Evaluation of a screening algorithm using the Strengths and Difficulties Questionnaire to identify children with mental health problems: A five-year register-based follow-up on school performance and healthcare use

Autoři: Rasmus Trap Wolf aff001;  Pia Jeppesen aff002;  Dorte Gyrd-Hansen aff001aff004;  Anne Sophie Oxholm aff001
Působiště autorů: University of Southern Denmark, Department of Public Health, Danish Centre for Health Economics, Odense, Denmark aff001;  Child and Adolescent Mental Health Centre, Mental Health Services Capital Region of Denmark, Copenhagen, Denmark aff002;  Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark aff003;  Centre for Clinical Research and Prevention, Capital Region of Denmark, Copenhagen, Denmark aff004
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pone.0223314



Treatment of mental health problems (MHP) is often delayed or absent due to the lack of systematic detection and early intervention. This study evaluates the potential of a new screening algorithm to identify children with MHP.


The study population comprises 2,015 children from the Copenhagen Child Cohort 2000 whose mental health was assessed at age 11–12 years and who had no prior use of specialised mental health services. A new algorithm based on the Strengths and Difficulties Questionnaire (SDQ) is utilised to identify MHP by combining parent-reported scores of emotional and behavioural problems and functional impairments. The screening is done on historical data, implying that neither parents, teachers nor health care professionals received any feedback on the screening status. The screening status and results of an IQ-test were linked to individual-level data from national registries. These national registers include records of each child’s school performance at the end of compulsory schooling, their health care utilisation, as well as their parents’ socio-economic status and health care utilisation.


10% of the children screen positive for MHP. The children with MHP achieve a significantly lower Grade Point Average on their exams, independently of their IQ-score, perinatal factors and parental characteristics. On average, the children with MHP also carry higher health care costs over a five-year follow-up period. The higher health care costs are only attributed to 23% of these children, while the remaining children with MHP also show poorer school performance but receive no additional health care.


The results demonstrate that children with MHP and a poor prognosis can be identified by the use of the brief standardised questionnaire SDQ combined with a screening algorithm.

Klíčová slova:

Health screening – Human performance – Child psychiatry – Children – Mental health and psychiatry – Schools – Health care utilization – Health care sector


1. Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual Research Review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry. 2015;56: 345–365. doi: 10.1111/jcpp.12381 25649325

2. Sawyer MG, Hazell PL. Health-Related Quality of Life of Children and Adolescents With Mental Disorders. J AM ACAD CHILD ADOLESC PSYCHIATRY. 2002; 8.

3. Costello EJ, Copeland W, Angold A. Trends in psychopathology across the adolescent years: What changes when children become adolescents, and when adolescents become adults?: Trends in psychopathology across the adolescent years. J Child Psychol Psychiatry. 2011;52: 1015–1025. doi: 10.1111/j.1469-7610.2011.02446.x 21815892

4. Copeland WE, Adair CE, Smetanin P, Stiff D, Briante C, Colman I, et al. Diagnostic transitions from childhood to adolescence to early adulthood. J Child Psychol Psychiatry. 2013;54: 791–799. doi: 10.1111/jcpp.12062 23451804

5. Reef J, van Meurs I, Verhulst FC. Children’s Problems Predict Adults’ DSM-IV Disorders Across 24 Years. Adolesc PSYCHIATRY. 2010;49: 8.

6. Hill RM, Pettit JW, Lewinsohn PM, Seeley JR, Klein DN. Escalation to Major Depressive Disorder among Adolescents with Subthreshold Depressive Symptoms: Evidence of Distinct Subgroups at Risk. J Affect Disord. 2014;158: 133–138. doi: 10.1016/j.jad.2014.02.011 24655777

7. Shankman SA, Lewinsohn PM, Klein DN, Small JW, Seeley JR, Altman SE. Subthreshold conditions as precursors for full syndrome disorders: A 15-year longitudinal study of multiple diagnostic classes. J Child Psychol Psychiatry. 2009;50: 1485–1494. doi: 10.1111/j.1469-7610.2009.02117.x 19573034

8. Patton GC, Coffey C, Romaniuk H, Mackinnon A, Carlin JB, Degenhardt L, et al. The prognosis of common mental disorders in adolescents: a 14-year prospective cohort study. The Lancet. 2014;383: 1404–1411. doi: 10.1016/S0140-6736(13)62116-9

