Dr Harriet Salbach-Andrae

PhD Nora Klinkowski

MD Klaus Lenz

MD Ulrike Lehmkuhl

PhD Klinkowski

MD Ae K Lenz

Keywords:

Objective The study examined parent-youth agreement regarding reports on psychopathology among adolescents suffering from psychiatric disorders. Method A total of 1,718 patients between the age of 11 and 18, as well as their parents, were assessed using the child behavior checklist (CBCL), and the youth self-report (YSR). Results Poor to low agreement between parent-and adolescent-reported problem behavior on the internalizing scale, the total problem scale and moderate agreement concerning the externalizing scale of the CBCL and the YSR were found. Independent from the amount of psychiatric diagnoses, adolescents reported significantly less behavioral problems than their parents. Concerning externalizing problems, parent-youth disagreement was stronger for patients suffering from comorbid psychiatric disorders, than for adolescents displaying only one psychiatric disorder. Conclusion In clinically referred children, parents are likely to emphasize the severity of the difficulties, whereas adolescents' under-report symptoms.

Introduction

There is a strong consensus of opinion that the clinical assessment of children and adolescents' psychopathology requires data from multiple informants [START_REF] Comer | A symptom-level examination of parent-child agreement in the diagnosis of anxious youths[END_REF][START_REF] Kendall | Methodological issues in treatment research for anxiety disorders in youth[END_REF]. When multiple informants, however, provide information, discrepancies among them are to be expected [START_REF] Edelbrock | Parentchild agreement on child psychiatric symptoms assessed via structured interview[END_REF]. Many researchers have reported significant discrepancies between youth-reported and parent-reported psychopathology in children and adolescents [START_REF] Achenbach | Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity[END_REF][START_REF] Cantwell | Correspondence between adolescent report and parent report of psychiatric diagnostic data[END_REF][START_REF] Crystal | Multimethod assessment of psychopathology among DSM-IV subtypes of children with attentiondeficit/hyperactivity disorder: self-, parent, and teacher reports[END_REF][START_REF] Ferdinand | Parent-adolescent disagreement regarding psychopathology in adolescents from the general population as a risk factor for adverse outcome[END_REF][START_REF] Ferdinand | Prognostic value of parentadolescent disagreement in a referred sample[END_REF][START_REF] Kolko | Emotional/behavioral problems in clinic and nonclinic children: correspondence among child, parent and teacher reports[END_REF][START_REF] Seiffge-Krenke | Discrepancies between mothers' and fathers' perceptions of sons' and daughters' problem behaviour: a longitudinal analysis of parent-adolescent agreement on internalising and externalising problem behaviour[END_REF][START_REF] Sourander | Parent-adolescent agreement on emotional and behavioral problems[END_REF].

In studies of non clinical samples, youth reported higher severity ratings than their parents or teachers [START_REF] Achenbach | Integrative guide for the 1991 CBCL/4-18, YSR and TRF profiles[END_REF][3][4][START_REF] Stanger | Three-year course of behavioral/emotional problems in a national sample of 4-to 16-year-olds: 3. Predictors of signs of disturbance[END_REF]. A few studies involved clinically referred samples and invariantly document a reverse discrep-ancy, where youth ratings of problem severity are lower than parent ratings [START_REF] Kazdin | Child, mother, and father evaluations of depression in psychiatric inpatient children[END_REF][START_REF] Phares | Adolescents', parents', and teachers' distress over adolescents' behavior[END_REF][START_REF] Thurber | Comparisons of parent and adolescent perspectives on deviance[END_REF]. In clinically referred children, parents are likely to emphasize the severity of the difficulties which is often likely to result in a ceiling effect, whereas the young persons' ratings are usually correspondingly lower.

Investigations have given most attention to examine how child and adolescent characteristics such as age, gender and problem type are related to informant discrepancies. Concerning age, a meta-analysis showed that agreement between informants' ratings was greater for younger than for older children [START_REF] Achenbach | Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity[END_REF]. The authors interpreted the results in the way that adolescents' behavior may be less observable by informants compared to childrens' behavior. Interestingly, some studies have not detected age differ-ences [START_REF] Choudhury | Childhood anxiety disorders: parent-child (dis)agreement using a structured interview for the DSM-IV[END_REF][START_REF] Kolko | Emotional/behavioral problems in clinic and nonclinic children: correspondence among child, parent and teacher reports[END_REF][START_REF] Verhulst | The child assessment schedule: parent-child agreement and validity measures[END_REF] or figured out that disagreement was higher for younger than for older children [START_REF] Grills | Multiple informant agreement and the anxiety disorders interview schedule for parents and children[END_REF]. A lot of discrepancies may be attributable to sample characteristics. For example, in Achenbach et al.'s [START_REF] Achenbach | Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity[END_REF] meta-analysis, they categorized child age dichotomously among children and adolescents aged 6-19 years. In addition, studies that found lower agreement for younger children often have not categorized child age in the same way as Achenbach et al. [START_REF] Achenbach | Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity[END_REF].

Attention has also been given to examine the connection between gender and informants agreement [START_REF] Engel | Parent-child agreement on ratings of anxiety in children[END_REF][START_REF] Kolko | Emotional/behavioral problems in clinic and nonclinic children: correspondence among child, parent and teacher reports[END_REF][START_REF] Verhulst | Agreement between parents' reports and adolescents' self-reports of problem behavior[END_REF]. In sum, the divergent results could be attributable to sample characteristics and in specific populations, gender effects may be occurring.

With regard to SES, various studies have not found a relation between SES and informant discrepancies, when other child and parent characteristics were included [START_REF] Chi | Motherchild relationships of children with ADHD: the role of maternal depressive symptoms and depression-related distortions[END_REF][START_REF] Kolko | Emotional/behavioral problems in clinic and nonclinic children: correspondence among child, parent and teacher reports[END_REF][START_REF] Ritsher | Inter-generational longitudinal study of social class and depression: a test of social causation and social selection models[END_REF].

In general, previous studies revealed a higher parent-child agreement regarding externalizing symptoms compared to internalizing symptoms [START_REF] Berg-Nielsen | When adolescents disagree with their mothers: CBCL-YSR discrepancies related to maternal depression and adolescent self-esteem[END_REF][START_REF] Seiffge-Krenke | Discrepancies between mothers' and fathers' perceptions of sons' and daughters' problem behaviour: a longitudinal analysis of parent-adolescent agreement on internalising and externalising problem behaviour[END_REF]. It has been argued that externalizing problems are more openly observable and directed at others. Internalizing problems, however, are reported more often by children and adolescents themselves and are only poorly recognized by their parents [START_REF] Bird | Aggregating data from multiple informants in child psychiatry epidemiological research[END_REF][START_REF] Edelbrock | Parentchild agreement on child psychiatric symptoms assessed via structured interview[END_REF][START_REF] Sourander | Parent-adolescent agreement on emotional and behavioral problems[END_REF].

Studies revealed that parent-child agreement for the diagnoses of childhood anxiety and depressive disorders showed low to moderate levels of informant agreement [START_REF] Angold | Parent and child reports of depressive symptoms in children at low and high risk of depression[END_REF][START_REF] Choudhury | Childhood anxiety disorders: parent-child (dis)agreement using a structured interview for the DSM-IV[END_REF][START_REF] Comer | A symptom-level examination of parent-child agreement in the diagnosis of anxious youths[END_REF]. Research has also investigated informant disagreement with regard to specific childhood externalizing problems (aggression, hyperactivity/inattention and oppositional behavior) and revealed low to moderate levels of informant agreement as well [START_REF] Edelbrock | Parentchild agreement on child psychiatric symptoms assessed via structured interview[END_REF][START_REF] Grills | Multiple informant agreement and the anxiety disorders interview schedule for parents and children[END_REF][START_REF] Jensen | Parent and child contributions to diagnosis of mental disorder: are both informants always necessary?[END_REF][START_REF] Macleod | Identification of childhood psychiatric disorder by informant: comparisons of clinic and community samples[END_REF].

A significant number of studies has shown that many children and adolescents meet the criteria for multiple psychiatric disorders [START_REF] Achenbach | Diagnosis, assessment, and comorbidity in psychosocial treatment research[END_REF]. The discovery that two or even more distinct psychiatric disorders jointly occur in one individual is very important, because psychiatric comorbidity often appears to connote greater impairment and chronicity [START_REF] Angold | Comorbidity[END_REF]. Comorbidity often suggests poorer response to treatment and worse longitudinal trajectories [START_REF] Weiss | Common and specific features of childhood psychopathology[END_REF]. To the best of our knowledge, no study has yet examined, whether parent-youth agreement differs when psychiatric comorbidities are present.

