Number 48 n February 24, 2012

Identifying Emotional and Behavioral Problems in
 

Children Aged 4–17 Years: United States, 2001–2007
 by Patricia N. Pastor, Ph.D.; Cynthia A. Reuben, M.A.; and Catherine R. Duran, B.S.

Office of Analysis and Epidemiology

Abstract

Objectives—This report examines two measures that identify children with

emotional and behavioral problems: high scores based on questions in the brief

version of the Strengths and Difficulties Questionnaire (SDQ) and a single question

about serious (definite or severe) overall emotional and behavioral difficulties.

Children were classified into four groups, those with: only high scores on the brief

SDQ, only serious overall difficulties, both high scores on the brief SDQ and

serious overall difficulties, and neither high scores on brief SDQ nor serious overall

difficulties. Children’s characteristics, conditions, and service use in these four

groups were compared.

Methods—Data from the 2001–2007 National Health Interview Survey

identified the emotional and behavioral problems, characteristics, conditions, and

service use of children aged 4–17 years.

Results—Approximately 7% of children had either high scores on the brief

SDQ or serious overall difficulties, with 2% having only high scores on the brief

SDQ, 3% having only serious overall difficulties, and 2% having both high scores

on the brief SDQ and serious overall difficulties. Characteristics of the three groups

of children identified with emotional and behavioral problems differed from each

other and from children without problems. Children in each of the groups with

emotional and behavioral problems, compared with children without problems, were

more likely to have developmental conditions and to have used services.

Additionally, children with serious overall difficulties (either with or without high

scores on the brief SDQ) were more likely to have developmental conditions,

receive special education, and use mental health services than children with only

high scores on the brief SDQ.

Keywords: Strengths and Difficulties Questionnaire • child mental health •

special education

Introduction

Emotional and behavioral problems

are among the most prevalent chronic

health conditions of childhood and often

have serious negative consequences for

a child’s academic achievement and

social development (1–5). Parents are

frequently the first adults to identify that

a child has a serious emotional or

behavioral problem and they play a

major role in arranging diagnostic and

treatment services for children (6).

Many epidemiologic studies of the

emotional and behavioral problems of

children have relied on parent responses

to survey questions to identify children

at high risk of these problems (7).

Surveys that collect information from

parents also have the advantage of using

a respondent who is knowledgeable

about other aspects of a child’s life,

including the child’s sociodemographic

characteristics, diagnosed developmental

conditions, and use of educational and

health care services.

The Strengths and Difficulties

Questionnaire (SDQ), developed and

copyrighted by Robert Goodman, is a

screening tool for identifying emotional

and behavioral problems in children.

This screening tool has been used for

epidemiologic studies in over 40

countries (http://www.sdqinfo.org). The

version of the SDQ based on parent

reports was selected by a panel of

mental health experts for inclusion in

the National Health Interview Survey

(NHIS) because it is a brief instrument

that can be used to collect information

about the symptoms of both

internalizing and externalizing child

mental health problems over a wide age

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

National Center for Health Statistics 
Page 2 National Health Statistics Reports n Number 48 n February 24, 2012

range (4–17 years) (8). The extended

version of the SDQ (approximately 30

questions) was included in the 2001,

2003, and 2004 NHIS. The extended

version of the SDQ includes questions

for four subscales that measure a child’s

emotional and behavioral symptoms in

four problem areas (emotions, conduct,

hyperactivity or inattention, and peer

relations), and a section with questions

covering the duration of a child’s

symptoms and the types of impairment

associated with these symptoms. A brief

version of the SDQ was included in the

NHIS in 2002, 2005, 2006, 2007, and

2010. The brief SDQ contains a subset

of five symptom questions drawn from

all the questions comprising the four

subscales in the extended version of the

SDQ. The brief version of the SDQ also

includes a single question about the

overall severity of a child’s emotional

and behavioral problems.

