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1.  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
2.  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
3.  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
4.  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
5.  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
6.  A comparison of four scoring methods based on the parent-rated Strengths and Difficulties Questionnaire as used in the Dutch preventive child health care system 
BMC Public Health  2008;8:106.
Validated questionnaires can support the identification of psychosocial problems by the Preventive Child Health Care (PCH) system. This study assesses the validity and added value of four scoring methods used with the Strengths and Difficulties Questionnaire (SDQ) for the identification of psychosocial problems among children aged 7–12 by the PCH.
We included 711 (of 814) children (response: 87%) aged 7–12 undergoing routine health assessments in nine PCH services across the Netherlands. Child health professionals interviewed and examined children and parents. Prior to the interview, parents completed the SDQ and the Child Behaviour Checklist (CBCL), which were not shown to the professionals. The CBCL and data about the child's current treatment status were used as criteria for the validity of the SDQ. We used four SDQ scoring approaches: an elevated SDQ Total Difficulties Score (TDS), parent-defined difficulties, an elevated score for emotional symptoms, conduct problems or hyperactivity in combination with a high impairment score, and a combined score: an elevated score for any of these three methods.
The Cohen's Kappa ranged from 0.33 to 0.64 for the four scoring methods with the CBCL scores and treatment status, generally indicating a moderate to good agreement. All four methods added significantly to the identification of problems by the PCH. Classification based on the TDS yielded results similar to more complicated methods.
The SDQ is a valid tool for the identification of psychosocial problems by PCH. As a first step, the use of a simple classification based on the SDQ TDS is recommended.
PMCID: PMC2359742  PMID: 18394152
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.  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
9.  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
10.  Evaluation of a mental health outreach service for homeless families 
Archives of Disease in Childhood  2002;86(3):158-163.
Aims: To describe the characteristics of homeless children and families seen by the mental health outreach service (MHOS), to evaluate the impact of this service on the short term psychosocial functioning of children and parents, and to establish perceptions of, and satisfaction with, the service.
Methods: Twenty seven children from 23 families who were in receipt of the MHOS and 27 children from 23 families residing in other hostels where no such service was available were studied. The MHOS was delivered by a clinical nurse specialist with expertise in child mental health, who offered the following interventions: assessment and brief treatment of mental health disorders in children; liaison with agencies; and training of homeless centre staff.
Results: Children in the experimental group had a significantly higher decrease in Strengths and Difficulties Questionnaire (SDQ) total scores. Having received the intervention was the strongest predictor of improvement in SDQ total scores. There was no significant impact on parental mental health (General Health Questionnaire) scores. Homeless families and staff expressed high satisfaction with the MHOS.
Conclusion: This MHOS for homeless families is an innovative intervention which meets the complex and multiple needs of a vulnerable population unable to access mainstream mental health services. The primary objective of the service was to improve child mental health problems; however, the service developed in a responsive way by meeting social and practical needs of families in addition to its clinical role.
PMCID: PMC1719131  PMID: 11861229
11.  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
12.  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
13.  The Strengths and Difficulties Questionnaire as a Predictor of Parent-Reported Diagnosis of Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder 
PLoS ONE  2013;8(12):e80247.
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.
PMCID: PMC3848967  PMID: 24312466
14.  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
15.  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
16.  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
17.  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
18.  Mental Health Services Use Predicted by Number of Mental Health Problems and Gender in a Total Population Study 
The Scientific World Journal  2013;2013:247283.
We examined the relationship between service use and the number of problem areas as reported by parents and teachers on questionnaires among children aged 7–9 years old in the Bergen Child Study, a total population study including more than 9000 children. A problem area was counted as present if the child scored above the 95th percentile on parent and/or teacher questionnaire. A total number of 13 problem areas were included. Odd ratios (ORs) for contact with child and adolescent mental health services (CAMH), school psychology services (SPS), health visiting nurse/physician, and school support were calculated with gender as covariate. The number of symptom areas was highly predictive of service use, showing a dose-response relationship for all services. Children scoring on ≥4 problem areas had a more than hundredfold risk of being in contact with CAMH services compared to children without problems. The mean number of problem areas for children in CAMH and SPS was 6.1 and 4.4 respectively, strongly supporting the ESSENCE model predicting multisymptomatology in children in specialized services. Even after controlling for number of problem areas, boys were twice as likely as girls to be in contact with CAMH, replicating previous findings of female gender being a strong barrier to mental health services.
PMCID: PMC3654282  PMID: 23690740
19.  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
20.  Change in Mental Health Status of Young Children Participating in a Respite Service 
The objective of this study was to determine the extent of changes in mental health status of children in a respite service as little has been reported on this aspect of respite care.
All families enrolled in a new centre-based respite program in a moderately large urban center in Canada were invited to participate. The child’s primary caregiver completed the Strengths and Difficulties Questionnaire (SDQ) at baseline, mid-point and endpoint, as did respite staff. A comparison group of primary caregivers seeking respite care also completed the same ratings at baseline and at one-follow-up point.
The children’s primary caregivers perceived high levels of mental health difficulties in their children at baseline; significantly more than respite providers. No significant changes were found between SDQ baseline and endpoint values for either primary caregivers or respite workers. The amount of change between baseline and midpoint was no different for the intervention and comparison group.
No evidence of a positive impact on child mental health status by the new respite program as measured by the SDQ was detected. Specific evidence-based child mental health interventions may need to be paired with respite care to improve child mental health outcomes.