The current study investigates parent-youth agreement regarding psychopathology in youths suffering from different numbers of psychiatric Axis I disorders according to the ICD-10 multi axial classification system. Our referred sample provides statistical power to detect uncommon relationships between youth-reported and parent-reported psychopathology in adolescents.

Method j Participants

Four thousand and twenty-two patients (>99% Caucasian) were screened for our chart review study. All of them had been referred to a child and adolescent psychiatry department of a major university hospital in Germany between January 1996 and December 2006. In order to make sure that all patients were able to understand the questions of the child behavior checklist (CBCL), 1,545 patients had to be excluded due to IQ < 85 or missing IQ data. 116 patients were not included in the study due to ambiguity of diagnoses. Another 843 patients were excluded due to unavailable or missing CBCL/youth self report (YSR) values (>8 items). Possible criteria for missing data not at random are drop out, deficient German and the presence of psychiatric diagnoses of parents. Thus, the study consisted of 1718 patients (963 male) between the age of 11 and 18 (mean age = 13.9, SD = 2.0).

Socioeconomic status (SES) was measured on an eleven-point scale assessing the parents' self-reported occupational status [START_REF] Englert | Das Frankfurter Kinder-und Jugendpsychiatrische Dokumentationssystem[END_REF]. The scale places each occupation into one of eleven categories (1 = unskilled laborer, 6 = professional employed, 7 = unskilled self-employed, 11 = professional self-employed). We distinguished three SES groups: High (groups 5, 6, 10, 11; e.g., manager, physician), middle (groups 3, 4, 9; e.g., electrician, nurse) and low (groups 1, 2, 7, 8; e.g., cashier, textile machine operator). In this study, SES was as follows: High SES (21.0%), middle SES (67.4%) and low SES (11.4%).

All patients were clinically assessed, and bestestimate diagnoses were assigned based on clinical ratings (e.g. CBCL [3] and YSR [4]), clinical observations, and semi-structured interviews with parents and their children (ÔBasisdokumentation' (BADO); [START_REF] Englert | Das Frankfurter Kinder-und Jugendpsychiatrische Dokumentationssystem[END_REF]). The BADO is an interview that collects information such as socio-demographic data, psychopathology, past medical history, somatic findings, diagnoses and therapeutic outcome. CBCL and YSR were filled out by parents and adolescents before the semi-structured interviews were accomplished. Thus, both parents and adolescents information were equally incorporated to obtain the clinical diagnoses. Senior board-certified child and adolescent psychiatrists verified all diagnoses in a case conference. For the purposes of this study, patients presenting two or even more distinct Axis I psychiatric disorder according to the ICD-10 multi axial classification system (**World Health Organization, 1996) were considered as ''comorbid''. Participants who had one Axis I psychiatric disorder according to the ICD-10 multi axial classification system were categorized as ''one-disorder'' and participants with no Axis I psychiatric disorder according to the ICD-10 multi axial classification system were grouped as ''no-disorder''. Table 1 presents sample characteristics. ICD-10 diagnoses for participants with one or more distinct Axis I psychiatric disorders are displayed in Table 2. The local Ethics Committee considered this chart review to be exempt from review, and written informed consent was not required. j Measures

Child behavior checklist (CBCL)

The CBCL parents' form [3] was designed to assess problem behavior in 4-18-year-old sons and daughters. It is one of the most established inventories in both, research and clinical practice with children and adolescents. The German version of the CBCL contains 112 items describing typical behavioral and emotional problems, each to be rated according to a 0-2 point scale ranging from ''not true'' (0) to ''somewhat or sometimes true'' (1) to ''very often true or often true'' [START_REF] Achenbach | Integrative guide for the 1991 CBCL/4-18, YSR and TRF profiles[END_REF]. The CBCL yields scores on the following eight syndrome scales: withdrawn, somatic complaints, anxious-depressed, social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior. The total problem scale subsumes the eight syndrome scales. The three syndrome scales withdrawn, somatic complaints and anxious/depressed constitute the broadband internalizing scale. The syndrome scales delinquent behavior and aggressive behavior comprise the broadband externalizing scale. Good reliability and validity of the CBCL were confirmed for the German version [START_REF] Dopfner | Reliability and factorial validity of the child behavior checklist-an analysis of a clinical and field sample[END_REF][START_REF] Schmeck | Discriminant validity of the child behaviour checklist CBCL-4/18 in German samples[END_REF]. Raw CBCL scores were transformed to T-scores.

Youth self-report (YSR)

The YSR [4] was modeled on the CBCL; it measures self-reported ratings of behavioral and emotional problems. The YSR can be used for ages 11 and up and the items are worded in the first person. It includes 112 items similar to those on the CBCL and provides also scores for the total problem scale: the above-mentioned eight syndrome scales and the internalizing and externalizing broadband scales. Do ¨pfner et al. [START_REF] Doepfner | Reliabilita ¨t und faktorielle Validita ¨t des youth self-reports[END_REF] supported the good reliability and validity scores of the German YSR translation. Raw YSR scores were transformed to T-scores.

j Statistical analyses

Using an analysis of variance and v 2 -tests, we analyzed age, SES and gender (Table 1) in relation to the three groups. To assess the clinical significance of between group differences, we evaluated the mean symptom levels of each group using standard cutoffscores for the CBCL and YSR [3,4]. T-scores above 63 for the two broadband scales as well as the total scale and above 70 for syndrome scales were defined as abnormal. T-scores of 60-63 for the two broadband scales as well as the total problem scale and T-scores of 67-70 for syndrome scales were defined as borderline range. The degree of agreement between parents' and adolescents' ratings on the CBCL and YSR was described using intraclass correlation coefficients (ICC; [START_REF] Bland | Statistical methods for assessing agreement between two methods of clinical measurement[END_REF]). Analyses of variance of repeated measures with Bonferroni correction for multiple comparisons were applied to assess differences in average CBCL and YSR total problem scores, externalizing subscores and internalizing subscores for each group (no-disorder, one-disorder, comorbid). Age, SES and gender served as covariates in the statistical analyses to control the influence of possible differences.

Results

ANOVA reveals that age differs significantly by groups (F(2. 1716) = 7.5, P < 0.001, see Table 1). Scheffe ´tests showed the no-disorder group to be significantly younger than the one-disorder and the comorbid group. Younger patients did not differ significantly from older patients according to the number of in-and outpatient psychiatric treatments (v 2 (df = 1) = 2.4, P < 0.12). There were statistically significant group differences based on SES (v 2 (df = 4) = 10.3, P < 0.05) and gender (v 2 (df = 2) = 29.2, P < 0.001; see Table 1). Table 3 presents the means and standard deviations for the entire sample. In sum, CBCL mean scores were globally higher than YSR mean scores. For the comorbid-group, parent-reported problems were within the abnormal range on the total problem scale, the internalizing scale and within the borderline range on the externalizing scale of the CBCL. Parent-reported problems for the one-disorder group were within the borderline range on the total problem scale and the internalizing scale of the CBCL. All other parent-reported problems and all self-reported problems (YSR) were rated within normal range. As expected, numerous syndrome scales were not within the borderline or abnormal range. Therefore, we only included the total problem scale, the internalizing, and the externalizing scale in the following statistical analyses.

Table 4 provides ICC for CBCL and YSR, for total problems, for externalizing and internalizing scales, separately for the three groups (no-disorder, onedisorder, comorbid). Comparing CBCL and YSR total scores as well as internalizing and externalizing scales, the ICC ranged from 0.16 (total problem score for the comorbid group) to 0.51 (externalizing scale for the no-disorder group).

ANOVA of repeated measures with Bonferroni correction for multiple comparisons (0.05/2 = 0.025) were used to examine the differences in mean scores between informants, and between the three groups. The effect of the informant was significant on the total problem scale (F(1. 1717) = 199.6, P < 0.001), the internalizing scale (F(1.1717) = 139.2, P < 0.001) and the externalizing scale (F(1.1717) = 166.2, P < 0.001). This reveals that parents reported significantly more problems than adolescents (see Table 2). Additionally, the group effect was also significant on the total problem scale (F(2.1716) = 123.1, P < 0.001), the internalizing scale (F(2.1716) = 59.8, P < 0.001) and the externalizing scale (F(2.1716) = 101.8, P < 0.001). Patients with comorbid disorders had the highest scores and adolescents displaying no psychiatric disorder had the lowest scores on all scales (see Table 2). The interaction between informants and groups was significant on the externalizing scale (F(2.1716) = 4.4, P < 0.01). Paired t tests were used for post-hoc comparisons; they displayed the highest discrepancies between CBCL and YSR for the comorbid group, followed by the one-disorder group. The no-disorder 4). No significant interaction was found for the total problem scale (F(2, 1716) = 1.2, P < 0.30) and the internalizing scale (F(2.1716) = 0.5, P = 0.58). The interaction between informants and gender was significant for the total problem scale (F(2.1716) = 62.1, P < 0.001), the externalizing scale (F(2.1716) = 55.0, P = 0.001) and the internalizing scale (F(2.1716) = 42.8, P = 0.001).