This report examines two measures

of emotional and behavioral problems

available from 7 contiguous years of the

NHIS (2001–2007): 1) high scores

derived from the symptom questions in

the brief SDQ and 2) responses of

serious (definite or severe) difficulties to

the single question on overall

difficulties. Data are presented that

describe the prevalence of emotional

and behavioral problems as defined in

three ways: having only high scores on

the brief SDQ, having only serious

overall difficulties, and having both high

scores on the brief SDQ and serious

overall difficulties. The

sociodemographic characteristics,

diagnosed developmental conditions,

and service use of all children with and

without emotional and behavioral

problems are also compared.

Methods

Data source

The information presented in this

report is based on questions from the

Family Core and Sample Child Core

components of the NHIS (http://

www.cdc.gov/nchs/nhis/quest_data_

related_1997_forward.htm). The NHIS

is a household survey conducted by the

Centers for Disease Control and

Prevention’s National Center for Health

Statistics and is fielded continuously

throughout the year. The survey involves

interviews of a nationally representative

sample of the civilian

noninstitutionalized population of the

United States. Some health and

demographic information is collected for

all household members. Additional

detailed health-related information is

collected for one randomly selected

child (the ‘‘sample child’’) in each

family that includes children 0–17 years.

Information about the sample child is

provided by an adult, usually a parent,

who is knowledgeable about the child’s

health. A detailed description of the

NHIS sample design and the survey

questionnaires for specific years are

available from: http://www.cdc.gov/nchs/

nhis/quest_data_related_1997_forward.

htm.

Between 2001 and 2007, the NHIS

included both measures of emotional

and behavioral problems used in this

analysis—high scores on the brief SDQ

and serious overall difficulties. In 2008

and 2009, only one of the measures,

serious overall difficulties, was included

in the NHIS. As a result, this report

combines data from 7 contiguous years

(2001–2007). Between 2001 and 2007,

the annual number of interviews

completed for all sample children aged

0–17 years in the NHIS varied from

13,579 in 2001 to 9,417 in 2007. The

final annual sample child response rate

ranged from 77% to 81%. This rate also

takes into account household and family

nonresponse. The procedures used in the

calculation of final annual sample child

response rates for specific years are

described in the Survey Description

Document available from: http://

www.cdc.gov/nchs/nhis/quest_data_

related_1997_forward.htm.

Measurement of emotional

and behavioral problems

Emotional and behavioral problems

of children aged 4–17 years were

identified using two measures from the

brief SDQ in the 2001–2007 NHIS: high

scores derived from the five symptom

questions in the brief SDQ and serious

overall difficulties based on a single

question about the severity of the child’s

problems in the areas of emotions,

concentration, behavior, or being able to

get along with other people. In the

initial section of this report the two

measures of emotional and behavioral

problems (high scores on the brief SDQ

and serious overall difficulties) are

examined separately. In the remainder of

the report, the two measures are used to

create four mutually exclusive groups of

children: those with only high scores on

the brief SDQ, those with only serious

overall difficulties, those with both high

scores on the brief SDQ and serious

overall difficulties, and those with

neither high scores on the brief SDQ

nor serious overall difficulties. For the

purpose of conciseness in the text,

tables, and figures, the term ‘‘both’’ is

used when a parent reported both high

scores on the brief SDQ and serious

overall difficulties, and ‘‘neither’’ when

a parent reported neither high scores on

the brief SDQ nor serious overall

difficulties.

High scores on the brief SDQ

were defined as a score of 6 or more

based on parent’s responses to the five

symptom questions in the brief SDQ.

The parent was asked the following

questions: ‘‘I am going to read a list of

items that describe children. For each

item, please tell me if it has been: not

true, somewhat true, or certainly true

for (sample child) during the past 6

months. [Sample child]: 1) Is generally

well behaved, usually does what adults

request, 2) has many worries, or often

seems worried, 3) is often unhappy,

depressed, or tearful, 4) gets along

better with adults than with other

children/youth, and 5) has good

attention span, sees chores or homework

through to the end.’’ Responses to these

questions in the SDQ were coded 0=

‘‘not true,’’ 1= ‘‘somewhat true,’’ and 2=

‘‘certainly true.’’ Responses to all

questions were scored 0, 1, 2, so that a

higher score indicated higher risk of

emotional and behavioral problems.

