[page 66] [Mental Illness 2012; 4:e14]

Mothers and fathers do notaccurately report each other’spsychopathologyRandal G. Ross, Sharon K. Hunter, Gary O. Zerbe, Kate HannaDepartment of Psychiatry, University of Colorado Denver, CO, USA

Abstract

It is unclear whether information obtainedfrom a one parent can be used to infer theother parent’s history of psychopathology. Twohundred and one parental dyads were asked tocomplete psychiatric interviews. Based onmaternal report, non-participating husbands/fathers had higher rates than participatingfathers of psychiatric illness. For fathers whodid participate, maternal report did not matchdirect interview of paternal psychopathologywith sensitivities less than 0.40 and positivepredictive values of 0.33 to 0.74. Psychopa -thology may be over-represented amongfathers who do not participate in research.Mother report of paternal symptoms is not aneffective proxy. Alternative methods need to bedeveloped to: i) improve father participation orii) identify psychiatric status in fathers who donot participate in research projects.

Introduction

A common problem when studying familiesis that husbands/fathers participate inresearch studies at only about 2/3 of the rate ofwives/mothers.1-3 Families where the hus-band/father does not participate in researchare associated with lower parental education,lower socioeconomic status, younger parentalage, non-majority racial or ethnic status, andless stable marriages than families where thehusband/father participates.1,4 Offspring fromfamilies where the father does not participatein research are more likely to be unplanned,smaller at birth, less healthy, have a more dif-ficult temperament, and have more siblings.1Costigan and Cox have argued that limitingresearch to families where the father partici-pates over-represents higher functioningfathers biasing results toward mothers as theprimary source of offspring difficulties. Thisargues not only that families with non-partici-pating husbands/fathers be included in familystudies, but that alternative methods to bothincrease husband/father participation and toidentify critical variables about non-participat-ing fathers (e.g. the use of public records) be

employed.1 Mental illness is one area wheremethods to increase information about hus-bands/fathers needs additional exploration. Ahistory of mental illness has negative conse-quences for families. Individuals with a histo-ry of mental illness are more likely to marrybefore the age of 20,5 more likely to be involvedin domestic violence,6 and more likely to havea marriage end in divorce.7 In addition,parental psychopathology is associated withincreased risk of psychopathology in offspring,and the effect size is similar whether the psy-chopathology occurs in the mother or in thefather.8 Given the consistent negative impactof mental illness on a broad swath of familyand offspring outcomes, additional efforts toidentify and evaluate mechanisms and poten-tial interventions are critical, and a number oflaboratories are involved in this area ofresearch. However, scientific progress in thisarea requires the accurate assessment of psy-chopathology.

The most commonly accepted mechanism toassess for psychopathology is direct interview,although self-report forms are also sometimesused. However, the high rate of husband/fathernon-participation in family studies combinedwith suggestions that non-participants differfrom participants in rates of depressive andpsychotic symptoms raises generalizabilityquestions for a direct interview strategy.9 Acommonly used option is to employ the otherparent’s report as a proxy for direct interview.The ability of family members to accuratelyidentify psychopathology has primarily beenassessed within the context of genetic studies,where samples are generally a combination ofcontrols and family members recruitedbecause at least one, and often more than one,individual within the family has been identi-fied as having a psychiatric illness of interest.Psychotic illnesses are the most accurately rec-ognized by their relatives, with a sensitivity of0.44-0.72 and specificity approaching 1.0;9-11substance use disorders are recognized with asensitivity of 0.44-0.56 and specificity of 0.94-0.96;12 depression recognition has a sensitivityof 0.18-0.68 and specificity of 0.74-0.97;9,12-14and, combined diagnostic categories (i.e. gen-eral recognition of psychopathology) have sen-sitivities of 0.37-0.84 with specificities of 0.61-0.86.12,14 Individuals who have a psychiatric ill-ness of interest have consistently higher sen-sitivity and specificity when reporting thesame illness in family members. Individualsthat are recruited from general populationsamples have the lowest sensitivity and speci-ficity at identifying psychiatric illnesses infamily members. Individuals without a specificpsychiatric illness but who are members of afamily with multiple cases of that illness havemore intermediate sensitivity and specificityprofiles. One of the limitations of the work todate is the focus on families with known men-