Post-hoc paired t-tests demonstrated the highest discrepancies between CBCL and YSR for males compared to females on the total problem scale, the internalizing and the externalizing scale (see Table 5). Furthermore, the interaction between informants and age was significant on all three scales (total problem scale: F(2.1716) = 54.3, P = 0.001; externalizing scale: F(2.1716) = 68.4, P = 0.001; internalizing scale: F(2.1716) = 34.7, P = 0.001). Paired t tests displayed higher discrepancies between CBCL and YSR for younger (11-14 years) patients than for older patients (15-18 years) on all three scales (total problem scale, internalizing and the externalizing scale; see Table 5).

No significant interaction was found between informant and SES.

Discussion

The objective of the present study was to assess parent-youth agreement regarding the psychopathology in a referred adolescent sample and to examine whether there are any discrepancies between patients suffering from no psychiatric disorder, one psychiatric disorder or more than one psychiatric disorder.

With regard to all three groups (no-disorder, onedisorder, comorbid), results show poor to low agreement between parent-and youth-reported problem behavior on the internalizing scale and on the total problem scale of the CBCL and the YSR. In contrast, parent-youth concordance concerning the externalizing scale of the CBCL and YSR revealed moderate agreement. These findings are consistent with previous studies comparing parent reports and youth self-reports of adolescent emotional and behavioral problems [START_REF] Achenbach | Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity[END_REF][START_REF] Cantwell | Correspondence between adolescent report and parent report of psychiatric diagnostic data[END_REF][START_REF] Ferdinand | Parent-adolescent disagreement regarding psychopathology in adolescents from the general population as a risk factor for adverse outcome[END_REF][START_REF] Yeh | Why are we here at the clinic? Parent-child (dis)agreement on referral problems at outpatient treatment entry[END_REF]. In line with existing research, the level of parent-adolescent concordance was higher for the externalizing scale than for the internalizing scale [START_REF] Berg-Nielsen | When adolescents disagree with their mothers: CBCL-YSR discrepancies related to maternal depression and adolescent self-esteem[END_REF][START_REF] Seiffge-Krenke | Discrepancies between mothers' and fathers' perceptions of sons' and daughters' problem behaviour: a longitudinal analysis of parent-adolescent agreement on internalising and externalising problem behaviour[END_REF]. This could be due to the fact that internalizing problems are less observable.

Our results reveal that adolescents reported significantly lower scores on the total problem scale, on all broadband scales and syndrome scales than their parents. Those findings contrast other studies, which showed that adolescents reported more internalizing and externalizing problem behavior than their parents [START_REF] Seiffge-Krenke | Discrepancies between mothers' and fathers' perceptions of sons' and daughters' problem behaviour: a longitudinal analysis of parent-adolescent agreement on internalising and externalising problem behaviour[END_REF][START_REF] Sourander | Parent-adolescent agreement on emotional and behavioral problems[END_REF]. Sample characteristics might be able to explain the differences between our study and previous ones. Most of the earlier studies assessed parentyouth agreement among the general population [START_REF] Cantwell | Correspondence between adolescent report and parent report of psychiatric diagnostic data[END_REF][START_REF] Ferdinand | Prognostic value of parentadolescent disagreement in a referred sample[END_REF][START_REF] Sourander | Parent-adolescent agreement on emotional and behavioral problems[END_REF]. For example, Phares and Danforth [START_REF] Phares | Adolescents', parents', and teachers' distress over adolescents' behavior[END_REF] assessed adolescent and adult reports of distress over clinically referred adolescents' problems and found that parents were more bothered by both, internalizing and externalizing behaviors than adolescents. It could be possible that the referral may have influenced the pattern of parent-youth (dis)-agreement.

Parental impression of problems that cause significant distress would be more important in obtaining a referral to a university mental health clinic rather than the adolescents' own perceptions of problems. Furthermore, the observed discrepancies might be denial of illness or lack of insight on the part of the adolescents.

It is remarkable that the syndrome scales in our sample do not reach borderline or even abnormal range. Possible underlying reason might be that the patients in our sample suffered from different types of psychiatric disorders. Hence, those patients score differently on particular syndrome scales and, thus, lower scores on the syndrome scales were achieved.

The groups differ significantly in the amount of CBCL and YSR scores. Patients suffering from comorbid disorders displayed the highest scores on the total problem score, as well as on the externalizing and internalizing scales. Patients displaying one Axis I psychiatric disorder scored higher on the total problem score and the internalizing and externalizing scale in comparison to patients displaying no psychiatric Axis I disorder. These findings strengthen the assumption that comorbidity is associated with higher levels of symptom severity. Higher levels of symptom severity often signals poorer response to treatment and worse longitudinal trajectories [START_REF] Beyers | Developmental aspects of delinquency and co-occuring aggression and depressed mood in male adolescents[END_REF][START_REF] Wilk | Comorbidity patterns in routine psychiatric practice: is there evidence of underdetection and underdiagnosis?[END_REF]. Thus, the development of better focused treatments and prevention programs for comorbid disorders are necessary.

Moreover, our results reveal that the number of psychiatric diagnoses has an impact on the amount of parent-adolescent discrepancy concerning the externalizing scale of the CBCL / YSR. With regard to informants' ratings of externalizing problems, parentyouth disagreement was the strongest for adolescents suffering from comorbid disorders, followed by the one-disorder group. Surprisingly, the three groups did not differ in parent-youth disagreement relating to the total problem scale and the internalizing scale of the CBCL/YSR. One possible explanation for the findings could be that internalizing problems are less observable and greater parent-child-disagreement exists independently from the number of psychiatric diagnoses. Informant discrepancy concerning externalizing problems increases in terms of the number of diagnoses of the child or adolescent. Possible reasons for these findings might be stronger denial of illness or the lack of insight for patients displaying comorbid psychiatric disorders.

In our study age and gender differed significantly between groups. One possible explanation for this result could be that in late childhood boys display more psychiatric disorders, whereas in adolescence girls show more psychiatric disorders. The reason why SES differed significantly between the three groups could be that psychiatric disorders are more often found in lower than in upper social class groups.

Besides, our results show that disagreement between informants' ratings was greater for younger children than for adolescents. This finding contrasts many studies which reported higher agreement between informants for younger than for older children [START_REF] Achenbach | Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity[END_REF][START_REF] Choudhury | Childhood anxiety disorders: parent-child (dis)agreement using a structured interview for the DSM-IV[END_REF][START_REF] Engel | Parent-child agreement on ratings of anxiety in children[END_REF][START_REF] Kolko | Emotional/behavioral problems in clinic and nonclinic children: correspondence among child, parent and teacher reports[END_REF][START_REF] Verhulst | The child assessment schedule: parent-child agreement and validity measures[END_REF]. This discrepancy might be due to sample characteristics. For example, in Achenbach et al.'s [START_REF] Achenbach | Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity[END_REF] meta-analysis, 269 samples in 119 studies were investigated and child age was categorized dichotomously among children and adolescents aged 6-19 years. In our study, participants were between 11 and 18 years.

Regarding gender differences, discrepancy between informants' ratings was greater for males compared to females. Thus, it might be possible that in clinical samples aged 11-18 years gender differences occur [START_REF] De Los | Informant discrepancies in the assessment of childhood psychopathology: a critical review, theoretical framework, and recommendations for further study[END_REF]. Future research should focus on specific populations, when relations between child gender and informant discrepancies are assessed.

With regard to SES and informant discrepancies our results showed no significant relation. This result stays in line with many previously cited studies that did not find a connection between SES and informant discrepancies [START_REF] Chi | Motherchild relationships of children with ADHD: the role of maternal depressive symptoms and depression-related distortions[END_REF][START_REF] Kolko | Emotional/behavioral problems in clinic and nonclinic children: correspondence among child, parent and teacher reports[END_REF][START_REF] Treutler | Are discrepancies among child, mother, and father reports on children's behavior related to parents' psychological symptoms and aspects of parent-child relationships?[END_REF].