In a previous validation study of

mental health indices in the NHIS,

Kessler and colleagues found that high

scores (6 or more) based on responses

to the five symptom questions in the

brief SDQ predicted serious mental
National Health Statistics Reports n Number 48 n February 24, 2012 Page 3

health disorders among adolescents,

which had been identified independently

using the Schedule for Affective

Disorders and Schizophrenia in

School-Age Children (K-SADS) (9).

When a cut-off score of 6 or more on

the brief SDQ was used, there was also

good individual-level concordance

between the results on the K-SADS and

high scores on the brief SDQ.

Serious overall difficulties were

based on parents’ responses to the

following question: ‘‘Overall, do you

think that [sample child] has any

difficulties in one or more of the

following areas: emotions,

concentration, behavior, or being able to

get along with other people?’’ Response

options were 1) ‘‘no’’; 2) ‘‘yes, minor

difficulties’’; 3) ‘‘yes, definite

difficulties’’; and 4) ‘‘yes, severe

difficulties.’’ Children whose parents

responded ‘‘yes, definite difficulties’’ or

‘‘yes, severe difficulties’’ were defined

as having serious overall difficulties.

Bourdon and colleagues, using data

from the extended version of the SDQ

in the 2001 NHIS, examined parent

reports of serious overall difficulties as

a scoring method for identifying

children at high risk of serious mental

health problems and found significant

associations between serious overall

difficulties and use of mental health and

special education services (8). These

results were interpreted as evidence that

the measure of serious overall

difficulties is an effective and efficient

screener for child and adolescent mental

health problems in the United States.

Additional analyses of serious overall

difficulties using results from the

2001–2003 NHIS also reported

associations between serious overall

difficulties and use of mental health and

special education services (10).

Sociodemographic

characteristics

Other variables used in the analysis

as covariates included: child’s sex, age

group (4–7, 8–10, 11–14, and 15–17

years), Hispanic origin and race [and

language of interview for Hispanic

children] (Hispanic [English language

interview], Hispanic [Spanish language

interview], non-Hispanic black,

non-Hispanic white, non-Hispanic other

races); family structure (mother-only,

two-parent, other family types); family

income as a percent of the poverty level

for families of given sizes and

composition (below 100%, 100%–199%,

200%–399%, and 400% or more of the

poverty level), and health insurance

status at the time of interview (private

[also includes military coverage],

Medicaid [also includes CHIP,

Medicare, a state-sponsored health plan,

or another government program],

uninsured). Children with both private

and Medicaid coverage were categorized

as having private coverage. The

language of interview for Hispanic

children was added to the race and

ethnicity variable as a measure of

acculturation.

Diagnosed developmental

conditions and use of

educational and health care

services

Diagnosed developmental conditions

were identified by asking a parent

whether a doctor or health professional

had ever told the parent that the child

had any of the following specific

conditions: attention deficit hyperactivity

disorder, intellectual disability (mental

retardation or other developmental

delay), or learning disability. Use of

special education was measured by

asking a parent if a child was receiving

special education services. Use of health

care services during the past 12 months

was assessed by asking if a parent had

seen or talked to a general doctor about

the child’s emotional or behavioral

problems or if a parent had seen or

talked to a mental health professional

about the child’s health (see ‘‘Technical

Notes’’ for specific wording of questions

about developmental conditions and use

of services).

