Reliability of the strengths and difficulties questionnaire among Finnish 4-9-year-old children

Pourcain B, Robinson EB, Bourgeron T, Baron-Cohen S, Børglum AD, Martin HC, Warrier V. An axis of genetic heterogeneity in autism is indexed by age at diagnosis and is associated with varying developmental and mental health profiles

There is growing recognition that earliest signs of autism need not clearly manifest in the first three years of life. To what extent is this variation in developmental trajectories associated with age at autism diagnosis? Does the genetic profile of autism vary with age at autism diagnosis? Using longitudinal data from four birth cohorts, we demonstrate that two different trajectories of socio-emotional behaviours are associated with age at diagnosis. We further demonstrate that the age at autism diagnosis is partly heritable (h2 SNP = 0.12, s.e.m = 0.01), and is associated with two moderately correlated (rg = 0.38, s.e.m = 0.07) autism polygenic factors. One of these factors is associated with earlier diagnosis of autism, lower social and communication abilities in early childhood. The second factor is associated with later autism diagnosis, increased socio-emotional difficulties in adolescence, and has moderate to high positive genetic correlations with Attention-Deficit/Hyperactivity Disorder, mental health conditions, and trauma. Overall, our research identifies an axis of heterogeneity in autism, indexed by age at diagnosis, which partly explains heterogeneity in autism and the profiles of co-occurring neurodevelopmental and mental health profiles. Our findings have important implications for how we conceptualise autism and provide one model to explain some of the diversity within autism.

Psychometric properties of the Norwegian version of the Strength and Difficulties Questionnaire in a preschool sample

PURPOSE

The Strength and Difficulties Questionnaire (SDQ) is widely used internationally, however less so in preschool populations and validations studies are thus needed. This study examined the psychometric properties of the Norwegian version parent report of the SDQ - preschool version (SDQ 2-4).

MATERIALS AND METHODS

Parents of 289 Norwegian children in the age span 1-6 years old filled out the SDQ 2-4, the Child Behavior Checklist (CBCL), and background information. Internal consistency, factor structure, and convergent validity were assessed.

RESULTS

The results showed satisfying internal consistency for the total difficulties score, but worse for some of the subscales. The five-factor structure showed a good fit. Good convergent and divergent validity was found in terms of correlations with CBCL. Sex differences were found on all scales, boys scoring higher on all problem scales.

CONCLUSIONS

The SDQ 2-4 can be a promising instrument to screen for emotional and behavioral difficulties among Norwegian preschoolers, particularly in high-risk populations.

The assessment of preschool children with ESSENCE symptoms: concordance between parents, preschool teachers and child psychologists

BACKGROUND

It is important to detect children with Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations (ESSENCE) in order to implement early intervention and support for the child and family. Standardized instruments for assessment in different contexts of behaviour problems, engagement and psychosocial health obtain an objective picture of the preschool child's mental health.

AIM

To explore and compare parents', preschool teachers' and child health care psychologists' assessment of behaviour, everyday function, engagement, social interaction and psychosocial health in children with ESSENCE symptoms.

METHOD

Parents of 152 children (114 boys and 38 girls, 4.5 ± 1 years) with ESSENCE symptoms, 155 preschool teachers and 8 child psychologists participated. Parents and preschool teachers assessed externalizing and internalizing behavioural problems using the Strengths and Difficulties Questionnaire (SDQ), including the SDQ supplement for assessing the impact of behavioral problems on daily function. Preschool teachers also assessed engagement and social interaction using the Children's Engagement Questionnaire (CEQ), and the child psychologists assessed psychosocial health with the Child Psychosocial Health Assessment (LillaLAPS) and template in conversations with parents of children with neurodevelopmental problems.

RESULTS

Parents', preschool teachers' and child psychologists' assessment of the child's ESSENCE symptoms overall agreed. Both parents and preschool teachers see a strength in the child's social abilities. Differences in mean values show that parents assess more conduct, emotional symptoms and problems in daily life and more social skills, compared to the preschool teachers rating more peer problems.

CONCLUSION

It is important to consider different contexts to identify the child's need for support in everyday life. Expanded use of validated screening instruments in clinical practice would promote detection of children not already identified as exhibiting neurodevelopmental problems.

Screening Children in India: Translation and Psychometric Evaluation of the Parents' Evaluation of Developmental Status and the Strength and Difficulties Questionnaire

Timely screening and surveillance of children for developmental delay and social-emotional learning difficulties are essential in Low- and Middle-Income Countries like India. Screening measures like the Parents' Evaluation of Developmental Status (PEDS) and Strength and Difficulties Questionnaire (SDQ) are considered suitable for India due to their low cost, easy accessibility, and no training requirement for administration. However, India lacks validated screening measures, and the PEDS and SDQ have yet to be validated for children in India. The study aimed to translate the PEDS and SDQ from English to Hindi and psychometrically evaluate the same measures on children aged 4-8 years in India. The original PEDS and SDQ forms and their translations were pilot tested on 55 participants and evaluated using data from 407 children with typical development (TD) and 59 children with developmental disability (DD). Parents and teachers reported no meaningful discrepancy between the original and translated (Hindi) questionnaires. Internal consistency for the PEDS was acceptable, but unacceptable for most subscales on the SDQ, for both TD and DD samples. Test-retest reliability was poor for the PEDS but adequate for the SDQ. Results from known-group validity testing showed that the PEDS scores could be used to distinguish between the TD and DD samples. The results from this study provide further support for the use of the PEDS and SDQ in developing countries like India.

The role of dieting, happiness with appearance, self-esteem, and bullying in the relationship between mental health and body-mass index among UK adolescents: a longitudinal analysis of the Millennium Cohort Study

Background

Mental illness and obesity are among the biggest challenges to population health, they are linked, and may be modifiable during adolescence. We aimed to determine intervening pathways between mental health and BMI z-score symptoms across adolescence.

