Factors Associated With Caregiver–Child Symptom Concordance Among Trauma-Exposed Children

Abstract

Concordance in caregivers’ and children’s reports of children’s trauma-related symptoms is often low, and symptom discrepancies are associated with negative clinical implications. The aim of the current study was to examine the degree of concordance between children’s and caregivers’ reports of trauma-related difficulties and determine whether any child or family characteristics were associated with symptom agreement. Three hundred thirteen trauma-exposed children (M = 9.55, SD = 1.77; 65.2% girls, 51.3% Black) and their nonoffending caregivers seeking treatment were included in the study. Children’s and caregivers’ reports of trauma-related difficulties were related, but low intraclass correlation coefficients indicated poor concordance across symptoms. Child’s gender was associated with levels of concordance for several trauma-related difficulties (e.g., anxiety, depression, anger, dissociation, and sexual concerns), with lower symptom agreement for girls. Child’s age, minority status, and relationship to caregiver emerged as factors related to levels of concordance for certain trauma-related symptoms. Child’s gender, age, minority status, and relationship to caregiver may predict symptom discordance for select trauma-related difficulties, whereas other family factors such as caregiver marital status and income may be unrelated. Given the importance of caregiver–child concordance in treatment success, additional research should investigate other factors that may influence trauma-related symptom agreement.

Keywords

symptom concordance PTSD children and caregivers

Childhood trauma exposure is undoubtedly a significant health concern. For several decades, longitudinal and cross-sectional studies have persuasively documented the links between trauma exposure during childhood and a plethora of psychological difficulties including post-traumatic stress disorder (PTSD), mood and anxiety disorders, externalizing difficulties, and interpersonal problems (Ackerman et al., 1998; Copeland et al., 2007; Putnam, 2003). Thus, childhood trauma is not relegated to a restricted type of clinical symptoms (e.g., PTSD) but rather is associated with widespread distress. To complicate matters, general samples of caregivers and children often diverge in their reports of children’s difficulties (Achenbach et al., 1987; De Los Reyes et al., 2015; De Los Reyes & Kazdin, 2004). Discordant reports of trauma exposure (Hungerford et al., 2010; Lewis et al., 2012; Oransky et al., 2013; Stover et al., 2010; for a review, see Goodman et al., 2010) and trauma-related symptoms (Dyb et al., 2003; Humphreys et al., 2017; Meiser-Stedman et al., 2008; Scheeringa et al., 2006; Wamser-Nanney, in press) are also common.

Yet, there is a dearth of information regarding what factors may be related to trauma-related symptom discordance. This lack of understanding is problematic. Clinically, it can be challenging to discern whose report to utilize when making clinical decisions regarding diagnosis, treatment planning, and progress (De Los Reyes et al., 2013; Goodman et al., 2010). Low concordance has also been perceived to indicate unreliability, but different informants may be contributing distinct, valid information and thus discrepancies should not be cast aside (Achenbach et al., 1987; Goodman et al., 2010). Despite this, parent–child symptom discordance has been related to higher levels of children’s behavior difficulties (De Los Reyes et al., 2013; Ferdinand et al., 2004, 2006; Guion et al., 2009; Pelton & Forehand, 2001) and poorer treatment response (De Los Reyes et al., 2010), including among trauma-exposed children (Humphreys et al., 2017). Levels of concordance therefore represent an important clinical issue. At this time, however, there is little understanding of what may lead to discrepancies in reports of children’s trauma-related psychopathology—knowledge that may have significant implications for research and treatment (De Los Reyes, 2013). The aims of the present study were thus to (1) report the level of caregiver and child trauma-related symptom discrepancies and (2) investigate whether child and family characteristics were associated with levels of concordance regarding trauma-related symptoms.

Concordance in Reports of Trauma Exposure and Trauma-Related Symptoms

Prior research has consistently established low levels of concordance between reporters when assessing child psychopathology (Achenbach et al., 1987; De Los Reyes et al., 2015; De Los Reyes & Kazdin, 2004). Significantly less work has been devoted to parent–child symptom concordance in the traumatic stress literature. However, concordance rates of trauma exposure between children and parents appear to be low (Goodman et al., 2010; Hungerford et al., 2010; Oransky et al., 2013; Stover et al., 2010). In line with prior research focusing on general child psychopathology, a few studies have documented low levels of post-traumatic stress symptoms (PTSS) agreement across caregivers and children (Dyb et al., 2003; Humphreys et al., 2017; Scheeringa et al., 2006). The nature of several trauma-related difficulties may contribute to high levels of symptom discordance. For example, reexperiencing symptoms and avoidance may be less evident to caregivers or may only occur in the context of a trauma trigger, which the caregiver may not be aware of (Scheeringa et al., 2006). Indeed, caregivers of trauma-exposed children may have limited insight into children’s PTSS (Oransky et al., 2013), and multiple studies of children who experienced a single-incident trauma have observed that children acknowledge higher levels of PTSS than caregivers (Dyb et al., 2003; Meiser-Stedman et al., 2008).

The findings regarding discordance between caregivers’ and children’s reports of trauma-related symptoms are problematic. If caregivers are unaware that their child has experienced a traumatic event and/or trauma-related distress, they may be less motivated to seek treatment (Lewis et al., 2012; Stover et al., 2010). Symptom agreement may also have relevance for treatment efficacy. Among children with PTSD receiving trauma-focused treatment, significant symptom reduction was associated with caregiver–child concordance at pretreatment across PTSD symptom clusters (Humphreys et al., 2017). The clinical implications of caregiver–child discordance underscore the importance of identifying factors that correspond with levels of caregiver–child concordance regarding trauma-related difficulties.

