Strengths and Difficulties Questionnaire: Its Efficacy for Screening and Assessment of a School Mental Health Program in Urban Bangalore

Anand Lakshman, Deepak Sagaram, Shalini Purohit, Arpitha Ravishankar, Dakshina U Kanthy

AddressHealth

Bangalore

Abstract

The aim of the study is to explore the use of Strengths and Difficulties Questionnaire (SDQ) as a tool to help in screening children for therapy as well as assess the efficacy of therapy by pre & post assessment. SDQ is a questionnaire that screens child mental health issues, comprising a total of 25 items divided in five subscales: emotional problems, hyperactivity, peer relationships, conduct and pro-social behavior, with five items in each subscale. The primary aim of this questionnaire is to identify children at high risk of psychiatric disorders and those who therefore warrant further assessment and intervention. The questionnaires were filled by the teachers as well as parents of all the students in 5 schools in urban Bangalore, India. The students of one school were divided on the basis of scores and were assigned to therapy groups based on the ages of children, developmental sequence of children, and the subscale with the most abnormal score. These therapies included Social Skills Training (Classes I-V for children having abnormal scores in subscales peer relationship & pro-social behavior), Cognitive Behavior Therapy (Classes VII-X for children having abnormal scores in subscale emotional problems) and Problem Solving Skills Training (Classes VI-VII for children having abnormal scores in conduct subscale).  At the completion of therapy a post assessment was conducted with the help of teachers and parents to learn about the outcome of the therapies. The SDQ was found to be very promising both as a screening tool as well as an assessment tool for our therapies. Keywords: Strengths and difficulties questionnaire, child mental health, screening instrument.

Introduction:

Childhood is the founding stone for acquisition of most of the skills that would be used through adulthood. Children gain proficiency in most of the physical tasks, emotional coping and socially accepted behavior during this stage. And more interestingly, these acquisitions are made not only with the help of interaction with the family but also with interactions with unfamiliar individuals who may or may not be in their similar age groups. This is the reason why school forms an extremely crucial part of the child’s skill acquisition and development process.

Since the child is busy learning the academic curriculum as well as trying to excel in the extracurricular aspects, mental health of the child may take a backseat. However, recently, there has been a growing awareness about these and the focus seems to be on the child’s overall development more than ever. This means that children’s physical health is given just as much importance as the development of social and interpersonal skills, the ability to face a crisis situation and develop resilience, encouraging motivational learning and so on. Today school counseling has become a very prominent field of psychology and schools have started employing counselors for the betterment of children’s mental wellbeing.

Though there is increasing awareness about mental health during childhood, most mental health issues are more likely to be manifested and brought to the surface through learning deficiencies and disciplinary issues. However, diagnosing these issues is no easy matter. Considering that late childhood and adolescence are stages for major physical and emotional changes, diagnosis and intervention become a little tricky. The percentage of adolescents at risk of developing psychological conditions seems to be as high as 14.5% to 25% globally and 8.7% to 31.2% in India (Seenivasan, P & Kumar, C P, 2014) Awareness of mental health issues and appropriate behavior on the part of both, the school authorities and the family of the child can greatly help in providing an enriching environment for growth despite certain psychological conditions. This assumption also seems to be corroborated by a number of different studies conducted on a global scale.

The Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997) is a useful tool that could be applied in a community setting to assess emotional and behavioral problems. It has been found to effectively predict the presence of conduct, hyperactivity, emotional, and psychiatric disorders. Previously, it has been used in Britain to screen a community cohort for child psychiatric disorders and it identified over 70% of individuals with conduct, hyperactivity, depressive and some anxiety disorders. Numerous studies have been conducted to examine the rates of psychiatric disorders among young people worldwide and these describe increase in particular psychiatric disorders, such as conduct and emotional problems. There is little epidemiological data on the prevalence of psychiatric disorders among Indian adolescents.

Aim of this study was to explore the use of SDQ as a tool that helps in screening children for group and/or individual therapeutic interventions. A teacher and parent rated version of the questionnaire were used.  SDQ was administered to 3,868  students in 5 schools, of which pre- and post-assessment was conducted in one school as part of a pilot to test the efficacy of the interventions being used.

Materials & Methods

Participants

The students were selected for intervention based on the SDQ scores. The questionnaires were filled by the teachers as well as parents of all the students in a school. The cases with scores over the previously determined and validated cutoff points for total score by Goodman (13) and each of the subscales of SDQ were determined. Students who fall under the abnormal scores were taken for interventions. The studied population included all children between 6 to 15 years of age whose parents consented to allow their wards to participate in the study. A total of 3,868 students from 5 schools were enrolled in the study. The parents of all children were sent a SDQ questionnaire and teachers were asked to fill a teacher rated SDQ for all students as well. A pilot study to assess the efficacy of the interventions was carried out on 980 students (from the intervention school) of which 172 had abnormal scores. The students from the later group were selected for interventions. The pilot study was conducted at one school in the city of Bangalore, India from the period September, 2013 to February, 2014.

