Normative data for the self-reported and parent-reported Strengths and Difficulties Questionnaire (SDQ) for ages 12-17

BACKGROUND

The Strengths and Difficulties Questionnaire (SDQ) is widely used to screen for psychosocial problems among adolescents. As the severity of such problems is known to be related to age and gender, screening could be improved by interpreting SDQ scale scores with age-specific and perhaps gender-specific norms. Up to now, such norms are lacking. The aim of the current study is to present gender-specific and joint normative data per year of age for the Dutch self-reported and parent-reported SDQ versions for use among 12- to 17-year-old adolescents.

METHODS

The norm groups for the self-reported and parent-reported SDQ versions consisted of 993 adolescents and 736 parents, respectively, from the general Dutch population. Per SDQ version, both gender-specific norms and joint norms (percentiles and cutoffs) per year of age were calculated through regression-based norming (Rigby in J Roy Stat Soc Ser C 54:507, 2005). Additionally, these norms were compared to the widely used British norms that are neither age-specific nor gender-specific.

RESULTS

By design, gender-specific 'abnormal' cutoffs (i.e., cutoffs aimed at identifying max. 10% of the most extremely scoring males and max. 10% of the most extremely scoring females) resulted in about equal percentages of 'abnormal' scoring male and female adolescents per SDQ scale. In contrast, joint 'abnormal' cutoffs (i.e., cutoffs aimed at identifying max. 10% of the most extremely scoring adolescents) resulted in relatively more male (7.6 to 13.6%, depending on age) than female (3.3 to 8.9%, depending on age) adolescents as scoring 'abnormal' on scales measuring externalizing behavior (self-reported and parent-reported SDQ versions), and relatively more female (3.9 to 14.3%, depending on age) than male (1.8 to 6.9%, depending on age) adolescents as scoring 'abnormal' on scales measuring internalizing behavior (self-reported SDQ version). In both types of norms, minor age effects were present. Among Dutch adolescents, the British norms yielded detection rates much lower than the expected 10%.

CONCLUSIONS

Our findings indicate that detection rates depend on the reference group that is used (British or Dutch general adolescent population; specific gender group or not). The normative data in this paper facilitate the comparison of an adolescent's scores to different reference groups, and allow for cross-country/cultural comparisons of adolescents' psychosocial behavior.

Care improves self-reported daily functioning of adolescents with emotional and behavioural problems

Emotional and behavioural problems (EBP) have a negative impact on various life domains of adolescents. Receiving care for EBP may improve the functioning of adolescents with EBP, but evidence on long-term outcomes in real-life settings is lacking. We, therefore, investigated self-reported functioning in different life domains of adolescents with various EBP, and the role of care during a three-year period. We used data from the TAKECARE study, which consist of a care and community cohort. We followed adolescents aged 12 and over (n = 733) during 3 years over five assessment rounds. Using the Strengths and Difficulties Questionnaire, self-reported functioning was measured in four life domains: home life, friendships, classroom learning and leisure activities. We categorized the respondents into four groups: (1) adolescents without emotional and behavioural problems (n = 298); (2) adolescents with emotional problems (n = 192); (3) adolescents with behavioural problems (n = 80); and (4) adolescents with both emotional and behavioural problems (n = 163). The development of functioning over time was analyzed using longitudinal ordinal (probit) regression analyses. Adolescents with both emotional and behavioural problems reported poorer functioning at baseline in all domains and adolescents who received care reported poorer functioning at baseline compared to adolescents who did not receive care. Regarding the change in functioning during the 3 years, adolescents who received care showed improved functioning in all domains. We found improved functioning after care, even if the problems may not have been solved. Psychosocial care can contribute to the functioning of adolescents with EBP, which can have major effects on their future life.