Methods

In this longitudinal cohort study, we used path models to examine self-reported dieting, happiness with appearance, self-esteem and bullying at 14 years as potential mediators of the cross-lagged relationship between mental health (via the Strengths and Difficulties Questionnaire) and Body Mass Index (BMI) z-score at 11 and 17 years by sex in the UK Millennium Cohort Study, a prospective cohort study of 18,818 children born in the UK between September 1st, 2000, and January 31st, 2002. Full, incomplete data on all singleton children still participating in the study by age 11 years were analysed in GSEM via maximum likelihood estimation (N = 12,450).

Findings

We found happiness with appearance and self-esteem, but not dieting or bullying, mediated the relationship between BMI age 11 and mental health age 17. Each increase in BMI z-score at 11 years was associated with 0.12 increase for boys and a 0.19 increase for girls in scores of unhappiness with appearance (boys: b 0.12, 95% C.I.; girls b 0.19, C.I. 0.14 to 0.23) and a 16% increase for boys and a 22% increase for girls in odds of low self-esteem (boys OR 1.16, 95% C.I. 1.07 to 1.26; girls: OR 1.22, 95% C.I. 1.15 to 1.30) at 14 years. In turn, for both boys and girls, being unhappy with appearance and low self-esteem at 14 years were associated with a greater likelihood of emotional and externalizing symptoms at 17 years.

Interpretation

Early prevention strategies to encourage healthy physical and mental development of children need to focus on the promotion of positive body-mage and self-esteem.

Funding

The National Institute for Health and Care Research (NIHR) School for Public Health Research (SPHR).

Parental Recreational Screen Media Practices and Behavioral Difficulties Among Danish 7-Year-Old Children

OBJECTIVE

This study aimed to investigate the association of parental recreational screen media practices, including time use and level of smartphone addiction, with behavioral difficulties in 7-year-old children.

METHODS

The study was based on cross-sectional data from the Odense Child Cohort, a community-based birth-cohort study. A total of 1152 parent-child dyads with complete data were included based on data from the 7-year examination conducted in 2018-21. Parental recreational screen use was self-reported as hours/day using the SCREENS-questionnaire, and their smartphone addiction was self-reported using the Smartphone Addiction Scale Short Version. Child behavioral difficulties were assessed by the parent-reported version of the Strengths and Difficulties Questionnaire (SDQ).

RESULTS

Parental recreational screen time was not consistently associated with behavioral difficulty SDQ subscales and total difficulty scores when adjusted for other determinants of child mental well-being such as sociodemographic factors, parental well-being, and number of siblings. Children had higher total behavioral difficulty scores (adjusted mean difference 2.12 (95% CI, 1.19-3.05)) when comparing fourth quartile versus first quartile of maternal smartphone addiction score. Also, higher maternal smartphone addiction scores were associated with more externalizing and internalizing behavioral problems of their child (adjusted mean difference 1.61 points (95% CI, 0.95-2.27), and 0.81 points (95% CI, 0.19-1.43)) for fourth quartile versus first quartile, respectively.

CONCLUSIONS

No cross-sectional association was found between total parental recreational screen use and behavioral difficulties in their 7-year-old children, but an association between maternal obsessive smartphone use and behavioral difficulties of their children was found.

Effectiveness of an Internet-Based and Telephone-Assisted Training for Parents of 4-Year-Old Children With Disruptive Behavior: Implementation Research

Background

There is a lack of effectiveness studies when digital parent training programs are implemented in real-world practice. The efficacy of the internet-based and telephone-assisted Finnish Strongest Families Smart Website (SFSW) parent training intervention on the disruptive behavior of 4-year-old children was studied in a randomized controlled trial setting in Southwest Finland between 2011 and 2013. After that, the intervention was implemented nationwide in child health clinics from 2015 onwards.

Objective

The main aim of this study was to compare the treatment characteristics and effectiveness of the SFSW parent training intervention between the families who received the intervention when it was implemented as a normal practice in child health clinics and the families who received the same intervention during the randomized controlled trial.

Methods

The implementation group comprised 600 families who were recruited in the SFSW intervention between January 2015 and May 2017 in real-world implementation. The RCT intervention group comprised 232 families who were recruited between October 2011 and November 2013. The same demographic and child and parent measures were collected from both study groups and were compared using linear mixed-effect models for repeated measurements. The child psychopathology and functioning level were measured using the Child Behavior Checklist (CBCL) version 1.5-5 for preschool children, the Inventory of Callous-Unemotional Traits (ICU), and a modified version of the Barkley Home Situations Questionnaire. Parenting skills were measured using the 31-item Parenting Scale and the shorter 21-item Depression, Anxiety and Stress Scale (DASS-21). The estimated child and parent outcomes were adjusted for CBCL externalizing scores at baseline, maternal education, duration of the behavior problems, and paternal age. The baseline measurements of each outcome were used as covariates.

Results

The implementation group was more likely to complete the intervention than the RCT intervention group (514/600, 85.7% vs 176/232, 75.9%, respectively; P<.001). There were no significant differences between the implementation and RCT intervention groups with regard to child measures, including CBCL externalizing score (–0.2, 95% CI –1.3 to 1.6; P=.83), total score (–0.7, 95% CI –3.0 to 4.5; P=.70), internalizing score (–0.3, 95% CI –1.0 to 1.6; P=.64), and ICU total score (–0.4, 95% Cl –1.9 to 1.2; P=.64). No significant difference was detected in the Parenting Scale total score (0.0, 95% Cl –0.1 to 0.1; P=.50), while DASS-21 total score differed nearly significantly (2.5, 95% Cl 0.0-5.1; P=.05), indicating better improvement in the implementation group.