Limitations

First, age, SES and gender differed significantly by diagnoses. However, since these variables served as covariates in the statistical analyses, they cannot be taken into account for the differences found in this study. A second limitation may be a referral bias, because the adolescents were referred to a child and adolescent psychiatric clinic at a university hospital. Nearly one third of the children referred to this department displayed two or even more distinct Axis I psychiatric disorders. Therefore, the findings probably cannot be generalized to other mental health settings. Thirdly, although the diagnoses were based on vastly structured multi-informant data with case conferences, and even if best-estimate diagnoses were given under the guidance of experienced broadly certified child and adolescent psychiatrists, we did not include an internationally accepted semistructured interview, which may have further strengthened the diagnostic classification. Because CBCL and YSR have an impact on the best-estimate diagnoses, it could be possible that some diagnoses were unreliable due to high parent-child disagreement according to CBCL and YSR. However, the parents and adolescents perspectives were valid in their own right and included in the diagnostic process. Fourthly, from the current results it cannot be inferred, which informant was ''correct'' regarding the discrepancies. Future studies should include a third informant, such as a teacher interacting with the adolescent at school. In the light of the clear advantage of investigating such a large group of referred adolescents, however, these limitations appear to be of minor importance.

Conclusion

In summary, agreement between youth-reported and parent-reported psychopathology in this large referred sample was poor to moderate. Our evidence reveals that, independent from the amount of psychiatric diagnoses, adolescents in a clinical setting reported significantly less behavioral problems than their parents. It can be assumed that the referral has influenced the result. In clinically referred children, parents are likely to emphasize the severity of the difficulties, whereas adolescents' score lower. Moreover, denial of illness or the lack of insight on the part of the youths might as well be responsible for the observed discrepancies. Concerning externalizing problems, parent-youth-discrepancies were stronger for patients suffering from comorbid disorders, than for adolescents displaying one psychiatric Axis I disorder respectively for adolescents displaying no psychiatric disorders.

  CBCL/YSR: externalizing scale CBCL/YSR: internalizing scale CBCL/YSR: total problem scale Female (N = 755) M Diff (SD) = 2.4 (10.0); t = 6.7; P < 0.001*** M Diff (SD) = 6.1 (11.0); t = 15.2; P < 0.001*** M Diff (SD) = 6.1 (10.1); t = 16.6; P < 0.001*** Male (N = 963) M Diff (SD) = 7.4 (10.7); t = 21.4; P < 0.001*** M Diff (SD) = 10.7 (11.8); t = 28.1; P < 0.001*** M Diff (SD) = 11.2 (10.6); t = 33.0; P < 0.001*** Age CBCL/YSR: externalizing scale CBCL/YSR: internalizing scale CBCL/YSR: total problem scale 11-14 years (N = 1,193) M Diff (SD) = 6.7 (10.7); t = 21.8; P < 0.001*** M Diff (SD) = 9.7 (11.7); t = 29.1; P < 0.001*** M Diff (SD) = 10.4 (10.5); t = 33.9; P < 0.001*** 15-18 years (N = 524) M Diff (SD) = 1.7 (9.9); t = 4.0; P < 0.001*** M Diff (SD) = 6.0 (11.3); t = 12.1; P < 0.001*** M Diff (SD) = 5.8 (10.2); t = 12.9; P < 0.001*** Groups CBCL/YSR: externalizing scale No-disorder (N = 189) M Diff (SD) = 4.5 (10.2); t = 6.1, P < 0.001*** One-disorder (N = 938) M Diff (SD) = 4.8 (10.8); t = 13.6; P < 0.001*** Comorbid (N = 591) M Diff (SD) = 6.1 (10.6); t = 11.5; P < 0.001*** CBCL child behavior checklist, YSR youth self-report, ICC intraclass coefficient, No-disorder no axis I psychiatric disorder, One-disorder one axis I psychiatric disorder; Comorbid two or more Axis I psychiatric disorder, M Diff mean difference, SD standard deviation

Table 1

 1 Sociodemographic measuresNo-disorder no axis I psychiatric disorder, One-disorder one axis I psychiatric disorder, Comorbid two or more Axis I psychiatric disorder, SD standard deviation, SES socioeconomic status

		No-disorder	One-disorder	Comorbid
		(N = 189)	(N = 938)	(N = 591)
	Admission age	13.4 year	14.0 year	13.9 year
		(SD = 1.8)	(SD = 1.9)	(SD = 2.1)
	Gender
	Male	132 (69.8%)	476 (50.7%)	355 (60.1%)
	Female	37 (30.2%)	462 (49.3%)	236 (39.9%)
	SES
	High	52 (27.0%)	199 (21.2%)	109 (18.4%)
	Middle	121 (64.0%)	639 (68.1%)	402 (68.0%)
	Low	16 (8.5%)	100 (10.7%)	80 (13.5%)

Table 2

 2 Distribution of axis I psychiatric diagnoses in the one-disorder and comorbid group

	One-disorder	Comorbid

Table 3

 3 Differences in T-scores of the CBCL and YSR between the groups and between informantsNo-disorder no Axis I psychiatric disorder, One-disorder one Axis I psychiatric disorder, Comorbid two or more axis I psychiatric disorder, CBCL child behavior checklist, YSR youth self-report, SD standard deviation

	CBCL/YSR scales	No-disorder		One-disorder		Comorbid
		CBCL mean (SD)	YSR mean (SD)	CBCL mean (SD)	YSR mean (SD)	CBCL Mean (SD)	YSR mean (SD)
	Total problem scale	55.7 (11.8)	46.5 (9.3)	61.3 (9.6)	52.7 (10.3)	66.5 (9.1)	56.9 (10.4)
	Scales
	Internalizing	56.1 (11.4)	47.3 (9.6)	61.9 (10.5)	53.5 (11.5)	64.9 (10.6)	55.9 (11.5)
	Externalizing	52.1 (12.2)	47.5 (9.8)	56.7 (11.3)	51.9 (10.7)	63.2 (11.6)	57.1 (11.2)
	Syndrome scales
	Withdrawn	57.5 (8.8)	52.5 (5.4)	62.1 (10.5)	56.0 (8.6)	63.7 (10.2)	56.5 (8.5)
	Somatic compl.	58.7 (8.1)	54.0 (5.4)	60.7 (9.3)	55.8 (7.2)	62.3 (9.9)	57.5 (8.3)
	Anxious-depr.	57.4 (7.9)	52.7 (5.1)	61.4 (9.4)	56.9 (8.7)	64.5 (10.1)	58.8 (9.4)
	Social problems	56.7 (8.4)	53.5 (6.1)	58.6 (8.9)	55.5 (7.9)	61.7 (10.5)	57.2 (8.8)
	Thought probl.	56.0 (7.5)	51.0 (3.5)	59.3 (9.0)	53.0 (5.6)	60.9 (9.7)	54.2 (7.3)
	Attention probl.	60.8 (10.2)	54.6 (6.6)	61.7 (9.4)	56.8 (8.3)	65.0 (9.6)	59.6 (9.4)
	Delinquent beh.	55.6 (7.5)	53.8 (5.9)	59.3 (9.3)	56.9 (7.9)	64.2 (9.9)	60.2 (9.1)
	Aggressive beh.	56.1 (9.0)	52.3 (5.2)	57.9 (9.1)	54.4 (6.9)	63.8 (11.2)	57.8 (8.7)

Table 5

 5 Post-hoc differences between CBCL and YSR using paired t tests Gender

Parent-adolescent agreement in a referred sample


MD Eniko Kiss
email: kiss@gyip.szote.u-szeged.hu

MD Ildiko ´Baji Krisztina Kapornai

MD Ildikó Baji

László Mayer

Ágnes Vetró

MD La ´szlo ´mayer

MD Ae K Kapornai

MD Ae L Mayer

MD A ´ Vetro ´

Assessing quality of life: mother-child agreement in depressed and non-depressed Hungarian

Keywords:

Introduction

The amount of research on the quality of life (QoL) of children has increased greatly over the last few years. The importance of this issue is underlined by the improved life expectancy in children with chronic, life threatening illnesses, the availability of more precise diagnostic tools in child and adolescent psychiatry, the resulting increase in recognition of psychiatric diseases in children and adolescents and the need for systematic assessment of therapeutic interventions. Quality of life as one of the newly incorporated outcome measures offers a unique opportunity to assess and follow the subjective consequences of the factors mentioned above. QoL in general has been defined as a multidimensional concept that encompasses the individual's subjective perception of well-being across all domains of life including physical, social and emotional contexts. The literature differentiates health-related QoL [START_REF] De Civita | Evaluating health-related quality-of-life studies in pediatric populations[END_REF] from the above which represents the patient's perception of health in various life domains including at least the three areas mentioned above. It refers to how illness affects functioning in different facets of life.