tal illness. There has been only a limited effortwhere recruitment is not biased toward multi-affected families. In more general populationsamples, sensitivity for substance use disor-ders drops to 0.19-0.34 and for depression toaround 0.29.15,16 A second limitation with pre-vious work has been the failure to includeinformation about the informant’s psychiatricsymptoms; i.e. does knowing whether themother has depression alter the interpretationof her report about the father’s depressivesymptoms? This report attempts to expand thatknowledge base by using a general populationsample of young parents and by exploring mul-tiple broad categories of psychiatric illness.The purpose of the current study is determineif, when one parent does not participate in aresearch project, that parent’s psychiatric his-tory can be inferred from information obtainedfrom the other parent. When asked to rate thelevel of involvement in child rearing, self andthe other parent’s reports are fairly dis-crepant.17 Conversely, when mothers andfathers are asked to independently report ontheir children’s psychopathology agreement isconsidered to be moderate, particularly whenbroad categorical diagnostic categories areused.18-20 It is unclear if the critical variable iswho is being rated (i.e. parents have higheragreement about their children than eachother) or what is being rated (there is higheragreement about psychopathology than level ofinvolvement). Thus, it is difficult to predict thepotential agreement between parental dyadson their psychopathology.

Mental Illness 2012; volume 4:e14

Correspondence: Randy Ross, University ofColorado Denver, 13001 E 17th Pl, Campus BoxF546, Aurora, CO 80045, USA. E-mail: randy.ross@ucdenver.edu

Key words: father, psychopathology.

Conflict of interests: the authors report no con-flicts of interests.

Funding: this work was supported in part bygrants from the National Institutes of Health(MH56539, MH068582, and MH086383).

Acknowledgements: a special thanks to all thefamilies who participated in this project.

Received for publication: 30 September 2011.Revision received: 23 April 2012.Accepted for publication: 22 May 2012.

This work is licensed under a Creative CommonsAttribution NonCommercial 3.0 License (CC BY-NC 3.0).

©Copyright R.G. Ross et al., 2012Licensee PAGEPress, ItalyMental Illness 2012; 4:e14doi:10.4081/mi.2012.e14

[Mental Illness 2012; 4:e14] [page 67]

Materials and Methods

ParticipantsThis report is part of a larger study focusing

on the relationship between parental psy-chopathology and infant development. Infantsand their parents were recruited through astate birth registry. Potential families wererandomly chosen from zip codes in a metropol-itan region and then sent a letter describingthe study and an addressed stamped postcardto return if they were interested in participat-ing. The approximately 8% of families whoreturned the postcard were further contacted.All families who agreed to participate wereincluded irrespective of the number of parentswho agreed to participate. Demographics ofparticipating families were monitored, andsampling rate by zip code adjusted with a goalthat familial participation matched, as closelyas possible, census-based local metropolitanarea demographics for race and ethnicity. Twocommunity-based families who contacted thestudy and requested to participate were alsoincluded. Infants participated in six to tenphysiological and developmental assessmentsbetween enrollment and 18 months of age.Attempts to recruit parents to complete diag-nostic interviews continued around each visit;attempts were made via phone, email, and viaa participating partner. Parents who agreed tocomplete diagnostic evaluation by their child’s18-month birthday may have scheduled theevaluation for a time noticeably after theirchild’s 18-month birthday. Parents received

$10 per hour (minimum $30) for participation.In general, parental diagnostic interviews tookless than 3 hours to complete and thus almostall participants received $30 for the diagnosticinterview. Investigative procedures wereapproved and monitored by a local InstitutionalReview Board.

Two hundred-one (201) families participat-ed. The infants include 112 females and 89males. One hundred eighty-one (90%) the bio-logical parents lived together. Demographicinformation is summarized in Table 1. Theracial and ethnic distribution was similar tothat found in the local metropolitan region.

