Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2016  |  Volume : 34  |  Issue : 4  |  Page : 354--358

Strength and difficulties questionnaire: A tool as prerequisite to measure child's mental health problems attending dental clinics

Nagendran Jayavel Pandiyan1, Amitha Hedge2,  
1 Department of Paediatric Dentistry, Penang International Dental College, Butterworth, Penang, Malaysia
2 Department of Paediatric Dentistry, A. B. Shetty College of Dental Sciences, Mangalore, Karnataka, India

Correspondence Address:
Nagendran Jayavel Pandiyan
Department of Paediatric Dentistry, Penang International Dental College, 5050, N.B. Towers, Jalan Bagan Luar, Butterworth, Penang


Introduction: Child«SQ»s behavior on dental visit depends on variables such as age, parental behavior, parental anxiety, medical/dental history, and dental procedures. Behavioral-screening questionnaire, such as the Strengths and Difficulties Questionnaire (SDQ), can be used to preassess the child«SQ»s mental health status which further predicts child behavioral pattern in dental clinics. Aim: To measure emotional status among children of 3-14 years age group attending dental clinics. Methodology: A total of 176 parents of children aged 3-14 years were involved in this study. The child«SQ»s emotional and behavioral statuses were assessed using SDQ. Results: On analyzing the SDQ data, it was found that 80% of children came under the abnormal category whereas only 8% of children were found to be in normal category. Twelve percent of children came under borderline category. On the individual behavioral subsets scores, 13% were rated as abnormal on emotional subset, 40% on conduct problems, 12% on hyperactivity, and 29% on peer problems subset. Conclusion: Findings of this study suggest that incorporating tools to identify the current emotional state would give a clue and allow the dentist to develop a behavior guidance plan to accomplish the necessary oral health care. However, the results are preliminary; studies with larger sample should be done to validate the results among diverse populations.

How to cite this article:
Pandiyan NJ, Hedge A. Strength and difficulties questionnaire: A tool as prerequisite to measure child's mental health problems attending dental clinics.J Indian Soc Pedod Prev Dent 2016;34:354-358

How to cite this URL:
Pandiyan NJ, Hedge A. Strength and difficulties questionnaire: A tool as prerequisite to measure child's mental health problems attending dental clinics. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2020 Aug 9 ];34:354-358
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Full Text


One major aspect of child management in the dental chair is managing dental anxiety, a worldwide problem and universal barrier to oral health care. [1] A pediatric dentist who treats children should be able to accurately assess the child's developmental level, dental attitudes, and temperament and to anticipate the child's reaction to care. Developmental delay, physical/mental disability, and acute or chronic disease are potential reasons for noncompliance during the dental appointment. In a healthy communicating child, behavioral influences often are subtle and difficult to identify. Contributing factors can include fears, general or situational anxiety, a previous unpleasant and/or painful dental/medical experience, inadequate preparation for the encounter, and parenting practices. [2],[3],[4],[5],[6],[7]

An evaluation of the child's cooperative potential is essential for treatment planning. No single assessment method or tool is completely accurate in predicting a patient's behavior, but awareness of the multiple influences on a child's response to care can aid in treatment planning. Initially, information can be gathered from the parent through questions regarding the child's cognitive level, temperament/personality characteristics. [3],[8],[9],[10],[11] Anxiety and fear, [2],[8],[12] reaction to strangers, [12] and behavior at previous medical/dental visits, as well as how the parent anticipates the child, will respond to future dental treatment. Later, the dentist can evaluate cooperative potential by observation of and interaction with the patient. Whether the child is approachable, somewhat shy, or definitely shy and/or withdrawn may influence the success of various communicative techniques.

Assessing the child's development, experiences, and current emotional state allows the dentist to develop a behavior guidance plan to accomplish the necessary oral health care. [13] During delivery of care, the dentist must remain attentive to physical and/or emotional indicators of stress. [14],[15] Changes in adaptive behaviors may require alterations to the behavioral treatment plan. [16]

In reviewing 52 epidemiological studies of child and adolescent disorders of mental health, Roberts et al. [17] found tremendous variations in prevalence rates ranging from 1% to 50%, with a mean prevalence rate of 15.8%. They also observed that the rates varied, depending on age, gender, and other factors, with approximate rates of 8% for preschoolers and 12% in studies including wider age ranges.