In general it is considered best to ask the opinion of the subject himself about his own QoL. However, the child can be too young or too ill to give adequate information. Parents are frequently asked about their offspring since they are readily available as proxies with a good insight and knowledge about their children. However, it has been widely recognized that child and proxy ratings may not agree on many issues. Parent-child agreement on symptoms of the children is generally low to moderate [START_REF] De Civita | Evaluating health-related quality-of-life studies in pediatric populations[END_REF][START_REF] Eiser | Can parents rate their child's health-related quality of life? Results of a systematic review[END_REF]. The study of interinformant agreement and factors affecting it remain an important issue in examining children and adolescents. While there are many publications about parent-child agreement on children's quality of life in physical illnesses such as epilepsy [START_REF] Ronen | The Canadian Pediatric Epilepsy Network (2003) Health-related quality of life in children with epilepsy: development and validation of self-report and parent-proxy measures[END_REF], asthma [START_REF] Coq | Which source should we use to measure quality of life in children with asthma: the children themselves or their parents?[END_REF], cystic fibrosis [START_REF] Havermans | Assessment of agreement between parents and children on health-related quality of life in children with cystic fibrosis[END_REF], cancer [START_REF] Levi | Health-related quality of life in childhood cancer: discrepancy in parent-child reports[END_REF][START_REF] Parsons | Health-related quality of life in pediatric bone marrow transplant survivors: according to whom?[END_REF][START_REF] Russel | Assessment of health-related quality of life in children with cancer[END_REF][START_REF] Sawyer | A comparison of parent and adolescent reports describing the health-related quality of life of adolescents treated for cancer[END_REF][START_REF] Vance | Issues in measuring quality of life in childhood cancer: measures, proxies, and parental mental health[END_REF], juvenile idiopathic arthritis [START_REF] April | Comparison between children with juvenile idiopathic arthritis (JIA) and their parents concerning perceived quality of life[END_REF], oral, oro-facial problems [START_REF] Jokovic | Agreement between mothers and children aged 11-14 years in rating child oral health-related quality of life[END_REF], there are less in psychiatric illnesses [attention-deficit/ hyperactivity: [START_REF] Baastiansen | Quality of life in children with psychiatric disorders: self-, parent, and clinician report[END_REF][START_REF] Klassen | Agreement between parent and child report of quality of life in children with attention-deficit/hyperactivity disorder[END_REF] and in general population [START_REF] Cremeens | Factors influencing agreement between child self-report and parent proxy-reports on the Pediatric Quality of Life Inventory 4.0 (PedsQL) generic core scales[END_REF][START_REF] Robitail | Validation of the European KID-SCREEN-52 pilot test health-related quality of life questionnaire: first results[END_REF][START_REF] Theunissen | The proxy problem: child report versus parent report in health-related quality of life research[END_REF]. There are only a few that compare ill population to a healthy one in the same study [START_REF] Coq | Which source should we use to measure quality of life in children with asthma: the children themselves or their parents?[END_REF][START_REF] Levi | Health-related quality of life in childhood cancer: discrepancy in parent-child reports[END_REF][START_REF] Russel | Assessment of health-related quality of life in children with cancer[END_REF] but their methodology varies greatly, thus making comparison and generalizability difficult.

Overall, these studies support the idea that parents perceive the impact of their child's illness more seriously than children themselves which shows in lower QoL ratings of parents than children. This has been the conclusion of numerous studies of somatically ill children [START_REF] Havermans | Assessment of agreement between parents and children on health-related quality of life in children with cystic fibrosis[END_REF][START_REF] Jokovic | Agreement between mothers and children aged 11-14 years in rating child oral health-related quality of life[END_REF][START_REF] Parsons | Health-related quality of life in pediatric bone marrow transplant survivors: according to whom?[END_REF][START_REF] Vance | Issues in measuring quality of life in childhood cancer: measures, proxies, and parental mental health[END_REF] but there are only few studies about psychiatric child populations. Baastiansen et al. [START_REF] Baastiansen | Quality of life in children with psychiatric disorders: self-, parent, and clinician report[END_REF] investigated children with different psychiatric illnesses and children without any psychiatric diagnosis. They found lower parental QoL ratings in all psychiatric illnesses and in the control sample. In this study, however, psychiatric diagnosis was based only on symptom checklist and thus conclusions regarding specific illnesses are not justified. Klassen et al. [START_REF] Klassen | Agreement between parent and child report of quality of life in children with attention-deficit/hyperactivity disorder[END_REF] investigated children with attention deficit/hyperactivity disorder and found that parents reported significantly worse QoL for four life domains (behavior, mental health, self esteem, and family cohesion) but better QoL for physical functioning while no difference was found between raters in domains like general health, family activities, and social life. No studies were found about QoL agreement in depressed child populations.

Based on the literature we would expect that parents of healthy youngsters rate higher well-being for their children than the offsprings for themselves [START_REF] Cremeens | Factors influencing agreement between child self-report and parent proxy-reports on the Pediatric Quality of Life Inventory 4.0 (PedsQL) generic core scales[END_REF][START_REF] Russel | Assessment of health-related quality of life in children with cancer[END_REF]. There are some studies on healthy and community samples however that did not find significant differ-ences between child and parent ratings [START_REF] Levi | Health-related quality of life in childhood cancer: discrepancy in parent-child reports[END_REF][START_REF] Verrips | Measuring health-related quality of life in adolescents: agreement between raters and between methods of administration[END_REF]. Theunissen et al. [START_REF] Theunissen | The proxy problem: child report versus parent report in health-related quality of life research[END_REF] in their study of a representative 8 to11-year-old Dutch population found that when the child and the parent both reported low QoL, the child reported relatively higher QoL than the parent. When the child and the parent both reported higher QoL, then the child's scores were lower than the parent's score. This would suggest that when the child is ill (QoL is low), the parent rates the negative effect of the illness higher than the child and when the child is healthy (QoL is high), the parent rates the child's problems lower than child self-report. Naturally, the lack of a gold standard which would define the true QoL of a given child complicates this issue further.

Parent-child agreement in general population samples is generally low to moderate and is dependent on the domain questioned and the method of interviewing [START_REF] Cremeens | Factors influencing agreement between child self-report and parent proxy-reports on the Pediatric Quality of Life Inventory 4.0 (PedsQL) generic core scales[END_REF][START_REF] Levi | Health-related quality of life in childhood cancer: discrepancy in parent-child reports[END_REF][START_REF] Verrips | Measuring health-related quality of life in adolescents: agreement between raters and between methods of administration[END_REF]. Eiser and Morse [START_REF] Eiser | Can parents rate their child's health-related quality of life? Results of a systematic review[END_REF] concluded in their review that there was better agreement between parents and chronically ill children than parents and healthy children. Supporting this result, Russel et al. [START_REF] Russel | Assessment of health-related quality of life in children with cancer[END_REF] found better agreement in cancer patients than healthy controls and Robitail et al. [START_REF] Robitail | Validation of the European KID-SCREEN-52 pilot test health-related quality of life questionnaire: first results[END_REF] showed higher concordance for children with special health care needs and their parents than for healthy parent-child pairs. Levi and Drotar [START_REF] Levi | Health-related quality of life in childhood cancer: discrepancy in parent-child reports[END_REF], however, found greater discrepancies in the reports of a cancer group. Comparison of agreement on quality of life between depressed children and their parents versus non-depressed children and parents was not reported previously.

The literature is ambiguous concerning variables affecting parent-child agreement about QoL of children. There are conflicting results concerning the effect of the child's age on agreement. Concordance increases with age in some studies in general child population [START_REF] Kiss | Validity and psychometric properties of the Quality of Life Questionnaire in a Hungarian child population[END_REF][START_REF] Robitail | Validation of the European KID-SCREEN-52 pilot test health-related quality of life questionnaire: first results[END_REF] and epileptic samples [START_REF] Ronen | The Canadian Pediatric Epilepsy Network (2003) Health-related quality of life in children with epilepsy: development and validation of self-report and parent-proxy measures[END_REF]. In a study of children with oral, dental problems less concordance was reported for older children [START_REF] Jokovic | Agreement between mothers and children aged 11-14 years in rating child oral health-related quality of life[END_REF]. Theunissen et al. [START_REF] Theunissen | The proxy problem: child report versus parent report in health-related quality of life research[END_REF] also found less agreement for 10 to 11-year-olds than 8 to 9-year-olds in their representative community sample. Child's age was not associated with agreement on QoL in children with cancer [START_REF] Vance | Issues in measuring quality of life in childhood cancer: measures, proxies, and parental mental health[END_REF]. Based on the conflicting results Eiser and Morse [START_REF] Eiser | Can parents rate their child's health-related quality of life? Results of a systematic review[END_REF] concluded in their review that there was no age effect on parent-child concordance of QoL.

