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1.  Screening Foster Children for Mental Disorders: Properties of the Strengths and Difficulties Questionnaire 
PLoS ONE  2014;9(7):e102134.
High prevalence of mental disorders among foster children highlight the need to examine the mental health of children placed out of home. We examined the properties of the Strengths and Difficulties Questionnaire (SDQ) in screening school-aged foster children for mental disorders.
Foster parents and teachers of 279 foster children completed the SDQ and the diagnostic interview Developmental and Well-Being Assessment (DAWBA). Using the diagnoses derived from the DAWBA as the standard, we examined the performance of the SDQ scales as dimensional measures of mental health problems using receiver operating characteristic (ROC) analyses. Recommended cut-off scores were derived from ROC coordinates. The SDQ predictive algorithms were also examined.
ROC analyses supported the screening properties of the SDQ Total difficulties and Impact scores (AUC = 0.80–0.83). Logistic regression analyses showed that the prevalence of mental disorders increased linearly with higher SDQ Total difficulties scores (X2 = 121.47, df = 13, p<.001) and Impact scores (X2 = 69.93, df = 6, p<.001). Our results indicated that there is an additive value of combining the scores from the Total difficulties and Impact scales, where scores above cut-off on any of the two scales predicted disorders with high sensitivity (89.1%), but moderate specificity (62.1%). Scores above cut-off on both scales yielded somewhat lower sensitivity (73.4%), but higher specificity (81.1%). The SDQ multi-informant algorithm showed low discriminative ability for the main diagnostic categories, with an exception being the SDQ Conduct subscale, which accurately predicted the absence of behavioural disorders (LHR− = 0.00).
The results support the use of the SDQ Total difficulties and Impact scales when screening foster children for mental health problems. Cut-off values for both scales are suggested. The SDQ multi-informant algorithms are not recommended for mental health screening of foster children in Norway.
PMCID: PMC4090209  PMID: 25006669
2.  Assessing the diagnostic accuracy of the identification of hyperkinetic disorders following the introduction of government guidelines in England 
Previous studies have suggested that both underdiagnosis and overdiagnosis routinely occur in ADHD and hyperkinesis (hyperkinetic disorders). England has introduced governmental guidelines for these disorders' detection and treatment, but there has been no study on clinical diagnostic accuracy under such a regime.
All open cases in three Child and Adolescent Mental Health Services (CAMHS) in the South East of England were assessed for accuracy in the detection of hyperkinetic disorders, using a two-stage process employing the Strengths and Difficulties Questionnaire (SDQ) for screening, with the cut-off between "unlikely" and "possible" as the threshold for identification, and the Development And Well-Being Assessment (DAWBA) as a valid and reliable standard.
502 cases were collected. Their mean age 11 years (std dev 3 y); 59% were clinically diagnosed as having a hyperkinetic disorder including ADHD. Clinicians had missed two diagnoses of hyperkinesis and six of ADHD. The only 'false positive' case was one that had become asymptomatic on appropriate treatment.
The identification of children with hyperkinetic disorders by three ordinary English CAMHS teams appears now to be generally consistent with that of a validated, standardised assessment. It seems likely that this reflects the impact of Governmental guidelines, which could therefore be an appropriate tool to ensure consistent accurate diagnosis internationally.
PMCID: PMC2586016  PMID: 18983672
3.  Cross-national differences in questionnaires do not necessarily reflect comparable differences in disorder prevalence 
To examine whether the widely used Strengths and Difficulties Questionnaire (SDQ) can validly be used to compare the prevalence of child mental health problems cross nationally.
We used data on 29,225 5- to 16-year olds in eight population-based studies from seven countries: Bangladesh, Brazil, Britain, India, Norway, Russia and Yemen. Parents completed the SDQ in all eight studies, teachers in seven studies and youth in five studies. We used these SDQ data to calculate three different sorts of “caseness indicators” based on (1) SDQ symptoms, (2) SDQ symptoms plus impact and (3) an overall respondent judgement of ‘definite’ or ‘severe’ difficulties. Respondents also completed structured diagnostic interviews including extensive open-ended questions (the Development and Well-Being Assessment, DAWBA). Diagnostic ratings were all carried out or supervised by the DAWBA’s creator, working in conjunction with experienced local professionals.
As judged by the DAWBA, the prevalence of any mental disorder ranged from 2.2% in India to 17.1% in Russia. The nine SDQ caseness indicators (three indicators times three informants) explained 8–56% of the cross-national variation in disorder prevalence. This was insufficient to make meaningful prevalence estimates since populations with a similar measured prevalence of disorder on the DAWBA showed large variations across the various SDQ caseness indicators.
The relationship between SDQ caseness indicators and disorder rates varies substantially between populations: cross-national differences in SDQ indicators do not necessarily reflect comparable differences in disorder rates. More generally, considerable caution is required when interpreting cross-cultural comparisons of mental health, particularly when these rely on brief questionnaires.
Electronic supplementary material
The online version of this article (doi:10.1007/s00127-011-0440-2) contains supplementary material, which is available to authorized users.
PMCID: PMC3405234  PMID: 22033632
Cross cultural; Questionnaire; Prevalence; Reporting bias
4.  Validity and Reliability of the Strengths and Difficulties Questionnaire in 5–6 Year Olds: Differences by Gender or by Parental Education? 
PLoS ONE  2012;7(5):e36805.