Diagnostic interviewsGiven the known difficulties in optimizing

paternal participation, the window for accept-able paternal participation was broad coveringa 16-to-17-month period from initial familyenrollment (generally when the infant wasaround 4-6 weeks of age) until the infant was18 months of age. Because of this broadrecruitment period, and because the overallstudy included genetic contributions to infantdevelopment, diagnostic evaluations focusedon lifetime diagnoses (e.g. whether the indi-vidual had met criteria for a diagnoses at anytime during their life, including but not limit-ed to current illness). Interviews focused onbiological parents (biological relationship sole-ly determined by parental report). Parentswere individually interviewed with 2 diagnos-tic instruments: the structured clinical inter-view for diagnostic and statistical manual ofmental disorders - fourth edition - about them-selves and the family interview for genetic

studies (FIGS) about the other biological par-ent of the infant.21,22 A Spanish version of thestructured clinical interview (SCID) and aSpanish version of the FIGS developed by ourlab were utilized when appropriate.23 While agenerally accepted Spanish version of theFamily Interview for Genetic Studies was notavailable at the time we initiated this study;later efforts have suggested that translationshave reasonable reliability and validity.24 Allinterviews were completed by an experiencedresearch mental health clinician (psychiatricM.D. or M.S.W.) with translator services uti-lized as necessary. In order to maintain suffi-cient time for the interviews, the interviewconcerning the other parent emphasized threemajor diagnostic areas: psychotic illnesses,affective illnesses, and non-nicotine substanceuse disorders. Anxiety, personality, and nico-tine use disorders were not a component of thestructured interview concerning the other par-ent. For the other parent interviews, a positivediagnosis was based on either a description ofa sufficient number of symptoms to meet diag-nostic criteria (e.g. depressed mood, poorsleep, etc.) or if the individual reported thatthe other parent had been diagnosed or treat-ed for a specific psychiatric illness. All evalua-tion summaries were reviewed by 2 or moreexperienced research clinicians, and theresulting diagnoses were best estimate diag-noses. While interrater reliability was notassessed for this sample, the SCID has goodinterrater reliabilities when experiencedresearch clinicians with advanced degrees areutilized, (k 0.65-1.00).25,26

Psychopathology can be conceptualized as

Article

Table 1. Parental demographics. Results based on information form, depending on the variable, between 200 and 201 mothers andbetween 195 and 201 fathers.

Mothers* Fathers*

Age in years (Mean + standard deviation)° 30.76±5.9 33.1±7.0Age range in years° 16.2-48.2 17.8-58.7

Race/ethnicityCaucasian non-Hispanic 145 (72%) 145 (72%)Caucasian Hispanic 36 (18%) 36 (18%)African-American 6 (3%) 10 (5%)Mixed 9 (4%) 4 (2%)Other/unknown 5 (2%) 5 (2%)

Socio-economic levelEducation (years)# 15±3 15±3Socioeconomic occupational index§ 48±23 55±22

Interview datacompleted self-report interview and had the other parent report on their symptoms 148 (74%) 147 (73%)completed self-report interview but the other parent did not report 50 (25%) 5 (3%)did not participate in self-report interview but had the other parent report 3 (2%) 43 (21%)with no psychiatric interview information 0 (0%) 6 (3%)

Marital statusmarried to the other biological parent 162 (81%)living with the other biological parent 16 (8%)not married to or living with the other biological parent 23 (11%)

*201 mothers, 201 fathers unless otherwise specified; °201 mothers, 197 fathers; #200 mothers, 196 fathers; §200 mothers, 195 fathers. Data based on Nakao and Treas.28

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either categorical or continuous variables.Continuous variables often have increased sta-tistical power and have the potential of notingdifferences even in non-clinical populations.However, psychopathology is often defined assymptoms severe enough to cause dysfunction,and many psychiatric interviews thus focus onsymptom identification. Some symptoms play alarger role in diagnostic schema that othersand some symptom clusters co-occur at rateshigher than chance. Given these issues, symp-tom counts are generally not considered appro-priate reflections of illness severity; categori-cal identification of psychopathological diag-nosis is often utilized as the primary definitionof psychopathology. All reports thereforefocused on the presence or absence of a histo-ry of psychopathology.