Conclusions

The internet-based and telephone-assisted SFSW parent training intervention was effectively implemented in real-world settings. These findings have implications for addressing the unmet needs of children with disruptive behavior problems. Our initiative could also provide a quick socially distanced solution for the considerable mental health impact of the COVID-19 pandemic.

Trial Registration

ClinicalTrials.gov NCT01750996; https://clinicaltrials.gov/ct2/show/NCT01750996

International Registered Report Identifier (IRRID)

RR2-10.1186/1471-2458-13-985

A Systematic Review of Some Reliability and Validity Issues regarding the Strengths and Difficulties Questionnaire Focusing on Its Use in Out-of-Home Care

PURPOSE

A systematic review was conducted to analyze the inter-rater reliability, cross-informant consistency, test-retest reliability, and temporal stability of the Strengths and Difficulties Questionnaire (SDQ), and its ability to discriminate.

METHOD

We searched three databases for articles about the SDQ (parent, teacher, and self-report version), used samples of children up to age 18 and reported inter-rater reliability, cross-informant reliability, test-retest reliability, temporal stability, specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

Focusing on the TDS, inter-rater, and cross-informant reliability showed acceptable values, but respondent types (e.g., mothers and fathers) are not interchangeable. Test-retest reliability and temporal stability were also acceptable, and not excessively high. Specificity and NPV were acceptable but not sensitivity and PPV.

DISCUSSION AND CONCLUSION

Greater transparency is needed about who the respondent is when the term "parents" is used. The SDQ is an important supplement to service-as-usual assessments by social care professionals.

School Performance After Pediatric Intensive Care-Association of Mental Well-Being, Chronic Illnesses, and Family Socioeconomic Status

OBJECTIVES

To describe school performance in pediatric intensive care survivors, as well as the influence of chronic diseases, psychological well-being, and family socioeconomic status on poor school performance.

DESIGN

Register-based observational descriptive follow-up study.

SETTING

A multicenter national study.

PATIENTS

All pediatric patients who were admitted to an ICU in Finland in 2009-2010. Children and adolescents of or beyond school age.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Questionnaires regarding the child's coping in school classes, chronic illnesses, as well as family socioeconomic factors were sent to every child alive 6 years after discharge from intensive care in Finland. Mental well-being was measured with the Strengths and Difficulties Questionnaire. There were 1,109 responders in an ICU group of 3,674 children. Seven-hundred fifty-three of the respondents were of school age or older. Of these, 13% (101/753) demonstrated poor school performance. Children with difficulties in school more often had a need for regular medication (71.3% vs 32.4%; p < 0.001), healthcare visits (91.1% vs 80.6%; p = 0.01), some regular therapy (60.4% vs 13.7%; p < 0.001), chronic illnesses (86.3% vs 48.4%; p < 0.001), or additional ICU admissions (36.5% vs 14.9%; p = 0.003). Schooling difficulties were reported more often in children with abnormal Strengths and Difficulties Questionnaire scores compared to those with normal or borderline scores (24.8% vs 5.4%; p < 0.001). In an adjusted logistic regression model, which included age, number of chronic diseases, and need for therapy, poor school performance was predicted by abnormal Strengths and Difficulties Questionnaire scores, nonacademic parental education, and paternal manual labor status.

CONCLUSIONS

Difficulties in school were more frequent when the child had chronic comorbid illnesses, especially neurologic or chromosomal abnormalities, had poor mental health, father was employed in manual labor, or parents were uneducated.

Maternal prenatal stress and postnatal depressive symptoms: discrepancy between mother and teacher reports of toddler psychological problems

PURPOSE

Maternal prenatal stress and postnatal depression are reported to increase the risk for early offspring psychological problems. We examined whether these two stressors predicted toddler emotional or behavioral problems based on the mother and teacher reports, respectively.

METHODS

A longitudinal study within the Odense Child Cohort (OCC). Prenatal stress was assessed (gestation week 28) using Cohen's Perceived Stress Scale (PSS). Depressive symptoms were assessed (3 months after birth) using the Edinburgh Postnatal Depression Scale (EPDS). Behavioral and emotional problems were assessed by mothers using the preschool version of Child Behaviour Checklist (CBCL) and by teachers using the caregiver-teacher report form (CTR-F).

RESULTS

N = 1302 mother-child dyads were included. CBCL (N = 1302) was collected at 29 months (SD 5.3) and C-TRF (N = 989) at 32.6 months (SD 6.9). N = 70 mothers (5.4%) were at high risk for postnatal depression (EPDS score > 12). Generalized additive models showed that prenatal stress (increase of + 1 on PSS-10 total score) predicted an increase in CBCL (+ 0.011) and C-TRF (+ 0.015) total scores. Postnatal depressive symptoms (increase of + 1 on EPDS total score) only predicted an increase in CBCL total score (+ 0.026).

CONCLUSION

Prenatal maternal stress was a significant predictor of both mother and teacher reported toddler emotional and behavioral problems, although effect sizes were small. Postnatal depressive symptoms were associated with increased maternal (but not teacher) reporting of toddler problems. Mothers reported more toddler psychological problems than teachers, and the mother-teacher discrepancy was positively correlated to maternal postnatal depressive symptoms.

Facilitating implementation of an evidence-based method to assess the mental health of 3-5-year-old children at Child Health Clinics: A mixed-methods process evaluation

BACKGROUND

A number of instruments for identifying mental health problems in children are available, but there is limited knowledge about how to successfully implement their use in routine practice. The Strengths and Difficulties Questionnaire (SDQ) is an instrument with sound psychometric properties. Because using multi-informant SDQs when assessing young children has been emphasized, parent- and preschool teacher reports on the SDQ were introduced at Child Health Clinics in a Swedish municipality. This paper aimed to describe a facilitation programme developed to support the introduction of SDQ in clinical practice and evaluate how nurses perceived the facilitation strategies used. Moreover, the dose (delivery) and reach (response rate and population coverage) of the questionnaires were assessed.