The Strengths and Difficulties Questionnaire (SDQ) is a relatively short instrument developed to detect psychosocial problems in children aged 3–16 years. It addresses four dimensions: emotional problems, conduct problems, hyperactivity/inattention problems, peer problems that count up to the total difficulties score, and a fifth dimension; prosocial behaviour. The validity and reliability of the SDQ has not been fully investigated in younger age groups. Therefore, this study assesses the validity and reliability of the parent and teacher versions of the SDQ in children aged 5–6 years in the total sample, and in subgroups according to child gender and parental education level.
The SDQ was administered as part of the Dutch regularly provided preventive health check for children aged 5–6 years. Parents provided information on 4750 children and teachers on 4516 children.
Factor analyses of the parent and teacher SDQ confirmed that the original five scales were present (parent RMSEA = 0.05; teacher RMSEA = 0.07). Interrater correlations between parents and teachers were small (ICCs of 0.21–0.44) but comparable to what is generally found for psychosocial problem assessments in children. These correlations were larger for males than for females. Cronbach’s alphas for the total difficulties score were 0.77 for the parent SDQ and 0.81 for the teacher SDQ. Four of the subscales on the parent SDQ and two of the subscales on the teacher SDQ had an alpha <0.70. Alphas were generally higher for male children and for low parental education level.
The validity and reliability of the total difficulties score of the parent and teacher SDQ are satisfactory in all groups by informant, child gender, and parental education level. Our results support the use of the SDQ in younger age groups. However, some subscales are less reliable and we recommend only to use the total difficulties score for screening purposes.
PMCID: PMC3356337  PMID: 22629332
5.  Normative data and psychometric properties of the parent and teacher versions of the strengths and difficulties questionnaire (SDQ) in an Iranian community sample 
Strengths and difficulties questionnaire (SDQ) is a widely used instrument for screening mental problems in children and adolescents. The main aim of this study was to evaluate the validity and psychometric properties of this questionnaire in comparison with the children behavior checklist (CBCL) and psychiatric interview.
The study was done in two stages. At stage one, 600 children aged between 6 and 12 were evaluated using the parent and teacher versions of SDQ and CBCL. At stage two, 25 children with the scores above the cut point reported by the developer of SDQ and 27 children with the score below this point were selected to be interviewed by a child and adolescent psychiatrist according to Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) classification and by another clinician using the K-SADS-PL (Schedule for Affective Disorders and Schizophrenia for School-Age Children- Present and Lifetime Version) as a semi structured interview.
The mean scores of SDQ subscales found in this study were comparable to what found in other studies in other countries. The cut-off points of SDQ were almost similar to that of other researches. The internal consistency and concurrent validity of this questionnaire was good.
The current study showed that both parent and teacher versions of SDQ in Persian language can be used as a valid tool in screening the mental problems in children and adolescents.
PMCID: PMC3129092  PMID: 21772865
SDQ; CBCL; mental problems; children; K-SADS
6.  Adolescents’ multiple, recurrent subjective health complaints: investigating associations with emotional/behavioural difficulties in a cross-sectional, school-based study 
Adolescence has been documented as the peak age of onset for mental health perturbations, clinical disorders and unsubstantiated health complaints. The present study attempted to investigate associations between multiple, recurrent subjective health complaints (SHC) with emotional/behavioural difficulties, as measured by the Strengths and Difficulties Questionnaire scale (SDQ), among Greek adolescents.
Questionnaires were administered in a large, nation-wide, random, school-based sample of Greek adolescents, aged 12–18 years. Data from 1170 participants were analyzed. Adolescents with multiple, recurrent SHC were compared in terms of their emotional/behavioural difficulties to their peers with lower levels of health complaints. SDQ scales were separately investigated for their associations with multiple, recurrent SHC, after adjustment for gender, age and socioeconomic status (ses). Further analysis included multiple logistic regression models with multiple, recurrent SHC as the dependent variable and gender, age, ses and SDQ Total difficulties score as independent factors. Potential gender and age interactions were also explored.
Almost half of the study participants reported multiple, recurrent SHC. Adolescents with multiple, recurrent SHC had higher scores on all SDQ scales, except from the Prosocial behavior scale, compared to their peers with lower levels of health complaints. Emotional Symptoms, Conduct Problems, Hyperactivity/Inattention and Peer Problems were associated with greater likelihood of having multiple, recurrent SHC, after adjustment for gender, age and ses. The multiple logistic regression models revealed that older adolescents and girls, as well as those with increased Total difficulties score had an increased risk for multiple, recurrent SHC reporting. No significant interaction between SDQ scales and gender or age was found.
Our study highlights the magnitude of psychological burden among adolescents experiencing multiple, recurrent SHC. Professionals in school and clinical settings should be cautious for impaired emotional/behavioural functioning when assessing adolescents with multiple, recurrent SHC, so as early identification of at-risk individuals and timely, appropriate referrals are facilitated.
PMCID: PMC3903038  PMID: 24461305
Subjective Health Complaints (SHC); Emotional/behavioural difficulties; SDQ scale; Adolescents
7.  Normative data and psychometric properties of the strengths and difficulties questionnaire among Japanese school-aged children 
Although child mental health problems are among the most important worldwide issues, development of culturally acceptable mental health services to serve the clinical needs of children and their families is especially lacking in regions outside Europe and North America. The Strengths and Difficulties Questionnaire (SDQ), which was developed in the United Kingdom and is now one of the most widely used measurement tools for screening child psychiatric symptoms, has been translated into Japanese, but culturally calibrated norms for Japanese schoolchildren have yet to be established. To this end, we examined the applicability of the Japanese versions of the parent and teacher SDQs by establishing norms and extending validation of its psychometric properties to a large nationwide sample, as well as to a smaller clinical sample.
