in activities with them. This is opposite of our usual expectation that kids will report anxiety symptoms that parents don’t notice because they are not disruptive.
CCPR: How do you explain the discrepancy?
Dr. De Los Reyes: An anxious kid might not want you to judge them, so they deny the reports of their difficulties. They don’t want to look bad, especially in front of strangers like you. So, when the parents’ and kid’s reports differ, you need to consider two possibilities. Either the kid is downplaying the concerns or the parents aren’t aware of circumstances where the child is doing quite well.
CCPR: What do you do here?
Dr. De Los Reyes: Same as before—look for more data. See if you can find out from peers and teachers how the child is doing. Maybe the child is standing back and not engaging on the school playground even though the child reports that they are “fine” in that situation. Then you have a better idea that the child is indeed anxious.
CCPR: What is the impact of cultural or racial influences on assessing these discrepancies?
Dr. De Los Reyes: If you have a non-white child who is having learning difficulties, what do you usually do? You tell the family to ask the school for psychoeducational testing. Let’s say that the testing comes back and shows that the child has problems with reading comprehension. She doesn’t do well answering questions about the standard stories on reading comprehension tests, like building and floating boats at the local park or “pet day at the fair,” so the school gives the student extra help. But three months later you see the child back and she’s doing no better than before.
CCPR: What went wrong?
Dr. De Los Reyes: Parents from different cultures or communities may over- or underreport symptoms. Also, our tests have been normed on groups of patients whose backgrounds are very similar, which means they might not be as accurate for people with different cultural, racial, and ethnic backgrounds. So if the tests indicate that this student is struggling, it might be because she has not been exposed to the information or experiences she needs to be successful on those tests.
CCPR: What do we do in this kind of situation?
Dr. De Los Reyes: Get assistance in culturally sensitive assessment specific to this child and family by talking with colleagues and using specific tools for thinking through the problem (Editor’s note: For more on cultural competence, see CCPR Jan/Feb/Mar 2021).
CCPR: Any final thoughts?
Dr. De Los Reyes: We should expect discrepancies and plan our assessments to include multiple informants and contexts: parents, teachers, peers, at home, at school, and in other activities. Assess the problem by getting independent data such as grades, other testing, and additional observations to either corroborate reports or suss out noise that can be disregarded. Since a clinical problem might be localized to a specific circumstance, plan treatment to address the problem where it occurs.
CCPR: Thank you for your time, Dr. De Los Reyes.