Elsevier

Psychiatry Research

Volume 264, June 2018, Pages 340-345
Psychiatry Research

The young adult Strengths and Difficulties Questionnaire (SDQ) in routine clinical practice

https://doi.org/10.1016/j.psychres.2018.03.001Get rights and content

Highlights

  • The young adult SDQ was developed for use in routine clinical practice.

  • The findings showed that the young adult SDQ functions in a similar way to the adolescent version.

  • Public mental health services may benefit from the use of the young adult SDQ as an outcome measure for psychiatric treatment.

Abstract

Expansion of the youth mental health sector has exposed a need for an outcome measure for young adults accessing services. The Strengths and Difficulties Questionnaire (SDQ) is a widely used consumer and carer outcome measure for children and adolescents. The aim of this study was to evaluate the psychometric properties of a young adult SDQ. The young adult SDQ was introduced for routine clinical practice at Eastern Health Child and Youth Mental Health Service (EH-CYMHS), complementing the well-established adolescent and child versions. Data for adolescents (aged 12–17) and young adults (aged 18–25) where both self-report and parent SDQs had been completed at entry point to the service were extracted from a two-year period. Overall, paired cases involved 532 adolescents and 125 young adults. Across both self-report and parent SDQs, a similar pattern of results was found between adolescents and young adults on mean scores, inter-scale correlations, internal consistency, and inter-rater agreement. The findings of the current study support the use of the young adult SDQ in public mental health as an instrument whose psychometric properties, to date, appear consistent with those of the adolescent version. Further investigation is warranted.

Introduction

The transition from adolescence to adulthood may present many challenges in the wake of growing independence and lifestyle changes. Most psychiatric disorders emerge during this transitional period although are often first detected in later stages of life (Patel et al., 2007). In Australia, young adults aged 18 – 25 years have been identified as having the highest prevalence of psychiatric disorders across the lifespan (Australian Institute of Health and Welfare, 2016). Yet while more than a quarter of Australian young adults will experience a psychiatric disorder, they are the age group least likely to access mental health services (Slade et al., 2009).

It has been argued that the boundary between Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) contributes to the low uptake of psychiatric treatment by young adults (Islam et al., 2016, Singh et al., 2005). Traditionally, CAMHS have provided specialist mental health treatment across a broad range of severe and complex psychiatric disorders to those aged 0–18 years. The treatment model at CAMHS involves the young person, family, and broader system (e.g., school). AMHS in comparison have emphasised individual treatment for adults aged 18–65 years with a focus on symptom monitoring and psychotropic medication for people with more chronic and disabling psychiatric conditions.

Over the past ten years, there has been a movement to redevelop services to specifically target the mental health needs of young adults (McGorry et al., 2013, Scott et al., 2009). This has seen the rise of youth services such as headspace which has now been embedded in community centres across Australia (Rickwood et al., 2015). In the public mental health sector, there has been a push to reconfigure existing structures to ensure treatments are developmentally orientated for young adults (McGorry, 2007). Eastern Health has followed this proposal by extending the upper age limit of CAMHS to capture the young adult cohort. The service has been relabelled Eastern Health Child and Youth Mental Health Service (EH-CYMHS) and provides specialist mental health treatment to young people aged 0–25 years residing in the eastern suburbs of Melbourne.

The use of outcome measures are important for assessing the effectiveness of psychiatric treatment against standards of practice. Indeed, a key international priority has been the implementation of routine outcome measures across public mental health (Trauer, 2010). Australia has made substantial progress in this domain with the appointment of the Strengths and Difficulties Questionnaire (SDQ) as the leading outcome measure for CAMHS nation-wide (National Mental Health Information Development Expert Advisory Panel, 2013). Unfortunately, there has been little movement in establishing a routine outcome measure for young adults, let alone a consensus on a national consumer or carer outcome measure for use in AMHS (Burgess et al., 2015). A variety of consumer self-report measures are employed in AMHS including the BASIS 32, K10 and Mental Health Inventory (Pirkis et al., 2005), and while the majority of young adults live with their parents (Australian Institute of Health and Wellbeing, 2015), there is no agreed measure routinely offered to parents or carers. With the recent advances in youth mental health, there is a need for an outcome measure to be designed for young adults accessing services. Given that the SDQ is already in widespread operation throughout CAMHS, it presents itself as a potentially viable candidate for this role.

The SDQ is a commonly used measure of child and adolescent psychological functioning (Goodman, 1997). It consists of 25 items across five domains: emotional symptoms, conduct problems, hyperactivity, peer problems, and prosocial behaviour. Extended versions also include an impact scale to ascertain the degree of distress, chronicity, social impairment, and burden on others (Goodman, 1999). The SDQ offers several advantages over the outcome measures currently operating in AMHS. Firstly, the multi-dimensional approach captures the broad range of mental health difficulties for children and adolescents that remain developmentally relevant for young adults. Of key clinical importance, the SDQ also has the benefit of including a self-report and an informant version which allows for the perspective of parents and carers. The inclusion of an informant version may be particularly relevant given the generational shift for young adults to live with their parents longer (Australian Bureau of Statistics, 2009, Cobb-Clark, 2008, McGorry et al., 2014). Furthermore, recent studies have shown that the combination of youth and parent ratings is the best predictor for detecting mental health disorders (Aebi et al., 2017, Kuhn et al., 2017). The SDQ also supplies a follow-up version that includes the 25-items, impact scale, and two additional questions to assess the perceived overall effectiveness of treatment. The inclusion of a routine feedback system allows the treating clinician to track clinically meaningful change (Kwan and Rickwood, 2015) and has the potential to enhance clinical judgement and ultimately increase the effectiveness of treatment (Kelley and Bickman, 2009).

