Introduction
Children with neurologic disorders (e.g., traumatic brain injury, epilepsy, etc.) are a growing population in the United States and worldwide who are at increased risk for adverse mental health outcomes (e.g., anxiety, depression; Ferro & Boyle,
2015; Stephenson et al.,
2015) and many are diagnosed with neurodevelopmental conditions (e.g., ADHD, autism; Nylander et al.,
2015). If undetected, mental health and/or neurodevelopmental conditions can contribute to diminished quality of life (LaGrant et al.,
2020). Furthermore, untreated concerns hinder adherence to medical regimens and the likelihood of optimal control over neurologic disorders (Blackman et al.,
2011). Early screening and intervention are associated with improved long-term outcomes (e.g., quality of life, academic achievement; Kuhlthau et al.,
2011). Though many factors contribute to unaddressed and untreated concerns in pediatric populations, low agreement between providers (e.g., neurologists, psychologists, nurse practitioners) and between providers-parents on these concerns can delay access to assessment and interventions (Schwartz et al.,
2018). Examining provider-provider and provider-parent perspectives on mental health and/or neurodevelopmental concerns specifically in children with neurologic disorders is an important extension of this work.
Efforts to understand mental health and neurodevelopmental concerns in children with neurologic disorders have increased in recent years and contributed to improvements in personal and family well-being (Whitney et al.,
2019). Still, screening and intervention standards appear differential across settings with screening processes being variable and conducted by a range of healthcare professionals and practices (Beers et al.,
2017; Brown & Wissow,
2010; Wissow et al.,
2013). While mental health and neurodevelopmental conditions in children with neurologic disorders are appreciated in the growing literature, research on interrater agreement between providers and providers-parents (i.e., primary care team members) is largely limited. Though many parents lack formal training in child development and are therefore, more likely to be discrepant from professional opinions, their perspectives afford valuable insight to the child’s daily life (i.e., outside of a clinical visit with a provider). Furthermore, parent perspectives are important in conceptualizing a child given a parent’s role in accessing youth medical and psychiatric services, which predicate on a parent recognizing the needs of the child and responding accordingly (Burnett-Zeigler & Lyons,
2010; Chan et al.,
2023).
Several barriers have been identified in efforts to address mental health and neurodevelopmental needs among children with neurologic disorders including little research on the reliability and validity of screening tools in this population (Bennett et al.,
2019) and a primary emphasis on treating medical concerns (Vinall et al.,
2016). In addition, interrater disagreement between youth, their parents, and care providers may be common with previous work reporting differences in ratings of youth quality of life (Eiser & Varni,
2013a; Pinquart & Shen,
2011; Vetter et al.,
2012), which were associated with later access to intervention (de Los Reyes,
2011). Investigators emphasized the importance of understanding both the direction and magnitude of informant discrepancies (Eiser & Varni,
2013a), which may inform predictions of patient outcomes and family adherence to treatment regimens (de Los Reyes,
2011). However, to our knowledge, no studies have examined the direction and magnitude of interrater agreement between care team providers (e.g., neuropsychologist, neurologist) and providers-parents on mental health and neurodevelopmental concerns in children specifically with neurologic disorders.
While parents and referring providers contribute important perspectives on youth, neuropsychological evaluations result in a more thorough phenotyping of the child across many domains (e.g., cognition, language, medical history, etc.) and opportunities for reconciling multiple provider and parent perspectives. Typically in evaluations, neuropsychologists conduct a meticulous review of a patient’s medical records to obtain histories and observations from multidisciplinary providers (e.g., primary care provider, neurologist, psychiatrist), as well as referral information. With this knowledge, neuropsychologists interview parents to obtain additional information (e.g., developmental history, academic performance, etc.), with opportunities to clarify discrepancies or points of confusion. While neuropsychological evaluations largely focus on assessing cognitive functions in individuals with neurologic conditions, there also exist opportunities to evaluate mental health status. Through this process, neuropsychologists balance perspectives from multidisciplinary providers and parents, in combination with neuropsychological tests and behavioral observations, to formulate an extensive conceptualization of the patient in a neuropsychological report. Therefore, the rich phenotyping available in these reports may be an important method to understand mental health and/or neurodevelopmental concerns in children with neurologic disorders from diverse perspectives.