Factors Related to Symptom Concordance

In spite of the need to understand drivers of trauma-related symptom discordance, research has not determined what factors may increase the risk for these discrepancies among pediatric trauma-exposed populations. Work from the general child literature indicates that relatively few factors exhibit uniform relations with levels of concordance (Achenbach et al., 1987; De Los Reyes et al., 2015; De Los Reyes & Kazdin, 2005). For example, a meta-analytic review observed few to no differences in levels of symptom agreement by gender (Achenbach et al., 1987; De Los Reyes & Kazdin, 2005). Child’s age has been related to symptom concordance in some studies, with younger children having higher levels of agreement than adolescents (Achenbach et al., 1987) but not consistently (De Los Reyes & Kazdin, 2005). Lower levels of concordance for Black and Hispanic children compared to White children have been reported in several studies (Walton et al., 1999; Youngstrom et al., 2000; Zimmerman, 2014). In one meta-analysis, lower family income was also related to lower levels of agreement (Duhig et al., 2000), yet other studies did not observe a relationship between concordance and income when other factors were accounted for, such as parental psychopathology, family stress, and parent–child relationship quality (Chi & Hinshaw, 2002; Kolko & Kazdin, 1993; Treutler & Epkins, 2003). Symptom agreement may also be lower for internalizing than for externalizing symptoms, which are more observable (Achenbach et al., 1987; De Los Reyes & Kazdin, 2005; Duhig et al., 2000; Hourigan et al., 2011).

Research regarding factors associated with levels of symptom concordance for trauma-related difficulties is quite limited. Further, child and family demographic factors have not demonstrated consistent relationships to PTSS concordance. This may be a function of differing types of trauma (e.g., motor vehicle accidents, traumatic injury, or community violence) and whether the study examined rates of agreement for trauma exposure or PTSS, or both. Among children exposed to community violence, older children have had lower levels of agreement for trauma exposure than younger children (Zimmerman, 2014). When levels of PTSS have been examined, however, younger children who experienced a car accident had higher levels of PTSS discordance (Dyb et al., 2003). Yet, among children who experienced a medical trauma, child’s age was not consistently related to differences in reports of types of PTSD symptoms (Stover et al., 2010). Caregiver–child agreement for traumatic events was higher for girls in a general sample of trauma-exposed children (Johnson, 2014) as well as among youth exposed to community violence (Zimmerman, 2014). Yet, another study did not find gender differences (Tingskull et al., 2015). Only one known study to date has examined gender in relation to PTSS and reported that girls had lower levels of PTSS symptom agreement than boys among children exposed to different types of trauma (Stover et al., 2010). Lower socioeconomic status has also been tied to higher levels of disagreement regarding trauma exposure (Zimmerman, 2014). Levels of concordance may differ by type of PTSD symptoms, but no consistent pattern has emerged in the small research base thus far. For instance, avoidance and hyperarousal symptoms had lower levels of caregiver–child agreement than reexperiencing symptoms (Stover et al., 2010). However, the opposite pattern was reported among children exposed to a motor vehicle accident or a sexual assault, in which reexperiencing symptoms had lower levels of concordance than avoidance and hyperarousal symptoms (Meiser-Stedman et al., 2008). Taken together, it is unclear if any conclusions can be drawn from the literature at this time, and additional work is needed to investigate caregiver–child concordance regarding PTSS.

Current Study

As relatively few studies examining levels of caregiver–child concordance in reports of trauma-related symptoms have been conducted to date, and findings have differed by study, additional trauma-focused research is needed to identify factors that may be associated with caregiver–child trauma-related symptom concordance. Further, the prior literature has often focused on specific trauma types (e.g., Dyb et al., 2003; Meiser-Stedman et al., 2008; Stover et al., 2010; Zimmerman, 2014), as opposed to general child trauma exposure, which may limit generalizability of the results as well as account for discrepant findings. The need for this research is underscored by the important clinical implications of high levels of discordance for trauma-related symptoms (Humphreys et al., 2017; Lewis et al., 2012; Stover et al., 2010). The aim of the present study was therefore to build upon the prior literature regarding caregiver–child concordance by examining levels of agreement for trauma-related difficulties in a clinical sample of children exposed to a variety of traumatic events. Child and family factors such as child age, gender, race, relationship to their caregiver, caregiver’s marital status, family income, and involvement with child protective services (CPS) were examined in relation to levels of trauma-related symptom agreement. In accordance with much of the prior literature (e.g., Dyb et al., 2003; Johnson, 2014; Walton et al., 1999; Youngstrom et al., 2000; Zimmerman, 2014), younger children, female children, and minority children were expected to present with higher levels of symptom discordance. Nonbiological caregivers, single caregivers, families with a lower income, and families with CPS involvement were also expected to have higher levels of discordance due to potentially higher levels of familial stress.

Method

Participants

Three hundred thirteen treatment-seeking children aged 8–12 (M = 9.55, SD = 1.77) and their nonoffending legal guardian(s) participated in the study. Sixty-five percent (65.2%) of the children were girls (34.8% boys) and about half of the sample identified as Black (51.3%, 43.6% White, 4.5% multiracial, and 0.6% Hispanic). Racial/ethnic status was recoded into two groups: racial minority (56.4%) and nonracial minority (43.6%). Thirty-seven percent (37.7%) of the children’s parents were never married, 30.7% divorced, 24.1% married, and 7.5% separated. Nearly 70% (69.7%) of the children were in the care of their biological parent(s). The remainder lived with their adoptive parent(s) (3.5%), other relatives (11.7%), or nonkinship foster homes or residential treatment facilities (14.8%). Annual household income was rated categorically in increments of US$10,000 from 1 (<US$10,000) to 10 (>US$90,000). Average income was 1.98 (SD = 1.77), which nearly corresponds to US$20,000–US$40,000.

All of the children had been exposed to at least one interpersonal traumatic event; however, the average number of traumas reported by children’s caregivers was 3.30 (SD = 2.46; range: 1–11). The majority of the children had experienced sexual abuse (88.1%). Children also experienced a variety of other traumatic events: 26.2% physical abuse, 22.4% death of a loved one, 22% serious illness, 21.1% domestic violence, 13.1% serious injury/accident, 13.1% impaired caregiver, 12.8% emotional abuse, 11.8% neglect, 11.8% community violence, 10.6% natural disaster, and 3.5% war/terrorism.

Measures

Demographics

At clinical intake, children’s caregivers completed a demographic information form that included questions such as child’s age, gender, race/ethnicity, annual family income, and caregivers’ education and occupation. Caregivers also reported which type(s) of trauma the child has experienced (i.e., sexual, physical, and emotional abuse; neglect; domestic and community violence; serious injury/accident; natural disaster; death of a loved one; or serious illness).

