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Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 37-41

Child–Parent agreement on quality of life of overweight children: Discrepancies between raters

Department of Rehabilitation Sciences, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong

Date of Web Publication29-Oct-2018

Correspondence Address:
Mr. Xavier CC Fung
Department of Rehabilitation Sciences, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SHB.SHB_35_18

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Introduction: Kid-KINDL, a health-related quality of life (HRQoL) instrument for children, contains paralleled child-reported and parent–proxy versions. However, parents may rate HRQoL differently from children do; thus, health-care providers may be misled by the parent-rated HRQoL to assess the health of children. Thus, understanding the agreement between parent- and child-rated HRQoL is important. This study aimed to investigate the agreement between child- and parent-rated Kid-KINDL, including total score and domain (physical, emotional, self-esteem, friend, family, and school) scores. Methods: A total of 96 dyads of 8 to 12-year-old overweight children were recruited. Child-reported and parent–proxy Kid-KINDL were completed by children and parents (70.8% mother; 19.8% father), respectively. Statistical significance of child–parent discrepancies was analyzed using paired t-test and magnitude of discrepancies was analyzed using Cohen's d. Regression analyses were used to examine the potential predictors (age, gender, body mass index, family income, and raters) on score differences. Results: Significant differences were found in total score (d = −0.26) and three subscales (emotional, d = 0.21; self-esteem, d = −0.33; and school, d = −0.56) with small-to-medium magnitudes. Regression analyses revealed that father as rater significantly explained the score differences in total (standard coefficient β = −0.266, P = 0.013), emotional (β = −0.224,P = 0.038), and school (β = −0.215, P = 0.045). Conclusion: Parents seemed to be optimistic when rating on their overweight children's HRQoL. Health-care providers should be aware of this issue when using parent-reported Kid-KINDL and do not miss out any risk on children's HRQoL. Furthermore, the results may suggest health-care providers improving child–parent interaction. They can not only align parent with child, but also align with every caregiver.

Keywords: Agreement, children, health-related quality of life, overweight, parent

How to cite this article:
Fung XC. Child–Parent agreement on quality of life of overweight children: Discrepancies between raters. Soc Health Behav 2018;1:37-41

How to cite this URL:
Fung XC. Child–Parent agreement on quality of life of overweight children: Discrepancies between raters. Soc Health Behav [serial online] 2018 [cited 2023 Oct 4];1:37-41. Available from:

  Introduction Top

As the prevalence of overweight (or obesity) is rising in the last decade, the public concern also applies to children worldwide.[1],[2] Previous studies had shown that overweight and obesity can lead to negative health conditions, including physical and psychosocial aspects.[2],[3],[4] Therefore, health-care providers are in need to understand overweight children's health conditions, for example, by assessing health-related quality of life (HRQoL), and hence, to provide suitable services to maintain children's well-being.

To understand the subjective health and well-being of overweight children, several HRQoL instruments can be used, for example, Kid-KINDL, Pediatric Quality of Life Inventory (PedsQL™), Sizing Me Up©, and Sizing Them Up©.[5],[6],[7] These instruments have both child-reported and parent–proxy versions. Yet, when both versions are used, the issue of parent–child disagreement may occur.[7],[8],[9] The inconsistency between child-reported and parent–proxy HRQoL may imply how parents misunderstood their children's health condition and unaware of difficulties that children face. For instance, Lin et al.[9] found that when comparing the score of PedsQL, obese children reported lower scores on physical, emotional, and social domain than their parents did in Taiwan. Parents of obese children in Taiwan seemed optimistic about their children's HRQoL. However, in Iran, Jafari et al.[8] found that parents reported lower scores than their obese children on all of the domains of PedsQL, i.e., physical, emotional, social, and school. That is, there might be differences on parent–child agreement across cultures.[8] Moreover, many of the parent–child agreement studies were using PedsQL;[10] using other instruments might provide more insights to this topic. Recently, Kid-KINDL was suggested to be used to compare HRQoL between child-reported and parent–proxy versions.[5] It consists of six domains, including physical well-being, emotional well-being, self-esteem, relationship with friends, relationship with family, and school performance.