Present Study
In the present study, a retrospective chart review of a convenience sample of children with neurologic disorders referred for a neuropsychological evaluation was conducted to explore interrater agreement between care team members (i.e., referring providers, parents, pediatric neuropsychologist) in detecting mental health and/or neurodevelopmental concerns in these children. A primary aim was to examine the direction and magnitude of interrater agreement between multiple care team members in detecting mental health and/or neurodevelopmental concerns. We also examined the sensitivity and specificity of referring providers and parents in identifying concerns when comparing their ratings to those of the pediatric neuropsychologist. Exploratory analyses investigated potential factors (e.g., age, intellectual abilities, adaptive skills) that may contribute to mental health and/or neurodevelopmental concerns in this sample. We hypothesized that interrater agreement would be low between referring providers, parents, and the pediatric neuropsychologist on youth mental health and neurodevelopmental concerns and that certain youth factors (e.g., age, intellectual abilities, adaptive behaviors) would be associated with more severe mental health concerns.
Discussion
The current study examined inter-rater agreement between three care team members (referring providers, parents, pediatric neuropsychologist) serving children with neurologic disorders and showed divergent perspectives; the neuropsychologist identified mental health and neurodevelopmental concerns for the first time in many children. Findings mirror previous research identifying differences in ratings of health-related quality of life across raters (Eiser & Varni,
2013b; Pinquart & Shen,
2011) and contribute to the literature by comparing ratings of mental health and/or neurodevelopmental concerns in children with neurologic disorders across these raters. It is important to note that a significant portion of the sample exhibited undiagnosed mental health and/or neurodevelopmental concerns prior to the neuropsychological evaluation that were not reported by parents or referring providers and instead, referral reasons focused on cognitive and/or academic difficulties.
Ratings of DSM-5 mental health diagnoses and subthreshold symptoms revealed in this study suggest that children with neurologic disorders are at risk for adverse mental health outcomes and/or neurodevelopmental conditions, many of which may not be reported by referring providers or parents for various reasons. Our findings add to the growing literature emphasizing the importance of identifying and communicating mental health concerns in this high risk population (Pinquart & Shen,
2011b). Perspectives from parents, referring providers, and neuropsychologists, among other team members, are equally important in understanding areas of strength and difficulty for children with neurologic disorders. Unsurprisingly, findings suggest that direct assessment (e.g., mental health questionnaires, neuropsychological evaluation, etc.) of psychiatric symptoms may be optimal to early screening and intervention efforts. Though different perspectives are common, low agreement between raters may interfere with clear diagnostic conceptualizations and/or treatment plans. Without access to effective interventions, youth who are advancing in age may have persisting or worsening mental health and/or neurodevelopment needs (Kuhlthau et al.,
2011; Novins et al.,
2013). This applies to both ongoing cognitive deficits that may be unrecognized and yield more learning challenges across schooling, and also persisting mental health symptoms including trauma, other anxiety presentations, or even depression.
The present study was limited to a retrospective chart review with a small sample and thus, findings should be interpreted with caution as medical records may be limited in flagging all concern areas for a patient. Referring providers were not interviewed in this study so it is possible that providers were already cognizant of mental health and/or neurodevelopmental concerns in youth. Alternatively, it is possible that referring providers were aware of child mental health and/or neurodevelopmental concerns and directing families to other services (e.g., psychotherapy, psychiatrist) to address these needs. Furthermore, with a small convenience sample of children with diverse neurologic disorders, it is not feasible to draw definitive conclusions about mental health and/or neurodevelopmental concerns in this population. It is also possible that differences in mental health and/or neurodevelopmental concerns may be attributed to different neurologic conditions; for example, children born prematurely may have different needs than children with a traumatic brain injury. Future studies with larger subgroups of children with neurologic conditions are needed to tease apart these potential differences.