Trauma Symptom Checklist for Young Children (TSCYC)

The TSCYC measures 3- to 12-year-old children’s trauma-related symptoms, including symptoms of PTSD, utilizing caregivers’ reports on 90 items (Briere, 2005; Briere et al., 2001). Caregivers rate their children’s symptoms on a 4-point Likert-type scale (0 = never to 3 = almost all of the time/very often). The TSCYC yields six subscales: Anxiety, Depression, Anger, PTSS, Sexual Concerns, and Dissociation. Good reliability has been previously demonstrated, with α coefficients ranging from .81 to .93, and the TSCYC has also been shown to have predictive validity for childhood trauma (Briere et al., 2001). For the present study, Cronbach’s α = .96 for the entire measure and the subscale αs ranged from .82 to .93.

Trauma Symptom Checklist for Children (TSCC)

The TSCC is a 54-item self-report measure of trauma-related difficulties for children aged 8–16 (Briere, 1996). The TSCC produces six subscales: Anxiety, Depression, Anger, PTSS, Sexual Concerns, and Dissociation. Children rate their level of symptoms on a 4-point Likert-type scale (0 = never to 3 = almost all of the time). The TSCC has evidence of reliability, with α coefficients for clinical scales ranging from .77 to .89 as well as adequate convergent, divergent, and predictive validity among normative and clinical samples (Briere, 1996). In the current sample, Cronbach’s α was .92 for the entire instrument and the subscales’ αs ranged from .78 to .89.

Procedures

The study relied upon archival data from trauma-exposed children and their nonoffending legal guardians who were seeking trauma-focused services from a Midwestern child advocacy center and who consented/assented to participate in research studies. Children and their legal guardians completed a battery of clinical measures as part of routine clinical practice at intake. Inclusion criteria for the study were as follows: (1) child was aged 8–12, (2) completed TSCYC and TSCC (this age range was used given the ages appropriate for the TSCYC [ages 3–12] and the TSCC [ages 8–16]), and (3) exposure to an interpersonal trauma (e.g., physical, sexual, or emotional abuse or witnessing domestic or community violence). Four children were excluded as they were not reported to have experienced an interpersonal trauma. There were 31 missing TSCYC measures and 33 missing TSCC measures. These cases were not included in the final sample of 313. Clinicians in the study included clinical psychologists, master’s-level social workers and counselors, and graduate students in these disciplines under the supervision of a licensed mental health professional. Caregiver–child symptom concordances were generated for the parallel symptom types from the TSCYC and the TSCC (i.e., anxiety, depression, anger, PTSS, dissociation, and sexual concerns). Levels of concordance were determined using standardized difference scores (De Los Reyes & Kazdin, 2004; Guion et al., 2009; Owens et al., 2007; Weems et al., 2007). All study procedures were approved by the University of Missouri–St. Louis.

Data Analytic Plan

All statistical analyses were performed with SPSS for Windows, Version 25. The first hypothesis that levels of caregiver–child symptom concordance would be low across symptom domains was assessed using six one-way random intraclass correlation coefficients (ICCs), one for each symptom construct. ICC values yield an index that reflects the ratio between subject variability and total variability. ICCs should be used against Pearson’s bivariate correlations as caregivers’ and children’s reports may be correlated but have actually low agreement (Fleiss & Cohen, 1973). Bivariate correlations were also computed to assess multicollinearity (see Table 1). To evaluate whether child and family factors were associated with higher levels of symptom concordance, six linear regression models were computed. Child’s age, gender, race, caregiver type, caregiver’s marital status, family income, and involvement with CPS were entered into the models as potential factors related to symptom concordance. Child’s gender was entered as 1 = male and 2 = female. Caregiver type was coded as 1 = biological parent and 2 = nonbiological parent. Caregiver’s marital status was entered as 0 = not married and 1 = married. Minority status was coded as 0 = White and 1 = minority. CPS involvement was entered as 0 = no CPS involvement and 1 = CPS involvement. The direction of the discordance (i.e., whether the caregiver or the child endorsed a higher level of symptoms) was also assessed using frequencies.

Table 1.

Bivariate Correlations, Skew, and Kurtosis for Trauma-Related Symptom Domains.

Symptom Domain	1	2	3	4	5	6	Skew	SE	Kurtosis	SE
1. TSCC–TSCYC anxiety	—	—	—	—	—	—	−.25	.14	0.46	.28
2. TSCC–TSCYC depression	.63**	—	—	—	—	—	−.36	.14	0.77	.28
3. TSCC–TSCYC anger	.48**	.58**	—	—	—	—	−.84	.14	1.71	.28
4. TSCC–TSCYC PTSS	.72**	.71**	.54**	—	—	—	−.83	.14	0.52	.28
5. TSCC–TSCYC dissociation	.52**	.59**	.47**	.66**	—	—	−.69	.14	0.85	.28
6. TSCC–TSCYC sexual concerns	.42**	.45**	.47**	.48**	.37**	—	−.13	.14	0.40	.28

Note. TSCC = Trauma Symptom Checklist for Children; TSCYC = Trauma Symptom Checklist for Young Children; PTSS = post-traumatic stress symptoms; SE = standard error.

**p < .01.

Results

Levels of Symptom Concordance

ICCs for the symptom subscales are presented in Table 2. Caregivers’ and children’s reports of all of the symptoms were significantly related to one another; however, the level of concordance was consistently poor across subscales. These low ICCs indicate high levels of divergence in reporting across trauma-related difficulties (i.e., anxiety, depression, anger, PTSS, dissociation, and sexual concerns).

Table 2.

ICCs Between Caregiver- and Child-Reported Symptoms.

Symptom Domain	ICC
TSCC–TSCYC anxiety	.35***
TSCC–TSCYC depression	.34***
TSCC–TSCYC anger	.25***
TSCC–TSCYC PTSS	.20*
TSCC–TSCYC dissociation	.14*
TSCC–TSCYC sexual concerns	.14*

Note. ICC = intraclass correlation coefficient; PTSS = post-traumatic stress symptoms; TSCC = Trauma Symptom Checklist for Children; TSCYC = Trauma Symptom Checklist for Young Children.