METHODS

The mixed-methods process evaluation was guided by Moore et al.'s framework. Process data were excerpted from monitoring data, the trial database, research group documents, study materials, group interviews with nurses, and a survey on nurses' opinions and experiences of the screening method and the implementation process. Data were analysed using descriptive statistics and qualitative content analysis.

RESULTS

Facilitation strategies used included: educational meetings, educational outreach visits, newsletters, facilitative administrative support, and adaptations made in procedures and materials when required. Although nurses described a variety of barriers at the organisational and individual level, they were in favour of using the SDQ in clinical practice and emphasised the importance of the facilitation strategies used for its implementation. While dose levels (77-91%) indicated that nurses essentially delivered the intervention as intended, parental response rates remained between 54 and 63% and population coverage at around 50%, throughout the intervention period.

CONCLUSION

The facilitation program was perceived to support the implementation of the SDQ at the yearly check-ups in the child healthcare setting, but further efforts are required to reach all families.

Joint and independent neurotoxic effects of early life exposures to a chemical mixture: A multi-pollutant approach combining ensemble learning and g-computation

BACKGROUND

Exposure to mercury (Hg) is associated with adverse developmental effects. However, Hg occurs with a multitude of chemicals. We assessed the associations of developmental exposure to multiple pollutants with children's neurodevelopment using a novel approach.

METHODS

Hg, polychlorinated biphenyls (PCBs), and perfluoroalkyl substances were measured in maternal and children's blood at 5-years (n=449 and 419). At 7-years, children were administered Boston Naming Test (BNT) and the Strengths and Difficulties Questionnaire (SDQ). We used the G-formula combined with SuperLearner to estimate independent and joint effects of chemicals at both ages. We constructed flexible exposure-response relationships and assessed interactions.

RESULTS

Most chemicals showed negative relationships with BNT scores. An inter-quartile range (IQR) increase in maternal Hg and perfluorooctanoic acid (PFOA) was associated with 0.15 standard deviation [SD] (95% Confidence Interval [CI]: -0.29,-0.03) and 0.14 SD (95%CI: -0.26,-0.05) lower scores in BNT, whereas a joint IQR increase in the mixture of chemicals was associated with 0.48 SD (95%CI: -0.69,-0.25) lower scores in BNT. An IQR increase in PFOA was associated with 0.11 SD (95%CI: 0.02,0.26) higher total SDQ difficulties scores. Maternal ∑PCBs concentrations were associated with lower SDQ scores (β=-0.09 SD; 95%CI: -0.19,0), whereas 5-years ∑PCBs showed a negative association (β=-0.09 SD; 95%CI: -0.21,0). Finally, a joint IQR increase in the mixture was associated with 0.22 SD (95%CI: 0.04,0.4) higher SDQ scores.

CONCLUSIONS

Using a novel statistical approach, we confirmed associations between prenatal mercury exposure and lower cognitive function. The potential developmental effects of PFASs need additional attention.

Web-Based Parent Training Intervention With Telephone Coaching for Disruptive Behavior in 4-Year-Old Children in Real-World Practice: Implementation Study

Background

Parent training is the most effective approach to the psychosocial treatment of disruptive behavioral problems in childhood. However, no studies exist on how well Web-based training programs work when they make the transition from the research setting to implementation in primary health care.

Objective

The study aimed to examine how the randomized controlled trial (RCT) and implementation study groups of the Strongest Families Smart Website (SFSW) intervention differed in child psychopathology, family demographics and treatment-related factors, such as therapeutic alliance and parents’ satisfaction rates. The intervention was conducted in the pediatric primary health care in Finland.

Methods

The study focused on 232 parents who had taken part in the SFSW intervention, which formed part of a 2-arm RCT study, and 882 families that would participate in the subsequent SFSW implementation study group. Both groups comprised parents whose children displayed high levels of parent-reported disruptive behavioral problems when they were screened in child health clinics at 4 years of age. Parents in both groups were provided with the SFSW intervention, which consisted of a Web-based training program with 11 weekly themes and associated telephone sessions.

Results

Demographic factors or duration of behavioral problems did not differ statistically or clinically between the RCT and implementation groups. Overall, 42.0% (362/862) of children in the implementation group and 35.4% (80/226) in the RCT intervention group had suffered from behavioral difficulties more than 1 year before the screening phase (χ₁²=3.2; P=.07). The mean duration of telephone coaching calls was very similar in the implementation and RCT intervention groups, that is, 38 and 37 min per call, respectively (t_279.5=0.26; P=.79). The total time spent on the website of the program was 451 min in the implementation group and 431 min in the RCT intervention group (t_318.8=1.38; P=.17). In the RCT intervention group, 52 of the 232 participants (22.4%) discontinued the program before the tenth week, whereas in the implementation group, 109 of the 882 participants (12.4%; odds ratio 2.05, 95% CI 1.4-3.0; P<.001) discontinued. Parents in both the implementation (77.1% to 98.5%, 498/742 to 731/742, respectively) and the RCT (64.8% to 98.2%, N=105/162- to 159/162, respectively) groups reported qualitatively similar and high level of posttreatment satisfaction rates in improved parenting skills, expectations, and stress relief. Parents in both groups reported a high level of satisfaction in skills and professionalism of the telephone coaches.

Conclusions

The implementation of population-based screening of Web-based parent training intervention with telephone coaching resulted in good feasibility, fidelity, accessibility, and similar satisfaction level post treatment when compared with intervention in RCT research setting. The discontinuation of treatment in the implementation group was exceptionally low.

