- Open Access
The Strengths and Difficulties Questionnaire (SDQ) in Africa: a scoping review of its application and validation
Child and Adolescent Psychiatry and Mental Health volume 12, Article number: 6 (2018)
- The Correction to this article has been published in Child and Adolescent Psychiatry and Mental Health 2018 12:11
Child and adolescent mental health in Africa remains largely neglected. Quick and cost-effective ways for early detection may aid early intervention. The Strengths and Difficulties Questionnaire (SDQ) is globally used to screen for mental health problems, but little is known about its use in Africa. We set out to perform a scoping review to examine existing studies that have used the SDQ in Africa.
A comprehensive scoping review methodology was used to identify all peer-reviewed studies ever published that have used the SDQ in Africa. Data were extracted and analysed to assess the countries, languages and SDQ versions used, the purpose of the SDQ studies, psychometric properties of the SDQ, and to consider knowledge gaps for future in-country and cross-country studies.
Fifty-four studies from 12 African countries were identified, most from South Africa. Many different languages were used, but authorized SDQs in those languages were not always available on the SDQinfo website. Authors frequently commented on challenges in the translation and backtranslation of mental health terminology in African languages. The SDQ was typically used to investigate internalisation/externalization disorders in different clinical populations, and was most frequently used in the evaluation of children and adolescents affected by HIV/AIDS. Sixteen studies (29.6%) administered the SDQ to participants outside the intended age range, only 4 (7.4%) used triangulation of all versions to generate assessments, and eight studies (14.8%) used only subscales of the SDQ. Only one study conducted thorough psychometric validation of the SDQ, including examination of internal consistency and factor analysis. Where ‘caseness’ was defined in studies, UK cut-off scores were used in all but one of the studies.
The SDQ may be a very useful tool in an African setting, but the scoping review suggested that, where it was used in Africa researchers did not always follow instrument guidelines, and highlighted that very little is known about the psychometric properties of the SDQ in Africa. We recommend comprehensive evaluation of the psychometric properties of the SDQ in various African languages, including internal consistency, factor structure, need for local cut-off values and ensuring cultural equivalence of the instrument.
Mental health disorders account for at least 14% of the global burden of disease , underlining its importance as a global public health concern. Three-quarters of people with mental health problems live in low- and middle-income countries (LMICs) [2, 3], where 75–85% with severe mental health concerns receive little or no treatment . This large treatment gap  has multiple underlying causes, including a scarcity in the number of trained mental health professionals , lack of advocacy and awareness, as well as the associated stigma of mental illness. When comparing mental health professional availability between high- and LMICs, Europe on average has nine psychiatrists for every 100,000 of the population, while Africa has 0.05 psychiatrists per 100,000 . In addition to the limited mental health services in LMICs, there is also a lack of contextually relevant, rigorous, mental health research in many of these geographical areas .
Mental health problems represent the greatest burden of disease among children and adolescents . Ninety percent of children and adolescents live in LMICs, yet only 10% of all child and adolescent mental health (CAMH) research has been conducted in LMICs . In sub-Saharan Africa, projected to be home to 40% of the world’s children by 2025, there are only about 60 qualified child and adolescent psychiatrists and very limited CAMH services. Given the rising incidence of mental health disorders and concomitant resource deficiencies, the treatment gap in Africa is widening [10, 11].
Identification, evaluation and implementation of simple, short and freely-available screening tools for CAMH difficulties may offer a powerful strategy to close the treatment gap, as it may enable the identification of children and adolescents in need of next-step evaluation and treatment. Screening tools might be particularly useful in primary care  and in educational settings. Currently a number of screening tools, including the Child Behaviour Checklist , SNAP-IV , Conners’ ADHD Rating Scales  and Social Communication Questionnaire  are used in Africa, but it is not clear where or how consistently these tools are used, or to what extent these have been evaluated for their reliability, validity and cultural appropriateness for the diverse populations and contexts in Africa .
In CAMH settings around the globe, the Strengths and Difficulties Questionnaire (SDQ) is widely used as a behavioural screening tool, as it has several advantages. It is relatively short, allows for rapid administration, measures both mental health difficulties and competencies, and can be administered by a non-professional with minimal training [18, 19]. The SDQ was developed by Goodman and colleagues  in the UK as an open-access, downloadable screening tool, available as a self-report (SDQ-S), parent/caregiver (SDQ-P) and teacher report version (SDQ-T). Goodman  recommended the optimal use of the instrument to be a multi-informant tool, with triangulation between parent, teacher and (where appropriate) adolescent self-report. Authorized translations of the tool are available on the SDQ website (http://www.sdqinfo.org) in 83 languages. A strict process of translation, back-translation and authorisation of the tools is maintained by the authors. These processes were designed to ensure the availability of the SDQ in a number of languages whilst maintaining the integrity of the instrument.
The SDQ consists of 25 items to assess a range of ‘strengths’ and ‘difficulties’ as behavioural markers of potential mental health problems. The items contribute to five subscales of five items each with a minimum score of 0 (lowest score) to 10 (highest score): conduct problems, hyperactivity/inattention, emotional symptoms, peer problems, and prosocial behaviour. The sum of the first four subscales generates a total difficulties score, which can range from 0 to 40. From the total difficulties and subscale scores, cut-off scores for clinical ‘caseness’ can be generated. The top 10% of scores based on UK population norms were used to define the ‘abnormal’ range, the next 10% as the ‘borderline’ range, and the remaining 80% of scores as the ‘normal range’ . A higher total difficulty score indicates a greater likelihood of significant problems. Four of the five subscales are scored in a similar way with higher scores indicating more difficulties. The prosocial subscale provides a reverse score where higher scores indicate more prosocial behaviours or strengths.
The reliability and validity of the SDQ has been examined in a number of studies across Europe , Asia, Australia and South America [21, 22], but with little or no reference to the use of the SDQ on the African continent. Given the growing awareness of the CAMH needs in Africa , it seemed timely to establish the landscape of all research ever performed in Africa that used any versions of the SDQ. We therefore set out to conduct a comprehensive scoping review of the SDQ aimed to describe the use of the SDQ, and to examine the reliability and validity of the SDQ for local use in Africa.
