Strengths and Difficulties Questionnaire seminar - video transcript

(Linda Pannekoek is a Senior Advisor and researcher at the Ministry of Health)

Good morning everyone and thank you all for coming.  I see a few familiar faces in the room here so I hope that there's always something new coming out of a presentation.  Just for my own interest, who of you is aware of what the Strengths and Difficulties Questionnaire or the SDQ is?  Okay, that's a fair few hands.  That's great.  I'll start with a bit of an introduction of what the Strengths and Difficulties Questionnaire is, so hopefully that will be clear to you all after this session, but please feel free to stick up your hand if you've got any questions, if I've forgotten something or if something's not entirely clear.  And as was just mentioned, there'll be a Q and A at the end as well so there's plenty of time for questions. 

My presentation today will focus on the results that we have from the Strengths and Difficulties Questionnaire based on the New Zealand Health Survey.  And last year I published the report on the Ministry of Health website.  There's a link at the bottom there but you can search for it and that will have more detailed results. 

So the Strengths and Difficulties Questionnaire is a screening measure for social, emotional and behavioural problems in children 2 to 14 years of age.  I will be presenting on the parent report version.  There's also a teacher report version, but that one is not part of the New Zealand Health Survey and there's also a self-report version for older children or young people from 11 to 17 years of age.  I also don't have results or data on that one.  And very exciting I found out this week that Oranga Tamariki is actually translated the SDQ recently into te reo and that's available on the SDQ website, which I think is a great piece of work. 

So as I said the SDQ screens for difficulties in children.  It is very important to keep in mind it's a screening measure.  It's got 25 items to which the parents respond.  So it's very quick and for how short it is I think it does a great job, but it's not a diagnostic tool, so that is important to keep in mind.  Widely used internationally and research internationally has shown that it seems to work well in most countries where it's been used or as far as I know (inaudible). 

So the questionnaire covers five aspects of children's development, in the areas of emotions, peer relationships, hyperactivity, conduct and pro social behaviour.  And the four areas that assess difficulties to get or make up the total difficulty score.  I've highlighted there.  The original work by Dr Goodman who developed the questionnaire in the UK set up thresholds to determine which children have a score that indicates that they may be at risk and these children should ideally be referred for a further assessment, maybe a clinical assessment and potentially some sort of intervention.  These cutoffs were based on a UK study in 1997, I believe.  So it's quite a while ago.  And their hypothesis -- or they based it on the fact that they wanted to identify around 10% of children as concerning.  And around 10% of children as borderline and 80% of the children as developing without any difficulties in the areas that are assessed by the questionnaire.  I realize that that's a little while ago.  And also it was done in the UK based on the prevalence of mental health issues in children in the UK then, but, as I said, research that (inaudible) everywhere around the world has found that actually these thresholds work quite well in identifying children that do have some level of difficulty that may require attention.  And I'll show later that we also find there's a strong association between children identified with issues and some of the other things we looked at. 

Just to give you a bit of an idea of the sort of things that parents are asked, an example of the emotional subscale items was many worries, a child worries a lot, and parents can respond, "not true, somewhat true," or "certainly true".  In the area of conduct an example is often fights with other children.  Hyperactivity: he or she is constantly fidgeting or squirming.  Peer problems, an example is being picked on or bullied by other children.  And the pro-social skill, one of the items is considerate of other people's feelings. 

So there's five questions in each of these areas but they're mixed so that they go ... yeah they're all mixed, so they don't go through one subscale first and then move on to the next area of behaviour.  Some questions are phrased positively and some are phrased negatively and in the scoring afterwards that's accounted for.

A little bit about the New Zealand Health Survey.  It surveys around 4,600 parents annually about children 0 to 14 years of age.  It has some core questions which are the same every year asking about things like health status, diet, risk behaviours, unmet need, a whole range of questions and then each year they have a module that goes into a little bit more depth in specific areas and the SDQ was part of the child developmental health and wellbeing module in 2012-2013, 2014-2015 and 2015-2016.  Also in 2016-2017, but when I did this piece of work that data wasn't available yet.  So I won't be able to show you results based on that. 

