International Journal of Mental Health & PsychiatryISSN: 2471-4372

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Research Article, Int J Ment Health Psychiatry Vol: 2 Issue: 2

Mother, Father, and Teacher Agreement on Disruptive Mood Dysregulation Disorder Symptoms in Children with Psychiatric Disorders

Susan Dickerson Mayes*, James D. Waxmonsky, Daniel A. Waschbusch, Richard E. Mattison, Raman Baweja, Usman Hameed and Ehsan Syed
Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA
Corresponding author : Susan D. Mayes, PhD
Department of Psychiatry H073, Hershey Medical Center, 500 University Dr. Hershey, PA 17033
Tel: (717) 531-6201
Fax: (717) 531-6250
E-mail: [email protected]
Received: January 19, 2016 Accepted: April 29, 2016 Published: May 04, 2016
Citation: Mayes SD, Waxmonsky JD, Waschbusch DA, Mattison RE, Baweja R, et al. (2016) Mother, Father, and Teacher Agreement on Disruptive Mood Dysregulation Disorder Symptoms in Children with Psychiatric Disorders. Int J Ment Health Psychiatry 2:2. doi:10.4172/2471-4372.1000123

Abstract

Objective: Disruptive Mood Dysregulation Disorder (DMDD) was established as a new DSM-5 disorder despite little published research, and there are no studies investigating agreement between informants on the presence of DMDD symptoms. Methods: Mothers, fathers, and teachers rated DMDD symptoms (irritable-angry mood and temper outbursts) in 768 children with psychiatric disorders ages 6-16.

Results: Mother and father ratings were similar, but parent-teacher agreement was poor. Mothers and fathers identified a substantially higher percentage of children with DMDD symptoms (30% and 25%) than did teachers (12%).

Conclusion: Our findings are consistent with previous studies demonstrating that parents perceive more externalizing and internalizing symptoms in their children than do teachers. This has implications for interpreting mother, father, and teacher report, which is particularly important for disorders like DMDD that have DSM-5 cross-setting diagnostic requirements. Given our findings, it seems prudent to obtain ratings from both parents and teachers and recognize that parents are likely to report greater DMDD symptoms than teachers.

Keywords: Disruptive mood dysregulation disorder; Irritable-angry; Temper; Psychiatric disorders; Parent-teacher agreement

Keywords

Disruptive mood dysregulation disorder; Irritable-angry; Temper; Psychiatric disorders; Parent-teacher agreement

Introduction

Disruptive mood dysregulation disorder (DMDD) is a new DSM-5 disorder with two core symptoms, persistently irritable or angry mood and severe recurrent temper outbursts in children 6-18 years. There is appreciable controversy surrounding DMDD because of the absence of published validity studies [1,2], poor agreement between clinicians on a diagnosis of DMDD [3], and overlap of DMDD with oppositional defiant disorder [4-6]. Because of these and other concerns, the World Health Organization’s ICD-11 task force recommends that DMDD not be included in the 2017 ICD-11 as a separate disorder and that oppositional defiant disorder should have a specifier indicating whether or not chronic irritability and anger are present [7]. Little research exists on DMDD, and there are no studies investigating agreement between mothers, fathers, and teachers on the presence of child DMDD symptoms.
Numerous international studies of parent-teacher agreement on externalizing and internalizing problems demonstrate that mothers and fathers rate their children as having more problems than do teachers. This has been shown for externalizing and internalizing problems in community samples [8-13] and in psychiatric and special education samples [10,14,15]. Similarly, studies focusing on specific DSM disorders reveal greater parent than teacher report of symptoms. This is the case for depression [16], anxiety [17], autism [18], ADHD [19], and ODD [19-23]. Parents are also twice as likely as teachers to consider their child a victim of bullying [24,25], and parents rate positive and prosocial behaviors higher than do teachers [8,26].
Studies investigating mother-father agreement indicate greater agreement between parents than between parents and teachers. A meta-analysis showed that mothers and fathers report similar levels of externalizing and internalizing problems in their children [27]. Some individual studies indicate higher maternal than paternal ratings [15,28,29], whereas another study found insignificant differences [30]. When discrepancies are reported, effect sizes for mother-father differences are much smaller than for parent-teacher differences.
Ours is the first study comparing mother, father, and teacher ratings of DMDD symptoms using the same standardized instrument in a large psychiatric sample of children and adolescents. Our goal is to determine if there is a significant pattern of differences between raters and if this corresponds with previous findings for externalizing and internalizing behaviors. If mothers, fathers, or teachers consistently report less or more irritable-angry mood and temper outbursts, this has implications for interpreting mother, father, and teacher report and supports the need to gather symptom reports from all relevant informants. This is particularly important for disorders that have DSM-5 cross-setting diagnostic requirements, such as DMDD.