The methodological framework for scoping reviews [23, 24] was followed. This included identifying the research question, searching for relevant studies, selecting studies, charting and summarizing the data, and reporting the results. The review objective, inclusion criteria and study methods for this scoping review were specified in advance. Inclusion criteria were (i) any of the versions of the SDQ was used in the study, (ii) the study took place in Africa, (iii) the article was data-driven (i.e. not a review paper), and (iv) the article had been peer-reviewed. We also expressly included studies performed in any language and with no time limit since the development of the SDQ. Given that this was a comprehensive scoping review and not a systematic review, no articles were excluded on the basis of any quality criteria.
A literature search to identify studies that used the SDQ to evaluate CAMH in Africa since its development in 1997, was conducted until December 2016. Online databases Ebscohost (Africa Wide Information, Medline, PsycINFO) and PubMed were searched with no date limitations, or language restrictions for any African study involving use of the SDQ, in December 2016 and a follow-up search was conducted in April 2017. A general search of Google Scholar was also conducted. The databases were searched using the following keywords: ‘Strengths and Difficulties Questionnaire’, ‘SDQ’, ‘Africa’, ‘children’, ‘adolescents’, and ‘mental health’. An additional search was conducted which included the use of ‘reliability’ and ‘validity’. Searches were not restricted to any search date, but included all available published studies. An additional search was conducted using key words ‘Strengths and Difficulties Questionnaire’, ‘SDQ’ combined with ‘Africa’, ‘adolescents’ and ‘mental health’. The terms ‘reliability’ and ‘validity’ were also used in addition to the combination of the above terms used. Additionally, examination of relevant bibliographies provided further references for review. Titles and abstracts were examined using the inclusion criteria, after which full articles were retrieved.
The initial online search produced 216 articles. Titles were screened for eligibility and 99 articles were identified. A further 37 articles were generated from reference lists and other sources, producing a total of 136 articles. Duplicates were removed, reducing the sample to 91 articles. The abstracts of these were then reviewed to confirm study location and use of the SDQ, producing a total of 72 articles. The 19 articles excluded in the abstract screening phase included review papers, those not conducted in Africa, and articles that used tools with the same acronym as the SDQ (e.g. self-description questionnaire). Eighteen of these were found to be review articles (not apparent from abstract review), reports, one study on African populations living outside of Africa, and presentations using the SDQ in Africa, and were thus excluded. Two independent reviewers assessed the articles for eligibility (NH, ELD). Disagreements were resolved by consensus between the reviewers and, in cases of an impasse, the two senior authors (PJdV, MSK) made the final decision. Figure 1 outlines the process involved in the literature review and final selection of articles. The final sample consisted of 54 articles included in the review (Table 1).
Full PDF versions of all included articles were collated by the first author and analysed by the first and second author to extract relevant information for the review. A summary table was generated (Table 1) which included the following fields: author, year, study location, participant age, study samples, aim of the paper, theme of study, SDQ report version used, SDQ language version used, translation process, clinical cut-off scores used, comparison to UK norms, internal consistency of the SDQ, as well as the results of each study.
The data gathered and extracted from the articles were analysed using thematic analysis. In keeping with the aim of the review to examine the use and cultural appropriateness of the SDQ in Africa, the deductive themes extracted included specific examination of the location of studies, languages used, instrument translations, cultural comments about use, and psychometric properties of the instrument. Other inductive themes which emerged during extracting and synthesis of data, were research theme of use, versions and subscales used. All findings are summarised in Table 1.
The review identified 54 studies [25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78], conducted in 12 African countries (Table 1). Below we summarise data based on (i) sociodemographic descriptors, (ii) SDQ versions, (iii) SDQ triangulation, (iv) tool properties and validation, (v) translation, back-translation and authorization, and (vi) the purpose of using the SDQ in Africa.
The 12 countries represented in the review included South Africa (n = 21 plus an additional 3 from two-country studies between South Africa and Malawi), Nigeria (n = 6 plus an additional study from a three-country study between Nigeria, Angola and Ghana), Ghana (n = 5, plus the additional three-country study with Nigeria and Angola), Uganda (n = 5), Tanzania (n = 3, plus an additional three-country study between Tanzania, Kenya and Ethiopia), Kenya (n = 2, plus the additional three-country study), Zambia (n = 3), Democratic Republic of Congo (n = 2), Angola (n = 1, based on the three-country study with Nigeria and Ghana), Egypt (n = 1), Ethiopia (n = 1, based on the three-country study with Tanzania and Kenya), and Malawi (n = 1, plus the additional 3 two-country studies with South Africa) (Fig. 2). As listed above, five studies represented samples from two countries, namely South Africa and Malawi in three studies, and two three-country studies, namely Tanzania, Kenya and Ethiopia as well as Nigeria, Angola and Ghana. All studies included male and female participants who ranged in age between 31 months and 24 years. Interestingly, 16 studies (29.6%) administered the self-report version to participants as young as six and as old as 24 years, despite the SDQ administration guidelines recommending the self-report version for 11–17 year olds [26, 30, 34, 37,38,39, 41, 42, 54,55,56, 62, 64, 66, 70, 75].
SDQ versions used
Of the 54 studies, four (7.4%) used all three versions (parent, teacher and self-report) of the SDQ [44, 49, 50, 57] (see Fig. 3). Seven studies (12.9%) employed 2 SDQ versions [29, 32, 40, 42, 43, 47, 65]. Thirty-one studies (57.4%) used only one version of the SDQ, of which 22 used the SDQ-S [26, 30, 34, 35, 37,38,39, 41, 45, 46, 53, 55, 56, 58, 60, 62, 64, 69,70,71, 75, 78], four the SDQ-T [25, 27, 36, 59] and five the SDQ-P [33, 48, 61, 67, 68] (see Table 2 for summary of results by SDQ versions). In the remaining 12 articles (22.2%), three used only the peer and conduct problem subscales from the SDQ self-report version [28, 31, 77], one used only the peer and emotional problem subscales , while a further two articles used only the conduct subscale of the self-report SDQ [52, 54]. In addition, the self-report prosocial subscale was used together with the parent prosocial subscale  and the teacher total difficulty score . Three studies did not specify which version of the SDQ was used [72,73,74]. One study used an unauthorised modified 10-item version of the SDQ-P  which assessed total difficulties. Overall, the SDQ self-report version was most frequently used (32 studies, 56.1%), followed by the parent report (15 studies, 26.3%), and the teacher report version (10 studies, 17.5%).