Regressions

The regression model for anxiety symptom concordance was significant, F(7, 305) = 2.86, p = .007, r² = .24, adj. r² = .06 (see Table 3). Child’s gender and relationship to their caregiver were significantly related to levels of concordance, with boys and nonbiological caregivers having more discordance regarding anxiety symptoms than girls and biological caregivers. Child’s age and minority status, caregivers’ marital status, family income, and involvement with CPS were not associated with level of anxiety agreement. Inspection of the direction of the symptom discordance indicated that in 58.5% of the cases, caregivers endorsed higher levels of anxiety symptoms than their children, while in the remaining 41.5% of the cases, children reported higher levels of anxiety than their caregivers.

Table 3.

Regression Model for Trauma-Related Symptom Concordance.

Symptom Domain	B	SE	β	t	95% CI	p
Anxiety
Child’s age	−0.50	0.49	−.06	−1.06	[−1.42, 0.42]	.28
Child’s gender	4.05	1.58	.14	2.56	[0.94, 7.17]	.01
Child’s minority status	1.78	1.56	.06	1.10	[−1.35, 4.81]	.27
Caregiver’s relationship	−5.48	1.84	−.19	−2.96	[−9.11, −1.84]	.003
Caregiver’s marital status	2.84	2.13	.08	1.33	[−1.34, 7.03]	.18
Income	0.17	0.98	.01	0.18	[−1.75, 2.10]	.85
CPS involvement	1.91	1.80	.06	1.05	[−1.64, 5.47]	.29
Depression
Child’s age	−1.08	0.50	−.12	−2.14	[−2.07, −0.09]	.03
Child’s gender	4.20	1.70	.13	2.46	[0.84, 7.56]	.01
Child’s minority status	−2.05	1.68	−.07	−1.21	[−5.37, 1.26]	.22
Caregiver’s relationship	−4.04	1.98	−.13	−2.03	[−7.95, −0.12]	.04
Caregiver’s marital status	0.43	2.29	.01	0.18	[−4.08, 4.94]	.85
Income	−0.79	1.05	−.04	−0.75	[−2.487, 1.28]	.45
CPS involvement	0.33	1.94	.01	0.16	[−3.50, 4.16]	.86
Anger
Child’s age	−0.44	0.51	−.04	−0.85	[−1.45, 0.57]	.39
Child’s gender	5.11	1.74	.16	2.93	[1.68, 8.53]	.004
Child’s minority status	−3.75	1.72	−.12	−2.18	[−7.13, 0.36]	.03
Caregiver’s relationship	−0.48	2.02	−.01	−0.24	[−4.48, 3.50]	.81
Caregiver’s marital status	2.84	2.33	.07	1.21	[−1.76, 7.44]	.22
Income	−0.50	1.07	−.02	−0.47	[−2.62, 1.61]	.63
CPS involvement	1.91	1.98	.06	0.96	[−1.99, 5.82]	.33
PTSS
Child’s age	−0.61	0.57	−.06	−1.07	[−1.75, 0.51]	.28
Child’s gender	3.63	1.95	.10	1.86	[−0.20, 7.47]	.06
Child’s minority status	−1.52	1.93	−.04	−0.79	[−5.32, 2.27]	.43
Caregiver’s relationship	−3.33	2.27	−.09	−1.46	[−7.81, 1.14]	.14
Caregiver’s marital status	1.65	2.62	.03	0.62	[−3.51, 6.81]	.52
Income	0.22	1.20	.01	0.18	[−2.15, 2.60]	.85
CPS involvement	1.28	2.23	.03	0.57	[−3.10, 5.67]	.56
Dissociation
Child’s age	−0.39	0.51	−.04	−0.76	[−1.41, 0.62]	.44
Child’s gender	3.69	1.75	.12	2.11	[0.25, 7.14]	.03
Child’s minority status	−2.06	1.73	−.07	−1.19	[−5.47, 1.33]	.23
Caregiver’s relationship	1.29	2.04	.04	0.63	[−2.72, 5.30]	.52
Caregiver’s marital status	−1.03	2.35	−.02	−0.44	[−5.66, 3.59]	.66
Income	0.29	1.08	.01	0.27	[−1.83, 2.42]	.78
CPS involvement	0.26	1.99	.009	0.13	[−3.67, 4.19]	.89
Sexual concerns
Child’s age	−1.02	6.52	−.09	−1.69	[−2.21, 0.16]	.09
Child’s gender	5.50	2.04	.15	2.69	[1.48, 9.53]	.008
Child’s minority status	−2.23	2.02	−.06	−1.10	[−6.21, 1.74]	.27
Caregiver’s relationship	1.18	2.38	.03	0.49	[−3.51, 5.87]	.62
Caregiver’s marital status	−1.05	2.75	−.02	−0.38	[−6.46, 4.35]	.70
Income	1.48	1.26	.06	1.17	[−1.00, 3.97]	.24
CPS involvement	0.42	2.33	.01	0.18	[−4.16, 5.02]	.85

Note. CI = confidence interval; CPS = child protective services; PTSS = post-traumatic stress symptoms; SE = standard error.

The regression model accounted for a significant amount of variance in levels of concordance for depressive symptoms, F(7, 305) = 2.86, p = .007, r² = .24, adj. r² = .06. Here, child’s age, gender, and their relationship to their caregiver were related to agreement regarding depression. Older children, boys, and nonparents exhibited higher levels of symptom concordance. Child minority status, caregivers’ marital status, family income, and CPS involvement were not significantly associated with symptom agreement for depression. For the majority of the cases (77.6%), the caregivers indicated higher levels of depressive symptoms than the children.

For anger symptoms, the regression model did not account for a significant amount of variance in levels of symptom agreement, F(7, 305) = 2.36, p = .02, r² = .22, adj. r² = .05. Child’s gender and minority status were the only factors related to agreement for levels of anger. Specifically, boys and minority children demonstrated higher levels of concordance for anger than girls and White children. The hypotheses regarding the relationships between the other child and family factors and levels of symptom agreement were not supported. In 69.6% of the cases, caregivers reported higher levels of anger symptoms than the children.

The overall regression model for PTSS was not significant, F(7, 305) = 1.22, p = .29, r² = .16, adj. r² = .03, and none of the variables were significantly related to PTSS symptom concordance. A statistical trend was noted for gender, with boys having a higher degree of concordance regarding PTSS than girls (p = .06). Similar to the other symptom types, caregivers endorsed higher levels of PTSS symptoms than the child in 71.2% of the cases.