The Japanese versions of the SDQ were completed by parents and teachers of schoolchildren aged 7 to 15 years attending mainstream classes in primary or secondary schools in Japan. Data were analyzed to describe the population distribution and gender/age effects by informant, cut-off scores according to banding, factor structure, cross-scale correlations, and internal consistency for 24,519 parent ratings and 7,977 teacher ratings from a large nationwide sample. Inter-rater and test-retest reliabilities and convergent and divergent validities were confirmed for a smaller validation sample (total n = 128) consisting of a clinical sample with any mental disorder and community children without any diagnoses.
Means, standard deviations, and banding of normative data for this Japanese child population were obtained. Gender/age effects were significant for both parent and teacher ratings. The original five-factor structure was replicated, and strong cross-scale correlations and internal reliability were shown across all SDQ subscales for this population. Inter-rater agreement was satisfactory, test-retest reliability was excellent, and convergent and divergent validities were satisfactory for the validation sample, with some differences between informants.
This study provides evidence that the Japanese version of the SDQ is a useful instrument for parents and teachers as well as for research purposes. Our findings also emphasize the importance of establishing culturally calibrated norms and boundaries for the instrument’s use.
PMCID: PMC3903008  PMID: 24444351
Child mental health; Questionnaire; Reliability; Validity; Normative banding; Strengths and difficulties questionnaire
8.  Training clinicians in mental health communication skills: Impact on primary care utilization 
Academic pediatrics  2010;10(5):346-352.
Although it is known that children with mental health problems utilize primary care services more than most other children, it is unknown how addressing mental health problems in primary care affects children’s subsequent services utilization. This study measures primary care utilization in the context of a randomized trial of a communication skills training program for primary care clinicians that had a positive impact on child mental health outcomes.
From 2002 to 2005, 48 pediatric primary care clinicians at 13 sites in rural upstate New York, urban Maryland, and Washington, DC were randomized to in-office training or to a control group. Consecutive primary care patients between the ages of 5 and 16 years were screened for mental health problems, as indicated by a possible or probable score on the Strengths and Difficulties Questionnaire (SDQ). For 397 screened children, primary care visits during the next 6 months were identified using chart review and administrative databases. Using generalized estimating equation regression to account for clustering at the clinician level, primary care utilization was compared by study group and SDQ status.
The number of primary care visits to the trained clinicians did not differ significantly from those made to control clinicians (2.5 for both groups, p=0.63). Children with possible or probable SDQ scores made, on average, 0.38 or 0.65 more visits on a per-child basis, respectively, during the six-month follow-up period than SDQ unlikely children (p-value=0.0002).
Seeing a trained clinician did not increase subsequent primary care utilization. However, primary care utilization was greater among children with mental health problems as measured by the SDQ. Addressing children’s mental health in primary care does not increase the primary care visit burden. Research on overall health services utilization is needed.
PMCID: PMC2933967  PMID: 20685190
Strengths and Difficulties Questionnaire; primary care utilization; child mental health
9.  A Population-Based Psychometric Validation Study of the Strengths and Difficulties Questionnaire – Hebrew Version 
This study presents the psychometric properties of the Strengths and Difficulties Questionnaire – Hebrew version (SDQ-H), used in the Israel Survey on Mental Health among Adolescents (ISMEHA). The SDQ-H was administered to a representative sample of 611 adolescents and their mothers. Structural validity was evaluated by exploratory and confirmatory factor analysis and the Development and Well-Being Assessment (DAWBA) inventory was used as “gold standard” to test convergent and discriminant validity. Internal consistency and normative scores were established. Agreement was found with the original factor structure, except for the Peer problem scale. Concurrent and discriminant validity varied from fair to very good for most scales. Total Difficulties scores showed better discriminant validity for the adolescents’ than the mothers’ report for internalizing disorders, and the opposite for externalizing disorders. Internal consistency for the Total Difficulties was 0.77 and for the Hyperactivity scale it was 0.73. It was lower for the other scales, particularly for the Peer problems scale. The findings suggest reasonable psychometric properties of the SDQ-H. Comparisons with other translated SDQ versions are presented.
PMCID: PMC3059623  PMID: 21423458
SDQ-Hebrew version; validity; reliability; normative scores
10.  A stepped-care model of post-disaster child and adolescent mental health service provision 
European Journal of Psychotraumatology  2014;5:10.3402/ejpt.v5.24294.
From a global perspective, natural disasters are common events. Published research highlights that a significant minority of exposed children and adolescents develop disaster-related mental health syndromes and associated functional impairment. Consistent with the considerable unmet need of children and adolescents with regard to psychopathology, there is strong evidence that many children and adolescents with post-disaster mental health presentations are not receiving adequate interventions.
To critique existing child and adolescent mental health services (CAMHS) models of care and the capacity of such models to deal with any post-disaster surge in clinical demand. Further, to detail an innovative service response; a child and adolescent stepped-care service provision model.
A narrative review of traditional CAMHS is presented. Important elements of a disaster response – individual versus community recovery, public health approaches, capacity for promotion and prevention and service reach are discussed and compared with the CAMHS approach.
Difficulties with traditional models of care are highlighted across all levels of intervention; from the ability to provide preventative initiatives to the capacity to provide intense specialised posttraumatic stress disorder interventions. In response, our over-arching stepped-care model is advocated. The general response is discussed and details of the three tiers of the model are provided: Tier 1 communication strategy, Tier 2 parent effectiveness and teacher training, and Tier 3 screening linked to trauma-focused cognitive behavioural therapy.