Agreement between mothers', fathers', and teachers' ratings of behavioural and emotional problems in 3-5-year-old children

BACKGROUND

The Strengths and Difficulties Questionnaire (SDQ), a valid and reliable instrument for measuring children's mental health, is available in parent- and teacher versions, making it an ideal tool for assessing behavioural and emotional problems in young children. However, few studies have evaluated inter-parent agreement on the SDQ, and in most studies on SDQ agreement, parent scores are either provided by only one parent or have been combined into one parent score. Furthermore, studies on SDQ inter-rater agreement usually only reflect degree of correlation, leaving the agreement between measurements unknown. The aim of the present study was therefore to examine both degree of correlation and agreement between parent and teacher SDQ reports, in a community sample of preschool-aged children in Sweden.

METHODS

Data were obtained from the Children and Parents in Focus trial. The sample comprised 4,469 children 3-5-years-old. Mothers, fathers and preschool teachers completed the SDQ as part of the routine health check-ups at Child Health Centres. Inter-rater agreement was measured using Pearson correlation coefficient and intraclass correlation (ICC).

RESULTS

Results revealed poor/fair agreement between parent and teacher ratings (ICC 0.25-0.54) and good/excellent agreement between mother and father ratings (ICC 0.66-0.76). The highest level of agreement between parents and teachers was found for the hyperactivity and peer problem subscales, whereas the strongest agreement between parents was found for the hyperactivity and conduct subscales.

CONCLUSIONS

Low inter-rater agreement between parent and teacher ratings suggests that information from both teachers and parents is important when using the SDQ as a method to identify mental health problems in preschool children. Although mothers and fathers each provide unique information about their child's behaviour, good inter-parent agreement indicates that a single parent informant may be sufficient and simplify data collection.

Emotional and behavioral problems among Jordanian adolescents: Prevalence and associations with academic achievement

BACKGROUND

Mental health concerns are important for adolescent's general wellbeing and they can be associated with their ability to function effectively in various aspects of their daily life.

AIM

The purpose of this study was to identify emotional and behavioral disorders (EBD) among Jordanian adolescents and their association with academic outcomes.

METHODS

A descriptive correlational design was used. A total of 810 adolescents participated in the study and completed the demographic survey and the Strengths and Difficulties Questionnaire (SDQ). The grade point average (GPA) was used as an indicator of the academic achievement. The GPA was correlated with the SDQ scores to identify the relationship between the EBD and academic achievement.

RESULTS

About 11.7% of the participants had psychological and behavioral problems. The most commonly reported problems were emotional symptoms (14.2%), conduct problems (12.5%), and hyperactivity (7.5%). There was a significant difference in psychological and behavioral problems according to the participants' gender. There was a significant negative relationship between the SDQ scores and the GPA.

CONCLUSION

There is a need to identify adolescents at risk of emotional and behavioral difficulties and refer them to appropriate care and support, which in turn would improve their academic achievement.

Investigating the Structural Model of the Strengths and Difficulties Questionnaire

Abstract. The Strengths and Difficulties Questionnaire (SDQ) aims to assess problems in the psychological adjustment of children and youths. In this paper, we present results from an analysis of the structure of the SDQ. Data were collected from a community sample of 582 children and adolescents aged 10–19 years in Poland. The results showed that the bi-factor model yielded a good fit to the data. Out of five original SDQ factors, only emotional symptoms and prosocial behavior scales were distinguished from the general factor of difficulties. Additionally, two independent facets that concerned the characteristics of unsettlement and cautiousness have been extracted from the hyperactivity and conduct scales. The achieved structure differs from the theoretically assumed structure, but the findings are consistent with the Circumplex of Personality Metatraits (CPM), which was adapted to interpret the results. Moreover, with the help of the CPM, an additional difficulty that can be introduced to the model was identified.

Strengths and Difficulties Questionnaire: internal validity and reliability for New Zealand preschoolers

OBJECTIVES

This observational study examines the internal construct validity, internal consistency and cross-informant reliability of the Strengths and Difficulties Questionnaire (SDQ) in a New Zealand preschool population across four ethnicity strata (New Zealand European, Māori, Pasifika, Asian).

DESIGN

Rasch analysis was employed to examine internal validity on a subsample of 1000 children. Internal consistency (n=29 075) and cross-informant reliability (n=17 006) were examined using correlations, intraclass correlation coefficients and Cronbach's alpha on the sample available for such analyses.

SETTING AND PARTICIPANTS

Data were used from a national SDQ database provided by the funder, pertaining to New Zealand domiciled children aged 4 and 5 and scored by their parents and teachers.

RESULTS

The five subscales do not fit the Rasch model (as indicated by the overall fit statistics), contain items that are biased (differential item functioning (DIF)) by key variables, suffer from a floor and ceiling effect and have unacceptable internal consistency. After dealing with DIF, the Total Difficulty scale does fit the Rasch model and has good internal consistency. Parent/teacher inter-rater reliability was unacceptably low for all subscales.

CONCLUSION

The five SDQ subscales are not valid and not suitable for use in their own right in New Zealand. We have provided a conversion table for the Total Difficulty scale, which takes account of bias by ethnic group. Clinicians should use this conversion table in order to reconcile DIF by culture in final scores. It is advisable to use both parents and teachers' feedback when considering children's needs for referral of further assessment. Future work should examine whether validity is impacted by different language versions used in the same country.