The SDQ was used only for 3 to 14 year old children.  In 2016-2017 they included two year olds.  So parents also responded if their child was two years old, but not in the years that I will be talking about.  The results are representative of the New Zealand population.  Certain populations are over sampled, so they over sample Maori families or households in areas of high deprivation.  But we use weights later on in the analysis to account for that, just to ensure that the results are robust enough to be able to look at sub-populations. 

A quick slide to show that there wasn't a lot of difference over the years.  So on the left you can see the total SDQ score using the threshold for concerning in which the percentage of children that fell above that.  So overall it was around 8% of children that had a concerning score on the SDQ overall.  Parents most frequently indicated issues with peer behaviours.  And it goes up and down a bit across the four different years but none of the differences were statistically significant and therefore I decided to combine the three years that I had data for at the time.  So 2012-2013 to 2015-2016 together again to have a big enough sample to have a robust findings.

So what did we find?  We found that on average across the three years around 8% of children had a concerning score on the SDQ.  Which is an estimated 57,000 in a year.  And out of 57,000 children 7% had a borderline score on the on the total SDQ scale.  So if we look at the concerning end of the SDQ, which is what I will be referring to in the rest of the presentation, we found that more boys and girls had issues.  So boys were one and a half times more likely to have a total score of concern.  Children living in the most deprived quintile of neighbourhood deprivation were three times more likely to have a total score of concern and Maori children are 1.8 times more likely.  We also found that 10 to 14 year olds were 1.3 times more likely than five to nine year old children to have that concerning score.  There was no significant difference on the overall scale for Pacific children compared to non-Pacific children.  But I'll show later that for 

some of the subscales, so the sub areas that we looked at, there were differences between Pacific and non-Pacific children.  And Asian children were less likely to have a total score of concern compared to non-Asian children.  Here I've split down the results by age groups.  So the blue bars are preschool children, three to four years.  Orange is five to nine years and the grey is 10 to 14 year olds.

It's important to note that the questionnaire for preschool children is slightly different from the one that's used for school-aged children, just to make sure that the behaviours that they ask about are appropriate for the age, because obviously they can't ask about things that are more school related behaviours because the children are not going to school yet.  Particularly for a conduct problem scale, that's the only sub-scale actually, there's two questions that are different for the three and four year olds.  And they also have determined different thresholds to see which children have a concerning score or not for the preschool children compared to school age children.

So what we can see is that hyperactivity issues go up with age, more 10 to 14 year old children had difficulties in that area compared to three and four year olds.  For conduct problems we didn't see a significant age trend.  Emotional symptoms seem to start higher and drop down and then climb up again for 10 to 14 year olds.  But the thresholds for three and four year olds was different.  And if we look at the main score on the sub-scale we actually see that the difficulties go up with age.  And no significant trend for peer problems. 

So I talk about children who fall above or below the thresholds for concerning scores in the SDQ.  But I think it's very important to keep in mind that it's actually a distribution and a child that falls just above the cutoff score or the threshold is not necessarily going to be any different from a child that falls just below it.  And as you can see here there's a scale from 0 to 10 for the hyperactivity sub-scale.  And the majority of children have very few difficulties.  So anywhere on the end(?) of zero means that there are very few difficulties.  What we saw was that hyperactivity issues went up with age.  If we looked at children falling above the threshold.  But if we look at the distribution we can actually see that for three and four year old children there were a lot fewer parents who indicated that there were no issues with hyperactivity whatsoever.  You can see on the far left it's around 8% for three and four year olds.  So 8% of parents didn't indicate any concern with hyperactivity, while for 10 and 14 year olds that was around 14%.  However on the severe end of difficulty, so close to the 10, there were fewer parents of preschool children indicating concerns.  And you can see a bit of a blip and in the middle there for the blue, so the three and four year olds, indicating that three and four year olds were more likely to have at least some degree of difficulties with hyperactivity.  And what we can't tell from this data is are these children on a path to more severe difficulties or is this related to their age.  Is it something they grow out of?  Is it a phase?  And in the literature there seems to be evidence going either way and I think there's more research needed looking at SDQ longitudinally to see how things change over time.

Also something to keep in mind is that a lot of children had issues in overlapping areas of behaviour.  Some children had issues only in one area.  So, for example, 6.9% of the parents indicated issues with peer problems and not with any of the other areas of behaviour that were looked at.  But 0.7% of parents indicated issues for their particular child in all four areas of behaviour.  So we see different patterns of the difficulties that children experience.  But overall more than one in four children experience difficulties in at least one of the four areas assessed.  It doesn't mean that they all had a total score, so when we combine it all together, of concern, the parents indicated that there was some difficulties in at least one of the areas. 