Triangulation of SDQ data through the use of multiple informants is recommended by the developers . Only four (7.4%) [44, 49, 50, 57] of the 54 studies in the review made use of all versions (parent, teacher and self-report) of the SDQ to satisfy triangulation of the screening tool. All four studies took place within South Africa, three made use of the Sesotho versions of the SDQ (parent, teacher and self-report), while the other study did not specify the language version used. The remaining 50 studies in the review did not make use of triangulation.
Psychometric properties and validation
Twenty-six studies (48.1%) included an evaluation of some aspect of the psychometric properties of the SDQ, for instance, 25 (46.2%) reported the Cronbach alpha scores for internal consistency [25, 29, 33, 36, 39, 42, 45,46,47,48,49,50, 52,53,54,55, 57, 58, 60, 61, 66, 68, 70, 71, 75, 76]. Four studies (7.4%) also presented Cronbach alpha scores from previously published studies [38, 62, 64, 69]. The overall reported Cronbach alpha scores ranged from 0.18–0.89. For the SDQ-S Cronbach alpha scores were reported in 14 studies (25.9%) and ranged between 0.18 and 0.80. Sixteen studies (29.6%) did not report on the psychometric properties for the SDQ-S. For the SDQ-P Cronbach alpha scores were reported in 9 studies (16.7%) and ranged between 0.24 and 0.73. Six studies (11.1%) did not report on psychometric properties of the SDQ-P. SDQ-T scores ranged between 0.35 and 0.89 in the 6 studies (11.1%) that reported Cronbach alphas, while four studies (7.4%) did not report on internal consistency or other psychometric properties of the SDQ-T (see summary in Table 2). One study made use of inter-item reliability on the SDQ-S  and another generated a composite score for all subscales used on the SDQ-S . Overall, twenty-four studies (44.4%) failed to report or examine Cronbach alpha scores. One study examined the factor structure of the SDQ among children in the Democratic Republic of Congo (DRC) using the SDQ-T, and the same study established clinical cut-off scores on the SDQ-T for the DRC population . One study examined the construct validity of all three versions of the SDQ in a sample of Sesotho children and adolescents in South Africa, as well as their caregivers and teachers . To do this, the SDQ was administered alongside the computerised diagnostic interview schedule for children (4th edition; CDISC-IV) to the sample and the subscales were matched with the CDISC-IV diagnostic groups based on the DSM-IV criteria . The emotional problem subscale was matched to detect anxiety disorders and affective disorders on the CDISC-IV, while the conduct problem subscale was matched to detect oppositional-defiant disorder and conduct disorder. In addition, the hyperactivity/inattention subscale was matched to detect ADHD. The peer problem and prosocial behaviour scales were not matched as there were no criteria in the CDISC-IV to find matched equivalent diagnostic groups . The study  suggested support for the SDQ-P version, but not for the SDQ-T and SDQ-S, and provided clinical cut-offs with some caution.
Translation, back-translation and authorization
With regards to translation and adaptation of the SDQ, 23 studies (42.6%) reported the process of translation and back-translation of the SDQ. Of these, eight translations were not listed as authorized on the SDQ website and have not been translated in consultation with the tool developers, namely Nyanja , Dholou , Sesotho [44, 49, 50, 52], Luganda , Swati , Shangaan [52, 63], Twi  and Ga . Challenges raised in the process of translations and adaptions included absence of a linguistic equivalent in some of the local languages for words such as ‘fidget’ , ‘nervous’ or ‘fidgeting’ . Of the studies in the review, the SDQ was available in seventeen different languages, while twenty studies did not specify language(s) used. Five studies, two in South Africa [26, 54] and one each in Ghana , Tanzania  and Nigeria  reported the use of interviewer support when using the self-report SDQ, due to low literacy levels. There are no authorised procedure at http://www.sdqinfo.com for interviewer administration of the SDQ. Of the 23 studies reporting on the translation and adaption of the SDQ, only seven provided evidence of the evaluation of translated words and its equivalences [35, 39, 40, 43, 49, 64, 66], evidence of translation team discussions regarding semantics was found in one study , and another used a qualitative approach to perform a cognitive review of the translated version of the SDQ .
In addition, three studies used English versions of the SDQ and thus did not require translation [34, 37, 78]. Of the remaining 51 studies, three used translated versions of the SDQ from the official site [25, 61, 71] and 27 did not discuss any process of translation. Elhamid and colleagues  did not discuss translation of the SDQ used but referenced the Arabic version that had been previously validated.
While some authors discussed the process and implications of instrument translation in both their methods and discussion, this was not universal, and showed varying degrees of detail across studies. Seventeen studies mentioned that back-translations were performed. Four studies did not provide specific details about the translation process, but rather referenced that the process was undertaken according to published guidelines or standard procedures [45, 49, 50, 55].
There is a distinct lack of consistent examination and reporting of translation processes for this tool. Devries  and Cortina  represent good examples of processes that take into account cultural appropriateness and linguistic equivalence in the translations of the SDQ. The use of trained mental health professionals who are native speakers, independent forward and blind back-translations, collaboration with teachers and staff to assess the tool, as well as pilot testing of tools in small and then bigger samples, are all steps that can be taken to assess the SDQ in a setting before use. The translation process for studies that made use of the SDQ-S commonly reported the use of a translation and back-translation process (n = 15; 27.8%), while the studies using the SDQ-P (n = 7; 13.0%) and SDQ-T (n = 4; 7.4%) more frequently did not report on the translation process (see Table 2).
Purpose of SDQ use in Africa
Use of the SDQ in Africa fell into two broad categories, (i) assessing internalising and externalising problems among children and adolescents in Africa, and (ii) assessing mental health in the context of HIV/AIDS.