Alongside these clinical benefits, the SDQ has been found to have sound psychometric properties. In a large-scale community sample of over ten thousand British children and adolescents, Goodman (2001) demonstrated that the SDQ has satisfactory internal consistency, inter-rater agreement, and test-retest stability within the parent, teacher, and adolescent SDQ versions. Similar psychometric properties have been found across many countries including the US, Bangladesh, China, Spain, Finland, the Netherlands, and Australia (Bourdon et al., 2005, Gómez-Beneyto et al., 2013, Koskelainen et al., 2001, Lai et al., 2010, Mellor, 2005, Mullick and Goodman, 2001, van Widenfelt et al., 2003). The SDQ has also been validated against psychiatric diagnosis (Becker et al., 2004) and can predict the presence of a psychiatric disorder over time (Goodman and Goodman, 2009). There has been some discrepancy in the factor structure underlying the 25 items addressing functioning (Dickey and Blumberg, 2004, Ruchkin et al., 2008), although in general the theoretically proposed five-factor model has been supported (Bøe et al., 2016, Goodman, 2001, Mojtabai, 2006).

Qualitative approaches have also found generally positive views on the usability of the SDQ from the perspective of young people and their parents (Moran et al., 2012, Stasiak et al., 2013). In these studies, focus group participants viewed the SDQ as meaningful, easy to understand, quick, simple, unambiguous, and covering relevant issues. The brief nature of the questionnaire and free availability (www.sdqinfo.com) are also desirable features for policy makers within the public mental health sector.

There appears to be only a handful of studies which have used the SDQ beyond its original age range. Van Roy et al. (2006) used the SDQ in a large scale Norwegian study for young people aged 10 – 19 years. The SDQ was found to be effective in identifying a high-risk group of youth who were deemed to benefit from specialist mental health services. Glenn et al. (2013) have also employed the SDQ in a small sample of adults aged 18–43 years with Down Syndrome. In their study, the SDQ was shown to effectively detect the presence of a psychiatric disorder and was identified as user friendly from the viewpoint of parents and carers. While these studies provide initial support for the use of the SDQ in older populations, further research into the validity of the SDQ for adults is required.

In summary, services are being redesigned to target the mental health needs of young adults. These changes have highlighted the inconsistency in self-report outcome measures and the absence of informant measures. To date, these issues do not appear to have been satisfactorily addressed in Australia or internationally. While no single instrument will meet all needs, the SDQ has a range of merits lending to its adaptability for young adults. In particular, the SDQ has the capacity for multiple informants, can provide feedback to clinicians, and has the ability to track clinically significant change over time (Kwan and Rickwood, 2015).

The aim of the current study was to investigate a young adult version of the SDQ in a public mental health setting. The validity of the young adult SDQ was tested by drawing comparisons with its adolescent counterpart on a cross-sectional basis. The study specifically examined mean scores, inter-scale correlations, internal consistency, and inter-rater agreement for self-report and informant ratings. It was hypothesised that the young adult SDQ would yield similar psychometric properties to the adolescent version and thus provide preliminary support for its potential use as an outcome measure in routine clinical practice.

Section snippets

Participants

Participants were drawn from the 1122 adolescents (12–17 years) and 363 young adults (18–25 years) seen for an initial appointment at EH-CYMHS between July 2012 and June 2014. Completed SDQs were obtained from 53% of adolescents and 43% of young adults, while informant ratings for adolescents and young adults provided 61% and 37% of completed SDQs respectively. The type of informant was not distinguished in this study, although the large majority of informant SDQs were completed by parents. In

Mean scores and standard deviations

The young adult group contained significantly more males than females compared with the adolescent group (χ2 = 10.91, df = 1657, p=0.001). The effect of gender on age group for the total difficulties score was examined using a two-way ANOVA. Examination of the total difficulties scores revealed no interaction effect between gender and age group (F = 1.01, df = 1653, ns). While males had lower total scores than did females, this did not vary between adolescents and young adults.

Mean scores and

Summary of findings

The current study set out to examine the use of the young adult SDQ in routine clinical practice. The psychometric properties of the young adult SDQ were investigated alongside the adolescent version. It was hypothesised that a similar pattern of results would emerge between the two age groups, thus providing initial support for the validity of young adult SDQ. In general, the results in this study confirm that the young adult SDQ operates in a similar manner to the adolescent version.

The SDQ

Acknowledgements

The generous support of the Eastern Health Foundation is gratefully acknowledged. The authors also wish to acknowledge the young people, parents, and clinicians at EHCYMHS whose routine use of outcomes informs their joint work. The authors thank Dr. Robert Goodman for both supplying the early draft of the young adult SDQ and for his encouragement to examine the validity of a young adult version. The authors also emphasise that any modifications of the SDQ can only occur with the support of Dr.

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

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