Frequently Asked Questions.
The Early Years DAWBA (2-4 years old) has been used less extensively than the standard DAWBA, but the initial findings are encouraging and several researchers are currently carrying out analyses that should lead to publication.
Professor Tamsin Ford and her colleagues are carrying out some of these analyses in conjunction with a Norwegian group. The findings linked to to the recent government survey (here is the link: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017).
This means that you will need to consider the continuous (i.e., "raw") scores within the light of your own population and, when using the SDQ with individuals, applying your clinical judgement and knowledge of other scores/individuals to assess the level of problem. With the SDQpro, however, the ability to create historical records for individuals gives you the ability to visualise SDQ score/subscore trajectories and, here, a change in > 2 "points" is likely to be significant.
We are hoping to improve and relaunch the 18+ SDQ at some point. Even then, we will have to wait until others do research on populations to understand what adult norms may be. We suspect for young adults (18/19 - 26), they are not that far from the norms for under 18s.
The use of the DAWBA to predict specific sorts of mental health problems generates a good proxy for what an experienced child psychologist or psychiatrist would diagnose, based as it is on the review by experienced psychologists and psychiatrists of detailed information and verbatim accounts from multiple informants. Indeed, the systematic nature of the data collection and analysis means that the DAWBA probably outperforms clinicians in terms of predicting future diagnoses.
As regards the SDQ, multi-informant SDQs are an excellent guide to "caseness" (i.e. predicting whether a child or adolescent has a significant mental health difficulty), but is weaker at predicting exactly what sort of disorder that is - weaker but not useless: if the child meets caseness criteria, the SDQ provides useful information on whether the disorder is likely to be behavioural, or emotional or autistic in type. However, diagnostic predictions from the SDQ are less strongly predictive than DAWBA-based predictions, and are most likely to be predictive at a group rather than individual level.
My recommendation is to use a stepped assessment where possible, beginning with the SDQ and proceeding to a DAWBA if the SDQ is positive [for mental health problems]. As we increasingly recognise how common child mental health problems really are, how persistent they can be, and how much they damage children and society in terms of suffering, economic cost and restricted futures, the case for stepped assessment becomes increasingly persuasive.
To return to your original question, expecting to identify mental health disorders accurately and cheaply with a single screener is generally unrealistic. Identifying high-risk cases with the likes of the SDQ is realistic, but characterising the type (or types) of disorder will generally require a more detailed supplementary assessment such as the DAWBA. Such a stepped approach is affordable in the UK - what is not affordable is to blight children's lives unnecessarily, costing more in the long-run. The fact that we commonly do so is a sad reflection of the low priority of mental health (despite fine but empty promises to the contrary)!
You are considering using the full 25-item adolescent self-report version of the SDQ, and this could be an excellent choice - but there are a number of points that need considering. One of the best features of using the core 25 items is that they cover a very broad range of child psychopathology - not just the depression symptoms that are covered by MDE measures, but also items that are typically raised in behavioural disorders, autism spectrum disorders, ADHD, anxiety disorders, obsessive-compulsive disorders and post-traumatic stress disorders. For this reason, the SDQ total difficulties score is a particularly comprehensive yet brief indicator of mental health difficulties in adolescence.
However, symptoms are not the same as functional impairment or even distress - and if it is critical to your remit that you measure impairment and distress directly, we suggest that you use the SDQ along with its very brief impact supplement attachment.
You raise the question of cut-offs, and there are indeed well-documented SDQ cut-offs - but we would caution you that people sometimes take these too literally. We humans like cut-offs since it simplifies our world to have good scores and bad scores. Sadly, reality is more complicated: on careful inspection, there is a continuous gradient from good to bad scores, without any step-wise transitions. The SDQ has particularly good dimensional properties, with every point increase in the total difficulties score proportionally raising current and future rates of psychopathology.
One option is to ignore this dimensionality and draw an arbitrary line in the sand - and this, to be honest, is what many SDQ users opt to do, and they mostly seem happy with the simplification.