Statistical analysis

Because of the small annual

variation in each of the measures of

emotional and behavioral problems, data

from the 2001–2007 NHIS were

combined to increase the reliability of

estimates. Among 63,037 sample

children aged 4–17 years in the

2001–2007 NHIS, 1,804 (3%) children

were missing data for the measures of

emotional and behavioral problems. Item

nonresponse rates for other variables in

the analysis were less than 1%-2% with

the exception of family income that was

missing for more than 25% of children

aged 4–17 years (see the ‘‘Technical

Notes’’ for a description of item

nonresponse and multiple imputation of

family income). The analyses in this

report were based on data from 61,233

interviews about sample children aged

4–17 years from 2001 through 2007,

which collected complete information

for all variables used to identify

emotional and behavioral problems. The

children with emotional and behavioral

problems included 1,411 children with

only high scores on the brief SDQ,

1,841 children with only serious overall

difficulties, and 1,189 children with both

high scores on the brief SDQ and

serious overall difficulties.

All estimates were calculated using

weighted data and are representative of

the U.S. noninstitutionalized population

of children aged 4–17 years. Average

annual estimates of the percentage of

children with emotional and behavioral

problems were calculated using data for

the time period 2001–2007. The

estimates and associated standard errors

shown in this report were generated

using SUDAAN version 10, a software

package designed to account for the

complex design of the NHIS sample

(11). Multinomial logistic regression

(MULTILOG procedure in SUDAAN)

was used to examine the adjusted

association between each of the child’s

sociodemographic characteristics and the

three categories of emotional and

behavioral problems as defined by: only

high scores on the brief SDQ, only

serious overall difficulties, and both

high scores on the brief SDQ and

serious overall difficulties. Modeladjusted risk ratios were estimated for

the three categories of children with

emotional and behavioral problems

compared with children with no

problems using generalized logit models

for nominal responses. MULTILOG

calculates model-adjusted risk ratios
Page 4 National Health Statistics Reports n Number 48 n February 24, 2012

based on the predicted marginals. The

multinomial regression analysis

excluded an additional 253 children due

to missing data on covariates.

Comparisons of estimates are based

on two-tailed significance tests at the

0.05 level without any adjustments for

multiple comparisons. Terms such as

‘‘greater than’’ and ‘‘less than’’ indicate

a statistically significant difference.

Terms such as ‘‘similar’’ or ‘‘no

difference’’ indicate that the estimates

being compared were not significantly

different. Lack of comment regarding

the difference between two estimates

does not mean that the difference was

tested and determined not to be

significant. Because of the crosssectional nature of the data collected in

the NHIS, an association between

variables does not indicate a causal

connection. More information

concerning the data source and

statistical analysis can be found in the

‘‘Technical Notes.’’

Results

Trends in high scores on the

brief SDQ and trends in

serious overall difficulties

The prevalence of high scores on the

brief SDQ for children aged 4–17 years

declined slightly during this 7 year period

(b=-0.03, se= 0.01, p <0.05) (Figure 1 and

Table 1). However, the downward trend

was not significant among children aged

4–10 or 15–17 years. Among children aged

11–14, the downward trend had borderline

significance (b=-0.05, se= 0.02, p = 0.05).

The prevalence of serious overall

difficulties showed no trend and fluctuated

around 5% during the 7 year period.

Prevalence of high scores

on the brief SDQ and

prevalence of serious overall

difficulties

From 2001 through 2007, the

average annual prevalence of emotional

and behavioral problems as measured by

high scores on the brief SDQ and

serious overall difficulties was 4.3% and

5.1%, respectively (Table 2). The

patterns of associations between each of

these measures of emotional and

behavioral problems and selected

sociodemographic characteristics were

similar. Both measures of emotional and

behavioral problems showed a lower

prevalence of difficulties among

younger children aged 4–7 years

compared with older children aged 8–17

years. Both measures showed a higher

percentage of male children with

emotional and behavioral problems than

female children. The prevalence of high

scores on the brief SDQ was 4.8%

among males compared with 3.7%

among females and the prevalence of

serious overall difficulties was 6.3%

among males compared with 3.8%

among females.