The effect of the child's gender on QoL agreement is also ambiguous. Eiser and Morse [START_REF] Eiser | Can parents rate their child's health-related quality of life? Results of a systematic review[END_REF] found no association between gender and mother-child agreement in their review. Jokovic et al. [START_REF] Jokovic | Agreement between mothers and children aged 11-14 years in rating child oral health-related quality of life[END_REF] showed better agreement in boys with oral problems and their mothers. Robitail et al. [START_REF] Robitail | Validation of the European KID-SCREEN-52 pilot test health-related quality of life questionnaire: first results[END_REF] reported higher agreement for girls and parents in a general population sample.

Results concerning the relationship between parent-child agreement in child QoL and the type of the domain studied are more straightforward. More observable domains such as school and physical wellbeing [START_REF] Robitail | Validation of the European KID-SCREEN-52 pilot test health-related quality of life questionnaire: first results[END_REF], behavior [START_REF] Klassen | Agreement between parent and child report of quality of life in children with attention-deficit/hyperactivity disorder[END_REF], illness characteristics such as oral [START_REF] Jokovic | Agreement between mothers and children aged 11-14 years in rating child oral health-related quality of life[END_REF] or respiratory symptoms [START_REF] Havermans | Assessment of agreement between parents and children on health-related quality of life in children with cystic fibrosis[END_REF] have closer reports while covert domains such as self-esteem, family cohesion [START_REF] Klassen | Agreement between parent and child report of quality of life in children with attention-deficit/hyperactivity disorder[END_REF], mental health [START_REF] Klassen | Agreement between parent and child report of quality of life in children with attention-deficit/hyperactivity disorder[END_REF][START_REF] Parsons | Health-related quality of life in pediatric bone marrow transplant survivors: according to whom?[END_REF], and emotional functioning [START_REF] Havermans | Assessment of agreement between parents and children on health-related quality of life in children with cystic fibrosis[END_REF] have wider discrepancies. These tendencies have been shown both in somatically ill and general child and adolescent populations. Socio-economical status (SES) seems to have no effect on agreement [START_REF] Cavallo | The HBSC Positive Health Group (2006) Girls growing through adolescence have a higher risk of poor health[END_REF][START_REF] Theunissen | The proxy problem: child report versus parent report in health-related quality of life research[END_REF].

There are certain methodological considerations for studying agreement. The most frequently used Pearson product-moment correlation coefficient [START_REF] Eiser | Can parents rate their child's health-related quality of life? Results of a systematic review[END_REF] provides information on the covariation among scores but does not indicate absolute agreement. More appropriate statistical methods are intraclass correlation coefficients (ICC) for continuous variables [START_REF] De Civita | Evaluating health-related quality-of-life studies in pediatric populations[END_REF] or kappa statistics for categorical ones. It is also useful to examine mean differences between parents' and children's reports [START_REF] Cremeens | Factors influencing agreement between child self-report and parent proxy-reports on the Pediatric Quality of Life Inventory 4.0 (PedsQL) generic core scales[END_REF]. In spite of the above considerations most comparison studies still apply Pearson r statistics. There is a need to compare samples from different backgrounds by more complex methods.

In the present study we hypothesized that parents of depressed children rate lower quality of life for their offspring compared to their children, while healthy children's parents rate higher quality of life than their children for themselves. This is probably due to the increased worry and attentiveness of an ill child's parent compared to the relative carefree attitude of a healthy child's parent. Our second hypothesis was that mother-child agreement on the quality of life of children (QoL) is higher in healthy samples than in depressed ones since there is no anxiety in the mother concerning the child's well-being. Finally, we thought that agreement increases with the age of the child regardless of illness status due to developing insight and increasing ability to share inner feelings and thoughts.

This study fills a gap in our knowledge because literature is scarce in examining parent-child agreement about QoL of children in psychiatric populations. There were no such studies on young depressed patients before. Since this disorder has an increasing prevalence into adolescence with long term impairment and continuity into adulthood, it is important to study the quality of life reported by different raters and its different aspects in this population. The relatively large sample size enables us to study age and gender effects as well. Furthermore, the present study is the first to report on the quality of life and motherchild agreement of an Eastern European depressed child population.

Methods

Depressed children and their parents were participating in a study of the risk factors of childhood onset depression. Children were recruited through 23 mental health facilities (six of which had both inpatient and outpatient units) across Hungary. Children presenting sequentially at each site were scheduled for assessment if they met the following criteria: 7.0 to 14.9 years old at study entry, not mentally retarded, no evidence of major systemic medical disorder, had available at least one biologic parent and a 7 to 17.9year-old sibling (required by the study's genetic component), and attained a predetermined cut-off score on one of various self-and proxy-reported depressive symptom scales designed for this project. Psychiatric diagnosis was set up by a semi-structured interview (Interview Schedule for Children and Adolescents-Diagnostic version, ISCA-D), a validated and reliable instrument [START_REF] Kiss | Factors influencing mother-child reports of depressive symptoms and agreement among clinically referred depressed youngsters in Hungary[END_REF][START_REF] Sherill | Interview schedule for children and adolescents (ISCA)[END_REF] based on DSM IV.A two-part psychiatric evaluation was conducted on two separate occasions about 6 weeks apart, by different clinicians. The first part of the evaluation included the Mood disorder section of the ISCA-D and the collection of demographic and anamnestic data from the parents by a structured questionnaire. Subjects also completed self-report forms. Children who fulfilled diagnostic criteria for MDD were scheduled for the second part, a full diagnostic evaluation. Results of the assessments and associated documentation (e.g., psychiatric records) were subjected to final consensus diagnostic procedure [START_REF] Maziade | Reliability of best-estimate diagnosis in genetic linkeage studies of major psychoses: results from the Quebec pedigree studies[END_REF]. Pairs of senior child psychiatrists trained as Best Estimate Diagnosticians separately reviewed all material and then together derived consensus diagnoses. ''Caseness'' was determined based on best-estimate consensus. Only those children were included in the present study that had major depressive disorder and were currently in episode. We excluded 11 children because proxy rater was different from the mother and 32 children due to incomplete data. The final sample consisted of N = 248 children.

Children included in the non-depressed sample (N = 1695) were 1st-8th grade elementary school students from two regions in Hungary whose parents gave written permission to participate. Parents and children received self-and proxy-report forms through the schools. Parents completed the forms at home, children in school during class under supervision. Completion was done anonymously, parentchild pairs were identified by 6-digit code numbers. 5224 families were contacted initially. 68% of parents agreed to participate, 55% of the children completed the forms. In the present analysis we excluded those children whose parental informant was not the biological mother (N = 274), those with chronic somatic illness (N = 72) and those who had substantial depressive symptoms (N = 381). Information about demographic data, chronic somatic illness and life events was collected by a self-report questionnaire from the mothers. Depressive symptoms were screened by the short version of the Child Depression Inventory [CDI,[START_REF] Kovacs | Children's Depression Inventory Manual[END_REF]. It has been shown to be a reliable and useful method for examining children and adolescents [START_REF] Allen | Self-reported depressive symptoms in school-age children at the time entry into foster care[END_REF][START_REF] Davanzo | Spanish translation and reliability testing of the child depression inventory[END_REF][START_REF] Larson | Prevalence and short-term stability of depressive symptoms in school children[END_REF][START_REF] Poli | Self-reported depressive symptoms in a school sample of Italian children and adolescents[END_REF]. We excluded those children who scored above sevenpoints, reported as a clinical cut-off for depression in the literature. Finally, we excluded those with incomplete data (N = 451). Children in this group were significantly older (mean age 13.6 years, SD 0.5), there were more boys (62.9%), and more divorce in the family (20.5%). No difference was found in financial situation, number of children in the family, and maternal years of education. Mean depression symptom score in the excluded group was 4.0 points (SD 2.9) and 19.6% scored above the clinical cutoff showing clinical level of symptoms. Demographic variables and illness characteristics of the depressed and non-depressed samples can be seen in Table 1. Children in the depressed sample were older there were more boys and maternal education was lower on average than in the control sample.