Methods

Sample
All 768 children were evaluated in our psychiatry outpatient clinic by licensed PhD psychologists. Diagnoses were broad, including ADHD, autism, oppositional defiant disorder, anxiety disorders, depression, learning disability, and intellectual disability. Comorbidity was common, and most children had two or more diagnoses. Children ranged in age from 6-16 years (M 8.9, SD2.5). IQs ranged from 26-150 (M101.7, SD18.1), and 12.5% had an IQ<80. Males comprised 75.4% of the sample, 94.1% were white, 46.2% had a parent with a professional or managerial occupation, and 53.8% had parents with nonprofessional positions or who were unemployed.
Instrument
For all 768 children in the study, mothers, fathers, and teachers rated each child’s behavior during the past 2 months on a 4-point scale (0 = almost never or not at all a problem, 1 = sometimes a problem, 2 = often a problem, and 3 = very often a problem) on the 165-item Pediatric Behavior Scale (PBS) [31]. Dependent variables were the two DSM-5 DMDD items on the PBS: “irritable, gets angry or annoyed easily” and “loses temper, has temper tantrums.” These scores were combined to obtain a total DMDD (irritable-angry mood plus temper outburst) score. The PBS has been used to assess DMDD symptoms in previous publications [5,6,32] and to diagnose and measure psychological problems in several published studies [33-39]. Internal consistency for the PBS subscale scores is high, with a median coefficient of 0.91 [31]. The PBS corresponds well with established measures. Strong correlations for both internalizing and externalizing symptoms on the PBS and Child Behavior Checklist were found in a general population study [40], and attention deficit ratings on the PBS were significantly associated with objective impairments in attention on a continuous performance test [41].
Data analyses
Paired mother, father, and teacher total DMDD scores (irritableangry mood plus temper outbursts) for each child were compared, as were the number of children considered by each informant to have DMDD symptoms (both irritable-angry mood and temper outbursts rated as often or very often a problem). Statistics for the total DMDD score were paired t-tests, Cohen’s d, Pearson and intraclass correlations, and explained variance. Kappa was used to assess agreement between informants on whether or not each child had DMDD symptoms. Institutional Review Board approval was obtained, and consent was waived by the Board because our study is a retrospective review of existing clinical data.

Results

Mother-father agreement
Agreement between mothers and fathers on the total DMDD score was significant with large correlations (Pearson r = 0.67, p<0.0001, explained variance 44.9%; ICC = 0.80, p<0.0001, explained variance 64.0%). However, the total DMDD score was higher for mothers than for fathers (t = 4.8, p<0.0001), although the effect size was small (d = 0.2). DMDD symptoms were reported by 30.1% of mothers and 25.0% of fathers. Mother-father agreement on whether or not a child had DMDD symptoms was moderate (kappa = 0.50). Children with mean DMDD symptoms rated as often a problem by mothers were considered by fathers to have DMDD symptoms a mean of often as well.
Mother-teacher agreement
Agreement between mothers and teachers on the total DMDD score was significant (Pearson r = 0.24, ICC = 0.38, p<0.0001), but explained variance was small (5.5% and 14.5%, respectively). The total DMDD score was higher for mothers than teachers (t = 15.6, p< 0.0001) with a medium to large effect size (d = 0.6). DMDD symptoms were reported by 30.1% of mothers and 12.4% of teachers. Mother-teacher agreement on whether or not a child had DMDD symptoms was poor (kappa = 0.11). Children with DMDD symptoms rated as often a problem by mothers were considered by teachers to have DMDD symptoms a mean of sometimes.
Father-teacher agreement
Agreement between fathers and teachers on the total DMDD score was significant (Pearson r = 0.25, ICC = 0.39, p<0.0001), but explained variance was small (6.0% and 15.6%, respectively). The total DMDD score was higher for fathers than teachers (t = 13.0, p<0.0001) with a medium effect size (d = 0.5). DMDD symptoms were reported by 25.0% of fathers and 12.4% of teachers. Father-teacher agreement on whether or not a child had DMDD symptoms was poor (kappa = 0.08).