In this paper, we argue that traditional CAMHS are not an appropriate model of care to meet the clinical needs of this group in the post-disaster setting. We conclude with suggestions how improved post-disaster child and adolescent mental health outcomes can be achieved by applying an innovative service approach.
PMCID: PMC4095762  PMID: 25045422
Disaster planning; mental health services; child; adolescent
11.  Results of the parent-rated Strengths and Difficulties Questionnaire in 22,108 primary school students from 8 provinces of China 
Shanghai Archives of Psychiatry  2013;25(6):364-374.
A valid screening tool for behavioral and emotional problems in children and adolescents is needed to promote psychological wellbeing and to prevent mental disorders in China's children.
Assess the use of the Chinese version of the internationally recognized Strengths and Difficulties Questionnaire (SDQ) – which assesses emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems and prosocial behaviors – in a large sample of urban and rural children from different parts of China.
The Chinese version of the parent-reported SDQ was administered to legal guardians (primarily parents) of a stratified random sample of 22,108 primary school children 5 to 13 years of age from eight provinces in China. The association between SDQ scores and socio-demographic characteristics was assessed and the percentile cutoff scores for ‘abnormal’, ‘borderline’ and ‘normal’ results in China were compared with those for Japan and the United Kingdom.
The internal consistency of the 4 of the 5 SDQ subscales were satisfactory but that for the ‘peer relationships problems’ subscale was quite poor (alpha=0.22). Guardians reported that boys were more likely than girls to have hyperactivity/inattention problems and that girls were more likely than boys to have problems with emotional symptoms. For both boys and girls hyperactivity/inattention problems decreased with age while peer relationship problems increased with age. Emotional symptoms, conduct problems and peer relationship problems were more common in children from rural areas and in children whose identified guardian was not a parent (i.e., a grandparent or other relative). The 90th percentile cutoff score for abnormal results was higher in Chinese children than the cutoff scores reported for children in Japan and the United Kingdom.
This study suggests that prevention programs for hyperactivity/inattention problems in boys need to start before the age of 10 and that training in methods of reducing the stress associated with peer relationships should start in early adolescence. Further work is needed to improve the cultural validity of the SDQ in China and to determine its sensitivity and specificity for identifying children who are in need of mental health services.
PMCID: PMC4054577  PMID: 24991179
12.  The validity, reliability and normative scores of the parent, teacher and self report versions of the Strengths and Difficulties Questionnaire in China 
The Strengths and Difficulties Questionnaire (SDQ) has become one of the most widely used measurement tools in child and adolescent mental health work across the globe. The SDQ was originally developed and validated within the UK and whilst its reliability and validity have been replicated in several countries important cross cultural issues have been raised. We describe normative data, reliability and validity of the Chinese translation of the SDQ (parent, teacher and self report versions) in a large group of children from Shanghai.
The SDQ was administered to the parents and teachers of students from 12 of Shanghai's 19 districts, aged between 3 and 17 years old, and to those young people aged between 11 and 17 years. Retest data was collected from parents and teachers for 45 students six weeks later. Data was analysed to describe normative scores, bandings and cut-offs for normal, borderline and abnormal scores. Reliability was assessed from analyses of internal consistency, inter-rater agreement, and temporal stability. Structural validity, convergent and discriminant validity were assessed.
Full parent and teacher data was available for 1965 subjects and self report data for 690 subjects. Normative data for this Chinese urban population with bandings and cut-offs for borderline and abnormal scores are described. Principle components analysis indicates partial agreement with the original five factored subscale structure however this appears to hold more strongly for the Prosocial Behaviour, Hyperactivity – Inattention and Emotional Symptoms subscales than for Conduct Problems and Peer Problems. Internal consistency as measured by Cronbach's α coefficient were generally low ranging between 0.30 and 0.83 with only parent and teacher Hyperactivity – Inattention and teacher Prosocial Behaviour subscales having α > 0.7. Inter-rater correlations were similar to those reported previously (range 0.23 – 0.49) whilst test retest reliability was generally lower than would be expected (range 0.40 – 0.79). Convergent and discriminant validity are supported.
We report mixed findings with respect the psychometric properties of the Chinese translation of the SDQ. Reliability is a particular concern particularly for Peer Problems and self ratings by adolescents. There is good support for convergent validity but only partial support for structural validity. It may be possible to resolve some of these issues by carefully examining the wording and meaning of some of the current questions.
PMCID: PMC2409296  PMID: 18445259
13.  Parent experiences questionnaire for outpatient child and adolescent mental health services (PEQ-CAMHS Outpatients): reliability and validity following a national survey 
Development and evaluation of the PEQ-CAMHS Outpatients, a parent completed questionnaire to measure experiences of outpatient child and adolescent mental health services (CAMHS) in Norway.
Literature review, parent interviews, pre-testing and a national survey of 17,080 parents of children who received care at one of the 86 outpatient CAMHS in Norway in 2006. Telephone interviews were conducted with a random sample of non-respondents. Levels of missing data, factor structure, internal consistency and construct validity were assessed.