9. Copeland WE, Wolke D, Shanahan L, Costello EJ. Adult Functional Outcomes of Common Childhood Psychiatric Problems: A Prospective, Longitudinal Study. JAMA Psychiatry. 2015;72: 892. doi: 10.1001/jamapsychiatry.2015.0730 26176785

10. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62: 593. doi: 10.1001/archpsyc.62.6.593 15939837

11. Arango C, Díaz-Caneja CM, McGorry PD, Rapoport J, Sommer IE, Vorstman JA, et al. Preventive strategies for mental health. Lancet Psychiatry. 2018;5: 591–604. doi: 10.1016/S2215-0366(18)30057-9 29773478

12. Weisz JR, Kuppens S, Ng MY, Eckshtain D, Ugueto AM, Vaughn-Coaxum R, et al. What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice. Am Psychol. 2017;72: 79–117. doi: 10.1037/a0040360 28221063

13. Cross S, Hickie I. Transdiagnostic stepped care in mental health. Public Health Res Pract. 2017;27. doi: 10.17061/phrp2721712 28474049

14. Levitt JM, Saka N, Hunter Romanelli L, Hoagwood K. Early identification of mental health problems in schools: The status of instrumentation. J Sch Psychol. 2007;45: 163–191. doi: 10.1016/j.jsp.2006.11.005

15. Anderson JK, Ford T, Soneson E, Coon JT, Humphrey A, Rogers M, et al. A systematic review of effectiveness and cost-effectiveness of school-based identification of children and young people at risk of, or currently experiencing mental health difficulties. Psychol Med. 2019;49: 9–19. doi: 10.1017/S0033291718002490 30208985

16. Kataoka SH, Zhang L, Wells KB. Unmet Need for Mental Health Care Among U.S. Children: Variation by Ethnicity and Insurance Status. Am J Psychiatry. 2002;159: 1548–1555. doi: 10.1176/appi.ajp.159.9.1548 12202276

17. Sturm R, Ringel JS, Andreyeva T. Geographic Disparities in Children’s Mental Health Care. PEDIATRICS. 2003;112: e308–e308. doi: 10.1542/peds.112.4.e308 14523217

18. Roberts RE, Fisher PW, Blake Turner J, Tang M. Estimating the burden of psychiatric disorders in adolescence: the impact of subthreshold disorders. Soc Psychiatry Psychiatr Epidemiol. 2015;50: 397–406. doi: 10.1007/s00127-014-0972-3 25358512

19. Balázs J, Miklósi M, Keresztény Á, Hoven CW, Carli V, Wasserman C, et al. Adolescent subthreshold-depression and anxiety: psychopathology, functional impairment and increased suicide risk: Adolescent subthreshold-depression and anxiety. J Child Psychol Psychiatry. 2013;54: 670–677. doi: 10.1111/jcpp.12016 23330982

20. Gustafsson J-E, Westling AM, Åkerman A, Eriksson B, Eriksson C, Fischbein L, et al. School, learning and mental health: a systematic review. Stockholm: The Health Committee, Royal Swedish Academy of Sciences; 2010.

21. Kristoffersen JHG, Obel C, Smith N. Gender differences in behavioral problems and school outcomes. J Econ Behav Organ. 2015;115: 75–93. doi: 10.1016/j.jebo.2014.10.006

22. Keilow M, Sievertsen HH, Niclasen J, Obel C. The Strengths and Difficulties Questionnaire and standardized academic tests: Reliability across respondent type and age. Goertz M, editor. PLOS ONE. 2019;14: e0220193. doi: 10.1371/journal.pone.0220193 31344079

23. French MT, Homer JF, Robins PK. What You Do in High School Matters: East Econ J. 2015;41: 370–386.

24. Gevrek D, Gevrek ZE, Guven C. Benefits of Education at the Intensive Margin: Childhood Academic Performance and Adult Outcomes among American Immigrants. East Econ J. 2015;41: 298–328. doi: 10.1057/eej.2015.6

25. Oreopoulos P, Salvanes KG. Priceless: The Nonpecuniary Benefits of Schooling. J Econ Perspect. 2011;25: 159–184. doi: 10.1257/jep.25.1.159

26. Skovgaard AM, Olsen EM, Houmann T, Christiansen E, Samberg V, Lichtenberg A, et al. The Copenhagen County child cohort: Design of a longitudinal study of child mental health. Scand J Public Health. 2005;33: 197–202. doi: 10.1080/14034940510005662 16040460

27. Goodman A, Goodman R. Strengths and Difficulties Questionnaire as a Dimensional Measure of Child Mental Health. J Am Acad Child Adolesc Psychiatry. 2009;48: 400–403. doi: 10.1097/CHI.0b013e3181985068 19242383

28. Goodman R. The Extended Version of the Strengths and Difficulties Questionnaire as a Guide to Child Psychiatric Caseness and Consequent Burden. J Child Psychol Psychiatry. 1999;40: 791. 10433412

29. Goodman R, Meltzer H, Bailey V. The strengths and difficulties questionnaire: A pilot study on the validity of the self-report version. Adolesc Psychiatry. 1998;7: 7.