However there are many statisticians who argue that a better response is to embrace dimensionality and not get too hung up on how many individuals are above or below some arbitrary cut-off, and to focus instead on the group mean. This is statistically more powerful, with the mean SDQ score of a group in the population being highly predictive of the mean rate of mental health disorders in that same population. We like this approach, but have to concede that dimensions can sometimes be harder for some clinicians and policy makers to interpret- in which case reversion to traditional cut-offs may be the needed.
There are many plausible impairment scales, it is perhaps worth pointing out that there are advantages to using the SDQ to measure both symptoms and impairment since there are long established SDQ algorithms for predicting diagnoses from the combination of symptoms and impairment (in line with DSM guidelines, e.g. for the diagnosis of ADHD).
Secondly, it is relevant that the adolescent self-reported SDQ includes an single item on whether the respondent thinks they have difficulties in any of the following areas: emotions, concentration, behaviour or being able to get on with other people. This is a very transparent question that is unlikely to raise ideological hackles. Policy makers who may be inclined to dismiss complex questionnaire scores find it easy to see the relevance, say, of the finding that 10% of the youth in their district think they have definite or severe difficulties with emotions, concentration, behaviour or being able to get on with other people.
In my view the best way to use the SDQ to judge change at the group level is to focus on the reduction in mean SDQ score - and particularly the total difficulty score. This uses all the available data and is much more statistically powerful than looking at the proportion with some particular percent decrease in the total difficulties score (JAACAP paper attached). As it says in this paper:
"Across the full range of the parent, teacher, and youth SDQ, children with higher total difficulty scores have greater psychopathology as judged by the prevalence of clinical disorder. This was true cross-sectionally and also in predicting to disorder status 3 years later."
There was no evidence of threshold effects for the SDQ at either high or low scores, but rather the odds of disorder increased at a constant rate across the range. Any decrease at the group level is good, and bigger changes are proportionately better."
In a given population, the proportion of children with a disorder is closely predicted by mean symptom score (JCPP paper attached). Many clinicians want a cut-off between what is good and what is bad, but for mental health as for so many other things, there is a continuum without any sharp cut-off.
As the author of the SDQ, I don't have the definitive answer, but I have some ideas that may be helpful. To start with, in my experience, there is no single best way to share SDQ results with parents, but there are several good ways that suit different parents (and equally several good ways to report back self-report SDQs to young people)
Many parents like to see how their child's SDQ scores compare with those of other people of the same age in key domains such as behaviour, emotions and impact). Colour coding scores into different bands for "close to average", "high" or "very high" work well for some people, giving them an instant overview.
However, other people find computer bands a bit mechanical and prefer it when completed SDQs are used not as an end point, but rather as a starting point for further exploration and dialogue.
For example:
"Looking over the answers you have given about your son, it seems as if he has a variety of emotional symptoms that are both upsetting him and and interfering with his getting on with his everyday life - including how well he gets on with you and the rest of the family. But a brief questionnaire can be misleading, making things seem better or worse than they really are.
You are experts on your son - in his case, do you think we need to be thinking further about stresses affecting him and what - if anything - could or should be done about that? Perhaps nothing needs to be done, perhaps it would be good to repeat the questionnaire in 6 or 12 months, or perhaps the time has already come to look further into what options are available. What do you think?"
That's just an example - the key lies in flexible responding based on training and experience.
As regards special schools my own experience is that the SDQ is often both suitable and helpful in special schools for the assessment by parent report and/or teacher report of individuals who do not have severe cognitive impairment - which can be operationalised as having a mental age of around 2 or more. Up to this sort of mental age, most parents and teachers find the questions relevant and answerable - and the answers can guide management and further assessment.
When the mental age is well below 2, it is more likely that respondents will find the questions inappropriate, or hard to interpret. The more complex the special needs, the more likely it is that the DAWBA will be appropriate: this includes the SDQ as well as sections on problems such as autism and repetitive behaviours that are more likely in children in special schools.
The SDQ and DAWBA are increasingly widely used in special schools and with children who have cognitive impairment. For example, they have been very successfully used in a large study at Great Ormond Street in the UK for the evaluation of emotional and behavioural problems in children with chromosomal abnormalities (copy number variants).