For dissociation, the model also did not account for a significant amount of variance in dissociative symptom agreement, F(7, 305) = 1.03, p = .40, r² = .04, adj. r² = .03. Child’s gender was associated with levels of dissociation symptom agreement, with boys exhibiting higher levels of concordance regarding dissociation compared to girls. Caregivers reported higher levels of dissociative symptoms in 60.4% of the cases.

The model for sexual concerns symptom agreement was not significant, F(7, 305) = 1.79, p = .08, r² = .04, adj. r² = .02. Only child’s gender was tied to levels of sexual concerns concordance, again boys had higher levels of concordance regarding sexual concerns than girls. Caregivers indicated higher levels of sexual concerns than children in 58.1% of the cases.

Discussion

Research has documented the discrepant reports of children’s exposure to traumatic events (Goodman et al., 2010; Hungerford et al., 2010; Lewis et al., 2012; Oransky et al., 2013; Stover et al., 2010) and trauma-related symptoms (author citation; Dyb et al., 2003; Meiser-Stedman et al., 2008; Scheeringa et al., 2006). Low levels of symptom agreement are problematic for several reasons, including that discordance regarding children’s symptoms has predicted poorer response to intervention (De Los Reyes et al., 2010; Humphreys et al., 2017). Therefore, while it is important to understand factors related to caregiver–child symptom agreement for trauma-related difficulties, the research in this area is still emerging and has often been limited to examination of specific types of trauma (e.g., Dyb et al., 2003; Meiser-Stedman et al., 2008; Stover et al., 2010; Zimmerman, 2014). The aim of the current study was to add to the small literature regarding caregiver–child symptom concordance for trauma-related symptoms and investigate factors related to symptom agreement among children exposed to a variety of traumatic events.

In line with prior research, results revealed low levels of symptom agreement for children’s trauma-related difficulties (Humphreys et al., 2017; Scheeringa et al., 2006). Indeed, the degree of agreement was poor across types of symptoms. Caregivers reported somewhat higher levels of difficulties than their children in more than half of the cases across difficulties, although the percentages varied by symptom type (range: 58.1%–77.6%). This pattern of findings is in contrast to some of the prior work in this area, which has indicated that caregivers endorse lower levels of PTSS than children (Dyb et al., 2003; Meiser-Stedman et al., 2008). As these studies used samples of children who experienced a motor vehicle accident, differences may be a function of differing forms of traumatic events and a treatment-seeking sample. Caregivers of children who experienced interpersonal traumatic events and who are seeking treatment may be somewhat more aware of, and be more willing to disclose, children’s symptoms, whereas children may be more hesitant to acknowledge their own level of trauma-related symptoms. Visual inspection of the ICCs indicated that concordance for anxiety and depression symptoms was somewhat higher than for dissociation and sexual concerns. Anxiety and depression symptoms may be easier for the caregiver to monitor than dissociation and sexual concerns. Trauma-related symptoms such as dissociation and sexual concerns may be more internal and less visible and thus may not be readily known to some caregivers (Scheeringa, 2011). In potential support of this, caregivers endorsed higher levels of symptoms than their children at a higher frequency (69.6%–77.6%) for depression, anger, and PTSS than for dissociation and sexual concerns (58.1%–60.4%). Some children may also have less insight or awareness into their degree of dissociation and sexual concerns, or these symptoms may be more difficult to communicate about than anxiety and depressive symptoms. As these findings are preliminary and the ICCs were not directly compared, additional work is needed to determine whether there are consistent patterns of symptom agreement for specific trauma-related symptoms. As the prior research has focused on PTSD symptoms and has not examined trauma-related difficulties more broadly, it is critical to replicate these findings. However, given the consistent low levels of symptom agreement, the results reiterate the need to assess children’s trauma-related difficulties utilizing both caregivers’ and children’s reports.

Child and family characteristics were expected to be related to levels of symptom agreement across domains of difficulty. Child’s age was only related to depression symptom agreement, with younger children having lower levels of concordance than older children. A prior study also reported that younger children had higher levels of PTSD discordance (Dyb et al., 2003). Nonetheless, this factor was not tied to the other symptom types, which may indicate that child’s age is related to few forms of trauma-related symptom agreement, consistent with one prior study focused on PTSD symptoms (Stover et al., 2010). Child’s gender was more consistently related to symptom agreement across difficulties, with significant relationships noted for anxiety, depression, anger, dissociation, sexual concerns, and a statistical trend for PTSS. Across symptom domains, girls exhibited lower levels of symptom concordance than boys, in line with prior research (Stover et al., 2010). It is unclear why higher levels of discordance would be present for girls. As the caregivers reported higher levels of symptoms than girls for many of the symptom types, most of which were internalizing in nature, girls may be underreporting their symptoms or caregivers of girls may be more likely to notice and report these types of difficulties. It may be useful to explore how child’s age and symptom type interact with child’s gender in association with both the degree and direction of discordance. Replication of gender differences for trauma-related symptoms is needed, as only one previous study has examined concordance for trauma-related difficulties by gender (Stover et al., 2010).

Child minority status expected to correspond with lower levels of symptom agreement; however, White children demonstrated lower levels of discordance for anger, and this factor was not related to the other forms of trauma difficulties. This finding is also in contrast to the prior literature where minority children have exhibited lower level of symptom agreement than White children including with general samples of children (Walton et al., 1999; Youngstrom et al., 2000) and among youth exposed to community violence (Zimmerman, 2014). It is uncertain why minority status would only be tied to anger and not the other forms of trauma symptoms and this finding may be spurious. Perhaps minority children and their caregivers are simultaneously over- or underreporting children’s level of anger. The reasons why symptom agreement may differ by cultural groups have not been determined but may be influenced by cultural mistrust of mental health providers and the need to downplay children’s symptoms or by cultural variations in what is considered problematic (De Los Reyes & Kazdin, 2005).