The combined self- and parent-rated SDQ score profile predicts care use and psychiatric diagnoses

The Strengths and Difficulties Questionnaire (SDQ) is widely used, based on evidence of its value for screening. This evidence primarily regards the single informant total difficulties scale and separate difficulties subscales. We assessed to what degree adolescents' SDQ profiles that combined all self- and parent-rated subscales were associated with use of care and psychiatric diagnoses, and examined the added value thereof over using only a single informant and the total scale. Cluster analysis was used to identify common SDQ profiles based on self- and parent-reports among adolescents aged 12-17 in mental healthcare (n = 4282), social care (n = 124), and the general population (n = 1293). We investigated associations of the profiles with 'care use' and 'DSM-IV diagnoses', depending on gender. We identified six common SDQ profiles: five profiles with varying types and severities of reported difficulties, pertaining to 95% of adolescents in care, and one without difficulties, pertaining to 55% of adolescents not in care. The types of reported difficulties in the profiles matched DSM-IV diagnoses for 88% of the diagnosed adolescents. The SDQ profiles were found to be more useful for predicting care use and diagnoses than SDQ scores reported by the adolescent as single informant and the total difficulties scale. The latter indicated the presence of problems among 42-63% of the adolescents in care, missing a substantial number of adolescents with reported emotional difficulties and borderline problem severity. These findings advocate the use of combined self- and parent-rated SDQ score profiles for screening.

Trajectories of care for children and adolescents with psychosocial problems: a 3-year prospective cohort study

BACKGROUND

Care for children and adolescents with psychosocial problems is aimed at reducing problems. There may be a relationship between the intensity and duration of care provision and improvement of these outcomes, but evidence on this issue is lacking. We therefore examined the association between care trajectories based on duration and intensity of care for children, and the reduction in psychosocial problems after 3 years.

METHODS

We obtained a cohort of all children entering psychosocial care in one region (n = 1,378), the TAKECARE cohort, and followed it for 3 years, with five assessment rounds. Retention in the final round was 85.8%. Psychosocial problems were measured using the parent report of the Total Difficulty Score of the Strength and Difficulties Questionnaire (SDQ-TDS). We constructed trajectories for intensity of care using growth mixture modelling and assessed the association between duration and intensity of care trajectories and SDQ-TDS after 3 years.

RESULTS

After 3 months 60.6% of children and adolescents were receiving care, after 1 year 38.7% were receiving care and after 3 years 26.0%. Regarding intensity of care, three trajectories were found: one with minimal intensity during all 3 years, a second with initially medium intensity and strong reduction within 1 year, and a third with high intensity and a reduction after 1 year. Although the psychosocial problems of children and adolescents were reduced during the 3-year period, the rate of decline was relatively less marked for children and adolescents with longer care trajectories.

CONCLUSION

Overall, children and adolescents with psychosocial problems who received care had improved outcomes at follow-up. However, increased provision of care does not automatically lead to reduction of problems, and although overall psychosocial problems are reduced, a substantial subgroup has longer lasting problems.

The role of functional health literacy in long-term treatment outcomes in psychosocial care for adolescents

Although among adolescents with psychosocial problems low health literacy may increase the risk of poor treatment outcomes, the contributing mechanisms within treatment remain unclear. A better understanding of these mechanisms could contribute to improved treatment processes and outcomes. This study aims to examine the relationship between functional health literacy, treatment processes (treatment adherence, learning processes), and treatment outcome (level of psychosocial problems) in adolescents in psychosocial care. We used data from a prospective cohort study among adolescents aged 12-18 (N = 390), collected in four successive measurements: at entry into care, and 3, 12, and 24 months thereafter. We used a mixed effect model to investigate the association between level of functional health literacy (adequate vs. inadequate) and treatment processes (treatment adherence, learning processes) and treatment outcome (level of psychosocial problems). Between adolescents with adequate and inadequate functional health literacy, we found no differences or change over time in adherence or learning processes. The level of psychosocial problems significantly declined over time (β = - 1.70, 95% CI [- 2.72, - 0.69], p = .001) to a similar degree in both groups, though, in all measurements, the level was consistently higher for adolescents with inadequate health literacy. We conclude that health literacy levels did not affect change in treatment processes nor in outcomes of psychosocial treatment. However, the consistently higher level of psychosocial problems among adolescents with inadequate health literacy suggests an unaddressed need in psychosocial care.

Differences in care provided to children with behavioral and emotional problems in a delineated region by using the Taxonomy of Care for Youth (TOCFY)

Behavioral and emotional problems can lead to severe restrictions in the functioning of children and to an impaired development. The types of support for children vary greatly between care providers. The aim of this study is to apply the Taxonomy of Care for Youth (TOCFY) and to make an inventory of the core elements and program elements of the various types of support for children with behavioral and emotional problems that were offered overall and per main types of providers in a delineated region. We assessed the types of support to children (N = 621) by applying TOCFY. The study showed that by using Tocfy we could make an inventory of the various types of support offered. 'Individual child support' and 'family support' were provided most often, and therefore, most interventions were aimed at the child or at the child and his/her parents/caretakers. Support was mostly provided without judicial interference and within an ambulatory/outpatient or home-based setting. TOCFY could be helpful by mapping of information on the support offered to children across various types of care providers. More information on the core and program elements of these types of support may help to optimize care for children and their families.