Data reductionA primary goal of this study was to determine

if one parent could accurately report on the otherparent’s psychopathology. There is increasingawareness that psychopathology crosses tradi-tional diagnostic boundaries, so a focus onbroader diagnostic categories was appropriate;Diagnoses were reduced to 4 symptomatic cate-gories: illnesses with psychotic symptoms(schizophrenia, schizoaffective disorder, bipolardisorder with psychosis, major depression withpsychosis, psychosis not otherwise specified),illnesses with manic-hypomanic symptoms(schizoaffective disorder-bipolar subtype, bipo-lar I, bipolar II, bipolar not otherwise specified),illnesses with affective symptoms (majordepression, schizoaffective disorder, bipolar I,bipolar II, bipolar not otherwise specified,depressive disorder not otherwise specified),substance use disorders (all non-nicotine sub-stance abuse or dependence diagnoses), andany of the above. Comorbidity in psychiatric ill-ness is high, and the categories were not mutu-ally exclusive.

Data analysesThe other parents’ reports were assessed for

their ability to substitute for the direct parentinterview. This analysis produced 4 statistics:sensitivity (the percentage of ill parents correct-ly identified by the other biological parent ashaving that illness), specificity (the percentageof non-ill parents correctly identified by theother biological parent as not having that ill-ness), positive predictive value (the likelihoodthat if identified as having an illness by theother biological parent, the direct interviewidentified the same illness), and negative pre-dictive value (the likelihood that if identified asnot having an illness by the other biological par-ent, the direct interview identified the same lackof illness). For disorders of low frequency, withmeasures of low sensitivity, the likelihood of cor-rectly identifying a non-case is high, whetherone used the instrument of interest or just

assumed all non-interviewed individuals arenegative. Thus, specificity and negative predic-tive value contained little information and wereincluded only for completeness. Sensitivity andpositive predictability were generally moreinformative statistics; a low sensitivity reflectsunder-identification of illness; a low positivepredictive value reflects over-identification of ill-ness. It should be emphasized that families wereselected randomly, regardless of illness status.Hence the study is cross-sectional and represen-tative of families returning postcards from thismetropolitan area. Unlike case-control studiesexamining these illnesses, prevalence, positivepredictive values, and negative predictive valuescan be validly estimated here. To addresswhether utilizing all available psychiatric diag-nostic information improved correct identifica-tion, all father diagnostic categories wereregressed, using a step-wise logistic regressionwith P<0.05 to enter, onto ten independent vari-ables; five from mother’s report of father’s psy-chiatric illness categories - including psychosis,mania, any affective disorder, any non-nicotinesubstance use disorder, and any psychiatric dis-order - and five SCID-based maternal diagnosticcategories - including psychosis, mania, anyaffective disorder, any non-nicotine substanceuse disorder, and any psychiatric disorder. Foreach subject, the logistic regression computed aprobability level based on the subject’s predic-tors. For any given probability level the programcomputed sensitivity, specificity, positive predic-tive value, and negative predictive. For eachdiagnostic category, the probability level waschosen to be the prevalence rate of the illness inthe paternal study group.

ResultsPsychopathology based on directparent interview

To adjust for the possibility that there is non-

random mating, the impact of gender on rates ofillness was examined using binary logisticregression adjusting for family membership.Participating mothers had higher rates of a self-reported history of illness with affective symp-toms than participating fathers and a trendtoward higher rates of a self-reported illnesswith psychotic symptoms. Participating fathershad higher rates of self-reported substance useillness. Gender had no significant impact on therates of manic/hypomanic illnesses or on ratesof any psychopathology. Rates of psychopatholo-gy for each gender are summarized in Table 2.The maternal lifetime affective diagnosis rate of42% may appear high, but it is similar to whathas been reported for lifetime depression forwomen with an average age in the early 30’s.27

