Different Eyes, Different Perspectives: Variations in Children’s Symptom Severity by Informant

BY ALEX WATTS, DATA ANALYST

Different Eyes, Different Perspectives: Variations in Children’s Symptom Severity by Informant
January 30, 2025 MHO

Different Eyes, Different Perspectives: Variations in Children’s Symptom Severity by Informant

The Child and Adolescent Behavioral Assessment (CABA) is based on the perspective of the patient (CABA-Youth) and/or an informant (CABA-Informant), which may include parents, guardians, or facility staff members.  Research consistently shows discrepancies are common in multi-informant clinical assessments, including the CABA, depending on who completes the assessment [1][2][3]. For example, patients who complete the CABA-Y often perceive their behavioral challenges as less severe at both admission and discharge compared to their parents’ ratings on the CABA-I. This month, MHO investigates whether informant type (i.e., parents, guardians or staff members) impact scores on the CABA-I.

We analyzed CABA-I admission and discharge assessments completed January 2018 – November 2024. The dataset included 79,434 patient assessments, with 8,552 completed by guardians, 31,847 by parents, and 39,035 by staff members. At admission, a majority of assessments were completed by parents (77.3%) while facility staff completed most at discharge (95.8%). This pattern likely reflects that parents/guardians are more familiar with the patient’s mental health before treatment, whereas staff are more familiar given they observe patients during treatment.

Non-Interactive Figure 1. CABA-I Informant type distribution at admission and discharge

Findings

When comparing the average scores for the overall CABA-I (see Figure 2 below), we found statistically significant differences among all groups. However, guardians’ and parents’ scores were closer to each other, with only small differences in severity. In contrast, staff members report moderately lower severity at both admission and discharge compared to parents and guardians.

To gain further insight, we compared scores across the three CABA-I subscales:

  1. Externalizing (outwardly expressed problematic behaviors such as destructiveness or bullying) – the largest differences in admission severity by informant type were seen here. In particular, staff rated patients moderately lower than parents or guardians at both admission and discharge.
  2. Internalizing (inwardly directed distress such as sadness) – parent ratings indicated slightly higher admission severity when compared to guardians, while there were no significant differences upon discharge. In particular, staff rated patients slightly to moderately lower than parents or guardians at both admission and discharge.
  3. Risk Behavior (e.g., drug use) – no noteworthy differences were found.

Interactive Figure 2. Average CABA-I overall and subscale severity scores by informant at admission and discharge


Why the difference?

Differences may stem from informants’ unique perspectives of patients. Staff members spend limited time with each child and may assess severity by comparing patients to one another. Parents and guardians lack this comparative perspective, possibly making symptoms seem more severe to them. Different expectations for the child’s behavior may also influence ratings, as behaviors perceived as highly problematic by one group may seem less so to another. Finally, the way informants interpret the causes of behavioral problems can affect ratings [1]. For instance, if staff attribute problems to systemic factors (e.g., family dynamics, school environment), they may rate severity lower than parents or guardians, who may attribute issues more directly to the child.

Takeaway

While informant perspectives provide valuable insights, they also introduce unique perspectives and biases, and these differences show the importance of context when interpreting CABA-I results. Given the differences in scores among informants, having the same type of informant complete assessments at both admission and discharge may enhance the reliability of symptom severity reporting for children.

References

[1] De Los Reyes, A., & Kazdin, A. E. (2005). Informant Discrepancies in the Assessment of Childhood Psychopathology: A Critical Review, Theoretical Framework, and Recommendations for Further Study. Psychological Bulletin, 131(4), 483–509. https://doi.org/10.1037/0033-2909.131.4.483

[2] Achenbach, T. M., McConaughy, S. H., & Howell, C. T. (1987). Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psychological Bulletin, 101(2), 213–232. https://doi.org/10.1037//0033-2909.101.2.213

[3] Achenbach, T. M., Krukowski, R. A., Dumenci, L., & Ivanova, M. Y. (2005). Assessment of Adult Psychopathology: Meta-analyses and implications of cross-informant correlations. Psychological Bulletin, 131(3), 361–382. https://doi.org/10.1037/0033-2909.131.3.361