Internalising and externalising problems among children and adolescents in Africa
The SDQ was used to examine internalising and externalising problems of children and adolescents in Africa in 21 of 54 studies. Some of the internalising disorders included emotional problems [27, 32, 36, 51, 59, 62], anxiety disorders , depression [43, 60], psychological functioning and mental health in homeless youth , orphans and vulnerable children exposed to maltreatment and stigma [44, 47, 55, 57], war-abducted adolescents , psychological well-being as it relates to parental migration [56, 70] and lack of parenting support . Externalising problems examined included hyperactivity/impulsivity , behavioural problems [27, 32, 36, 51, 59, 62], effects of corporal punishment on mental health and educational outcomes [46, 75], antisocial behaviour and substance use , and caregiver association with substance use and mental health .
Mental health difficulties in the presence of HIV/AIDS
The majority of articles (24 of 54) identified in this review used the SDQ to explore child and adolescent mental health in the context of HIV/AIDS (17 studies from South Africa, three from Ghana, two from Zambia, Kenya and Malawi, and one from Tanzania) and compared mental health and HIV associations between orphaned and non-orphaned children in South Africa [26, 28, 31, 54, 76, 77]. Peer problems were among the common mental health difficulties for children orphaned due to AIDS [26, 28, 31, 77], followed by posttraumatic stress disorder [26, 28] and conduct problems [28, 31]. Studies included examination of emotional and behavioural difficulties in HIV positive adolescents [29, 61, 64], the impact of parental HIV/AIDS status and death on the mental health of the child , psychosocial adjustment of children affected by HIV/AIDS , evaluation of community art therapy intervention on the mental health of children affected by HIV , randomised controlled trials pilot evaluation , caregiver social support , positive parenting , and in the provision and outcomes of community-based organizations for children and adolescents [54, 67, 73, 74].
Given the divide between need for and access to CAMH services particularly in low- and middle-income settings such as in Africa, screening tools such as the SDQ that are simple, accessible and freely-available has the real potential to improve early identification and access to care in Africa and other LMIC settings. However, for clinically-meaningful implementation, it is essential that any instrument not designed in the context should be examined to ensure it has good psychometric properties (e.g. is reliable and valid in the new context), is culturally appropriate, and is used in adherence to the guidelines of the developers of the instrument. We therefore set out to explore the current knowledge-base about the use of the SDQ in Africa.
We identified 54 peer-reviewed publications from 12 African countries, most from South Africa. The SDQ was typically used to investigate internalisation/externalization disorders in different clinical populations, including vulnerable populations such as orphans, children in war-torn areas, and migrants. Interestingly, the SDQ was most frequently used in the evaluation of children and adolescents affected by HIV/AIDS. Many different languages were used, but authorized SDQs in those languages were not always available on the official SDQinfo website. Authors frequently commented on challenges in the translation and back-translation of mental health terminology in African languages. Sixteen studies (29.6%) administered the SDQ to participants outside the intended age range, only 4 (7.4%) used triangulation of all versions to generate assessments, and 8 studies (14.8%) used only subscales of the SDQ. Where ‘caseness’ was defined in studies, UK cut-off scores were used in all but one of the studies. Only one study conducted a thorough psychometric validation of the SDQ, including examination of internal consistency, generating cut-off scores, and factor analysis .
The African continent is highly multi-cultural and multilingual. Screening tools such as the SDQ initially validated for a UK population, have been reported to have good psychometric properties in high-income settings , but, as shown in this scoping review, these findings have not been replicated in Africa. The results presented in the current review suggest that the SDQ has been used in several African countries among various groups of children and adolescents, without comprehensive validation for use in these settings. The many studies that have used the SDQ in Africa reporting limited or no validation therefore raises concerns about the robustness of findings reported in the African CAMH literature to date.
We were surprised to observe the application of the SDQ outside the scope and guidelines of the instrument. We strongly believe that all researchers who work in Africa have an ethical duty to ensure adherence to instrument guidelines and to work in collaboration with tool developers. Given the limited research resources available in Africa, we have to ensure high-quality research at all times.
An additional potential area of concern was the limited use of triangulation of measures in only four studies all conducted in South Africa. Whilst the philosophical position of the SDQ developers is to encourage triangulation of data in clinical practice, many different research questions could be answered without triangulation of data, for instance, investigation of the psychometric properties of a specific version of the SDQ . We also acknowledge that the low rate of triangulated use of the SDQ may have been purely pragmatic, for instance, for the assessment of homeless youth, a self-report version may have been the only option for assessment. For this reason, we are cautious not to overinterpret the limited use of triangulation reported here. Further examination of triangulated data would, however, be of interest to examine measurement invariance between parent, teacher and self-report versions, and cross-culturally. To date, measurement invariance for the different versions of the SDQ have yielded conflicting, and ambiguous findings [83, 84].
Context-specific validation of the SDQ is crucial, as demonstrated in a recent South African study that evaluated the psychometric properties of the SDQ in 3451 adolescents aged 12–16 . The results showed reasonable, yet variable, internal consistency, but identified significant gender-based differences in scores. More importantly, it showed a very unusual profile of ‘caseness’. Using UK cut-off values (designed to identify the top 10% of scorers), 26% of 12–16 year olds were found to be at high risk of emotional problems and 33.7% to be at high risk for peer problems (de Vries et al. 2017 , Table 3). Based on these observations, the authors raised the need for extreme caution in making cross-country comparisons. For intra-county clinical use, the study recommended the use of local cut-off scores to define clinical ‘caseness’ in any screening procedure. For example, a suggestion had been made to use the SDQ-S for mass screening as part of the South African Integrated School Health programme (personal communication, MSK). UK cut-off scores for caseness would have led to a two- to three-fold overidentification of young people ‘at risk’, which could have caused potential distress among young people, and could have placed the already very limited mental health services under overwhelming strain.
The scoping review and our recent findings  also raised the question about the cultural appropriateness and challenges with translation and back-translation of the SDQ to ensure valid use . Africa has 2000–3000 languages, and only a handful of these have been included in SDQ translations. We suggest that it will be important to understand the local perceptions of mental health and the linguistic subtleties in the description of symptomatology, in order to evaluate how best to translate and validate instruments such as the SDQ [82, 86].