Parent participationOne hundred fifty-two (76%) fathers and 198

(99%) mothers participated in a structured psy-chiatric interview about their own psychiatrichistories. This includes 4 fathers (3% of the par-ticipating fathers) and two mothers (1% of theparticipating mothers) who were mono-lingualSpanish speakers. Relative to fathers who com-pleted a diagnostic interview, fathers who didnot complete a diagnostic interview (non-partic-ipating fathers) were younger (31.1±7.7 yearsvs 33.6±6.8 years, students t = 2.1, P=0.03), hada lower number of years of education (14±4 vs15±3, students t=2.2, P=0.04), had a lowerNakao and Treas socioeconomic occupationalscore (47+22 vs 57±22, student’s t=2.5,P<0.01),28 were less likely to be Caucasian Non-Hispanic/Latino (57% vs 77%, Fisher’s Exact Test= 0.01), and were less likely to be married to orliving with the biological mother (69% versus95%; Fisher’s Exact Test <0.0001). The numberof non-participating mothers (n=3) was too lowto assess for differences between participatingand non-participating mothers.

One hundred ninety mothers reported on thebiological fathers; 93% of these mothers reported

Article

Table 2. Percentage of parents with a lifetime history of illness based on a direct interviewof the subject. Information based on direct interview of the mother (for mothers’ diag-noses) and of the father (for fathers’ diagnoses).

Diagnostic category Mothers Fathers Impact of gender*P value

Number of participating subjects 198 152Percentage of families with participating parent 99 76

Any psychotic illness 4.0 0.7 0.08Any manic/hypomanic illness 6.6 3.3 0.64

Any affective illness 41.9 17.8 <0.001Any non-nicotine substance use disorder 26.3 36.2 <0.001

Any of these diagnostic categories 52.5 45.4 0.43*Presence or absence of illness in each diagnostic category was regressed, using binary logistic regression, onto gender and family. P-valuesreflect the impact of gender after adjusting for family. There was no significant effect, for any diagnostic category, for family.

[Mental Illness 2012; 4:e14] [page 69]

Article

Table 4. Sensitivity, specificity, positive predictive value and negative predictive value for the other parent’s report of mental illness categories.For example, of 148 mothers in the study, criteria for a diagnosis of a lifetime history for a psychotic illness was met based on direct interviewfor 4 mothers, based on father interview for 2 mothers, and was identified by both interviews for 1 mother; thus, using the direct interviewof the mother as the gold standard, the father’s interview about the mother had a sensitivity of 0.25, specificity of 0.99, positive predictivevalue of 0.50 and a negative predictive value of 0.98. Similarly, 53 of 147 fathers had a history of a substance use disorder based on directinterview of the father, 26 of the 147 had a substance use diagnosis history based on maternal report, and a history of a substance use diag-nosis was identified by both sources for 15 of the 147 fathers. using direct interview of the father as the gold standard, the mother’s interviewabout the father had a sensitivity of 0.28, specificity of 0.93, positive predictive value of 0.58 and negative predictive value of 0.70.

Diagnostic Subjects with Cases based Cases based on Cases with Sensitivity Specificity Positive Negativecategory both direct on direct the other parent’s agreement from Predictive Predictive

interview interview interview both Value Valueand spousal sourcesinterview

Psychotic illnessMother 148 4 2 1 0.25 0.99 0.50 0.98Father 147 1 0 0 0 1.00 0.99

Manic or hypomanic illness Mother 148 7 7 5 0.71 0.99 0.71 0.99Father 147 5 4 1 0.20 0.98 0.25 0.97

Affective illness Mother 148 56 24 18 0.32 0.94 0.75 0.70Father 147 27 19 9 0.33 0.92 0.47 0.86

Substance use disorder* Mother 148 35 9 6 0.17 0.97 0.67 0.79Father 147 53 26 15 0.28 0.93 0.58 0.70

Any of these illnessesMother 148 72 31 27 0.38 0.95 0.87 0.62Father 147 67 36 27 0.40 0.89 0.75 0.64

* Excludes nicotine use disorders.

that they had had contact with the biological fatherwithin 1 day of reporting on that father. One hun-dred forty-seven of these biological fathers alsocompleted a structured psychiatric interviewabout themselves. One hundred fifty-one biologi-cal fathers reported on the biological mother; 99%of these fathers reported that they had had contactwith the biological mother within 1 day of report-ing on that mother. One hundred forty-eight ofthese mothers also completed a structured psychi-atric interview about themselves.