7,906 (46.0%) parents or primary caregivers responded to the questionnaire. Low levels of missing data suggest that the PEQ-CAMHS is acceptable. The questionnaire includes three scales supported by the results of factor analysis: relationship with health personnel (8 items), information and participation (4 items), and outcome (3 items). Item-total correlations were all above 0.6 and Cronbach's alpha correlations ranged from 0.88-0.94. The results of comparisons of scale scores with several variables relating to global satisfaction, outcome, cooperation, information, involvement and waiting time support the construct validity of the instrument.
The PEQ-CAMHS Outpatients questionnaire includes important aspects of outpatient CAMHS from the perspective of the parent. It has evidence for data quality, internal consistency and validity and is recommended in surveys of parent experiences of these services. Future research should assess test-retest reliability and further tests of construct validity that include clinical data are recommended.
PMCID: PMC3120777  PMID: 21600010
14.  Why do British Indian children have an apparent mental health advantage? 
Previous studies document a mental health advantage in British Indian children, particularly for externalising problems. The causes of this advantage are unknown.
Subjects were 13 836 White children and 361 Indian children aged 5-16 years from the English subsample of the British Child and Adolescent Mental Health Surveys. The primary mental health outcome was the parent Strengths and Difficulties Questionnaire (SDQ). Mental health was also assessed using the teacher and child SDQs; diagnostic interviews with parents, teachers and children; and multi-informant clinician-rated diagnoses. Multiple child, family, school and area factors were examined as possible mediators or confounders in explaining observed ethnic differences.
Indian children had a large advantage for externalising problems and disorders, and little or no difference for internalising problems and disorders. This was observed across all mental health outcomes, including teacher-reported and diagnostic interview measures. Detailed psychometric analyses provided no suggestion of information bias. The Indian advantage for externalising problems was partly mediated by Indian children being more likely to live in two-parent families and less likely to have academic difficulties. Yet after adjusting for these and all other covariates, the unexplained Indian advantage only reduced by about a quarter (from 1.08 to 0.71 parent SDQ points) and remained highly significant (p<0.001). This Indian advantage was largely confined to families of low socio-economic position.
The Indian mental health advantage is real and is specific to externalising problems. Family type and academic abilities mediate part of the advantage, but most is not explained by major risk factors. Likewise unexplained is the absence in Indian children of a socio-economic gradient in mental health. Further investigation of the Indian advantage may yield insights into novel ways to promote child mental health and child mental health equity in all ethnic groups.
PMCID: PMC3428791  PMID: 20840505
Cross-cultural comparison; British Indians; advantaged groups; information bias; minority ethnic mental health; externalising problems
15.  Prevalence of Psychiatric Disorders among Children and Adolescents in Northeast China 
PLoS ONE  2014;9(10):e111223.
To describe the prevalence of DSM-IV disorders and comorbidity in a large school-based sample of 6–17 year old children and adolescents in northeast China.
A two-phase cross-sectional study was conducted on 9,806 children. During the screening phase, 8848 children (90.23%) and their mothers and teachers were interviewed using the Strengths and Difficulties Questionnaire (SDQ). During the diagnostic phase, 1129 children with a positive SDQ and 804 randomly selected children with a negative SDQ (11%), and their mothers and teachers, were interviewed using the Development and Well-Being Assessment (DAWBA).
The overall prevalence of DSM-IV disorders was 9.49% (95% CI = 8.10–11.10%). Anxiety disorders were the most common (6.06%, 95% CI = 4.92–7.40), followed by depression (1.32%, 95% CI = 0.91–1.92%), oppositional defiant disorder (1.21%, 95%CI = 0.77–1.87) and attention-deficit hyperactivity disorder (0.84%, 95% CI = 0.52–1.36%). Of the 805 children with a psychiatric disorder, 15.2% had two or more comorbid disorders.
Approximately one in ten Chinese school children has psychiatric disorders involving a level of distress or social impairment likely to warrant treatment. Prevention, early identification and treatment of these disorders are urgently needed and pose a serious challenge in China.
PMCID: PMC4215989  PMID: 25360718
16.  How impaired are children and adolescents by mental health problems? Results of the BELLA study 
European Child & Adolescent Psychiatry  2009;17(Suppl 1):42-51.
The consideration of impairment plays a crucial role in detecting significant mental health problems in children whose symptoms do not meet diagnostic criteria. The assessment of impairment may be particularly relevant when only short screening instruments are applied in epidemiological surveys. Furthermore, differences between childrens’ and parents’ perceptions of present impairment and impairing symptoms are of interest with respect to treatment-seeking behaviour.
The objectives were to assess parent- and self-reported impairment due to mental health problems in a representative sample of children and adolescents; to describe the characteristics of highly impaired children with normal symptom scores; and to investigate the associations between symptoms in different problem areas and impairment.
The mental health module of the German Health Interview and Examination Survey for Children and Adolescents (the BELLA study) examined mental health in a representative sub-sample of 2,863 families with children aged 7–17. Self-reported and parent-reported symptoms of mental health problems and associated impairment were identified by the extended version of the strengths and difficulties questionnaire (SDQ) in children 11 years and older.
Considerable levels of distress and functional impairment were found with 14.1% of the boys and 9.9% of the girls being severely impaired according to the parental reports. However, self-reported data shows a reversed gender-difference as well as lower levels of severe impairment (6.1% in boys; 10.0% in girls). Six percent of the sampled children suffer from pronounced impairment due to mental health problems but were not detected by screening for overall symptoms. Childrens’ and parents’ reports differed in regard to the association between reported symptom scores and associated impairment with children reporting higher impairment due to emotional problems.