Study Design

The cases were divided among four groups based on the age and classes they studied (I-III, IV-VI, VI-VIII & VII-X). The cases were selected by two Clinical Psychologists using the SDQ Scoring Values (Table 1).

Table1: SDQ scoring values

Social Skills Training (SST) was used as an intervention for the first two groups (classes I-III and IV-VI). The children who scored low in the peer and pro-social domain were part of this intervention group. The intervention group received seven sessions of group SST over a 15 week period. Social skills can refer to a wide range of behaviors and abilities, which can be categorized as behaviors associated with social interactions (Kavale & Forness, 1996), and social competence (McFall, 1982). These dimensions of social interactions and competence can include friendliness, helpfulness, self-control, the ability to cooperate, and the ability to share (LaGreca, 1987). The positive attributes of these social behaviors result in successful social interactions for the child while the negative attributes are viewed as deficits that can lead to problems such as aggression, impulsiveness, acting out, and an overall inability to get along with peers in social situations (LaGreca, 1987). Social skill and competency deficits are readily identified at the pre- and early adolescence age. Poor social skills and relationship difficulties with peers, family and teachers are associated with many forms of psychopathology, including depression (Segrin, 2000), conduct disorders (Gaffney & McFall, 1981; Spence, 1981), social phobia (Spence, Donovan, & Brechman-Toussaint, 1999), autism and Asperger's syndrome (Harris, 1998) and early onset schizophrenia (Schulz & Koller, 1989). 

Problem Solving Skills Training (PSST) was implemented for students of classes VI-VIII based on abnormal scores in the Conduct Disorder domain. The intervention group received two sessions of group PSST over an 8-week period. Conduct disorder is one of the most frequent bases of clinical referral in child and adolescent treatment services, has relatively poor long-term prognosis and is transmitted across generations. Some evidence suggests that older children profit more from treatment than do younger children, perhaps due to their cognitive development (Durlak et al, 1991). A study by Kazdin 1992 evaluated the effects of problem-solving skills training (PSST) and parent management training (PMT) on children (JV = 97, ages 7-13 years) referred for severe antisocial behaviour. p. PSST and PMT combined led to more marked changes in child and parent functioning and placed a greater proportion of youth within the range of non-clinic (normative) levels of functioning. 

Finally students from classes VII-X were part of the Cognitive Behaviour Therapy (CBT) group based on their abnormal scores in the Emotional domain. The intervention group received seven sessions of group CBT over a 15-week period. In a randomized trial of a group Cognitive Intervention by Gregory N Clarke 1995, it was concluded that Depressive disorder can be successfully prevented among adolescents with an elevated future risk.

Instrument

The SDQ is a user-friendly screening questionnaire, which can be used to assess behavioural problems and mental health disorders. It can be administered to the parents and teachers of four- to 16- year olds and to the 11- to 16-year-olds themselves. Goodman, Ford, Simmons, Gatward and Meltzer reported the scale’s internal reliability to be accepTable, with a Cronbach alpha coefficient of 0.73. The questionnaire consists of 25 questions subdivided into five categories: conduct, hyperactivity, peer problems, emotional, and pro-social, with five questions in each scale. The sum of the first four subscales consist the total difficulty score. Each of the categories is given a score and then summed to get a total difficulties score, except the pro-social score, which is assigned a separate score. The scores can then be used to make separate predictions for conduct–oppositional disorders, hyperactivity–inattention disorders, and anxiety–depressive disorders. The questionnaire has 3 forms: parent-report, teacher-report and self-report. The parent and teacher report form was used in the present study.

Statistical Analysis

The schools were classified on the basis of board of affiliation ( State, ICSE & CBSE) and Mean SDQ score, Mean abnormal score and Mean normal scores were computed for all the participating schools. To evaluate the probable outcome of interventions being used a comparison was done with the help of pre-post Mean SDQ scores. Paired Student’s t-test was used to assess the efficacy of the intervention

Results

Five schools of different syllabi participated in this study, with there being two schools affiliated with the ICSE board and Karnataka State Board and one school affiliated with the CBSE board, as shown in Table 2. The schools selected for the study varied in their socio-economic background making the data representative of the larger population.

Table 2: Showing the classification schools as per syllabus.

Table3: Showing distribution of SDQ data.

SDQ was administered on 3868 children from the five schools of which 1930 teacher responses and 2120 parent responses were received. Of the 2499 children enrolled in the two ICSE board schools, 977 teacher and 1450 parent responses were received. The CBSE board school had 278 children enrolled, of which we received 196 teacher responses and 237 parent responses. The STATE board schools had 1091 children, we received 757 and 433 responses from teachers and parents respectively (Table 3). This indicates that the SDQ is easy to answer and is willingly accepted by parents and teachers. The availability of SDQ translated into the local language (Kannada) has made it easier and more reachable.

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The total number of children on whom the SDQ was administered was 3868 for the year 2012-2013, where teacher’s responses for the SDQ were 1930 and parent responses 2120. In the year 2012-2013, ICSE board has 2499 SDQ responses, 977 teacher responses and 1450 parent response respectively. CBSE has 278 SDQ responses, 196 teacher responses and 237 parent responses respectively and State board has 1091 SDQ responses, 757 teacher responses and 433 parent responses as shown in Table 3. This indicates the SDQ is easy to answer and is willingly accepted by parents and teachers, the availability of SDQ in Kannada version has made it easier and more reachable.