30. Theunissen MHC, de Wolff MS, Reijneveld SA. The Strengths and Difficulties Questionnaire Self-Report: A Valid Instrument for the Identification of Emotional and Behavioral Problems. Acad Pediatr. 2019;19: 471–476. doi: 10.1016/j.acap.2018.12.008 30639760

31. Nielsen LG, Rimvall MK, Clemmensen L, Munkholm A, Elberling H, Olsen EM, et al. The predictive validity of the Strengths and Difficulties Questionnaire in preschool age to identify mental disorders in preadolescence. Hashimoto K, editor. PLOS ONE. 2019;14: e0217707. doi: 10.1371/journal.pone.0217707 31158249

32. Ortuño-Sierra J, Aritio-Solana R, Fonseca-Pedrero E. Mental health difficulties in children and adolescents: The study of the SDQ in the Spanish National Health Survey 2011–2012. Psychiatry Res. 2018;259: 236–242. doi: 10.1016/j.psychres.2017.10.025 29091822

33. Goodman R. The Strengths and Difficulties Questionnaire: A Research Note. J Child Psychol Psychiatry. 1997;38: 581–586. doi: 10.1111/j.1469-7610.1997.tb01545.x 9255702

34. Stringaris A, Goodman R. The Value of Measuring Impact Alongside Symptoms in Children and Adolescents: A Longitudinal Assessment in a Community Sample. J Abnorm Child Psychol. 2013;41: 1109–1120. doi: 10.1007/s10802-013-9744-x 23677767

35. Meltzer H, Gatward R, Goodman R, Ford T. The Mental Health of Children and Adolescents in Great Britain: (622732007–001) [Internet]. American Psychological Association; 2000.

36. Woerner W, Becker A, Rothenberger A. Normative data and scale properties of the German parent SDQ. Eur Child Adolesc Psychiatry. 2004;13. doi: 10.1007/s00787-004-2002-6 15243780

37. Arnfred J, Svendsen K, Rask C, Jeppesen P, Fensbo L, Houmann T, et al. Danish norms for the Strengths and Difficulties Questionnaire. Dan Med J. 2019;66.

38. Jensen VM, Rasmussen AW. Danish education registers. Scand J Public Health. 2011;39: 91–94. doi: 10.1177/1403494810394715 21775362

39. Ministry of Education. 7-point grading scale [Internet]. 2017 [cited 12 Nov 2018]. http://eng.uvm.dk/general-overview/7-point-grading-scale

40. Danmarks Statistik. Forbrugerprisindeks [Internet]. 2018 [cited 3 Jul 2018]. https://dst.dk/da/Statistik/emner/priser-og-forbrug/forbrugerpriser/forbrugerprisindeks

41. Danske Regioner. Pris- og lønudvikling 1988–2018 fordelt på løn og priser [Internet]. 2018 [cited 3 Jul 2018]. http://regioner.dk/aftaler-og-oekonomi/oekonomisk-vejledning/oekonomisk-vejledning-2018

42. Sahl Andersen J, De Fine Olivarius N, Krasnik A. The Danish National Health Service Register. Scand J Public Health. 2011;39: 34–37. doi: 10.1177/1403494810394718 21775348

43. Wallach Kildemoes H, Toft Sørensen H, Hallas J. The Danish National Prescription Registry. Scand J Public Health. 2011;39: 38–41. doi: 10.1177/1403494810394717 21775349

44. Lynge E, Sandegaard JL, Rebolj M. The Danish National Patient Register. Scand J Public Health. 2011;39: 30–33. doi: 10.1177/1403494811401482 21775347

45. Wechsler David. WISC-IV : Technical and Interpretive Manual 4th edition. San Antonio, TX: The Psychological Corporation; 2003.

46. Deb P, Norton EC, Manning WG Jr.. Health Econometrics Using Stata. Stata Press; 2017.

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