Comparing psychopathology in participating vsnon-participating fathers

Rates of psychopathology, based on mater-nal report, for participating versus non-partici-

pating fathers are summarized in Table 3.Mothers reported higher rates of overall psy-chopathology for non-participating fathersthan for participating fathers. Nonpartici -pating fathers also had higher reported ratesthan participating fathers of psychiatric disor-ders, and trended towards higher rates ofaffective and substance use disorders. The lowrate of maternal non-participation providedinsufficient power to compare non-participat-ing to participating mothers.

Comparison of the other parent’sreport versus direct interviews forpsychopathology

Interview information from both the individ-ual and the other biological parent was avail-

able for one hundred forty-eight mothers andone hundred forty-seven fathers. Using thestructured interview of the individual (self-report of symptoms) as the standard, sensitiv-ity, specificity, positive predictive value andnegative predictive value are summarized inTable 4. In general, when direct interview ofthe father suggested illness, the percentage ofmothers who accurately identified that illnesswas low (sensitivities ranging from 0.00 to0.32). Similarly, when mothers identified apsychiatric illness in the biological fathers, thelikelihood that a direct interview of the fatheridentified the same illness in themselves wasalso low (positive predictive values of 0.25 to0.58, with the positive predictive value for psy-chosis undefined). When examining the moregeneral question of whether the mother couldaccurately report whether the father had any ofthe studied illnesses, sensitivity and positivepredictive values were only mildly better (0.40and 0.75 respectively). Fathers’ abilities toaccurately identify maternal illness were simi-larly poor.

For the rarer diagnostic psychosis andmania/hypomanic categories, the logisticregression provided no benefit over the accu-racy of identifying paternal illness based onmother report of diagnostic symptoms. For themore common illness categories of affectivedisorder, substance use disorders and any psy-chiatric disorder, the regression analysis sup-

Table 3. Percentage of psychopathological illness for participating and non-participatingfathers as reported by the mothers.

Diagnostic category Participating Non-participating Fishers Exact Test P value

Psychotic illness 0.0 4.7 0.05Manic or hypomanic illness 2.7 7.0 0.19

Affective illness 12.9 25.6 0.06Substance use disorder* 14.3 27.9 0.07

Any of these illnesses 23.8 39.5 0.05Sample includes 190 fathers; 147 of whom participated in a structured diagnostic interview and 43 of whom did not. *Excludes nicotine use disorders.

ported a model using two or more pieces ofdiagnostic information (Table 5). For thesethree diagnostic categories, adding maternaldiagnostic information improved sensitivityfor paternal illness with effects on positive pre-dictive value either minimal or positive.Interestingly, the best predictor of paternalsubstance use disorder was knowing whethermother had a history of any psychopathology,although her report of paternal substance usehistory was also included in the final model.

Discussion

In this study of families, maternal participa-tion in a structured diagnostic interview ishigh (99%). The results are different forfathers. The percentage of cases where thebiological father is either unknown or unavail-able is low (around 4%) and yet 25% of biolog-ical fathers did not participate, despite repeat-ed recruitment efforts across a time periodextending up to 18 months after an infant’sbirth. The issue of under-participation offathers in research protocols is an ongoingproblem,2,3,29 and the rate of paternal participa-tion found here is similar to other reports.1Maternal reports of paternal psychopathologywere much higher in fathers who did not par-ticipate in the study relative to fathers who didparticipate, particularly in rates of illicit sub-stance use and psychotic disorders. Many psy-chopathological illnesses are associated withsymptoms which might reduce participation,including low motivation in depressive andpsychotic illnesses, paranoid thinking in psy-chotic illness, or impaired cognition and orga-nizational skills that are often concurrent withpsychosis, altered mood, or acute intoxication.It is also possible that father nonparticipationis reflective of a less positive maternal-pater-nal relationship that influences mothers to bemore likely to report psychiatric symptoms.This study was not designed to differentiatebetween these possibilities. However, if the

maternal report of increased psychopathologyin non-participating fathers reflects trueincreases in psychopathology, this raises con-cerns that studies which limit themselves tofamilies with two participating parents mayhave under-representation of husband/fatherpsychiatric illness and are therefore at risk foroverestimating the role of wife/mother relativeto husband/father psychiatric illness.