Quality of life was examined by the Invertar Lebensqualitat Kindern und Jugendlichen (ILK) selfreport questionnaire in both samples. The questionnaire consists of seven items inquiring about QoL during the last week in different domains of life important to children. It was developed by Mattejat et al. and was validated in German and Hungarian samples [START_REF] Kiss | Validity and psychometric properties of the Quality of Life Questionnaire in a Hungarian child population[END_REF][START_REF] Mattejat | Das inventar zur erfassung der lebensqulitat bei kindern und jugendlichen (ILK)-eine pilotstudie[END_REF][START_REF] Matttejat | Zur erfassung der lebesqualitat bei psychisch gesto ¨rten kindern und jugendlichen-eine u ¨bersicht[END_REF]. The ILK measures quality of life in children aged 6-18, it has child, adolescent and parent versions. The first two versions have similar wording, the parent version is identical to the adolescent one and similar in content to the child version. Scoring is on a 5-point Likert scale, 1 is the best, 5 is the worst QoL. The child version offers faces as scoring options. The questionnaire is easy to answer, it takes 5-10 min to complete, can be read out loud to a child unable to read. Since it is not illness specific, it can be used for both healthy and ill populations making comparison possible. It consists of two additional items for ill populations that inquires about QoL modifying effects of the illness and its therapy.

The items include the domains of school, family, peer relations, alone activities, physical health, mental health and global well-being. Evaluation is possible by the individual items or by total score. The later is calculated by adding the individual scores and subtracting the sum from 35 in order to reverse the direction of the severity of the score. Thus possible total values will fall between 0 and 28, 0 being the worst, 28 the best quality of life ratings [START_REF] Kiss | Validity and psychometric properties of the Quality of Life Questionnaire in a Hungarian child population[END_REF][START_REF] Mattejat | Das inventar zur erfassung der lebensqulitat bei kindern und jugendlichen (ILK)-eine pilotstudie[END_REF][START_REF] Matttejat | Zur erfassung der lebesqualitat bei psychisch gesto ¨rten kindern und jugendlichen-eine u ¨bersicht[END_REF].

Previous studies showed adequate reliability and validity of the questionnaire on a Hungarian sample. Internal consistency was adequate for the parent and adolescent versions (Cronbach a: 0.78 and 0.73, respectively) and moderate for the child version (Cronbach a: 0.66). Test-retest reliability of the total score was also adequate: higher values were found for the parent forms (ICC 0.77) and the adolescent forms (ICC 0.75) and somewhat lower but still acceptable for the child version (ICC 0.67). Test-retest reliability scores of the individual items were the following: parent form 0.54-0.78, adolescent form 0.57-0.71, child form 0.25-0.64 [START_REF] Kiss | Validity and psychometric properties of the Quality of Life Questionnaire in a Hungarian child population[END_REF].

Demographic data, life events and information about chronic illness were collected from the parents by a General Information Sheet developed for the study of childhood onset depression [START_REF] Kapornai | The International Consortium for Childhood-Onset Mood Disorders (2007) Early developmental characteristics and features of major depressive disorder among child psychiatric patients in Hungary[END_REF]. It was used as a self-report questionnaire in the control sample while as a structured questionnaire as part of the diagnostic evaluation in the depressed sample. Years of maternal education served as a proxy for socioeconomic status.

We examined reliability of the self-rated and proxy rated ILK forms first. Then we used multivariate linear regression to test for the effect of individual variables on mother-child agreement. Absolute agreement score was used as the dependent variable. It was computed by subtracting the child's score from the mother's score. The absolute difference score ignores the signs of differences. Its magnitude was assessed by relating it to the maximum possible score. Independent variables in the model were the child's age and gender, presence or absence of depressive illness, and maternal education as a proxy for SES. In order to be comparable with other studies we also computed Pearson r coefficients and ICC and used the following ratings for comparison: <0.2 poor, 0.21-0.4 fair, 0.41-0.60 moderate, 0.61-0.80 substantial, 0.81-1.00 excellent to perfect. Means were compared by paired t test. All data were normally distributed, Kolmogorov-Smirnov tests were significant which justified the use of parametric tests. Associations were regarded significant if P was less than 0.05.

Results

Reliability ratings were in the moderate range for both samples and for all raters (Cronbach alphas for depressed children 0.713, and their mothers 0.715; for non-depressed children 0.608, and their mothers 0.752). The mean values of quality of life scores were lower in the depressed sample than in the non-depressed one regardless of the reporter. Mothers of depressed children rated the QoL of their children significantly lower than children themselves. Mothers of non-depressed children scored significantly higher on the QoL of their offspring than their children. The same direction of differences could be observed in most of the domains. Mothers of depressed children rated lower satisfaction of children in the areas of school, family, peer relations and mental health than their offsprings. No difference was found in the domain of alone activities, while mothers rated better quality of life for physical health than their depressed offspring. Mothers of non-depressed children rated significantly better QoL in the domains of school, alone activity, physical and mental health while worse QoL in family life than their children. No difference was found in the areas of peer relations and global QoL (Table 2).

Multivariate linear regression model showed that the presence of depression in the child was the only significant variable affecting mother-child agreement about the child's quality of life. Age and gender of the child and maternal education did not have a significant effect (df = 1814, F = 25.988, P = 0.00, R 2 = 0.04).

Agreement indices of the two samples can be seen in Table 3. Pearson r correlations and ICC values showed similar associations. Mothers' and children's total scores correlated more closely in the non-depressed sample than in the depressed one. Moderate a Total score ratings from 0 to 28, higher scores represent better quality of life b domain score ratings from 1 to 5, lower ratings represent better quality of life * P < 0.05, ** P < 0.01, *** P < 0.001 associations could be observed in satisfaction with school regardless of illness status. The rest of the correlations were poor to fair. The difference between raters in the depressed sample was greater than in the non-depressed sample (3.98 or 14% vs. 2.6 or 9%, respectively). Exploring differences in the individual domains in the depressed sample the highest disagreement was seen in the area of mental health and global rating of well-being. Interestingly, the absolute difference in the area of alone activity was the same (23%) in both samples. Besides that difference, the rest of the domains showed larger inter-rater differences in the depressed sample (range from 18 to 25%) than in the non-depressed one (range from 11 to 16%).

Discussion

Depressed and non-depressed child populations were compared in the present study concerning their quality of life and the agreement between self and proxy ratings. The results add to current knowledge about quality of life issues and inter-informant agreement of depressed versus non-depressed youth. There has not been such a study published before on an Easter European child population.

In accordance with our hypothesis parents of depressed children rated lower quality of life overall and in most domains than their children. Higher parental ratings of the negative effect of illness compared to the child has been shown in various somatic disorders, in attention-deficit/hyperactivity [START_REF] Klassen | Agreement between parent and child report of quality of life in children with attention-deficit/hyperactivity disorder[END_REF] and in psychiatric outpatient population [START_REF] Baastiansen | Quality of life in children with psychiatric disorders: self-, parent, and clinician report[END_REF]. In Baastiansen's study patients suffering from mood disorder were included in the sample but diagnosis was based on a symptom checklist. The depressed population in our sample was diagnosed by a more precise semistructured interview based on DSM IV criteria. In a study of quality of life of epileptic children Ronen et al. [START_REF] Ronen | The Canadian Pediatric Epilepsy Network (2003) Health-related quality of life in children with epilepsy: development and validation of self-report and parent-proxy measures[END_REF] showed that while parents equally considered present and future concerns caused by the illness, children considered present concerns far more important than future ones. This finding might explain the difference in the opinion of the parent and that of the sick child about quality of life with the illness. They also suggest that the burden of care giving of the parent might cause misjudgment of the child's problems. It is also possible that the child is unable to fully comprehend the impact of illness on his or her life. Parents of non-depressed children in our study rated better quality of life for their children that children for themselves. Levi and Drotar [START_REF] Levi | Health-related quality of life in childhood cancer: discrepancy in parent-child reports[END_REF] did not find significant differences between the opinions of children and their parents in a healthy control group. The sample size in this study was very small which can explain the differences in their results compared to ours. In a more recent study Russel et al. [START_REF] Ronen | The Canadian Pediatric Epilepsy Network (2003) Health-related quality of life in children with epilepsy: development and validation of self-report and parent-proxy measures[END_REF] found better QoL reported by parents than children in a healthy comparison sample in 8 out of 10 domains of life. Our results support the tendency of parents to relate more serious negative effects to depressive disorder than their children themselves and to undervalue their non-depressed offsprings' problems compared to the children. On the one hand these findings underline the importance of parental education and guidance in chronic pediatric conditions besides the medical treatment of the child, and on the other the need for surveillance and prevention based on children's opinion in the community.