Our findings highlighted a few additional important issues. Firstly, there has been a steadily growing body of research on CAMH in Africa, suggesting a heightened awareness amongst practitioners and researchers of the need to identify and document mental health conditions. In this review we identified a significant number of articles in 2016, suggesting a recent growth spurt in research. The review further highlighted that mental health challenges for African children and adolescents often occur within contexts of significant large-scale trauma, such as in situations of conflict, conflict-linked migration and the persistent and long-standing HIV/AIDS epidemic with the accompanying personal and societal devastation. Close to 18 million children and adolescents on the African continent have been orphaned due to HIV/AIDS , it is therefore not surprising that 27 studies in the review examined children and adolescents’ mental health in relation to HIV/AIDS. Some studies were set among homeless children and adolescents  and those exposed to war . This is not necessarily the case in other regions in which the SDQ had been applied. This raises the empirical question about the extent to which the SDQ, developed in a high-income setting, typically applied in a stable, non-crisis environment could, even if applied with great due diligence, be appropriate for the identification of mental health challenges in such challenging contexts.
Lessons learnt for future SDQ research in Africa
One of the key findings from our review is the importance of ensuring that use of screening tools such as the SDQ should be used in adherence with developer guidelines and authorization. Where instruments are translated without authorization, used outside the prescribed age-ranges or where only subsections or items are used, there is a real risk of incorrect and potentially misleading findings.
Secondly, given the fact that only one study in the review period had performed a comprehensive evaluation of the psychometric properties of the SDQ in a specific African country, there is a clear need to see similar studies in other African countries. The study by de Vries  illustrated the potential value of such evaluation. We support the recommendation that UK cut-offs should not be used to determine ‘caseness’ in African countries and that further validation work is required to compare normative cut-off values with gold standard diagnostic instruments to establish the true sensitivity and specificity of the SDQ .
de Vries and colleagues  also recommended that the SDQ could be useful as an ‘in-country’ instrument, but that it should be used with great caution as a ‘cross-country’ comparative measurement tool. There is clearly an increasing realisation of the need for cross-cultural measurement instruments in CAMH [83, 84, 89]. However, we acknowledge that, to date, most CAMH screening tools have not been developed with a global user in mind. In an Africa setting this task is significant and a range of challenges will need to be considered from the subtle cultural, ethnic, pragmatics of language [82, 89] to the large number of languages and variability of literacy levels. de Vries  recommended qualitative exploration of the cultural use of mental health language in order to develop mental health measurements that can capture similar global concepts appropriately and adequately in local settings.
In terms of policy-making, it is important to emphasize that measurement instruments should be selected for inclusion in policies and implemented not based on evidence and use in high-income countries, but only when local evidence has been generated to support the safe and meaningful use of these tools.
We acknowledge a number of limitations in this study. Only four databases were searched to identify articles for this review. It is therefore theoretically possible that some studies were not identified. However, the four databases included typically covers the significant majority of all peer-reviewed journals. In particular, we did not have any language exclusion in order to ensure that we were able to identify potential publications from French- and other African language-speaking sources. In terms of translation/back-translation and authorization of SDQs, it is possible that there may have been approved SDQ versions not yet included on the SDQinfo website. For instance, the most recent Afrikaans and isiXhosa SDQ-S used in de Vries et al.  have been authorised by Goodman but are not yet uploaded on SDQinfo. It is possible that some of the ‘languages’ and dialects used in some of the studies may not have required specific translation/back-translation and authorization.
The SDQ is an easy to use, reliable screening tool for early identification of mental health disorders in children and adolescents, and has been used in numerous countries and languages. The comprehensive scoping review of the SDQ in Africa showed that it has been used in about a quarter of African countries, and that it may be a useful screening instrument to identify children and adolescents at risk of mental health problems. However, the limited and variable psychometric knowledge about the SDQ in Africa suggests that the tool should be used with caution to define ‘caseness’, and that research teams across the continent should perform careful psychometric evaluation of the SDQ in their countries and languages. We suggest that, apart from standard psychometric evaluation, the multicultural and multilingual nature of Africa also necessitates careful cultural evaluation of the instruments to ensure equivalence for clinical and research use. It throws down the gauntlet for practitioners, researchers and academics who work in this field, to pay meticulously attention to the rigour with which these instruments are applied.
Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, Rahman A. No health without mental health. Lancet. 2007;370(9590):859–77.
Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLOS Med. 2006;3(11):e442.
Mendenhall E, De Silva MJ, Hanlon C, Petersen I, Shidhaye R, Jordans M, Luitel N, Ssebunnya J, Fekadu A, Patel V, et al. Acceptability and feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Soc Sci Med. 2014;118:33–42.
World Health Organisation. Mental health action plan 2013–2020. Geneva: World Health Organisation; 2013.
Jansen S, White R, Hogwood J, Jansen A, Gishoma D, Mukamana D, Richters A. The, “treatment gap” in global mental health reconsidered: sociotherapy for collective trauma in Rwanda. Eur J Psychotraumatol. 2015;6:1–6.
Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet. 2007;370(9590):878–89.
Okasha A. Mental health in Africa: the role of the WPA. World Psychiatry. 2002;1(1):32–5.
Kieling C, Baker-Henningham H, Belfer M, Conti G, Ertem I, Omigbodun O, Rohde LA, Srinath S, Ulkuer N, Rahman A. Child and adolescent mental health worldwide: evidence for action. Lancet. 2011;378(9801):1515–25.
Global Burden of Disease Pediatrics C. Global and national burden of diseases and injuries among children and adolescents between 1990 and 2013: findings from the global burden of disease 2013 study. JAMA Pediatr. 2016;170(3):267–87.
Robertson B, Omigbodun O, Gaddour N. Child and adolescent psychiatry in Africa: luxury or necessity? Afr J Psychiatry. 2010;13:329–31.
UNICEF. Fact Sheet: Generation 2030 Africa Report; 2014.