Discussion

Comparison with previous research
Our findings are consistent with all studies reviewed in our introduction showing that parents rate externalizing and internalizing problems higher than teachers, that agreement between mothers and fathers is far superior to parent-teacher agreement, and that there is a slight tendency for mothers to rate problems higher than fathers. The significant correlations between parent and teacher DMDD symptom ratings in our study indicate that mothers, fathers, and teachers, to a substantial degree, report the same symptoms. However, symptom severity is much greater according to parents than teachers. Children with DMDD symptoms rated as often a problem by mothers were considered by teachers to have DMDD symptoms only sometimes. As a result of this disparity, mothers and fathers identified a substantially higher percentage of children with DMDD symptoms (30% and 25%) than did teachers (12%). Mothers were 2.4 times more likely and fathers were 2.0 times more likely to report DMDD symptoms in their child than teachers.
Explanations for informant discrepancies
Interestingly, parents also systematically rate their children higher than teachers on positive behaviors [8,26]. This, combined with the higher ratings on negative behaviors, may indicate that parents have a greater awareness than teachers of all aspects of the child’s behavior (both positive and negative) or that what parents perceive as a positive or negative deviation from the norm, teachers perceive as closer to normal. Children do behave differently in different settings and with different individuals [42]. In a study of preschool children, mothers reported that their child had fewer behavior problems in preschool than at home [23]. Teacher perceptions are based on observations and student and staff report in school, whereas parents base their impressions on observations in multiple settings, plus the child’s report of what occurs in school and elsewhere. Teachers may have contact with the child only a few hours a day and may have known the child less than a year, whereas parents have daily contact over the child’s lifespan. Teachers’ attention is divided in classrooms of 20 or more students, whereas parents have intimate and individual contact with their children. Interestingly, a study of bullying using videotaped playground observations showed that teachers were unaware of bullying in about 80% of the episodes [43]. Taken together, these findings suggest that teachers may be less aware of symptoms and problem behavior than parents.
Limitations and directions for future research
Our study focused specifically on DMDD symptoms (i.e., irritableangry mood and temper outbursts) and not additional DSM-5 DMDD diagnostic criteria, which include DMDD symptoms present in at least two settings for at least 12 months without a symptom free period for 3 or more consecutive months, temper outbursts occurring an average of three or more times per week, and onset before age 10. These additional criteria need to be investigated in future research in children clinically diagnosed with DMDD. Ours is a single-site study relying on ratings of DMDD symptoms during the past 2 months by mothers, fathers, and teachers. Assessments using other methods (e.g., structured interviews) over a longer period of time are needed.

Conclusion

For a DMDD diagnosis, the DSM-5 requires that the two DMDD symptoms are “observable by others (e.g., parents, teachers, peers)” and “are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these” (p. 156). The DSM-5 does not specify who should be the informant. Given the cross-setting requirement and the informant discrepancies found in our study, it seems prudent to obtain ratings from both parents and teachers. Recognizing that parents are likely to report greater DMDD symptoms than teachers is important when conducting diagnostic evaluations, and different symptom thresholds may be needed for parents and teachers.

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