Mother-child agreement is studied by various methods in the literature. We used the most frequently applied but limited Pearson correlation and the intraclass correlation coefficient. Agreement was better in the non-depressed sample by all methods. This contradicts previous results on QoL concordance in physically ill populations. It is possible that a somatic condition shows more observable, better understood negative consequences and therefore more reliably grasped by the parents, while the effects of psychiatric illnesses are less straight forward, more covert and thus less observable. This would explain why agreement is better in chronic physical illnesses and worse in psychiatric diseases compared to healthy populations while having similarly lower levels of parental QoL ratings compared to child self-reports in both conditions. The highest agreement in both samples was in the domain of school life. It has been known to be among the most observable domains and also one about which the opinion of an outsider, the teacher, is readily available. QoL concerning school life proved to be the most highly agreed domain in other studies as well [START_REF] Parsons | Health-related quality of life in pediatric bone marrow transplant survivors: according to whom?[END_REF][START_REF] Robitail | Validation of the European KID-SCREEN-52 pilot test health-related quality of life questionnaire: first results[END_REF].

Absolute differences helped us to investigate further. An important finding of this study is that QoL of mental health was the most controversial domain in the opinions of depressed child-mother dyads. It might even offer an explanation for the greater disagreement in the depressed sample compared to the non-depressed one, major depression being one of the most important factors influencing mental health. Mothers of depressed children probably do not understand the internal states of their children and receive limited information from their ill children. It was shown previously that mental health is the domain that correlates most closely to global quality of life in a community sample using the same instrument [START_REF] Kiss | Validity and psychometric properties of the Quality of Life Questionnaire in a Hungarian child population[END_REF]. Satisfaction with activities and time spent alone shows similarly high disagreement in both samples; therefore it is not specific to the depressed population.

The effect of age on agreement was not significant in our sample but there was a tendency for increased concordance as children got older. In Robitail's study [START_REF] Robitail | Validation of the European KID-SCREEN-52 pilot test health-related quality of life questionnaire: first results[END_REF] involving an European community sample agreement was higher for adolescent-parent dyads than for child-parent dyads. However, age was used as a dichotom variable in this study. In the other two publications examining psychiatric samples the effect of age on agreement was not investigated [START_REF] Baastiansen | Quality of life in children with psychiatric disorders: self-, parent, and clinician report[END_REF][START_REF] Klassen | Agreement between parent and child report of quality of life in children with attention-deficit/hyperactivity disorder[END_REF]. Eiser and Morse [START_REF] Eiser | Can parents rate their child's health-related quality of life? Results of a systematic review[END_REF] concluded in their review that age did not have an effect on mother-child concordance about QoL of children. Similar results emerged concerning the effect of gender on agreement. There were no differences between boys and girls and their mothers' agreement in our sample. The presence of depression was the only factor which considerably and significantly influenced -more precisely decreased agreement between mothers and children about QoL of children.

The present study has some limitations. Interview circumstances were not the same in the two samples. Depressed children and their mothers were interviewed by trained interviewers using a semi-structured psychiatric interview. Following the interview parents and children self-rated the QoL forms separately. Non-depressed children self-rated the same forms in a school setting; their parents filled the questionnaires at home. It is possible that circumstances of the interview (length, involvement, feelings toward interviewer) influenced the answers of the interviewees during the self-report [START_REF] Verrips | Measuring health-related quality of life in adolescents: agreement between raters and between methods of administration[END_REF]. However, it is impossible in real-life testing to ensure the exact same circumstances in different populations. At the same time the same forms and the same methods were used in both samples to help the comparison of data.

The lack of a ''gold standard'', that is an undoubtly reliable and adequate pool of information about the illness specifics of the child, is a further limitation of the study of agreement in child psychiatry. Even if such a standard did exist, untrained informants probably use different thresholds and have different abilities, skills and judgment biases which influence their opinions. Therefore, reports of different informants must be compared to each other without exact knowledge of their validity. For this reason the study of inter-informant agreement and factors influencing it are especially important.

It has been shown in previous studies that parents' own well being also influences their opinion about their child's quality of life. Specifically, parental depression [START_REF] Vance | Issues in measuring quality of life in childhood cancer: measures, proxies, and parental mental health[END_REF], parental stress [START_REF] Vance | Issues in measuring quality of life in childhood cancer: measures, proxies, and parental mental health[END_REF][START_REF] White-Koning | Determinants of child-parent agreement in quality-of-life reports: a European study of children with cerebral palsy[END_REF] and parental QoL [START_REF] Cremeens | Factors influencing agreement between child self-report and parent proxy-reports on the Pediatric Quality of Life Inventory 4.0 (PedsQL) generic core scales[END_REF] were studied. However, their potential role in affecting agreement has not been certified. It is a limitation of our study that we had no valid information about mothers' own QoL or depression levels. There is a clear need to carry on the evaluation of factors related to differences in self and proxy ratings and their agreement in child psychiatry and pediatrics.

Since the above examined variables explained only a small variance of disagreement, evaluation of other possible contributing factors should continue. A very important clinical question is how many or rather what kinds of raters are necessary in order to collect clinically useful amount of valid information. One possibility is conceptualizing the contexts and perspectives that influence the behavior and identify at least 3 informants based on this model [18]. As a matter of fact, informant discrepancies themselves may be conceptualized as a useful component in a clinical setting taking into consideration the origin of discrepancies [START_REF] De Los | Informant discrepancies in the assessment of childhood psychopathology: a critical review, theoretical framework, and recommendations for further study[END_REF].

Conclusion

Our results underline the need of assessing at least one parent beside the child when inquiring about the QoL. Based on our results we can conclude that proxy rating is equally important in children regardless of age and gender. It is important for clinicians to keep in mind that the already low parent-child agreement is further decreased by chronic psychiatric conditions like major depression. The examiner should be knowledgeable of the effect of the child's physical and psychological state on agreement when questioning parents and children.

Major depression as a chronic psychiatric condition decreases the quality of life of children significantly, lowers inter-rater agreement and the difference is the greatest in the domain of mental health. It should be the aim of future studies to investigate whether the same is true for quality of life issues in other psychiatric disorders.

j

  Acknowledgement This work was partly supported by National Institute of Mental Health Program Project grant, MH 56193.

Table 1

 1 Demographic characteristics of the depressed and non-depressed samples

Table 2

 2 Quality of life ratings of mothers and children in the depressed and non-depressed samples

		Depressed sample (N = 248)		Non-depressed sample (N = 1,695)
		Mother	Children	Paired t	Mother	Children	Paired t
	Total score a	16.50	17.85	)4.29***	24.04	23.44	7.30***
	Domains of quality of life b
	School	3.07	2.86	2.99**	1.89	1.95	)3.63***
	Family	2.34	2.12	3.27***	1.34	1.28	3.67***
	Peer relations	2.50	2.14	4.7***	1.54	1.52	0.94
	Alone activity	2.13	2.25	)1.47	1.56	2.06	)16.81***
	Physical health	2.05	2.23	)2.63**	1.39	1.47	)3.92***
	Mental health	3.39	3.00	4.93***	1.69	1.76	)2.89**
	Global QoL	3.02	2.54	6.8***	1.54	1.52	1.3

Table 3

 3 Agreement indices of the depressed and non-depressed samples Abs dif Absolute difference score, mother-child score, QoL quality of life a Percent of maximum possible difference

		Depressed sample (N = 248)			Non-depressed sample (N = 1,695)
		Pearson r	ICC	Abs dif	% a	Pearson r	ICC	Abs dif	% a
	Total score	0.208	0.206	3.98	14	0.314	0.314	2.6	9
	School	0.461	0.459	0.73	18	0.533	0.533	0.45	11
	Family	0.280	0.279	0.77	19	0.212	0.211	0.38	10
	Peer relations	0.222	0.221	0.85	21	0.187	0.184	0.54	14
	Alone activity	0.099	0.095	0.92	23	0.080	0.071	0.93	23
	Physical health	0.184	0.182	0.75	19	0.190	0.186	0.47	12
	Mental health	0.127	0.120	0.99	25	0.202	0.201	0.64	16
	Global QoL	0.151	0.144	0.89	22	0.159	0.159	0.51	13
	ICC Intraclass correlation,

European Child & Adolescent Psychiatry (2009) Vol. 18, No. 5 Ó Steinkopff Verlag 2009

Agreement about quality of life of depressed versus non-depressed children

Demographic variables

Depressed sample (N = 248)

Non-depressed sample (N = 1,695)