The assessment of impairment caused by mental health problems provides important information beyond the knowledge of symptoms and helps to identify an otherwise undetected high risk group. In the assessment of impairment, gender-specific issues have to be taken into account. Regarding the systematic differences between childrens’ and parents’ reports in the assessment of impairment, the child’s perspective should be given special attention.
PMCID: PMC2757610  PMID: 19132303
impairment; burden; prevalence; mental health; children and adolescents
17.  The characteristics and activities of child and adolescent mental health services in Italy: a regional survey 
BMC Psychiatry  2012;12:7.
To date, no studies have assessed in detail the characteristics, organisation, and functioning of Child and Adolescent Mental Health Services (CAMHS). This information gap represents a major limitation for researchers and clinicians because most mental disorders have their onset in childhood or adolescence, and effective interventions can therefore represent a major factor in avoiding chronicity. Interventions and mental health care are delivered by and through services, and not by individual, private clinicians, and drawbacks or limitations of services generally translate in inappropriateness and ineffectiveness of treatments and interventions: therefore information about services is essential to improve the quality of care and ultimately the course and outcome of mental disorders in childhood and adolescence.
The present paper reports the results of the first study aimed at providing detailed, updated and comprehensive data on CAMHS of a densely populated Italian region (over 4 million inhabitants) with a target population of 633,725 subjects aged 0-17 years.
Unit Chiefs of all the CAMHS filled in a structured 'Facility Form', with activity data referring to 2008 (data for inpatient facilities referred to 2009), which were then analysed in detail.
Eleven CAMHS were operative, including 110 outpatient units, with a ratio of approximately 20 child psychiatrists and 23 psychologists per 100,000 inhabitants aged 0-17 years. All outpatient units were well equipped and organized and all granted free service access. In 2008, approximately 6% of the target population was in contact with outpatient CAMHS, showing substantial homogeneity across the eleven areas thereby. Most patients in contact in 2008 received a language disorder- or learning disability diagnosis (41%). First-ever contacts accounted for 30% of annual visits across all units. Hospital bed availability was 5 per 100,000 inhabitants aged 0-17 years.
The percentage of young people in contact with CAMHS for mental disorders is in line with those observed in previous epidemiological studies. The overall number of child psychiatrists per 100,000 inhabitants is one of the highest in Europe and it is comparable with the most well equipped areas in the US. This comparison should be interpreted with caution, however, because in Italy, child psychiatrists also treat neurological disorders. Critical areas requiring improvement are: the uneven utilisation of standardised assessment procedures and the limited availability of dedicated emergency services during non-office hours (e.g., nights and holidays).
PMCID: PMC3310734  PMID: 22289204
Child and Adolescent Mental Health Services (CAMHS); Process of care; Adolescence; Child Psychiatry
18.  Is relatively young age within a school year a risk factor for mental health problems and poor school performance? A population-based cross-sectional study of adolescents in Oslo, Norway 
BMC Public Health  2005;5:102.
Several studies have shown that children who are relatively young within a school year are at greater risk for poorer school performance compared with their older peers. One study also reported that relative age within a school year is an independent risk factor for emotional and behavioral problems. The objective of this study was to test the hypothesis that relatively younger adolescents in the multiethnic population of Oslo have poorer school performance and more mental health problems than their relatively older classmates within the same school year.
This population-based cross-sectional study included all 10th-grade pupils enrolled in 2000 and 2001 in the city of Oslo. The participation rate was 88%. Of the 6,752 pupils in the study sample, 25% had a non-Norwegian background. Mental health problems were quantified using the abbreviated versions of Symptom Check List-25 (SCL-10) and the Strength and Difficulties Questionnaire (SDQ). Information on school performances and mental health problems were self-reported. We controlled for confounding factors including parental educational level, social support, gender, and ethnicity.
The youngest one-third of pupils had significantly lower average school grades than the middle one-third and oldest one-third of their classmates (p < 0.001). Of the mental health problems identified in the questionnaires, the groups differed only on peer problems; the youngest one-third reported significantly more problems than the middle and oldest groups (p < 0.05). Age within a school year and gender showed significant interactions with total SDQ score, SDQ peer problems score, SDQ pro social score, and SCL-10 score. After stratifying for gender, the peer problem scores differed significantly between age groups only among boys. The SCL-10 score was significant, but only in girls and in the opposite direction to that expected, with the oldest pupils having significantly higher scores than the other two groups (p < 0.05).
In adolescents from a multicultural city in Norway, relative age within a school year significantly influenced academic performance. In contrast to data from Great Britain, relative age within a school year was not an important risk factor for mental health problems in adolescents in Oslo.
PMCID: PMC1260023  PMID: 16207379
19.  Mental Health in Children with Cerebral Palsy: Does Screening Capture the Complexity? 
The Scientific World Journal  2013;2013:468402.
Introduction. Children with cerebral palsy (CP), one of the most common childhood neurological disorders, often have associated medical and psychological symptoms. This study assesses mental health problems compared to population controls and the ability of a mental health screening tool to predict psychiatric disorders and to capture the complexity of coexisting symptoms. Methods. Children with CP (N = 47) were assessed according to DSM-IV criteria using a psychiatric diagnostic instrument (Kiddie-SADS) and a mental health screening questionnaire (SDQ). Participants from the Bergen Child Study, a large epidemiological study, served as controls. Results. Children with CP had significantly higher means on all problem scores including impact scores. Two in three children scored above 90th percentile cutoff on Total Difficulties Score (TDS), and 57% met criteria for a psychiatric disorder, yielding a sensitivity of 0.85 and a specificity of 0.55. Mental health problems coexisted across symptom scales, and peer problems were highly prevalent in all groups of psychiatric disorders. Conclusion. A high prevalence of mental health problems and cooccurrence of symptoms were found in children with CP compared to controls. Screening with SDQ detects mental health problems, but does not predict specific disorders in children with CP. ADHD is common, but difficult to diagnose due to complexity of symptoms. Mental health services integrated in regular followup of children with CP are recommended due to high prevalence and considerable overlap of mental health symptoms.
