CARATkids Validated for Asthma, Allergic Rhinitis in Children

A study supported CARATkids as a suitable tool for assessing asthma and allergic rhinitis simultaneously in children aged 6 – 12 years who have both conditions.1

“We found CARATkids to display good content validity, internal consistency, reliability, construct validity, and responsiveness,” wrote study investigator Hadla Sami El Didi, BEng, from the University of Porto in Portugal, and colleagues.1

CARATkids, standing for the Control of Allergic Rhinitis and Asthma Test for Children, is the first patient-reported outcome measure designed to assess allergic rhinitis and asthma simultaneously in children.

A panel of 26 specialists in asthma and allergic rhinitis originally developed the test in Portuguese for adults.2 Two consensus meetings, following COSMIN guidelines, rated CARAT’s development as “inadequate” because children and caregivers were not involved before the cognitive interview stage. Other patient-reported outcome measures for childhood asthma have also reported inadequate development. However, since these ratings applied to the adult version of CARAT, investigators considered them not to affect its suitability for clinical use.1

Research teams have already validated the test in several languages and countries, including Brazil, Turkey, Italy, and the Netherlands. Yet, despite all the validations, investigators recognized the need for a review of the test’s psychometric properties.1

The team conducted a systematic review of 3 databases—Ovid/MEDLINE, Web of Science, and Scopus—to assess the measurement properties of CARATkids, following PRISMA and COSMIN guidelines. Studies included (n = 9) focused on the development, cultural adaptation, or validation of CARATkids, as well as studies comparing CARATkids with other patient-reported outcome measures. The sample’s mean ages ranged from 8 to 9.34 years; most studies were conducted in Portugal (n = 4), with others conducted in Italy (n = 2), the Netherlands (n = 1), Brazil (n = 1), and Turkey (n = 1).1

In this study, investigators evaluated the quality of CARATkids development, the methodological quality of primary studies, the overall rating, and the certainty of evidence for each measurement property. The team also performed a meta-analysis of CARATkids’ measurement properties.

In the meta-analysis, CARATkids demonstrated sufficient content validity, though the certainty of evidence was low. Internal consistency was rated as “indeterminate,” with a meta-analytical Cronbach alpha of 0.81 (95% confidence interval [CI], 0.79 – 0.83) (low certainty). CARATkids also exhibited sufficient reliability, with a meta-analytical intraclass correlation coefficient of 0.86 (95% CI, 0.61 – 0.96); again, certainty of evidence was low.1

The study determined that the minimal clinically important difference (MCID) for CARATkids is 2.76. Investigators found sufficient evidence for construct validity, with absolute meta-analytical Spearman coefficients from 0.37 to 0.71 (certainty of evidence ranged from low to high). CARATkids had strong correlations with most instruments, including VAS global, VAS asthma, cACT, and TNSS; the EQ-5DY and VAS nose did not have strong correlations with CARATkids.1

Investigators also found sufficient responsiveness with VAS nose, VAS global, and AcT. The instruments of VAS asthma and TNSS had inconsistent responsiveness. CARATkids showed high responsiveness, although the only exception was its correlation with VAS asthma, which was weaker at 0.49 (95% CI, 0.36–0.61), indicating that CARATkids was less aligned with changes captured by this measure.1

Investigators noted several limitations, including the absence of gold standard assessment control for allergic and asthma control, the reduction of heterogeneity in leave-one-out sensitivity analysis, the small number of included primary studies, and insufficient evidence on the quality of other patient-reported outcome measures.

“…this is the first systematic review with meta-analysis to evaluate and summarize the measurement properties of a pediatric PROM designed for assessing the control of allergic rhinitis and asthma simultaneously,” investigators concluded.1 “The findings indicate that CARATkids presents good content validity. Strong internal consistency and good reliability were also observed, albeit with low certainty of evidence… Overall, these findings support the suitability of CARATkids for the assessment of asthma and allergic rhinitis in children from 6 to 12 years who present both diseases simultaneously. Future studies may aim to further validate the content and structural validity of CARATkids.”

References

1. El Didi HS, Pereira AM, Jácome C, et al. Control of Allergic Rhinitis and Asthma Test for Children (CARATkids): A systematic review and meta-analysis of its measurement properties. Pediatr Allergy Immunol. 2025;36(9):e70191. doi:10.1111/pai.70191

2. Vieira RJ, Sousa-Pinto B, Cardoso-Fernandes A, et al. Control of Allergic Rhinitis and Asthma Test: A systematic review of measurement properties and COSMIN analysis. Clin Transl Allergy. 2022;12(9):e12194. doi:10.1002/clt2.12194