Among the examined caregiver and family factors, only the child’s relationship to their caregiver was related to symptom agreement for anxiety and depression symptoms. Interestingly, although we predicted that biological parents would demonstrate higher levels of concordance for trauma-related symptoms, biological parents exhibited lower levels of symptom agreement for anxiety and depression. Children with nonbiological parents may have experienced more severe traumatic events and are presenting with higher levels of symptoms that are more visible to both the children and their caregivers. Nonetheless, this pattern of results was only present for anxiety and depressive symptoms. Due to small cell sizes, we did not tease apart different types of children’s relationships with their caregivers, which may be important to better understand these findings.

The other caregiver or family factors—income, caregiver marital status, or CPS involvement—did not correspond with symptom concordance for any of the symptom types. These factors were expected to relate to levels of symptom agreement, possibly due to the impact of higher levels of familial stress. The prior literature has not examined these factors in relation to symptom agreement for trauma-related difficulties; therefore, further research is needed to replicate these findings. It is possible that other, more direct indices of familial and parental stress would have emerged as significant factors. Alternatively, familial factors may not be related to, or may play a small role in, symptom agreement for trauma-related symptoms. Instead, it may be that specific factors regarding the caregiver–child dyad may be more relevant such as caregiver warmth, effective communication, and quality of the attachment relationship. Additional research that more thoroughly assesses both familial and caregiver–child factors will be informative in furthering our understanding regarding the roles of the family and the caregiver–child relationship in symptom agreement for trauma-related difficulties.

Limitations

The present study has several limitations that merit discussion, such as the use of cross-sectional data and a sample seeking trauma-focused services from a child trauma specialty clinic. Causal conclusions cannot be drawn from these results, and future research utilizing a longitudinal design is warranted. Further, the use of a treatment-seeking sample is not representative of the general population of trauma-exposed children. When a population is specifically seeking treatment from a trauma-focused clinic, caregivers have some degree of knowledge regarding the child’s trauma exposure and are willing to initiate intervention or at least comply with recommendations or mandates from other child-serving sectors (e.g., law enforcement, CPS, and courts). These caregivers may then possess a greater degree of understanding and support than other caregivers. Children referred for trauma-focused care are likely exhibiting enough trauma-related distress to warrant treatment and thus are likely experiencing a higher level of symptoms than the larger population of trauma-exposed children. There may be important differences in which factors relate to concordance regarding trauma-related symptoms in nonclinical samples, and studies that utilize a more general sample of trauma-exposed children and their caregivers will help to broaden our understanding of whether, and how, correlates of concordance differ across the range of trauma-exposed children.

The present study was restricted to children aged 8–12 due to the appropriate age ranges for the TSCYC and the TSCC. The TSCYC and the TSCC are widely used instruments for trauma-exposed children; however, future studies should consider using measures that can be used with a wider age range of children. It is possible that differing factors may influence levels of trauma-related concordance across developmental periods. Although these measures assess similar content, the TSCYC and the TSCC were not developed as parallel measures and the items do not directly correspond. Differences in the items may have contributed to the low degree of concordance across trauma-related difficulties and impacted the results. Future research using parallel measures of trauma-related symptoms for caregivers and children would allow for a more precise understanding of factors that correspond with concordance of trauma-related difficulties.

We also limited our sample to children who experienced a variety of interpersonal traumatic events, and work is needed to compare children who experienced a noninterpersonal trauma to children who experienced an interpersonal trauma, as there may be key differences between forms of traumas. The majority of the children in the sample had experienced sexual abuse, and rates of other trauma types were high. This sample may therefore be a more severe subsample of trauma-exposed children who largely experienced sexual abuse, and additional studies are still needed using samples with more of a range of traumas. Although this was outside of the study aims, factors related to symptom agreement may differ by forms of interpersonal traumas, and work is needed to investigate differences in trauma types as well as key trauma characteristics (e.g., severity, chronicity, and relationship to the perpetrator). Further, the measures in the present study did not allow for a thorough examination of differences for the PTSD symptom clusters. There may be key differences in symptom agreement based on the clusters of PTSD symptoms (Stover et al., 2010).

The utilization of child and parent reports of trauma-related difficulties is limited in that many factors may impact children’s and caregivers’ reporting of symptoms, including degree of insight, attentional biases, and understanding or interpretation of measure items. Future research would benefit from additional reports of children’s symptoms, such as measures administered by a clinician. This would also allow for a more thorough comparison of children, caregiver, and clinician reports of children’s symptoms. Further, although the caregiver may be aware their child has experienced a trauma, the current study lacked data regarding how much knowledge the caregiver has regarding the trauma which may be critical, as underreporting of trauma exposure by caregivers is related to underreporting of trauma-related symptoms (Lewis et al., 2012; Zimmerman & Pogarsky, 2011). In addition to caregiver’s awareness and understanding of the child’s traumatic experience, future research should include other caregiver–child relationship factors that may impact child–caregiver symptom concordance such as attachment quality, levels of communication, and support in child–caregiver symptom concordance (Chi & Hinshaw, 2002; Kolko & Kazdin, 1993; Treutler & Epkins, 2003). Additionally, caregivers’ own trauma exposure and trauma-related difficulties may be relevant in understanding parenting behavior and caregiver–child relationships (Christie et al., 2019; Dixon et al., 2005; Lovejoy et al., 2000). Caregivers’ trauma exposure and present level of trauma symptoms may also skew their perceptions of their children’s level of trauma symptoms. Thus, factors related to the caregiver and the parent–child relationship should be considered to further this area of research.

Conclusions

Despite these limitations, the present study contributes to the literature regarding symptom discordance among trauma-exposed children by investigating several demographic and family characteristics, including previously unexamined factors, in relation to several trauma-related difficulties among children exposed to a variety of traumas. The current study extended the previously observed finding that levels of PTSS symptom agreement is low between caregivers and children by demonstrating that concordance is low for not just PTSS but for trauma-related difficulties more broadly. Further, child factors, particularly child’s gender, may be an important factor in understanding trauma-related discordance, and child’s age, minority status, and relationship to caregiver may play a role in certain aspects of trauma-related distress (e.g., anxiety, depression, and anger). As prior research has repeatedly demonstrated important clinical implications related to symptom concordance (De Los Reyes et al., 2010, 2013; Ferdinand et al., 2004, 2006; Guion et al., 2009; Humphreys et al., 2017; Pelton & Forehand, 2001), additional research in this area is needed to better identify and understand drivers of caregiver–child disagreement to hopefully improve clinical outcomes.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Rachel Wamser-Nanney