To show you that the SDQ is actually picking up something I looked at how the results of the SDQ are related to doctor diagnosed issues with mental health or development.  Obviously the numbers are going to be really small because not many children are diagnosed already with depression.  I looked at five to 14 year olds, just to make sure that -- in 0 to 4 year olds there's very few children diagnosed with any of these conditions.  In the overall New Zealand child population 0.8% of children were diagnosed by a doctor with depression, but if we look at children who had a concerning score in the SDQ this was 5.3%.  Anxiety overall in New Zealand 3.1% and we had a concerning SDQ score this was 14.6%.  And in the table on the right you can see how much more likely children with a concerning SDQ were to be diagnosed with any of these conditions.  So children aged 5 to 14 with a concerning score on the SDQ were 18 times as likely, for example, to be diagnosed with ADHD by a doctor.  Keeping in mind that the numbers are small here because very few children already have a diagnosis in young ages.

When we look at different sub-populations in New Zealand we see quite a bit of difference in the rate of difficulties that we can see based on the SDQ.  The lines here are 10%, which is what the SDQ originally was set up to identify as concerning and 20% for borderline.

8%, as I said, of New Zealand children had a concerning score and you can see the blue, the concerning, for the overall New Zealand population in the left hand corner was all pretty close to the 10% that we expected to see, but we identified more peer problems than the 10% that the threshold will set up to identify.  And more peer problems were seen across the four ethnic groups or three ethnic groups.

When we look at it by neighbourhood deprivation we can see a gradient for all the different sub-scales.  So the total scale on the left going to conduct problems on the right.  And on the left is the lowest bars of quintile 1 and dark blue on the right are quintile 5.

Just looking at the numbers.  So when we compare quintile 5 to quintile 1 on the total SDQ we find that children living in the most deprived neighbourhoods were three times as likely to have a concerning score on the SDQ compared to children living in the least deprived areas.  For peer problems this was two and a half times and for conduct problems 2.3 times. 

The New Zealand health survey also asks parents about whether they have any stress related to parenting.  One of the questions they ask is, "In general how well do you feel you're coping with the day to day demands of raising children?"  This is about any children they have, not about the particular child that they completed the SDQ for.  But what we can see is that parents with a child with a concerning SDQ were more likely to indicate that they had issues with coping with the demands of raising children.  So the blue bars are parents who had a child with no concern on the SDQ and in orange are the ones who indicated that they did have concerns about their child's behaviour on the SDQ.  And on the right hand we see not coping very well and not very well at all.  And the bar is bigger for the orange for the parents who indicated concerns on the SDQ, indicating that they were coping less well and this was statistically significant for all comparisons other than for coping well where the rate was fairly similar.

Another question over the past month, "How often have you felt that your child was much harder to care for than most children the same age?"  Here it was about a particular child that the SDQ was completed for and we see the same pattern.  More parents with a child with a concerning SDQ indicating that they felt like their child was harder to care for and fewer indicating that they never thought that they felt their child was harder to care for. 

Same question again, "How often have you felt that your child does things that really bother you?"  More parents of children with a concerning SDQ indicated that they felt like their child did things that bother them.  "How often have you felt angry?"  Again, the same results as identifying the same pattern for all these items.  And they were all statistically significant.  What is interesting is also that parents with a child with a concerning SDQ were more likely to indicate that they had no one to turn to for day to day support raising children.

More recently I've been doing work looking at household food insecurity.  So there's another questionnaire that asks about whether the household has the right amount and the appropriate access to food and so the blue bars here showed households that were moderately to severely food insecure.  So they were lacking access or quality of food in the household and may not be the particular child because some evidence shows that it's often the parents who limit their intake while they provide for their children first.  And the orange is the food secure group.  And what we can see here is that food insecure households, the children living in those households were much more likely to have concerns on the SDQ.  For the total score, so on the left and for all the four other sub-scales of the SDQ as well and the differences were all statistically significant.  So I think this is really showing that the SDQ is picking up something, you know, it's picking up issues that the child may experience and maybe picking up broader issues that are experienced in the household.  Thank you.