The Strengths and Difficulties Questionnaire: Factor Structure of the Father-Report and Parent Agreement in 2-Year-Old Children

There is limited research on the preschool version of the Strengths and Difficulties Questionnaire (SDQ), and comparisons between mothers and fathers as informants and whether the factor structure shows measurement invariance across parents is lacking. Our study involved mothers (n = 6,246) and fathers (n = 3,759) of 2-year-old children from the Growing Up in New Zealand birth cohort. Confirmatory factor analysis was used to evaluate the factor structure of the SDQ and test for measurement invariance across mothers and fathers. For fathers, we found support for a modified five-factor model that accounts for a positive construal method effect. Internal consistency was good for measures except peer problems. Full measurement invariance of this modified model was found across mothers and fathers, and parents showed moderate agreement in their SDQ ratings (0.34 ≤ r ≤ 0.44). More research is needed on whether mother- and father-reports differ in sensitivity when screening for early childhood psychiatric disorders.

Exploring Nurses', Preschool Teachers' and Parents' Perspectives on Information Sharing Using SDQ in a Swedish Setting - A Qualitative Study Using Grounded Theory

Evidence-based methods to identify behavioural problems among children are not regularly used within the Swedish Child healthcare. A new procedure was therefore introduced to assess children through parent- and preschool teacher reports using the Strengths and Difficulties Questionnaire (SDQ). This study aims to explore nurses', preschool teachers' and parents' perspectives of this new information sharing model. Using the grounded theory methodology, semi-structured interviews with nurses (n = 10) at child health clinics, preschool teachers (n = 13) and parents (n = 11) of 3-, 4- and 5-year-old children were collected and analysed between March 2014 and June 2014. The analysis was conducted using constant comparative method. The participants were sampled purposively within a larger trial in Sweden. Results indicate that all stakeholders shared a desire to have a complete picture of the child's health. The perceptions that explain why the stakeholders were in favour of the new procedure-the 'causal conditions' in a grounded theory model-included: (1) Nurses thought that visits after 18-months were unsatisfactory, (2) Preschool teachers wanted to identify children with difficulties and (3) Parents viewed preschool teachers as being qualified to assess children. However, all stakeholders had doubts as to whether there was a reliable way to assess children's behaviour. Although nurses found the SDQ to be useful for their clinical evaluation, they noticed that not all parents chose to participate. Both teachers and parents acknowledged benefits of information sharing. However, the former had concerns about parental reactions to their assessments and the latter about how personal information was handled. The theoretical model developed describes that the causal conditions and current context of child healthcare in many respects endorse the introduction of information sharing. However, successful implementation requires considerable work to address barriers: the tension between normative thinking versus helping children with developmental problems for preschool teachers and dealing with privacy issues and inequity in participation for parents.

Behavioral difficulties in 7-year old children in relation to developmental exposure to perfluorinated alkyl substances

BACKGROUND

Perfluorinated alkyl substances (PFAS) are suspected endocrine disruptors that are highly persistent and neurotoxic in animals. Human epidemiological studies of exposure-related deviations of children's behaviors are sparse. We assessed the associations between prenatal, 5- and 7-year PFAS exposures and behavioral problem scores in 7-year Faroese children.

METHODS

Concentrations of perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), and perfluorodecanoic acid (PFDA), perfluorooctane sulfonate (PFOS), and perfluorohexane sulfonic acid (PFHxS) were measured in maternal serum and in serum from children at ages 5 and 7years (n=539, 508, and 491, respectively). We used multivariable regressions and structural equations models to estimate the covariate-adjusted associations between serum-PFAS concentrations and behavioral difficulties, as assessed by the strengths and difficulties questionnaire (SDQ) at age 7.

RESULTS

Serum-PFOS and PFHxS concentrations declined over time, whereas PFOA, PFNA, and PFDA tended to increase. No associations were observed between prenatal PFAS concentrations and SDQ scores. However, a two-fold increase in 5-year serum-PFOA, PFNA, and PFDA concentrations was associated with increases in total SDQ scores by 1.03 (95% CI: 0.11, 1.95), 0.72 (95% CI: 0.07, 1.38) and 0.78 points (95% CI: 0.01, 1.55), respectively. For SDQ subscales, significant associations were found in regard to hyperactivity, peer relationship, and conduct problems, as well as internalizing and externalizing problems and autism screening composite scores. Cross-sectional analyses at age 7years showed possible sex-dimorphic associations between PFAS concentrations and SDQ scores, where girls had consistently positive associations with SDQ scores whereas boys exhibited a pattern of negative or null associations.

CONCLUSIONS

Higher serum PFAS concentrations at ages 5- and 7-years, but not prenatally, were associated with parent-reported behavioral problems at age 7.

Short-term effects of the "Together at School" intervention program on children's socio-emotional skills: a cluster randomized controlled trial

BACKGROUND

Together at School is a universal intervention program designed to promote socio-emotional skills among primary-school children. It is based on a whole school approach, and implemented in school classes by teachers. The aim of the present study is to examine the short-term effects of the intervention program in improving socio-emotional skills and reducing psychological problems among boys and girls. We also examine whether these effects depend on grade level (Grades 1 to 3) and intervention dosage.

METHODS

This cluster randomized controlled trial design included 79 Finnish primary schools (40 intervention and 39 control) with 3 704 children. The outcome measures were the Strengths and Difficulties Questionnaire (SDQ) and the Multisource Assessment of Social Competence Scale (MASCS) with teachers as raters. The intervention dosage was indicated by the frequencies six central tools were used by the teachers. The data was collected at baseline and 6 months later. Intervention effects were analyzed using multilevel modeling.

RESULTS

When analyzed across all grades no intervention effect was observed in improving children's socio-emotional skills or in reducing their psychological problems at 6-month follow-up. Among third (compared to first) graders the intervention decreased psychological problems. Stratified analyses by gender showed that this effect was significant only among boys and that among them the intervention also improved third graders' cooperation skills. Among girls the intervention effects were not moderated by grade. Implementing the intervention with intended intensity (i.e. a high enough dosage) had a significant positive effect on cooperation skills. When analyzed separately among genders, this effect was significant only in girls.