Rumpf HJ, Meyer C, Hapke U, John U. Screening for mental health: validity of the MHI-5 using DSM-IV Axis I psychiatric disorders as gold standard. Psychiatry Res. 2001;105(3):243–53.
Bangirana P, Nakasujja N, Giordani B, Opoka RO, John CC, Boivin MJ. Reliability of the Luganda version of the child behaviour checklist in measuring behavioural problems after cerebral malaria. Child Adolesc Psychiatry Mental Health. 2009;3(1):38.
Zeegers I, Rabie H, Swanevelder S, Edson C, Cotton M, van Toorn R. Attention deficit hyperactivity and oppositional defiance disorder in HIV-infected South African children. J Trop Pediatr. 2010;56(2):97–102.
Richter L, Mabaso M, Hsiao C. Predictive power of psychometric assessments to identify young learners in need of early intervention: data from the Birth to Twenty Plus Cohort, South Africa. S Afr J Psychol. 2016;46(2):175–90.
Bozalek F. Autism screening in children: using the social communication questionnaire in a Western Cape population. University of Cape Town; 2013.
Ertl V, Pfeiffer A, Saile R, Schauer E, Elbert T, Neuner F. Validation of a mental health assessment in an African conflict population. Psychol Assess. 2010;22(2):318–24.
Goodman R, Ford T, Simmons H, Gatward R, Meltzer H. Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. Br J Psychiatry. 2000;177:534–9.
Goodman R, Renfrew D, Mullick M. Predicting type of psychiatric disorder from Strengths and Difficulties Questionnaire (SDQ) scores in child mental health clinics in London and Dhaka. Eur Child Adolesc Psychiatry. 2000;9:129–34.
Goodman R. The Strengths and Difficulties Questionnaire: a research note. J Child Psychol Psychiatry. 1997;38:581–6.
Vostanis P. Strengths and Difficulties Questionnaire: research and clinical applications. Curr Opin Psychiatry. 2006;19(4):367–72.
Woerner W, Fleitlich-Bilyk B, Martinussen R, Fletcher J, Cucchiaro G, Dalgalarrondo P, Lui M, Tannock R. The Strengths and Difficulties Questionnaire overseas: evaluations and applications of the SDQ beyond Europe. Eur Child Adolesc Psychiatry. 2004;13(Suppl 2):Ii47–54.
Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.
Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69.
Kashala E, Elgen I, Sommerfelt K, Tylleskar T. Teacher ratings of mental health among school children in Kinshasa, Democratic Republic of Congo. Eur Child Adolesc Psychiatry. 2005;14:208–15.
Cluver L, Gardner F. The psychological well-being of children orphaned by AIDS in Cape Town, South Africa. Ann Gen Psychiatry. 2006;5:1–9.
Kashala E, Lundervold A, Sommerfelt K, Tylleskar T, Elgen I. Co-existing symptoms and risk factors among African school children with hyperactivity-inattention symptoms in Kinshasa, Congo. Eur Child Adolesc Psychiatry. 2006;15:292–9.
Cluver L, Gardner F, Operario D. Psychological distress amongst AIDS-orphaned children in urban South Africa. J Child Psychol Psychiatry. 2007;48(8):755–63.
Menon A, Glazebrook C, Campain N, Ngoma MS. Mental health and disclosure of HIV status in Zambian adolescents with HIV infection. Epidemiol Soc Sci. 2007;46(3):349–54.
Okello J, Onen TS, Musisi S. Psychiatric disorders among war-abducted and non-abducted adolescents in Gulu district, Uganda: a comparative study. Afr J Psychiatry. 2007;10:225–31.
Cluver L, Gardner F, Operario D. Effects of stigma on the mental health of adolescents orphaned by AIDS. J Adolesc Health. 2008;42:410–7.
Elhamid AA, Howe A, Reading R. Prevalence of emotional and behavioural problems among 6–12 year old children in Egypt. Soc Psychiatry Psychiatr Epidemiol. 2009;44(1):8–14.
Casale M, Cluver L, Crankshaw T, Kuo C, Lachman JM, Wild LG. Direct and indirect effects of caregiver social support on adolescent psychological outcomes in two South African AIDS-affected communities. Am J Community Psychol. 2015;55:336–46.
Doku PN. Parental HIV/AIDS status and death, and children’s psychological well-being. Int J Mental Health Syst. 2009;3:1–8.
Menon A, Glazebrook C, Ngoma MS. Mental health of HIV positive adolescents in Zambia. Med J Zamb. 2009;36(4):151–6.
Bakare MO, Ubochi VN, Ebigbo PO, Orovwigho AO. Problem and pro-social behaviour among Nigerian children with intellectual disability: the implication for developing policy for school based mental health problems. Ital J Pediatr. 2010;36(1–7):37.
Doku PN. Psychosocial adjustment of children affected by HIV/AIDS in Ghana. J Child Adolesc Mental Health. 2010;22(1):25–34.
Mueller J, Alie C, Jonas B, Brown E, Sherr L. A quasi-experimental evaluation of a community-based art therapy intervention exploring the psychosocial health of children affected by HIV in South Africa. Tropi Med Int Health. 2011;16(1):57–66.
Puffer ES, Drabkin AS, Stashko AL, Broverman SA, Ogwang-Odhiambo RA, Sikkema KJ. Orphan status, HIV risk behaviour, and mental health among adolescents in rural Kenya. J Pediatr Psychol. 2012;37(8):868–78.
Abbo C, Kinyanda E, Kizza RB, Levin J, Ndyanabangi S, Stein DJ. Prevalence, comorbidity and predictors of anxiety disorders in children and adolescents in rural north-eastern Uganda. Child Adolesc Psychiatry Mental Health. 2013;7:1–11.
Atilola O, Singh Balhara YP, Stevanovic D, Avicenna M, Kandemir H. Self-reported mental health problems among adolescents in developing countries: results from an international pilot sample. J Dev Behav Pediatr. 2013;34(2):129–37.
Cortina MA, Fazel M, Hlungwani TM, Kahn K, Tollman S, Cortina-Borja M, Stein A. Childhood psychological problems in school settings in rural Southern Africa. PLoS ONE. 2013;8(6):e65041.