Understanding factors that contribute to parent–child agreement may help to improve parent perception on their children and provide suitable caring. Previous literature had identified that age, gender, and body mass index (BMI) could be account for the parent–child agreement.[7],[8] However, relationship between family income and parent–child agreement was unclear.[7] On the other hand, Upton et al.[10] raised a potential factor which may also contribute to parent–child agreement, i.e., proxy rater: mother and father may hold different perception on their children, and hence affect the proxy rating.[10]

Therefore, the current study aimed to use Kid-KINDL to assess parent–child agreement on overweight/obese children in Hong Kong. Subscale score differences and item score differences were analyzed. Several regression analyses were additionally performed to identify factors related to the agreement.

  Methods Top


Participants were 8 to 12-year-old overweight/obese children and one of their parents (96 dyads completed and returned the questionnaires). Specifically, 72.2% of the proxy raters were mothers, 19.1% were fathers, and 8.7% were others such as grandparents [Table 1]. Of the 69.8% family, their monthly income were below $25,000 Hong Kong dollar.[11] Moreover, weight status of each child was classified by the BMI [cf. So et al.; [Table 2].[12]
Table 1: Demographic information

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Table 2: Body mass index cutoffs for classifying overweight/obese children

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Kid-KINDL is a 24-item instrument for assessing HRQoL, which provides paralleled child-reported and parent–proxy versions. The Chinese version of both child-reported and parent–proxy Kid-KINDL was used in this study, which has been validated with promising psychometric properties.[13] Kid-KINDL consists of six subscales, which assess children's physical well-being, emotional well-being, self-esteem, relationship with friends, relationship with family, and school performance. Using a 5-point Likert scale ranging from 1 (never) to 5 (all the time), the total and subscale scores were linearly transformed into a 0–100 scale. In addition, a higher score indicates a better HRQoL.[14]

In addition to the Kid-KINDL, a background information sheet was used to collect demographic information of participants, including age, height, weight, family income, and the proxy rater.


Before data collection, the study was approved by the Human Subjects Ethic Review Board of the Hong Kong Polytechnic University. Then, questionnaires were distributed in primary schools in Hong Kong for children to complete child-reported Kid-KINDL in class, and children took questionnaires back home for their parents/caregivers to complete the background information and parent–proxy Kid-KINDL. Both parents and children signed a written inform consent. Afterward, questionnaires were returned by children when they came to school.

Statistical analysis

Child–parent discrepancies in subscale and item scores were analyzed using paired t-test. Cohen's d ([child-reported score] − [parent-reported score]/[standard deviation of child-reported score]) was used to report the magnitude of discrepancies. When d >0.2, it indicated that children rated higher than their parents did; when d<− 0.2, it indicated that children rated lower than their parents did.[7],[9] Furthermore, regression analyses were constructed to examine the potential predictors (i.e., age, gender, BMI, family income, and proxy rater) on significant score differences shown by paired t-tests. As for the proxy rater, they were coded using mother rater as the reference group.

  Results Top

Differences on domain and item scores

Significant differences were found in total score (d = −0.26) and three subscale scores [emotional, d = 0.21; self-esteem, d = −0.33; and school, d = −0.56; [Table 3]. At the item level, parents reported lower rating than their children for two items on emotional (E2, d = 0.42; E4, d = 0.23) and one item on friends (Fr1, d = 0.45). Parents reported higher rating than their children for one item on physical (P4, d = −0.41), three items on self-esteem (Se1, d = −0.38; Se2, d = −0.29; Se3, d = −0.25), one item on family (Fa4, d = −0.31), two items on friends (Fr2, d = −0.23; Fr4, d = −0.33), and two items on school [Sc3, d = −0.54; Sc4, d = −0.58; [Table 4].
Table 3: Comparisons between child- and parent-reported Kid-KINDL subscale scores for overweight children

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Table 4: Comparisons between child- and parent-reported Kid-KINDL item scores for overweight children

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Regression analysis on domain and item score differences

Based on the above results, regression analyses were conducted for differences on total, emotional, self-esteem, and school domains. The analyses revealed that father as rater (compared to mother rater) significantly explained the score differences on total (standard coefficient β = −0.266, P = 0.013), emotional (β = −0.224, P = 0.038), school (β = −0.215, P = 0.045), and marginally significant on score differences on self-esteem [β = −0.207, P = 0.058; [Table 5].
Table 5: Regression analysis on subscale score difference between parents and overweight children