CONCLUSIONS

These first, short-term results of the Together at School intervention program did not show any main effects on children's socio-emotional skills or psychological problems. This lack of effects may be due to the relatively short follow-up period given the universal, whole school-based approach of the program. The results suggest that the grade level where the intervention is started might be a factor in the program's effectiveness. Moreover, the results also suggest that for this type of intervention program to be effective, it needs to be delivered with a high enough dosage.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02178332 ; Date of registration: 03-April-2014.

Die deutsche Selbstbeurteilungsversion des Strengths and Difficulties Questionnaire (SDQ-Deu-S)

Zusammenfassung. Die vorliegende Studie überprüft die Faktorenstruktur, psychometrischen Eigenschaften und Grenzwerte der deutschen Selbstbeurteilungsversion des Strengths and Difficulties Questionnaire (SDQ-Deu-S). Die Daten dieser Studie basieren auf einer Stichprobe von N = 1 501 Kindern und Jugendlichen im Alter von 11 bis 16 Jahren. Die angenommene Fünf-Faktoren-Struktur des SDQ-Deu-S konnte anhand exploratorischer und konfirmatorischer Faktorenanalysen bestätigt werden. Die Reliabilitäten der fünf Skalen (Cronbachs Alpha .55 – .77, Retest .58 – .67) fielen jedoch gering aus. Lediglich die SDQ-Gesamtproblemskala erreichte eine zufriedenstellende interne Konsistenz. Es werden alters- und geschlechtsspezifische Grenzwerte vorgeschlagen, die sich an die von Goodman (1997) empfohlenen Zielvorgaben von 80 – 10 – 10 % für die Bestimmung von Grenzwerten in die drei Kategorien unauffällig, grenzwertig und auffällig anlehnen: Die Grenzwerte für die meisten SDQ-Subskalen liegen um etwa einen Punkt und für die SDQ-Gesamtproblemskala um max. zwei Punkte niedriger als die Grenzwerte für die SDQ-Selbstberichtsversion von Goodman, Meltzer und Bailey (1998) .

Feasibility of the Strengths and Difficulties Questionnaire in assessing children's mental health in primary care: Finnish parents', teachers' and public health nurses' experiences with the SDQ

BACKGROUND

The aim of the study was to evaluate the feasibility of the Strengths and Difficulties Questionnaire (SDQ).

METHOD

Following the administration of the SDQ in medical check-ups of 4-9 year-old children (n = 2 682) the involved parents, teachers and public health nurses were asked to complete a feedback questionnaire of the SDQ.

RESULTS

Parents took a maximum of 10-15 minutes to complete the SDQ, and only the public health nurses reported that its use was rather burdensome. The SDQ was an age-appropriate method and it was helpful in increasing information and agreement about the child's mental health and need for support. Using the SDQ was a positive experience for parents, but they expected more dialogue with the professionals about the child's situation. The respondents criticised the questionnaire somewhat for being difficult to interpret and complete.

CONCLUSIONS

The SDQ was found to be a feasible method for screening children's mental health in primary health care together with parents, teachers and public health nurses. Using the SDQ was a positive experience for parents. However, they reminded the professionals of the importance of sensitive dialogue when assessing the mental health of the child.

A systematic review of evidence for the psychometric properties of the Strengths and Difficulties Questionnaire

This article synthesized evidence for the validity and reliability of the Strengths and Difficulties Questionnaire in children aged 3–5 years. A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines was carried out. Study quality was rated using the Consensus-based Standards for the Selection of Health Measurement Instruments. In total, 41 studies were included (56 manuscripts). Two studies examined content and cultural validity, revealing issues with some questions. Six studies discussed language validations with changes to some wording recommended. There was good evidence for discriminative validity (Area Under the Curve ≥ 0.80), convergent validity (weighted average correlation coefficients ≥ 0.50, except for the Prosocial scale), and the 5-factor structural validity. There was limited support for discriminant validity. Sensitivity was below 70% and specificity above 70% in most studies that examined this. Internal consistency of the total difficulty scale was good (weighted average Chronbach’s alpha parents’ and teachers’ version 0.79 and 0.82) but weaker for other subscales (weighted average parents’ and teachers’ range 0.49–0.69 and 0.69–0.83). Inter-rater reliability between parents was moderate (correlation coefficients range 0.42–0.64) and between teachers strong (range 0.59–0.81). Cross-informant consistency was weak to moderate (weighted average correlation coefficients range 0.25–0.45). Test-retest reliability was mostly inadequate. In conclusion, the lack of evidence for cultural validity, criterion validity and test-retest reliability should be addressed given wide-spread implementation of the tool in routine clinical practice. The moderate level of consistency between different informants indicate that an assessment of a pre-schooler should not rely on a single informant.

Cutting a long story short? The clinical relevance of asking parents, nurses, and young children themselves to identify children's mental health problems by one or two questions

BACKGROUND AND AIMS

Assessing young children's mental health is a crucial and challenging task. The aim of the study was to evaluate the clinical relevance of asking parents, nurses, and young children themselves to identify children's mental health problems by only one or two questions.

METHODS

In regular health check-ups of 4- to 9-year-old children (n = 2682), parents and public health nurses assessed by one question whether the child had any emotional or behavioral difficulties. The child completed a self-evaluation enquiry on his/her emotional well-being. A stratified proportion of the participating parents were invited to a diagnostic interview.

RESULTS

Sensitivities were fairly good for the parents' (68%), nurses' (65%), and their combined (79%) one-question screens. Difficulties identified by parents and nurses were major risks (OR 10-14) for any child psychiatric disorders (P < 0.001). The child's self-evaluation was related to 2-fold to 3-fold risks (P < 0.05) for any psychiatric diagnosis, for any emotional diagnosis, and for negative situational factors.