Kinyanda E, Kizza RB, Abbo C, Ndyanabangi S, Levin J. Prevalence and risk factors of depression in childhood and adolescence as seen in 4 districts of north-eastern Uganda. BMC Int Health Hum Rights. 2013;13:1–10.
Marais L, Sharp C, Pappin M, Lenka M, Cloete J, Skinner D, Serekoane J. Housing conditions and mental health of orphans in South Africa. Health Place. 2013;24:23–9.
Bhana A, Mellins CA, Petersen I, Alicea S, Myeza N, Holst H, Abrams E, John S, Chhagan M, Nestadt DF, et al. The VUKA Family Program: piloting a family-based psychosocial intervention to promote health and mental health among HIV infected early adolescents in South Africa. AIDS Care. 2014;26(1):1. https://doi.org/10.1080/09540121.09542013.09806770.
Devries KM, Child JC, Allen E, Walakira E, Parkes J, Naker D. School violence, mental health, and educational performance in Uganda. Pediatrics. 2014;133(1):e129–37.
Escueta M, Whetten K, Ostermann J, O’Donnell K. Team TPOfOPR. Adverse childhood experiences, psychosocial well-being and cognitive development among orphans and abandoned children in five low income countries. BMC Int Health Hum Rights. 2014;14:1–13.
Lachman JM, Cluver L, Boyes M, Kuo C, Casale M. Positive parenting for positive parents: HIV/AIDS, poverty, caregiver depression, child behaviour and parenting in South Africa. AIDS Care. 2014;26(3):304–13.
Marais L, Sharp C, Pappin M, Rani K, Skinner D, Lenka M, Cloete J, Serekoane J. Community-based mental health support for orphans and vulnerable children in South Africa: a triangulation study. Vulnerable Child Youth Stud. 2014;9(2):151–8.
Sharp C, Venta A, Marais L, Skinner D, Lenka M, Serekoane J. First evaluation of a population-based screen to detect emotional-behavioural disorders in orphaned children in sub-Saharan Africa. AIDS Behav. 2014;18:1174–85.
Skeen S, Tomlinson M, Macedo A, Miltz A, Croome N, Sherr L. Child development in HIV-positive and HIV-affected children in South Africa and Malawi: what role for community organisations? Child Youth Serv Rev. 2014;45:90–7.
Waller R, Gardner F, Cluver L. Shared and unique predictors of antisocial and substance use behaviour among a nationally representative sample of South African youth. Aggress Violent Behav. 2014;19:629–36.
Asante KO, Meyer-Weitz A, Petersen I. Correlates of psychological functioning of homeless youth in Accra, Ghana: a cross-sectional study. Int J Mental Health Syst. 2015;9:1–9.
Collishaw S, Gardner F, Aber JL, Cluver L. Predictors of mental health resilience in children who have been parentally bereaved by AIDS in urban South Africa. J Abnorm Child Psychol. 2015;44:1–12.
Hermenau K, Eggert I, Landolt MA, Hecker T. Neglect and perceived stigmatisation impact psychological distress of orphans in Tanzania. Eur J Psychotraumatol. 2015;6:1–9.
Mazzucato V, Cebotari V, Veale A, White A, Grassi M, Vivet J. International parental migration and the psychological well-being of children in Ghana, Nigeria and Angola. Soc Sci Med. 2015;132:215–24.
Pappin M, Marais L, Sharp C, Lenka M, Cloete J, Skinner D, Serekoane M. Socio-economic status and socio-emotional health of orphans in South Africa. J Community Health. 2015;40(1):92–102.
Profe W, Wild LG. Mother, father, and grandparent involvement: associations with adolescent mental health and substance use. J Fam Issues. 2015;38:1–22.
Abdulmalik J, Ani C, Ajuwon AJ, Omigbodun O. Effects of problem-solving interventions on aggressive behaviours among primary school pupils in Ibadan, Nigeria. Child Adolesc Psychiatry Mental Health. 2016;10(1):31.
Bella-Awusah T, Ani C, Ajuwon A, Omigbodun O. Effectiveness of brief school-based, group cognitive behavioural therapy for depressed adolescents in south west Nigeria. Child Adolesc Mental Health. 2016;21(1):44–50.
Bhana A, Mellins CA, Small L, Nestadt DF, Leu CS, Petersen I, Machanyangwa S, McKay M. Resilience in perinatal HIV + adolescents in South Africa. AIDS Care. 2016;28(sup2):49–59.
Chirwa-Mwanza A, Menon JA. Relational aggression in adolescents at selected schools in Lusaka Urban. Med J Zamb. 2015;42(3):108–17.
Cortina MA, Stein A, Kahn K, Hlungwani TM, Holmes EA, Fazel M. Cognitive styles and psychological functioning in rural South African school students: understanding influences for risk and resilience in the face of chronic adversity. J Adolesc. 2016;49:38–46.
Dow DE, Turner EL, Shayo AM, Mmbaga B, Cunningham CK, O’Donnell K. Evaluating mental health difficulties and associated outcomes among HIV-positive adolescents in Tanzania. AIDS Care. 2016;28(7):825–33.
Doku PN. Depression, delinquency and peer problems among children and adolescents affected by HIV/AIDS in Ghana: the mediating role of child labour. J Depress Anxiety. 2016;5(2):1–8.
Hecker T, Hermenau K, Salmen C, Teicher M, Elbert T. Harsh discipline relates to internalizing problems and cognitive functioning: findings from a cross-sectional study with school children in Tanzania. BMC Psychiatry. 2016;16:118.
Hensels IS, Sherr L, Skeen S, Macedo A, Roberts KJ, Tomlinson M. Do not forget the boys - gender differences in children living in high HIV-affected communities in South Africa and Malawi in a longitudinal, community-based study. AIDS Care. 2016;28(Suppl 2):100–9.
Lentoor AG, Asante KO, Govender K, Petersen I. Psychological functioning among vertically infected HIV-positive children and their primary caregivers. AIDS Care. 2016;28(6):771–7.
