Parent and Teacher Mental Health Ratings of Children Using Primary-Care Services: Interrater Agreement and Implications for Mental Health Screening

Objective: To examine interrater agreement when screening for child mental health problems during primary-care visits. Methods: Children aged 5 to 10 (n = 227) and one of their parents were systematically recruited from the waiting rooms of 15 primary-care sites located in Baltimore, Md; Washington, DC; and rural New York from 2002 to 2005. The parent and teacher of the child completed the Strengths and Difficulties Questionnaire to measure the child's emotions, behaviors, and functional impairment. Results: Parents and teachers identified a similar proportion of children as having high symptoms (25% vs 23%) and high impairment (27% vs 32%) but rarely agreed in their assessments of specific children. Parent ratings alone missed 52% of children rated by teachers as having both high symptoms and high impairment (κ = 0.15). Only 6% of these discrepant visits were for mental health problems, making it unlikely that teacher reports would have been solicited. Conclusions: Parent reports failed to detect half of school-aged children considered to be seriously disturbed by their teachers. Efforts to improve detection of mental health problems by using screening tools in primary care may require algorithms that help providers judge when to solicit teacher reports and how to interpret conflicting information from parents and teachers.