The high prevalence of psychiatric disorders in children and adolescence is not exclusive to Western societies. The range of disorders seen in children in developing countries is not too different from that in the West, and includes emotional disorders (anxiety, depression, and phobias), behavioral disorders (conduct), neuropsychiatric disorders (hyperkinetic disorders), learning disabilities, and pervasive developmental disorders (autism, Asperger's syndrome).

The importance of early detection of emotional and behavioral problems is being recognized worldwide. However, till date, there has been little systematic research into childhood psychiatric disorders in the developing countries. [18]

Strengths and Difficulties Questionnaire (SDQ) is a brief mental health-screening questionnaire that measures 25 attributes, some positive and others negative. [19] The 25 items are grouped into five subscales of five items each, generating scores for conduct, hyperactivity, emotional, peer problems, and prosocial behavior. All scales excluding the last are summed to generate a total difficulties score (0-40). Category bands and total difficulties scores can be classified as normal, borderline, and abnormal. This tool will give a prediction on mental health status of children.

Behavioral-screening questionnaire, such as the SDQ, can be used to measure child mental health status and as predicting tool of child's behavioral pattern in dental clinics.

Literature review reveals that limited studies had been done on investigating the association between child mental health and behavioral pattern of a child in the dental clinic. Therefore, the objective of this study was to evaluate the child's emotional status among children of 3-14 year age group attending dental clinics in Malaysia, a country with a diverse ethnic population of children.


A cross-sectional survey of 3-14-year-old children attending pediatric dentistry clinic was conducted. About 200 consent forms were obtained from the parents of children. A total of 176 parents agreed to participate in the study. Children of those parents who did not give consent were excluded from the study. Information on nonrespondents was not collected and was therefore not a part of the analysis.

The questionnaires were distributed to the parents for completion. The parents were asked to read the questionnaire and answer it to the best of their ability. Every effort was made to ensure that the parents had privacy when completing the questionnaire. Researchers were available to answer any of the parents' questions or to clarify instructions. The information was kept confidential.

Assessment of children's mental health was conducted using SDQ by parents based on cutoff provided by Goodman. The SDQ is a user-friendly screening questionnaire, which can be used to assess behavioral problems and mental health disorders.

The questionnaire comprised 25 questions under the headings conduct disorder (e.g., often fights with other children or bullies them), prosocial behavior (e.g., often volunteers to help others such as parents, teachers, and other children), hyperactivity/inattention (e.g. restless, overactive, cannot stay still for long), peer relationship problem (e.g., picked on or bullied by other children), and emotional symptoms (e.g., many fears, easily scared). Each of the above-mentioned categories was provided with the options not true, somewhat true, and certainly true. A score of 0 was assigned to the answer "not true," a score of 1 to the answer "somewhat true" and a score of 2 to "certainly true."

SDQ can be completed by the parents or the teachers of 4-16 year olds. Besides common areas of emotional and behavioral difficulties, the extended SDQ also has an impact supplement, inquiring whether the informant thinks that the child has a problem in these areas and, if so, asks about resulting distress and social impairment. [20] This present study on Malaysian children has not included in the analysis of impact scores. The SDQ has been shown to be of acceptable reliability and validity, performing at least the longer-established Rutter questionnaires and Child Behaviour Checklist as well. [21] Originally published in English, [20] the SDQ has subsequently been translated into over forty languages. Languages or dialects represent different ethnic groups in Malaysian culture; spoken language is often the most appropriate determinant of ethnicity. However, since English is a common language which was understood by all, English version of the questionnaire was used.

Data collection procedure

Most parents of children could read English, and they filled the questionnaires. Children showing intellectual disability and without a primary caregiver who could not report the child behavior were excluded from the study.

Statistical analysis

Descriptive statistics were computed. The frequency distribution for the "normal," "borderline," and "abnormal" categories on total SDQ and subsets was computed.