Enrolment of children in psychosocial care: problems upon entry, care received, and outcomes achieved

Psychosocial care systems have been designed so that specific problems are treated by specific care types. There is insufficient evidence as to which problem types are actually presented to the various care types. This study assessed types and severity of problems among children and adolescents upon enrolment in psychosocial care, compared to children not enrolled; also outcomes after 3 and 12 months, overall and per care type. We obtained data on a cohort of 1382 Dutch children aged 4-18 years (response rate 56.6%), included upon enrolment in psychosocial care, and on 443 not-enrolled children (response rate 70.3%), all from one region. Results showed that enrolled children had more problems than children not enrolled in care. In child and adolescent mental healthcare (CAMH), relatively many children had internalizing problems, and in child and adolescent social care (CASC) relatively many children had externalizing, parenting, family and multiple problems. Regardless of the type of problem, care duration in preventive child healthcare (PCH) was relatively short; and in CASC and CAMH longer. After 3 and 12 months, rates of problem solution were highest in PCH. These rates were also substantial among children not in care. To conclude, our findings show that the system of psychosocial care functions as intended regarding the distribution of problems across care types. Extended demarcation of clients by problem type and severity towards type and contents of care may further improve the system.

Less reduction of psychosocial problems among adolescents with unmet communication needs

Patient-professional communication has been suggested to be a major determinant of treatment outcomes in psychosocial care for children and adolescents. However, the mechanisms involved are largely unknown and no longitudinal studies have been performed. Our aim was, therefore, to assess over the course of 1 year, the impact of patient-centered communication on psychosocial problems of adolescents in psychosocial care, including the routes mediating this impact. We obtained data on 315 adolescents, aged 12-18 years, enrolled in child and adolescent social or mental health care. We assessed patient-centered communication by comparing the needs and experiences of adolescents with regard to three aspects of communication: affective quality, information provision, and shared decision-making. Changes in psychosocial problems comprised those reported by adolescents and their parents between baseline and 1 year thereafter. Potential mediators were treatment adherence, improvement of understanding, and improvement in self-confidence. We found a relationship between unmet needs for affective quality, information provision, and shared decision-making and less reduction of psychosocial problems. The association between the unmet need to share in decision-making and less reduction of psychosocial problems were partially mediated by less improvement in self-confidence (30 %). We found no mediators regarding affective quality and information provision. Our findings confirm that patient-centered communication is a major determinant of treatment outcomes in psychosocial care for adolescents. Professionals should be aware that tailoring their communication to individual patients' needs is vital to the effectiveness of psychosocial care.

Expectations of barriers to psychosocial care: views of parents and adolescents in the community

Parents with a child suffering from psychosocial problems frequently experience barriers to psychosocial care, which may hinder access. Expectations of barriers may have the same effect, but evidence is lacking. The aim of this study is to examine parents' and adolescents' expectations of barriers regarding psychosocial care for the child, along with associated child and family characteristics. We obtained data on an age-stratified random sample of school children/pupils aged 4-18 via questionnaires (N = 666; response rate 70.3 %). Expectations of barriers to psychosocial care were measured with the "Barriers to Treatment Participation Scale-Expectancies" questionnaire (BTPS-exp). Results showed that 64 % of the parents of children below age 12, 59 % of the parents of adolescents (age 12-18), and 84 % of the adolescents expected one or more barriers. Parents and adolescents expected barriers most frequently with respect to irrelevance of treatment. Mainly parents with low educational level and their adolescents expected barriers regarding treatment, and quite a few characteristics of parents of adolescents were associated with expecting multiple barriers regarding treatment demands and issues, for example, single parents, parents of lower educational level and of adolescent boys, and parents of adolescents with psychosocial problems. We conclude that adolescents especially, but also their parents and parents of younger children, expect major barriers to psychosocial care, which may greatly hinder appropriate care seeking. This evidence may support professionals and policymakers in their attempts to improve access to psychosocial care.