In terms of using “three points” as a cut-off, and whether this is clinically significant: I’m afraid we have never defined what we consider to be “clinically significant” on the SDQ, although it is possible that some other users have done (if you wanted you could search for relevant papers on our SDQ journal article repository http://sdqinfo.org/py/sdqinfo/f0.py). To put that value in context, in the national British Child and Adolescent Mental Health Surveys of 1999 and 2004, the standard deviation for self-report age 11-16 was 5.2 SDQ points, and the standard deviation for teacher-report age 5-10 was 5.9 points. We don’t have normative US data for self-and teacher-report on our website (again, this may exist in the literature), but instead only have parent-report (http://sdqinfo.org/norms/USNorm.html). This indicates a standard deviation for the total difficulty score of 5.7 for 4-17-year-olds, very similar to the corresponding value of 5.8 for 5-16-year-olds found in the British national study. Putting these things together, an increase of around three SDQ points would probably represent a change of just over half a standard deviation – which would seem like an important change from a practical and public health point of view. (In terms of the issue of statistical significance, this would obviously depend primarily on your sample size)
As regards using a percentage threshold-based measure rather than a change in mean score: Is there a reason why you prefer this, as opposed to comparing the mean score on the population before and after? That could be a good alternative, as we have previously shown that every one-point increase in the SDQ does correspond with a decrease in the prevalence of disorder (https://www.ncbi.nlm.nih.gov/pubmed/19242383). As such, our argument has always been that any significant decrease in the mean SDQ score can be assumed to correspond to an improvement in the underlying mental health of the population. The advantage of this approach would be it would have potentially greater statistical power, and remove the need to select an inherently arbitrary threshold.
If you do decide to go for the “three points” approach, we believe you will need to consider the proportion of children who have had a deterioration in their SDQ score alongside the proportion who have improved. We would expect a non-trivial proportion of students to both increase and decrease their SDQ scores by any given amount (e.g. three points) due to a mix of random factors (e.g. how the child feels on a particular day) and genuine “churn” in the population such that any time some children have improving mental health and some have deteriorating mental health. As such, knowing that e.g. 10% of children improved by at least three percentage points would not by itself seem very interpretable to us , without knowing what the corresponding proportion was who decreased by that amount. This could be another argument for focusing on the change in the mean score, and then perhaps segmenting that mean change into proportions of the population increasing or decreasing by a given amount (e.g. change by: <=-3 points, -2 to -1 points, 0 points, 1-2 points, >=3 points).
One final thing: You don’t say over what time period you are conducting this study. If it is e.g., over a full school year, then using standard SDQ twice would be fine, and maybe the simplest thing to do. However, if the follow-up period is less than six months, there is a bit of an issue in that the SDQ has a six-month reference window, so your follow-up period would be including some of the pre-intervention time as well. One option that you can consider would be using our “follow-up SDQ”, which has the same questions but has a one-month reference period and also a couple of additional questions about whether the intervention was helpful. The standard wording, in the versions on the website (http://sdqinfo.org/py/sdqinfo/b3.py?language=Englishqz(USA)) is “since coming to the clinic”, but we could modify this for you to language of your choice, e.g. “since participating in the healthy schools programme”.
In SDQpro, each client/individual gets a unique, persistent ID (we call this the PlusIID). This allows all client/individual's interviews to be related and tracked as long as your account exists. SDQpro also enables creation of patient/student/client group lists which makes the SDQ much, much easier to use.
In SDQscore (the traditional, paper-based scoring system), each interview gets a unique, persistent ID (we call this the IID). The IID is linked only to your account; you must provide mechanisms to associate IIDs with individuals.
Self-entered and email-able assessments via SDQpro are based on a single $2 fee per child on completion of the first assessment, thereafter all assessment with that specific child are free for the remainder of the academic year as determined by the organisation administering the SDQ. All reports and results data are included in this fee, and there are no charges for registration, assessment storage, exports or software for any SDQ services. Self-entered assessments and paper-based assessments can mixed for individual clients. Note that the $2 per child pricing is an introductory offer for the 2025-26 academic year; it will rise to $3 per child in September 2026.
Organisations using SDQscore typically are paying US$0.50 per assessment. Users are asked to confirm prices as they are incurred. The reason for the second confirmation is the optional PDF ... if you want to save cash costs, print just the HTML or take a screen-shot and save it; the same information is on the HTML report that is included with the score. The PDF is more attractive and people find it easier to save.