The pediatric neuropsychologist employed multimethod (e.g., interview, questionnaires, neuropsychological assessments), multi-informant (e.g., parent, youth) methods, which likely contributed to increased detection of mental health concerns for the first time in this sample. In addition, the neuropsychologist deliberately and routinely asked each youth about mood, symptoms of anxiety, experiences of depression, social relationships, and exposure to traumatic experiences, regardless of primary referral reason. It is evident that these multimethod, multi-informant assessments significantly increased the likelihood that youth at-risk for psychiatric disorders were detected accurately, even within one neuropsychological evaluation. Findings may highlight the importance of expanding the traditional scope of neuropsychological evaluations (i.e., focus on neurocognitive domains and functioning) to routinely assessing for mental health and neurodevelopmental symptoms during evaluations.
In contrast, inter-rater agreement was higher between the three raters in ratings of DSM-5 neurodevelopmental diagnoses and subthreshold symptoms than agreement for mental health concerns. Higher agreement may be explained by near perfect agreement between referring providers and parents; however, neurodevelopmental concerns may not be fully captured by these two raters given that the neuropsychologist identified 13 children with neurodevelopmental concerns above the DSM-5 diagnostic threshold and 39 additional children with subthreshold symptoms for the first time. Findings may be explained, in part, by increased awareness of risks for inattention, hyperactivity, social difficulties, or other neurodevelopmental concerns in children with neurologic disorders among providers and parents given extensive research and practice guidelines in this area (Blackman et al.,
2011; Maslow et al.,
2011). Our findings align with those in the broader pediatrics literature that indicate poor inter-rater agreement between different care team members (e.g., parents, teachers, providers, etc.) on mental health (Brown & Wissow,
2010; Wissow et al.,
2013) and neurodevelopmental (Wolraich et al.,
2004) concerns in youth.
Findings from the three subgroups of mental health concerns (MH-P0N0, MH-P0N1, MH-P1N1) revealed significant differences across subgroups for certain domains of well-being (e.g., anxiety, depression, attention, executive function), but not others (e.g., adaptive behaviors). For both youth self-rated anxiety and depression, the two subgroups with mental health concerns (i.e., MH-P0N1, MH-P1N1) exhibited significantly higher internalizing symptoms (1.5–2 SD) than children without mental health concerns (i.e., MH-P0N0); however, differences between the two subgroups with mental health concerns were not significant. Given this, it appears that symptom severity may not entirely explain why some parents report mental health concerns that match those of the neuropsychologist while other parents do not. In addition to elevated anxiety and depression scores, youth in the two mental health subgroups (i.e., MH-P0N1, MH-P1N1) also endorsed inattention, hyperactivity/impulsivity, and learning problems above the clinical cutoffs, which may suggest an additive challenge to ongoing mental health concerns. Therefore, these five domains of functioning—anxiety, depression, inattention, hyperactivity/impulsivity, and learning problems—may be particularly important for providers, parents, and other care team members to regularly assess, monitor, and address during routine follow-up neurological care.
Children were also categorized into subgroups based on presence of neurodevelopmental concerns and findings revealed more robust patterns of differences between subgroups for certain domains (e.g., adaptive behaviors, attention, executive function), but not indices of mental health (e.g., anxiety, depression). Findings revealed significant differences between the three neurodevelopmental subgroups with the highest symptom severity among those with concerns noted by parents and the neuropsychologist (i.e., ND-P1N1) for adaptive behaviors on the ABAS-3 and all subscales of the parent-rated Conners-3. It is possible that reduced adaptive behaviors and high symptom severity are important factors in understanding why some parents report neurodevelopmental concerns and other parents do not.
Limitations
There are limitations to the present study that warrant a discussion. First, the present study was a retrospective chart review of a convenience sample of children with neurologic disorders and thus, is not fully representative of this population. Second, the sample included youth with diverse neurologic disorders with heterogenous etiologies and treatment plans, which limit findings to the group as a whole rather than specific medical conditions. Third, questionnaires (e.g., MASC-2, CDI-2) were not systematically completed by youth and the three raters, which limits findings and highlights an important future direction. Fourth, additional demographic factors (e.g., race, ethnicity, socioeconomic status) were not available and hinder our ability to understand how these factors may influence mental health and/or neurodevelopmental concerns in this population. Lastly, detailed information about pre-existing mental health and/or neurodevelopmental disorders (e.g., age of diagnosis, diagnosing provider) were not available.
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