Claudia L. Campbell

References

Achenbach

T. M.

McConaughy

S. H.

Howell

C. T.

(1987). Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psychological Bulletin, 101, 213–232. https://doi.org/10.1037/0033-2909.101.2.213

Ackerman

P. T.

Newton

J. E.

McPherson

W. B.

Jones

J. G.

Dykman

R. A.

(1998). Prevalence of posttraumatic stress disorder and other psychiatric diagnoses in three groups of abused children (sexual, physical, and both). Child Abuse & Neglect, 22, 759–774. https://doi.org/10.1016/S0145-2134(98)00062-3

Briere

(1996). Professional manual for the Trauma Symptom Checklist for Children (TSCC). Psychological Assessment Resources. https://doi.org/10.1111/j.1475-3588.2008.00492.x

Briere

(2005). Trauma Symptom Checklist for Young Children (TSCYC). Psychological Assessment Resources, Inc.

Briere

Johnson

Bissada

Damon

Crouch

Gil

Hanson

Ernst

(2001). The Trauma Symptom Checklist for Young Children (TSCYC): Reliability and association with abuse exposure in a multi-site study. Child Abuse & Neglect, 25, 1001–1014. https://doi.org/10.1016/S0145-2134(01)00253-8

Chi

T. C.

Hinshaw

S. P.

(2002). Mother–child relationships of children with ADHD: The role of maternal depressive symptoms and depression-related distortions. Journal of Abnormal Child Psychology, 30, 387–400. https://doi.org/10.1023/A:1015770025043

Christie

Hamilton-Giachritsis

Alves-Costa

Tomlinson

Halligan

S. L.

(2019). The impact of parental posttraumatic stress disorder on parenting: A systematic review. European Journal of Psychotraumatology, 10(1), 1–13. https://doi.org/10.1080/20008198.2018.1550345

Copeland

W. E.

Keeler

Angold

Costello

E. J.

(2007). Traumatic events and posttraumatic stress in childhood. Archives of General Psychiatry, 64, 577–584. https://doi.org/10.1001/archpsyc.64.5.577

De Los Reyes

(2013). Strategic objectives for improving understanding of informant discrepancies in developmental psychopathology research. Development and Psychopathology, 25(3), 669–682. https://doi.org/10.1017/S0954579413000096

10.

De Los Reyes

Alfano

C. A.

Beidel

D. C.

(2010). The relations among measurements of informant discrepancies within a multisite trial of treatments for childhood social phobia. Journal of Abnormal Child Psychology, 38, 395–404. https://doi.org/10.1007/s10802-009-9373-6

11.

De Los Reyes

Augenstein

T. M.

Wang

Thomas

S. A.

Drabick

D. A. G.

Burgers

D. E.

Rabinowitz

(2015). The validity of the multi-informant approach to assessing child and adolescent mental health. Psychological Bulletin, 141, 858–900. https://doi.org/10.1037/a0038498

12.

De Los Reyes

Kazdin

A. E.

(2004). Measuring informant discrepancies in clinical child research. Psychological Assessment, 16, 330–334. https://doi.org/10.1037/1040-3590.16.3.330

13.

De Los Reyes

Kazdin

A. E.

(2005). Informant discrepancies in the assessment of childhood psychopathology: A critical review, theoretical framework, and recommendations for further study. Psychological Bulletin, 131, 483–509. https://doi.org/10.1037/0033-2909.131.4.483

14.

De Los Reyes

Thomas

S. A.

Goodman

K. L.

Kundey

S. M. A.

(2013). Principles underlying the use of multiple informants’ reports. Annual Review of Clinical Psychology, 9, 123–149. https://doi.org/10.1146/annurev-clinpsy-050212-185617

15.

Dixon

Brown

Hamilton-Giachritsis

(2005). Risk factors of parents abused as children: A mediational analysis of the intergenerational continuity of child maltreatment (Part I). Journal of Child Psychology and Psychiatry, 46, 47–57. https://doi.org/10.1111/j.1469-7610.2004.00339.x

16.

Duhig

A. M.

Renk

Epstein

M. K.

Phares

(2000). Interparental agreement on internalizing, externalizing, and total behavior problems: A meta-analysis. Clinical Psychology: Science and Practice, 435–453. https://doi.org/10.1093/clipsy.7.4.435

17.

Dyb

Holen

Braenne

Indredavik

M. S.

Aarseth

(2003). Parent-child discrepancy in reporting children’s post-traumatic stress reactions after a traffic accident. Nordic Journal of Psychiatry, 57, 339–344. https://doi.org/10.1080/08039480310002660

18.

Ferdinand

R. F.

van der Ende

Verhulst

F. C.

(2004). Parent-adolescent disagreement regarding psychopathology in adolescents from the general population as a risk factor for adverse outcome. Journal of Abnormal Psychology, 113, 198–206. https://doi.org/10.1037/0021-843X.113.2.198

19.

Ferdinand

R. F.

van der Ende

Verhulst

F. C.

(2006). Prognostic value of parent–adolescent disagreement in a referred sample. European Child & Adolescent Psychiatry, 15, 156–162. https://doi.org/10.1007/s00787-005-0518-z

20.

Fleiss

J. L.

Cohen

(1973). The equivalence of weighted kappa and the intraclass correlation coefficient as measures of reliability. Educational and Psychological Measurement, 33, 613–619. https://doi.org/10.1177/001316447303300309

21.

Goodman

K. L.

De Los Reyes

Bradshaw

C. P.

(2010). Understanding and using informants’ reporting discrepancies of youth victimization: A conceptual model and recommendations for research. Clinical Child and Family Psychology Review, 13, 366–383. https://doi.org/10.1007/s10567-010-0076-x

22.

Guion

Mrug

Windle

(2009). Predictive value of informant discrepancies in reports of parenting: Relations to early adolescents’ adjustments. Journal of Abnormal Child Psychology, 37, 17–30. https://doi.org/10.1007/s10802-008-9253-5

23.

Hourigan

S. E.

Goodman

K. L.

Southam-Gerow

M. A.

(2011). Discrepancies in parents’ and children’s reports of child emotion regulation. Journal of Experimental Child Psychology, 110, 198–212. https://doi.org/10.1016/j.jecp.2011.03.002

24.