PMCID: PMC3654290  PMID: 23690745
20.  Factors Contributing to the Utilization of Adult Mental Health Services in Children and Adolescents Diagnosed with Hyperkinetic Disorder 
The Scientific World Journal  2012;2012:451205.
Objectives. To examine whether age of First diagnosis, gender, psychiatric comorbidity, and treatment modalities (pharmacotherapy or psychotherapy) at Child and Adolescent Mental Health Services (CAMHS) moderate the risk of Adult Mental Health Services (AMHS) utilization in patients diagnosed with hyperkinetic disorder at CAMHS. Methods. Data were derived from the Madrid Psychiatric Cumulative Register Study. The target population comprised 32,183 patients who had 3 or more visits at CAMHS. Kaplan-Meier curves were used to assess survival data. A series of logistic regression analyses were performed to study the role of age of diagnosis, gender, psychiatric comorbidity, and treatment modalities. Results. 7.1% of patients presented with hyperkinetic disorder at CAMHS. Compared to preschool children, children and adolescents first diagnosed with hyperkinetic disorder at CAMHS were more likely to use AMHS. Female gender and comorbidity with affective disorders, schizophrenia, schizotypal and delusional disorders increased the risk of use of AMHS. Pharmacological or combined treatment of hyperkinetic disorder diagnosed at CAMHS was associated with increased risk of use at AMHS. Conclusions. Older age of first diagnosis, female gender, psychiatric comorbidity, and pharmacological treatment at CAMHS are markers of risk for the transition from CAMHS to AMHS in patients with hyperkinetic disorder diagnosed at CAMHS.
PMCID: PMC3361257  PMID: 22654608
21.  Green and Blue Spaces and Behavioral Development in Barcelona Schoolchildren: The BREATHE Project 
Environmental Health Perspectives  2014;122(12):1351-1358.
Background: Green spaces have been associated with improved mental health in children; however, available epidemiological evidence on their impact on child behavioral development is scarce.
Objectives: We investigated the impact of contact with green spaces and blue spaces (beaches) on indicators of behavioral development and symptoms of attention deficit/hyperactivity disorder (ADHD) in schoolchildren.
Methods: This study was based on a sample of 2,111 schoolchildren (7–10 years of age) from 36 schools in Barcelona in 2012. We obtained data on time spent in green spaces and beaches and Strengths and Difficulties Questionnaires (SDQ) from parents, and ADHD/DSM-IV questionnaires from teachers. Surrounding greenness was abstracted as the average Normalized Difference Vegetation Index (NDVI) in buffers of 100 m, 250 m, and 500 m around each home address. Proximity to green spaces was defined as living within 300 m of a major green space (≥ 0.05 km2). We applied quasi-Poisson mixed-effects models (with school random effect) to separately estimate associations between indicators of contact with green spaces and SDQ and ADHD total and subscale scores.
Results: We generally estimated beneficial associations between behavioral indicators and longer time spent in green spaces and beaches, and with residential surrounding greenness. Specifically, we found statistically significant inverse associations between green space playing time and SDQ total difficulties, emotional symptoms, and peer relationship problems; between residential surrounding greenness and SDQ total difficulties and hyperactivity/inattention and ADHD/DSM-IV total and inattention scores; and between annual beach attendance and SDQ total difficulties, peer relationship problems, and prosocial behavior. For proximity to major green spaces, the results were not conclusive.
Conclusion: Our findings support beneficial impacts of contact with green and blue spaces on behavioral development in schoolchildren.
Citation: Amoly E, Dadvand P, Forns J, López-Vicente M, Basagaña X, Julvez J, Alvarez-Pedrerol M, Nieuwenhuijsen MJ, Sunyer J. 2014. Green and blue spaces and behavioral development in Barcelona schoolchildren: the BREATHE Project. Environ Health Perspect 122:1351–1358;
PMCID: PMC4256702  PMID: 25204008
22.  A qualitative process evaluation of electronic session-by-session outcome measurement in child and adolescent mental health services 
BMC Psychiatry  2014;14:113.
Regular monitoring of patient progress is important to assess the clinical effectiveness of an intervention. Recently, initiatives within UK child and adolescent mental health services (CAMHS) have advocated the use of session-by-session monitoring to continually evaluate the patient’s outcome throughout the course of the intervention. However, the feasibility and acceptability of such regular monitoring is unknown.
Semi-structured qualitative interviews were conducted with clinicians (n = 10), administrative staff (n = 8) and families (n = 15) who participated in a feasibility study of an electronic session-by-session outcome monitoring tool, (SxS), which is based on the Strengths and Difficulties Questionnaire (SDQ). This study took place in three CAMHS clinics in Nottinghamshire. The interview transcripts were thematically analysed.