I recommend that all SDQ users take a look at SDQpro (https://www.sdqpro.org/). Initially, SDQpro may seem more expensive, but if you are planning to use multiple SDQs across the year (paper or digital) you may find it more cost effective, as well as giving you access to much more extensive results data for individuals and/or group(s).
You raise an interesting question, and one that we have thought a lot about. The topics in the DAWBA menu have to be listed in some order, and we have chosen to list them in fixed rather rather than random order since this increases comparability across subjects. We do not have a "random" option.
We are aware, though, that if you force respondents to go through the topics in a fixed order, that might lead them to answer initially questions that do not have much relevance for them (or their child) and this can indeed lead to their getting bored and giving up early. For an internet measure, you cannot prevent respondents from logging off if they get bored, so it is important to keep their interest as long as possible.
In our experience built up over decades, the best way to do this is NOT to insist on a fixed or random order but to encourage respondents to start by looking at the menu and completing the section that seems most relevant to them or their child - and then go on to the section that seems to them to be the next most relevant to them or their child, etc. That is why the instructions that are presented along with the menu of options include:
- Choose the next topic
- For more information on how to choose, click here.
- When they click, what they see is: Choosing the next topic
- When you go back to the list of colour-coded topics:
- Red topics are the ones you haven't yet answered.
- Please choose the next new topic that seems most relevant to you/ your son/Your daughter.
In our experience, this generally works well. If your respondents are not reading the instruction to focus on answering the most relevant sections first (and, to be honest, most humans are not good at reading instructions), then perhaps your team could also tell them individually before they start completing the DAWBA about the desirability of starting with the most relevant sections. It would be even better if your team were also able to reinforce another point that we do already make (but that they might not read): Even if none of the new topics seems particularly relevant, it would help us a lot if you'd work your way through them anyway. If there's nothing much to say, you will find that they are very quick to answer. (This is true because of the way the skip rules work)
"Instead of lies and cheats it had was argumentative" - this is the preschool version. Lies and cheats is not as relevant to preschoolers, whereas argumentative is more relevant and taps in to the same underlying construct, namely behavioural/conduct disorder.
"Steals from home school ..." again, because of age differences, stealing is less relevant (and spiteful more relevant) to preschoolers.
The SDQ is a fully-structured measure that is designed to be self-completed: and as such it does not need any training in the person administering it, they can just hand the paper out. (Indeed, if the practitioner were actively helping the person completing the questionnaire to choose the right answers then that would make the responses no longer comparable with the norms provided - and so this is not advised)
Some practitioners do decide to use the responses on the SDQ as a starting point for further discussion. But that is not part of the SDQ per se, rather practitioner decision.
We only have one set of SDQ cut-offs that we use, not a variable set by country. And in any case, the US norms are very similar to the UK norms - see this article: https://www.sciencedirect.com/science/article/abs/pii/S0890856709616312
We generally try to discourage people from getting too hung up on the precise cut-off numbers for particular regions, since really the SDQ score cut-offs are somewhat arbitrary, and the scores should be interpreted as dimensions.
Each time an assessment is created in the SDQpro system it will list both the user that generated it and the date it was generated amongst other relevant information such as the suborganisation and group(s) the assessed person was part of. This can be viewed on an individual, group, suborganisational or organisational level via a range of visualisations and exports by any professional user using the system dependent on their respective access level.
SDQpro will also allow you to monitor the status of any assessment; whether it has been generated, has expired or been completed (including relevant completion dates). Active assessments can be viewed in an .xlsx format to act as a reminder or allow you resend login links to informants. Completed assessments can also be exported in a .xlsx format with a range of filters allowing you to specify how you want to view the results (e.g. date range, informant type etc).
Furthermore, SDQpro has the option to view data in a visualisation color-coded table, allowing the user to view and filter assessment results by variable such as date, severity of scores and level of risk, with reports easily accessible for review and distribution to the relevant parties. As with other tools this can be viewed on a number of levels (organisation, suborganisation, group, individual) depending on user permissions.