Levetan JL, Wild LG. The implications of maternal grandmother coresidence and involvement for adolescent adjustment in South Africa. Int J Psychol. 2016;51(5):356–65.
Mazzucato V, Cebotari V. Psychological well-being of Ghanaian children in transnational families. Popul Space Place. 2017;23(3):e2004.
Okewole AO, Adewuya AO, Ajuwon AJ, Bella-Awusah TT, Omigbodun OO. Maternal depression and child psychopathology among attendees at a child neuropsychiatric clinic in Abeokuta, Nigeria: a cross sectional study. Child Adolesc Psychiatry Mental Health. 2016;10(1):30.
Puffer ES, Green EP, Sikkema KJ, Broverman SA, Ogwang-Odhiambo RA, Pian J. A church-based intervention for families to promote mental health and prevent HIV among adolescents in rural Kenya: results of a randomized trial. J Consult Clin Psychol. 2016;84(6):511–25.
Skeen S, Macedo A, Tomlinson M, Hensels IS, Sherr L. Exposure to violence and psychological well-being over time in children affected by HIV/AIDS in South Africa and Malawi. AIDS Care. 2016;28(Suppl 1):16–25.
Sherr L, Skeen S, Hensels IS, Tomlinson M, Macedo A. The effects of caregiver and household HIV on child development: a community-based longitudinal study of young children. Child Care Health Dev. 2016;42(6):890–9.
Thumann BF, Nur U, Naker D, Devries KM. Primary school students’ mental health in Uganda and its association with school violence, connectedness, and school characteristics: a cross-sectional study. BMC Public Health. 2016;16:662.
Tucker LA, Govender K, Kuo C, Casale M, Cluver L. Child prosociality within HIV-affected contexts: the impact of carer ill-health and orphan status. Vulnerable Child Youth Stud. 2016;11(4):352–62.
Cluver L, Gardner F, Operario D. Poverty and psychological health among AIDS-orphaned children in Cape Town, South Africa. AIDS Care. 2009;21(6):732–41.
Okewole AO, Awhangansi SS, Fasokun M, Adeniji AA, Omotoso O, Ajogbon D. Prodromal psychotic symptoms and psychological distress among secondary school students in Abeokuta, Nigeria. J Child Adolesc Mental Health. 2015;27(3):215–25.
Goodman A, Goodman R. Population mean scroes predict child mental disorder rates: validating SDQ prevalence estimators in Britian. J Child Psychol Psychiatry. 2011;52:100–8.
Skinner D, Sharp C, Marais L, Serekoane M, Lenka M. Assessing the value of and contextual and cultural acceptability of the Strengths and Difficulties Questionnaire (SDQ) in evaluating mental health problems in HIV/AIDS affected children. Int J Mental Health. 2014;43(4):76–89.
Mellor D. Furthering the use of the strengths and difficulties questionnaire: reliability with younger child respondents. Psychol Assess. 2004;16(4):396–401.
de Vries PJ, Davids EL, Mathews C, Aaro LE. Measuring adolescent mental health around the globe: psychometric properties of the self-report Strengths and Difficulties Questionnaire in South Africa, and comparison with UK, Australian and Chinese data. Epidemiol Psychiatr Sci. 2017. https://doi.org/10.1017/S2045796016001207.
Stevanovic D, Atilola O, Vostanis P, Pal Singh Balhara Y, Avicenna M, Kandemir H, Knez R, Franic T, Petrov P, Maroco J, et al. Cross-cultural measurement invariance of adolescent self-report on the pediatric quality of life inventory™ 4.0. J Res Adolesc. 2016;26(4):687–95.
Stevanovic D, Jafari P, Knez R, Franic T, Atilola O, Davidovic N, Bagheri Z, Lakic A. Can we really use available scales for child and adolescent psychopathology across cultures? A systematic review of cross-cultural measurement invariance data. Transcult Psychiatry. 2017;54(1):125–52.
Cha ES, Kim KH, Erlen JA. Translation of scales in cross-cultural research: issues and techniques. J Adv Nurs. 2007;58(4):386–95.
Schmidt S, Bullinger M. Current issues in cross-cultural quality of life instrument development. Arch Phys Med Rehabil. 2003;84(4 Suppl 2):S29–34.
Andrews G, Skinner D, Zuma K. Epidemiology of health and vulnerability among children orphaned and made vulnerable by HIV/AIDS in sub-Saharan Africa. AIDS Care. 2006;18(3):269–76.
Cauce AM, Paradise M, Ginzler JA, Embry L, Morgan CJ, Lohr Y, Theofelis J. The characteristics and mental health of homeless adolescents. J Emot Behav Disord. 2000;8(4):230–9.
Atilola O. Cross-cultural child and adolescent psychiatry research in developing countries. Global Mental Health. 2015;2:e5.
PJdV and MSK contributed to the conception and design of the study. ELD and NH screened the studies, extracted and analysed the data. ELD and NH drafted the manuscript, while PJdV and MSK participated in the data interpretation and critically reviewed the manuscript. All authors read and approved the final manuscript.
The financial assistance of the National Research Foundation (NRF), CDC/ Medical Research Council (MRC) (South Africa): Health Systems Unit and Struengmann Fund (SF) toward this research is hereby acknowledged. Opinions expressed and conclusions arrived at are those of the authors and are not necessarily to be attributed to the NRF, CDC/MRC or SF.
The authors declare that they have no competing interests.
Availability of data and materials
All data generated and analysed are included in the manuscript.
Consent for publication
Ethics approval and consent to participate
National Research Foundation (South Africa): Innovation Postdoctoral Research Fellowship (ELD); CDC/Medical Research Council (South Africa): Health Systems Unit (NH, MSK) and Struengmann Fund (PJdV).
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
The original version of this article has been revised to correct table 1
A correction to this article is available online at https://doi.org/10.1186/s13034-018-0217-4.
About this article
Cite this article
Hoosen, N., Davids, E.L., de Vries, P.J. et al. The Strengths and Difficulties Questionnaire (SDQ) in Africa: a scoping review of its application and validation. Child Adolesc Psychiatry Ment Health 12, 6 (2018). https://doi.org/10.1186/s13034-017-0212-1