We found clinicians accepted the need to complete outcome measures, particularly valuing those completed by the patient. However, there were some difficulties with engaging clinicians in this practice and in the training offered. Generally, patients were supportive of completing SxS in the waiting room prior to the clinic session and assistance with the process from administrative staff was seen to be a key factor. Clinicians and families found the feedback reports created from SxS to be helpful for tracking progress, facilitating communication and engagement, and as a point of reflection. The use of technology was considered positively, although some technological difficulties hindered the completion of SxS. Clinicians and families appreciated the brevity of SxS, but some were concerned that a short questionnaire could not adequately encapsulate the complexity of the patient’s issues.
The findings show the need for appropriate infrastructure, mandatory training, and support to enable an effective system of session-by-session monitoring. Our findings indicate that clinicians, administrative staff and young people and their parents/carers would support regular monitoring if the system is easy to implement, with a standard ‘clinic-wide’ adoption of the procedure, and the resulting data are clinically useful.
PMCID: PMC4021403  PMID: 24731701
Session by session; CAMHS; Qualitative evaluation; Parent; Clinician; Outcome measures
23.  General practitioner experience and perception of Child and Adolescent Mental Health Services (CAMHS) care pathways: a multimethod research study 
BMJ Open  2012;2(6):e001573.
This is a pilot study with the objective of investigating general practitioner (GP) perceptions and experiences in the referral of mentally ill and behaviourally disturbed children and adolescents.
Quantitative analyses on patient databases were used to ascertain the source of referrals into Child and Adolescent Mental Health Services (CAMHS) and identify the relative contribution from GP practices. Qualitative semistructured interviews were then used to explore challenges faced by GPs in referring to CAMHS.
GPs were chosen from the five localities that deliver CAMHS within the local Trust (Peterborough City, Fenland, Huntingdon, Cambridge City and South Cambridgeshire).
For the quantitative portion, data involving 19 466 separate referrals were used. Seven GPs took part in the qualitative interviews.
The likelihood of a referral from GPs being rejected by CAMHS was over three times higher compared to all other referral sources combined within the Cambridge and Peterborough NHS Foundation Trust. Interviews showed that detecting the signs and symptoms of mental illness in young people is a challenge for GPs. Communication with referral agencies varies and depends on individual relationships. GPs determine whether to refer on a mixture of the presenting conditions and their perceived likelihood of acceptance by CAMHS; the criteria for the latter were poorly understood by the interviewed GPs.
There are longstanding structural weaknesses in the services for children and young people in general, reflected in poor multiagency cooperation at the primary care level. GP-friendly guidelines and standards are required that will aid in decision-making and help with understanding the referrals process. We look to managers of both commissioning and providing organisations, as well as future research, to drive forward the development of tools, protocols, and health service structures to help aid the recognition and treatment of mental illness in young people.
PMCID: PMC3533003  PMID: 23148343
Mental Health; Primary Care; Referrals
24.  Psychometric properties of online administered parental strengths and difficulties questionnaire (SDQ), and normative data based on combined online and paper-and-pencil administration 
To examine the psychometric properties of the online administered parental version of the Strength and Difficulties Questionnaire (SDQ), and to provide parental norms from a nationwide Swedish sample.
A total of 1443 parents from of a national probability sample of 2800 children aged 10-13 years completed the SDQ online or as usual (i.e., using paper-and-pencil).
The SDQ subscales obtained from the online administration showed high internal consistency (polychoric ordinal alpha), and confirmatory factor analysis of the SDQ five factor model resulted in excellent fit. The Total Difficulties score of the SDQ and its other subscales were significantly related to the Disruptive Behavior Disorders (DBD) rating scale. Norms for the parent version of SDQ obtained from the Internet were identical to those collected using paper-and-pencil. They were thus combined and are presented sorted by child gender and age.
The SDQ seems to be a reliable and valid instrument given its high internal consistency, clear factor structure and high correlation with other instruments capturing the intended constructs. Findings in the present study support its use for online data collection, as well as using norms obtained through paper-and-pencil-administration even when SDQ has been administrated online.
PMCID: PMC3898053  PMID: 24325882
Psychometrics; Conduct problems; Online assessment; Norms; Disruptive behavior disorder
25.  Changes in Scoliosis Patient and Parental Assessment of Mental Health in the Course of Cheneau Brace Treatment Based on the Strengths and Difficulties Questionnaire 
In the presented study we aimed to investigate the influence of bracing time on perception of mental health by both parents and children with Adolescent Idiopathic Scoliosis (AIS) longitudinally, in relation to socio-demographic and scoliosis-related data. The study design was comprised of three questionnaire assessments, with the second and the third evaluation taking place 6 and 12 months after the beginning of the study, respectively. Thirty-six AIS females treated conservatively and their parents completed the Polish versions of The Strengths and Difficulties Questionnaire-25 (SDQ-25). The results indicated psychiatric disorder was unlikely, but concern all SDQ-25 parent and patient domains and general results. Patient results do not differ significantly in regards to the total score and the particular domains of the SDQ-25. Parents SDQ-25 results differ significantly in regards to the emotional symptoms domain only (p = .023, after Bonferroni correction, the difference is insignificant). The study groups differ significantly within the 2nd evaluation in regards to hyperactivity/inattention domain (p = .026) and within the last evaluation in regards to emotional symptoms domain (p = .009). After Bonferroni correction the differences are insignificant. In general, parents and their children with AIS perceived patients’ mental health in a similar way. Patient and parent assessment of mental health was unchanged after a 12-month brace treatment period. Poor psychological outcome was associated with more severe spinal deformity, brace-wearing duration and age of patient.
PMCID: PMC3648678  PMID: 23667301
Longitudinal analysis; AIS; Brace treatment; Spinal deformity; Mental health; SDQ-25

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