One method to increase accuracy of paternalpsychiatric diagnosis would be to increasefather participation. In this study, extendingthe recruitment efforts out to 18 months andallowing for scheduling for several monthsafter that increased father participation rates.For a 6 month period, from when their child is6 weeks to when their child is 7½ months ofage, the likelihood of father involvement in astructured interview increased by 1% approxi-mately every 4 days. After that time point,recruitment slowed, but continued at a steadyrate. For the next 14 months, up to when thechild was approximately 22 months of age, thelikelihood of father participation increased by1% approximately every two weeks. After 22months of age, only 4 additional fathers partic-ipated; however, there were no active recruit-ment efforts after the child’s 18-month visit. Itis unclear if additional extension of recruit-ment efforts would further increase paternalparticipation rates. Extending the duration ofrecruitment efforts seems most appropriatewhen looking for a lifetime history of psy-chopathology. Extending the duration ofrecruitment efforts may be less useful whenresearching questions related to an acuteexposure, such as a child’s environmentalexposure to a father’s psychiatric illness at aspecific stage of development. Given the rapid-ity at which fetuses and young infants develop,the window to assess fathers may be relativelyshort, perhaps during a specific trimester dur-ing pregnancy or during the first few weeksafter birth. However, to our knowledge, accura-cy of father recall of psychiatric illness over a2- to 3-year time frame has never been studied.If reasonable recall can be demonstrated, more

extended data collection periods may also beappropriate for developmentally-specific expo-sure. As an alternative to increasing fatherrecruitment, this study examined the accuracyof maternal report of paternal psychiatric ill-ness as a proxy for direct evaluation of thefather. For symptom categories with at least10 affected individuals, the other parents’reports had low sensitivities (0.17-0.33),despite the broad diagnostic categories uti-lized. The any psychopathology category,reflective of general recognition of psy-chopathology, demonstrated slightly better, butstill low utility sensitivities of 0.38-0.40. Inaddition, maternal report of paternal psy-chopathology had low positive predictive val-ues for any specific illness grouping, rangingfrom 0.24-0.58 (with psychosis positive predic-tive value undefined). The positive predictivevalue of 0.75 for any psychopathology was mod-erately better, although still low enough toraise concerns. In short, maternal report ofbroad symptom-based paternal psychopatholo-gy is of low utility at compensating for lowpaternal participation.

In an attempt to increase the accuracy ofpaternal diagnosis based on informationobtainable from the mother, logistic regres-sions were completed utilizing all resultsbased on mother interview, including reportsof self and the other biological parent. Formore common paternal psychiatric illness cat-egories, including information about mother’spsychiatric status improved the accuracy ofpaternal diagnosis. Possible contributors tothis finding include non-random mating (e.g.mothers with a history of psychiatric illnessare more likely than mothers without such ahistory to become involved with a father with ahistory of a substance use disorder), secondaryeffects (e.g. fathers with a history of a sub-stance use disorder increase psychopathologyin the other biological parent), or view pointdifferences (e.g. mothers with a history ofaffective illness are more aware of their part-ners’ affective illness than mothers withoutsuch a history).

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Article

Table 5. Best predictors and sensitivity, specificity, positive predictive value and negative predictive value for father mental illness categories;sample includes 147 fathers father-mother dyads.

Paternal diagnosis Best model* Sensitivity Specificity Positive predictive value Negative predictive val

Psychotic illness NoneManic or hypomanic illness Father mania 0.20 0.98 0.25 0.97

Affective illness Father affective 0.50 0.85 0.42 0.89Mother sub use Mother affective

Substance use disorder° Mother any 0.78 0.65 0.54 0.85Father sub use

Any of these illnesses Father any 0.62 0.84 0.76 0.73Mother sub use

*Father diagnoses are based on maternal report; maternal diagnoses are based on a structured diagnostic interview of the mother. Sub use = a history of any non-nicotine substance use disorder. Mania = historyof mania or hypomania; sub use = history of a substance use disorder; any equals a history of psychotic, affective, or substance use psychiatric illness. °Excludes nicotine use disorders.