Humphreys

K. L.

Weems

C. F.

Scheeringa

M. S.

(2017). The role of anxiety control and treatment implications of informant agreement on child PTSD symptoms. Journal of Clinical Child & Adolescent Psychology, 46, 903–914. https://doi.org/10.1080/15374416.2015.1094739

25.

Hungerford

Ogle

R. L.

Clements

C. M.

(2010). Children’s exposure to intimate partner violence: Relations between parent-child concordance and children’s adjustment. Violence and Victims, 25, 185–201. https://doi.org/10.1891/0886-6708.25.2.185

26.

Johnson

S. D.

(2014). Comparing factors associated with maternal and adolescent reports of adolescent traumatic event exposure. Family Process, 53, 214–224. https://doi.org/10.1111/famp.12050

27.

Kolko

D. J.

Kazdin

A. E.

(1993). Emotional/behavioral problems in clinic and nonclinic children: Correspondence among child, parent and teacher reports. Journal of Child Psychology and Psychiatry, 34, 991–1006. https://doi.org/10.1111/j.1469-7610.1993.tb01103.x

28.

Lewis

Thompson

Kotch

J. B.

Proctor

L. J.

Litrownik

A. J.

English

D. J.

Runyan

D. K.

Wiley

T. R.

Dubowitz

(2012). Parent–youth discordance about youth-witnessed violence: Associations with trauma symptoms and service use in an at-risk sample. Child Abuse & Neglect, 36, 790–797. https://doi.org/10.1016/j.chiabu.2012.09.009

29.

Lovejoy

M. C.

Graczyk

P. A.

O’Hare

Neuman

(2000). Maternal depression and parenting behavior: A meta-analytic review. Clinical Psychology Review, 20(5), 561–592. https://doi.org/10.1016/S0272-7358(98)00100-7

30.

Meiser-Stedman

Smith

Glucksman

Yule

Dalgleish

(2008). The posttraumatic stress disorder diagnosis in preschool- and elementary school-age children exposed to motor vehicle accidents. American Journal of Psychiatry, 165, 1326–1337. https://doi.org/10.1176/appi.ajp.2008.07081282

31.

Oransky

Hahn

Stover

C. S.

(2013). Caregiver and youth agreement regarding youth’s trauma histories: Implications for youth’s functioning after exposure to trauma. Journal of Youth and Adolescence, 42, 1528–1542. https://doi.org/10.1007/s10964-013-9947-z

32.

Owens

J. S.

Goldfine

M. E.

Evangelists

N. M.

Hoza

Kaiser

N. M.

(2007). A critical review of self-perceptions and the positive illusory bias in children with ADHD. Clinical Child and Family Psychology Review, 10, 335–351. https://doi.org/10.1007/s10567-007-0027-3

33.

Pelton

Forehand

(2001). Discrepancy between mother and child perceptions of their relationship: I. Consequences for adolescents considered within the context of parental divorce. Journal of Family Violence, 16, 1–15. https://doi.org/10.1023/A:1026527008239

34.

Putnam

F. W.

(2003). Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 269–278. https://doi.org/10.1097/00004583-200303000-00006

35.

Scheeringa

M. S.

(2011). PTSD in children younger than the age of 13: Toward developmentally sensitive assessment and management. Journal of Child & Adolescent Trauma, 4, 181–197. https://doi.org/10.1080/19361521.2011.597079

36.

Scheeringa

M. S.

Wright

M. J.

Hunt

J. P.

Zeanah

C. H.

(2006). Factors affecting the diagnosis and prediction of PTSD symptomatology in children and adolescents. American Journal of Psychiatry, 163, 644–651. https://doi.org/10.1176/ajp.2006.163.4.644

37.

Stover

C. S.

Hahn

J. J. Y.

Berkowitz

(2010). Agreement of parent and child reports of trauma exposure and symptoms in the early aftermath of a traumatic event. Psychological Trauma: Theory, Research, Practice, and Policy, 2, 159–168. https://doi.org/10.1037/a0019156

38.

Tingskull

Svedin

C. G.

Agnafors

Sydsjö

deKeyser

Nilsson

(2015). Parent and child agreement on experience of potential traumatic events. Child Abuse Review, 24, 170–181. https://doi.org/10.1002/car.2287

39.

Treutler

C. M.

Epkins

C. C.

(2003). Are discrepancies among child, mother, and father reports on children’s behavior related to parents’ psychological symptoms and aspects of parent–child relationships? Journal of Abnormal Child Psychology, 31, 13–27. https://doi.org/10.1023/A:1021765114434

40.

Walton

J. W.

Johnson

S. B.

Algine

(1999). Mother and child perceptions of child anxiety: Effects of race, health status, and stress. Journal of Pediatric Psychology, 24, 29–39. https://doi.org/10.1093/jpepsy/24.1.29

41.

Wamser-Nanney

(in press). Caregiver-child symptom concordance: Links to premature termination from trauma-focused therapy. Journal of Interpersonal Violence.

42.

Weems

C. F.

Pina

A. A.

Costa

N. M.

Watts

S. E.

Taylor

L. K.

Cannon

M. F.

(2007). Predisaster trait anxiety and negative affect predict posttraumatic stress in youths after Hurricane Katrina. Journal of Consulting and Clinical Psychology, 75, 154–159. https://doi.org/10.1037/0022-006X.75.1.154

43.

Youngstrom

Loeber

Stouthamer-Loeber

(2000). Patterns and correlates of agreement between parent, teacher, and male adolescent ratings of externalizing and internalizing problems. Journal of Consulting and Clinical Psychology, 68, 1038–1050. https://doi.org/10.1037//0022-006X.68.6.1038

44.

Zimmerman

G. M.

(2014). The covariates of parent and youth reporting differences on youth secondary exposure to community violence. Journal of Youth and Adolescence, 43, 1576–1593. https://doi.org/10.1007/s10964-014-0099-6

45.

Zimmerman

G. M.

Pogarsky

(2011). The consequences of parental underestimation and overestimation of youth exposure to violence. Journal of Marriage and Family, 73, 194–208. https://doi.org/10.1111/j.1741-3737.2010.00798.x