CONCLUSION

The one-question screen for parents and public health nurses together quite adequately identified the young children with mental health problems. The child's self-evaluation provided relevant and complementary information on his/her mental health and especially emotional problems.

"Together at school"--a school-based intervention program to promote socio-emotional skills and mental health in children: study protocol for a cluster randomized controlled trial

Background

Schools provide a natural context to promote children’s mental health. However, there is a need for more evidence-based, high quality school intervention programs combined with an accurate evaluation of their general effectiveness and effectiveness of specific intervention methods. The aim of this paper is to present a study protocol of a cluster randomized controlled trial evaluating the “Together at School” intervention program. The intervention program is designed to promote social-emotional skills and mental health by utilizing whole-school approach and focuses on classroom curriculum, work environment of school staff, and parent-teacher collaboration methods.

Methods/Design

The evaluation study examines the effects of the intervention on children’s socio-emotional skills and mental health in a cluster randomized controlled trial design with 1) an intervention group and 2) an active control group. Altogether 79 primary school participated at baseline. A multi-informant setting involves the children themselves, their parents, and teachers. The primary outcomes are measured using parent and teacher ratings of children’s socio-emotional skills and psychological problems measured by the Strengths and Difficulties Questionnaire and the Multisource Assessment of Social Competence Scale. Secondary outcomes for the children include emotional understanding, altruistic behavior, and executive functions (e.g. working memory, planning, and inhibition). Secondary outcomes for the teachers include ratings of e.g. school environment, teaching style and well-being. Secondary outcomes for both teachers and parents include e.g. emotional self-efficacy, child rearing practices, and teacher-parent collaboration. The data was collected at baseline (autumn 2013), 6 months after baseline, and will be collected also 18 months after baseline from the same participants.

Discussion

This study protocol outlines a trial which aims to add to the current state of intervention programs by presenting and studying a contextually developed and carefully tested intervention program which is tailored to fit a national school system. Identification of effective intervention elements to promote children’s mental health in early school years is crucial for optimal later development.

Trial registration

ClinicalTrials.gov register: NCT02178332.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1042) contains supplementary material, which is available to authorized users.

Reliability of the strengths and difficulties questionnaire in Japanese preschool children aged 4-6 years

BACKGROUND

The Strengths and Difficulties Questionnaire (SDQ) has been widely used as a brief behavioral screening. The aim of this study was to examine the internal consistency and test-retest reliability of the 3- to 4-year-old version of the SDQ (SDQ 3-4) in Japanese preschool children.

METHODS

The SDQ 3-4 was administered to 754 parents who had 4- to 6-year-old children attending kindergartens or childcare centers in Wako City, Japan, at 2 different times (Time 1 and Time 2) over a 2-week interval between June and July 2012. Cronbach's α and correlation coefficients were used to examine internal consistency and test-retest reliability, respectively.

RESULTS

Of 393 parents who returned their responses at Time 1 (response rate 52.1%), 383 were used for analysis after excluding 10 responses with missing data. Their children's mean age was 4.7 (standard deviation 0.7) years. The internal consistency (Cronbach's α) was good for the total difficulties score (0.74) and the prosocial behavior scale (0.70). However, it was slightly worse for the emotional symptoms, conduct problems, and hyperactivity scales (0.61-0.66) and poor for the peer problems scale (0.45). Of the 383 included respondents at Time 1, 211 parents returned their responses at Time 2 (response rate: 55.1%). Test-retest reliability (correlation coefficients) was good (0.73-0.82), except for the peer problems scale (0.58).

CONCLUSIONS

The results support the reliability of the SDQ 3-4 being satisfactory for the total difficulties score and prosocial behavior scale and being acceptable for the emotional symptoms, conduct problems, and hyperactivity scales in Japanese preschool children aged 4-6 years.

The strengths and difficulties questionnaire as a predictor of parent-reported diagnosis of autism spectrum disorder and attention deficit hyperactivity disorder

The Strengths and Difficulties Questionnaire (SDQ) is widely used as an international standardised instrument measuring child behaviour. The primary aim of our study was to examine whether behavioral symptoms measured by SDQ were elevated among children with autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) relative to the rest of the population, and to examine the predictive value of the SDQ for outcome of parent-reported clinical diagnosis of ASD/ADHD. A secondary aim was to examine the extent of overlap in symptoms between children diagnosed with these two disorders, as measured by the SDQ subscales. A cross-sectional secondary analysis of data from the Millennium Birth Cohort (n = 19,519), was conducted. Data were weighted to be representative of the UK population as a whole. ADHD or ASD identified by a medical doctor or health professional were reported by parents in 2008 and this was the case definition of diagnosis; (ADHD n = 173, ASD n = 209, excluding twins and triplets). Study children's ages ranged from 6.3-8.2 years; (mean 7.2 years). Logistic regression was used to examine the association between the parent-reported clinical diagnosis of ASD/ADHD and teacher and parent-reported SDQ subscales. All SDQ subscales were strongly associated with both ASD and ADHD. There was substantial co-occurrence of behavioral difficulties between children diagnosed with ASD and those diagnosed with ADHD. After adjustment for other subscales, the final model for ADHD, contained hyperactivity/inattention and impact symptoms only and had a sensitivity of 91% and specificity of 90%; (AUC) = 0.94 (95% CI, 0.90-0.97). The final model for ASD was composed of all subscales except the 'peer problems' scales, indicating of the complexity of behavioural difficulties that may accompany ASD. A threshold of 0.03 produced model sensitivity and specificity of 79% and 93% respectively; AUC = 0.90 (95% CI, 0.86-0.95). The results support changes to DSM-5 removing exclusivity clauses.