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For item score differences, BMI significantly explained differences on P4 (β = 0.260, P = 0.018) and Fr2 (β = −0.263, P = 0.015). Gender significantly explained differences on Fr4 (β = −0.238, P = 0.028), Sc4 (β = −0.214, P = 0.047), and marginally significant on Sc3 (β = −0.183, P = 0.089). Father as rater was marginally significant on Se1 (β = −0.191, P = 0.078), Se2 (β = −0.194, P = 0.073), and Sc3 (β = −0.204, P = 0.055). Age was marginally significant on Sc4 [β = −0.204, P = 0.060; [Table 6].
Table 6: Regression analysis on item score difference between parents and overweight children

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  Discussion Top

The results revealed that parents scored higher on their children's self-esteem, school, and overall HRQoL, while scored lower on emotional domain. In other words, parents seemed to be unaware of their children's health issues, especially on psychosocial aspects such as self-esteem and school performance. Results of this study were in line with a review article, which suggested that parents of healthy children (i.e., nonclinical sample) usually have higher rating on their children's HRQoL.[10] Specifically, there is a self-esteem domain in Kid-KNIDL, whereas PedsQL does not have, and significant parent–child differences in this domain were found. These results were not consistent with those of another Asian study on overweight/obese children,[9] for example, there was no significant difference on physical, family, and friends' domains in this study, but Lin et al.[9] did found significant differences on physical and social aspects. The different measurement methods used between studies (PedsQL vs. Kid-KINDL) may somewhat explain the different findings. Yet, cultural differences may be another possible explanation, as previous literature indicates that parent–child discrepancies vary from one place to another.[8]

Interestingly, father as proxy rater was the only predictor of all the parent–child differences at domain level. The differences between fathers and children were smaller when compared to that of mothers and children. When I look into the items, father as rater might be a factor to predict differences on self-esteem and school performance, i.e., “I was proud of myself,” “I felt on top of the world,” and “I worried about my future.” Hay et al.[15] had revealed that fathers and mothers used different approaches to evaluate their children, for example, father's rating was related to the cognitive ability of children. More importantly, the rating from father, instead of mother, can be the predictor of children's problems in their later life.[15] Applying to this situation, fathers may use children's cognitive ability to estimate whether children were proud of themselves or worried about future because these are related to ability and performance. Furthermore, a recent study on clinical samples showed that mother tended to overestimate the psychological distress of their children, while there was no significant difference on father–child agreement.[16] The current study provides further support on the point of view that fathers may report better estimation on their children's health condition than mothers did.

Only one physical item had significant difference that parents scored higher on their children's energy than children's own rating, and BMI positively predicted this disagreement. Overweight children may have negative perception on their physical ability as their BMI increases.[17],[18] BMI also predicted parent–child discrepancy about friends (Fr2: Other kids liked me). As BMI was associated with social distance,[19] it might be observed by their parents. Thus, parents might indirectly know children's friendship. Gender was the predictor of Fr4 (I felt different from other children), Sc3 (I worried about my future), and Sc4 (I worried about bad marks or grades). The discrepancies between parents and boys were lower when compared to that of parents and girls, which is consistent with a previous study.[20] However, family income was not a significant factor among all domain or item differences, which was inconsistent with other findings.[7],[16] More evidences are needed to understand the relationship between family income and parent–child agreement.

There are some limitations in this study. First, the sample was relatively small (96 dyads) and collected using convenience sampling method, which may affect the statistical significance, and cannot be the representative sample in Hong Kong. Second, this study did not compare overweight/obese children with normal weight children. Hence, no information about parent–child agreement of normal weight children in Hong Kong could be provided in this study. Last, cross-sectional design was used in this study, and no causal relationships could be identified.

  Conclusion Top

This study found out the parent–child disagreement on HRQoL of overweight/obese children in Hong Kong, with the use of Kid-KINDL. Moreover, fathers and mothers rated their children's HRQoL differently. Health-care providers should be aware of this issue in the future assessment. Future studies should include more participants with diverse samples to investigate this topic in detail.


I sincerely thank all the participants, including the children and parents. I also thank the assistance from the following organizations: Buddhist Wong Cheuk Um Primary School, Hong Kong Playground Association, and HKTA Wun Tsuen Ng Lai Wo Memorial School.

Financial support and sponsorship

This research was supported in part by (received funding from) the startup fund in the Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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