The mean age of the children in the study sample was 6.96 years, with standard deviation of 2.9 years [Table 1] and with a gender distribution of 57% females and 43% males.{Table 1}

Ethnically, our sample was very diverse. About 43% children were Indians, 33% were of Chinese race, followed by Malays 25%.

On analyzing the SDQ data, it was found that 80% of children came under the abnormal category whereas only 8% of children were found to be in normal category, and 12% of children came under borderline category [Table 2]. On the individual behavioral subsets scores, 13% were rated as abnormal on emotional subset, 40% on conduct problems, 12% on hyperactivity, and 29% on peer problems subset [Table 3].{Table 2}{Table 3}

Among the children rated as abnormal, 28% were of Chinese ethnicity, 24% were of Malay children, and 48% were of Indian origin [Table 4]. Among male children, 76% were rated as abnormal, and among females, the abnormal rate was 82% [Table 5]. Among various age groups, the abnormal category rate was 31% in 5.1-7 years, 21% in 3.1-5 years, 29% in 11.1-14 years, 15% in 7.1-9 years, and 11% in 9.1-11 years [Table 6].{Table 4}{Table 5}{Table 6}


There is little knowledge available, concerning child/adolescent emotional and behavioral problems in Malaysian children; hence, this is a first exploratory study that investigated the psychological status of 176 children of different ethnic backgrounds, aged 3-14 years attending pediatric dental clinics in Malaysia. In our study, 80% of all children were categorized as "abnormal" based on parent's rating on SDQ which is very high compared to other studies. Most studies reported the prevalence of psychiatric morbidity among children from community samples between 10% and 20%. [22] These estimates vary depending on the instrument used and the study design. Screening tools yield higher results while diagnostic interviews of the screened population often result in lower estimates. A few studies have shown higher prevalence rates of psychiatric disorders in children and adolescents who live in developing countries when compared to their peers from developed countries, probably due to their poor socioeconomic conditions and the higher environmental difficulties faced by the children and adolescents who live in less developed countries. [23] In a similar study done for screening emotional and behavioral problems in school children of Karachi, Pakistan, it has been shown that 34% of their children were abnormal. [24]

In our study, conduct and peer problems are higher. A recent study on Sri Lankan school children using similar method showed significantly higher rates of behavioral problems as compared to the British population. [25]

According to the present study, female gender was significantly associated with psychopathology in children aged 3-14 years. A higher prevalence among boys was found in most studies, except the one conducted in Alain which found a female preponderance. [26] Nearly 40% of children were rated by their parents with conduct problem. The same trend is also seen in the Brazilian study where children had a higher prevalence of conduct disorders. [27] This may be due to the samples being from poor quality education background and lack of discipline with the resulting behavioral problems.

With no comparative data available neither on Malaysian children nor on comparative samples from the Asian region based on the SDQ and a weak psychometric support for the use of different factor scores based on analyses of the Malaysian data in this study, [25] the cutoff scores were based on British norms.

Moreover, in this study, racial differences could not be significantly proven as the sampling distribution was not of equal proportions.

This study did find elevated rates of psychological problems in Malaysian children compared with the Sri Lankan and British sample, but methodological and contextual issues moderate conclusions regarding these findings. First, Goodman [28],[29] cautions that the use of behavioral bandings to determine "caseness" is an imprecise method of defining the disorder. Second, significance tests were not conducted on the caseness data reported above; therefore, differences between rates across informants are descriptive only. Moreover, correlations between informants were low to modest as is commonly found in studies of this type. Because the exact proportions of cutoff scores vary according to country, age, and gender, Goodman [28],[29] recommends that banding and caseness criteria are adjusted for these characteristics, setting thresholds higher or lower to avoid false positives and/or negatives.


Findings of this study suggest that incorporating tools to identify the current emotional state of children would give a clue and allow the dentist to develop a behavior guidance plan to accomplish the necessary oral health care.

The results of this new exploratory clinical study are necessarily preliminary, being based on relatively small samples of young children, which make the comparison of results difficult. However, further assessment is needed to confirm this model with children of broad age range, and further assessment using a larger sample size including community samples and diverse clinical samples should be planned.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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