[Mental Illness 2012; 4:e14] [page 71]

Article

Adding information about maternal historyof substance use disorder improved both sensi-tivity and positive predictive value for paternalsubstance use disorders. While the overallaccuracy of identifying paternal psychopathol-ogy remained modest, these results suggestthat, with additional research, alternativemore accurate methods to infer paternal psy-chopathology may be possible.

Other methodologies for clarifying paternalpsychopathology have been attempted. Gavinand colleagues attempted to visit the father inthe father’s home.30 However, at least with low-income adolescent fathers, this approach wasrelatively ineffective achieving only 60% pater-nal participation. Caspi and colleagues notedthat absolute levels of maternally-reportedpaternal antisocial behavior are markedlylower than paternal self-report;31 thus mater-nal report was a poor direct proxy for paternalantisocial personality disorder diagnosis.However, maternal report was correlated withpaternal self-report, suggesting that if thescale was recalibrated, maternal report mightprovide a reasonable proxy. The low positivepredictive values of maternal report in the cur-rent study suggests that this approach may notbe equally valuable for other forms of psy-chopathology; however, the current study doessuggest that additional indirect information,including psychiatric information about theinformant, may improve accuracy of paternaldiagnosis. A combination of these efforts orinvolvement of additional family memberssuch as grandparents may be necessary to gainreasonable insight into non-participating hus-band/father psychopathology.30

Results on the ability of mothers to identifypaternal psychopathology are based on thosefamilies where fathers participated. Fathernon-participation may be reflective of lessmaternal-paternal interaction, and the lowaccuracy of maternal report may be even lowerthan reported here. A notable limitation of thisstudy is the focus on lifetime diagnoses (e.g. ahistory of psychopathology at any time duringan individual’s life). Lifetime diagnoses areappropriate when considering genetic contri-butions to illness but may have less applicabil-ity when focusing on environmental effects. Itis possible that there may be greater agree-ment between sources when specific symp-toms (e.g. sleep impairment or depressedmood) are considered; however, given the dif-ficulty at using symptom count to define sever-ity of psychiatric illnesses, it is unclearwhether greater agreement at the symptomlevel would provide information relevant tolong-term outcome of either the family or thechild. The moderate sample size did not permitappropriate validation of the predictors chosenby the step-wise logistic regression analyses.In addition, the moderate sample size limitedthe accuracy of estimated frequency of illness,

particularly for low frequency illness cate-gories like schizophrenia and mania. For thesample size utilized here, results for higherfrequency illness categories like affective dis-orders and substance use disorders may bemore reliable.

Husbands and fathers play a major role inthe health of a family, including both the sta-bility of a marriage and the quality of childdevelopment. Yet, fathers under participate inresearch studies. One methodological optionwould be to substitute maternal report of psy-chopathology for direct interview of the father.This is the first report, using a broad array ofdiagnoses in a population based sample, toassess this possibility. In this study, mothersreported that the biological fathers who did notparticipate in a diagnostic interview had high-er rates of psychopathology. However, giventhe low accuracy of the report, it is unclearwhether the non-participating fathers trulyhad higher levels of psychopathology orwhether this difference was a proxy for anoth-er issue, such as generally lower involvementin family activities. Either way, research proj-ects which limit enrollment to families wherefathers agree to participate are selecting forhealthier fathers and/or healthier relation-ships and may underestimate the impact ofhusband/father psychopathology. Mother directreport of father psychopathology is not aneffective proxy for direct paternal interview.Using a broader array of information, includ-ing psychiatric information about the femaleinformant, improved accuracy; however, bene-fits were modest. Alternative methods toincrease paternal involvement and/or identifyproxies for psychopathology will need to bedeveloped if we are to fully understand pater-nal impact on infant development.

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