PMCID: PMC3085671  PMID: 21541101
respite care; child; mental health; evaluation; service de relève; santé mentale; enfants; évaluation
21.  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
22.  Transition to adult mental health services for young people with Attention Deficit/Hyperactivity Disorder (ADHD): a qualitative analysis of their experiences 
BMC Psychiatry  2013;13:74.
There is little research on the process of transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS). More recently, there is growing recognition that Attention Deficit/Hyperactivity Disorder (ADHD) may persist into adulthood requiring services beyond age 18. However, despite National Institute for Health and Clinical Excellence (NICE) Guidance which recommends specialist services for adults with ADHD, there is currently a lack of such services in the UK. The aim of the current study is to explore the experiences of young people with ADHD during transition from CAMHS to AMHS.
Semi-structured qualitative interviews with ADHD patients accessing CAMHS clinics in Nottinghamshire were analysed using thematic analysis.
Ten semi-structured interviews were transcribed and analysed. We found that patients’ relationships with their clinician were a key factor in both their reported experience of CAMHS and the transition process. Perceived responsibility of care was also pivotal in how the transition process was viewed. Nature and severity of problems and patients expectations of adult services were also contributing factors in the transition process. The need for continued parental support was openly accepted and thought to be required by the majority of young people with ADHD during transition.
Timely preparation, joint working, good clinician relationships and parental support serve to facilitate the process of transition for young people with ADHD. Nature and severity of problems are perceived to impede or facilitate transition, with predominantly more ‘complex presentations’ with associated mental health problems more familiar to AMHS (e.g. self-harm, depression) making for smoother transitions to adult services. Transitions to AMHS were more difficult when ADHD was viewed as the main or sole clinical problem. Further exploration of young people’s experiences of transition and their engagement with and experience of adult services is required to provide an overall picture of facilitators to successful transition and integration into adult services.
PMCID: PMC3605266  PMID: 23497082
ADHD; Transition; CAMHS; AMHS; Thematic analysis
23.  Soliciting stakeholders’ views on the organization of child and adolescent mental health services: a system in trouble 
Despite a high prevalence of mental health problems among children and adolescents Belgium, like many other Western countries, does not have a clear strategy for the organization of child and adolescent mental healthcare services (CAMHS).
This paper describes stakeholders’ views on the organization of CAMHS based on a qualitative study. Ten in-depth interviews with high profile stakeholders were complemented by roundtable discussions (n = 30).
This diagnostic analysis illustrated that the system is in serious trouble characterized by fragmentation and compartmentalization.
The findings create a sense of urgency that should be used to initiate a system reform of the Belgian CAMHS system.
PMCID: PMC3942294  PMID: 24359535
Adolescent; Child; Health services research; Mental health services; Organizational policy
24.  Mental Health Problems among Adolescents with Early-Onset and Long-Duration Type 1 Diabetes and Their Association with Quality of Life: A Population-Based Survey 
PLoS ONE  2014;9(3):e92473.
To evaluate mental health problems and associations between mental health problems and health-related quality of life in adolescents with type 1 diabetes in comparison with the general population.
A total of 629 11- to 17-year-olds with early-onset and long-lasting type 1 diabetes and their parents completed comprehensive questionnaires. Mental health was assessed using the parent- and self-report versions of the Strengths and Difficulties Questionnaire (SDQ). The Revised Children's Quality of Life Questionnaire (KINDL-R) was used to measure quality of life. The comparison group (n = 6,813) was a representative sample from the German KiGGS study.
The proportion of youths with mental health problems (defined as abnormal SDQ total difficulties score) was, based on self-reports, 4.4% in the patient group and 2.9% in the general population (adjusted OR = 1.61, p = 0.044); and based on proxy reports, 7.9% in the patient group and 7.2% in the general population (OR = 1.05, p = 0.788). Youths with type 1 diabetes and self-reported mental health problems scored worse in the KINDL-R subscales of physical well-being (adjusted average difference β = −16.74, p<0.001) and family (β = −11.09, p = 0.017), and in the KINDL-R total score (β = −8.09, p<0.001), than peers with self-reported mental health problems. The quality of life of diabetic adolescents and proxy-reported mental health problems did not differ from peers with proxy-reported mental health problems adjusted for confounders.
Compared with the general population with mental health problems, the quality of life of adolescents with type 1 diabetes who report mental health problems is more severely impaired. This observation calls for early prevention and intervention as part of pediatric diabetes long-term care.
PMCID: PMC3956941  PMID: 24637957
25.  Epidemiological Study of Youth Mental Health Using Strengths and Difficulties Questionnaire (SDQ) 
Prevention and treatment of youths` mental disorders are important, not just for to diminish their present problems but to improve their functions in adulthood. This study was performed to evaluate the mental health status of 6-18 years old youths in a community-based sample using the strength and difficulties questionnaire (SDQ).
Parent of 2000 youths (6-18 years old) were selected from 250 clusters from different municipality areas of Isfahan, Iran and they responded to extended version of SDQ parent`s form. The mean score in each subscale and prevalence of symptom and relation with some demographic features were determined.
The total score of SDQ was 26%, means that 26% of youth had psychiatric problems. By determining the subscale score, it reveals that conduct disorder (34.7%) was the most common problem in youth followed by peer relationship problems (25.4%), emotional problems (24.5%), hyperactivity (23%) and impairment of prosocial behavior (5.7%).
Our findings showed that mental health of youth population in Isfahan especially the conduct problem needs more attention.
PMCID: PMC3420028  PMID: 22924116
Youth; Strength and difficulties Questionnaire; SDQ; Mental health; Relational problem; Conduct problem

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