Table 4: Showing Mean of SDQ scores

The Mean total score of SDQ responses for all schools was 12.6 of that 22.8 had normal score and 10.9 had abnormal score, amongst ICSE schools Mean SDQ was 12.7 where Mean normal score is 23.0 and Mean abnormal score is 11.0 and for State board schools the mean SDQ score was 13.7 where 23.1 have normal score and 11.9 have abnormal score. For  the CBSE school Mean SDQ score was 7.7 where Mean normal score is 6.2 and Mean abnormal score is 19.2, the CBSE board includes only one school that could one of the reasons for lower mean score as compared to ICSE and State board, as shown in Table 4.

Table 5: Comparison of Mean SDQ score for the Intervention school

Table 5 indicates the comparison of Mean SDQ scores for the year 2012-13 and 2014-15 that is 12.6 and 11.4 respectively. A difference in Mean normal score is also seen which is 10.9 and 8.4 respectively. Finally the Mean normal scores are 22.8 and 20 respectively. It can be seen that Mean SDQ score falls under the normal category of SDQ scoring values as seen in Table 1.

Table 6: Pre and Post Mean SDQ scores for the intervention groups of intervention school

The last Table i.e. Table 6 analyzes the pre and post Mean SDQ scores for the intervention groups that were selected from the intervention school. The number of students that participated in the year 2012-13 has dropped by 7 numbers. A glance at the Mean SDQ scores gives a very clear indication that there is significant drop in the scores post intervention. This can be seen when Table 5 and Table 6 are compared.

The calculated p value for the Student’s paired t test was highly significant  (p < 0.01) which indicate  that the interventions have had very likely impact on the mean SDQ scores.

Discussion

The purpose of this study was to examine the efficacy of the various interventions on high risk sample of children based on SDQ scores. Our study population consists of urban school children and does not take into account the rural population whose perceptions may be different.

Also being a school based population the response rate is affected by parental and teacher consent and acceptance respectively on each pupil. In a Study by Shoba Srinath, Satish Chandra Girimaji et al (July 2005) suggested that the screening tools were most sensitive in the urban middle class areas therefore there could have been an under-or over- representation of mean SDQ scores. However, it has been shown that, on the whole, SDQs completed by parents and teachers are better indicators than SDQs completed by adolescents themselves ( Bharath Kumar Reddy K R, Asthik Biswas, Harini Rao, 2011). Thus this study uses the scores from parents and teachers that make it more valid.

The schools were selected randomly with no specific criteria for syllabus board and that shows the difference in total number of participants. In our study mental problems screened by using SDQ shows a slightly higher normal score in schools with ISCE and State board as compared to CBSE board. Considering the mean abnormal scores it can be seen that for ICSE and State board it comes under normal scoring value while the CBSE board comes under borderline scoring value (Table 1). This could be attributed to the fact that the strength in ISCE and State board (n=3590) was higher as compared to CBSE board (n=278) also the teacher and parent response rate combined for the ISCE and State board (n= 3617) was considerable more than CBSE board (n=433).

The results of intervention at the end of the 1st year of this study provided evidence of considerable changes that are consistent with the SDQ findings.

The mean SDQ scores, mean Normal score and Mean Abnormal score (Table 6) for the intervention school in the pre-assessment year (2012-2013) are higher when put side by side to the scores of the post-assessment year (2014-2015).

The significant decline of scores in the post-assessment year (2014-2015) indicates that there is positive implication of the group interventions (CBT, PSST & SST) on the targeted sample. The interventions were done in a group so as to include all possible students who had abnormal scores.

As seen in the results (Table 5 & Table 6) the intervention-group children seem to have progressed significantly in their acquisition of the desired skills. Also the familiarity of the SDQ among the parents and teachers by participating in consecutive years may have influenced the mean SDQ scores. The natural growth of children also has an implication towards the betterment of their skills which adds to the significant drop of the scores from Abnormal scoring values to Normal scoring values (Table 1 & Table 6).

In conclusion, this study documents support for the early effectiveness of the intervention in terms of the children's social cognition, academics, peer relations, and aggressive–disruptive behaviors. Furthermore, at least in the early phases of this long-term intervention, the intervention seems equally effective in each of these domains for both boys and girls.

One focus of future research will be to conduct a follow up of the same participants and comparing the results through clinical interviews.

Conclusion

Mental health problems are common among the school going children in India. Early detection and effective intervention can help in their holistic development and betterment of coping skills.

The SDQ gives a practical assessment of the mental health profile also and its effectiveness in the prognosis can help identify children with psycho-social problems and it plays a important role in its use as a preventive tool. It is availability in various languages and also its adaptability in different cultural settings makes it easy to use tool.

This study throws lights upon the positive effects of interventions over the span of the academic year in schools. That can bring considerable change in psychological development for the future generations.

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