For both measures of problems, the

lowest prevalence was observed among

Hispanic children whose parents were

interviewed in Spanish, 3.0% for high

scores on the brief SDQ and 2.5% for

serious overall difficulties (Table 2). The

prevalence of high scores on the brief

SDQ was similar among non-Hispanic

white children and Hispanic children

whose parents were interviewed in

English. Compared with non-Hispanic

white children, a higher percentage of

Year 

NOTES: Estimates based on household interviews of a sample of the civilian noninstitutionalized population. 

SDQ is Strengths and Difficulties Questionnaire. 

DATA SOURCE: CDC/NCHS, National Health Interview Survey. Percent 

0 

2 

4 

6 

8 

10 

Serious overall difficulties 

High scores on brief SDQ 

2001 2002 2003 2004 2005 2006 2007

Figure 1. Prevalence of high scores on the brief SDQ and serious overall difficulties

among children aged 4–17 years, by year: United States, 2001–2007

non-Hispanic black children had high

scores on the brief SDQ. The prevalence

of serious overall difficulties did not

vary between non-Hispanic white

children and non-Hispanic black

children.

For both measures, the prevalence

of emotional and behavioral problems

among children in mother-only families

was twice the percentage observed in

two-parent families (Table 2). Each of

the measures of problems also showed a

negative association with the child’s

family income as a percent of the

poverty level. The prevalence of high

scores on the brief SDQ ranged from

7.6% of children with family income

below 100% of the poverty level to

2.1% among the most affluent children

(family income 400% or more of the

poverty level). Similarly, the prevalence

of serious overall difficulties varied

from 7.3% of children with family

income below 100% of the poverty level

to 3.5% of the most affluent children.

The prevalence of children with

problems identified by each of the

measures was twice as high for children

with Medicaid compared with children

with private health insurance. The
Only high scores 

on brief SDQ 

Neither 

92.6% 

Both 

2.1% 

2.2% 

Only serious 

overall difficulties
 

3.1%
 

NOTES: Estimates based on household interviews of a sample of the civilian noninstitutionalized population. 

SDQ is Strengths and Difficulties Questionnaire.
 

DATA SOURCE: CDC/NCHS, National Health Interview Survey. 

National Health Statistics Reports n Number 48 n February 24, 2012 Page 5

prevalence of high scores on the brief

SDQ among uninsured children (4.8%)

was higher than the prevalence among

privately insured children (3.1%), but

lower than the prevalence among

children with Medicaid coverage (7.5%).

In contrast, the prevalence of serious

overall difficulties among uninsured

children (4.3%) was similar to the

prevalence among privately insured

children (4.0%), but lower than the

prevalence among children with

Medicaid coverage (8.3%).

Prevalence of emotional and

behavioral problems

identified by only high

scores on the brief SDQ,

only serious overall

difficulties, and both

Approximately 7.4% of all children

were rated as having either high scores

on the brief SDQ or serious overall

difficulties. Among all children, 2.2%

had only high scores on the brief SDQ,

3.1% had only serious overall

difficulties, and 2.1% had both high

scores on the brief SDQ and serious

overall difficulties (Figure 2 and

Table 3).

For each of the three categories of

emotional and behavioral problems, the

prevalence was lower among the

youngest children (4–7 years) compared

with the oldest children (15–17 years)

(Figure 3 and Table 3). The prevalence

of only high scores on the brief SDQ

was 1.7% among the youngest children

compared with 2.6% among the oldest

children. Similarly, the prevalence of

only serious overall difficulties was

2.5% among the youngest children

compared with 3.3% among the oldest

children. The prevalence of both high

scores on the brief SDQ and serious

overall difficulties ranged from 1.1%

among the youngest children to 2.7%

among the oldest children.

Differences between males and

females varied depending on the

category of problems (Figure 4 and

Table 3). The prevalence of only high

scores on the brief SDQ was similar for

males and females, 2.3% and 2.1%,

respectively. However, the prevalence of

serious overall difficulties, either with or

without high scores on the brief SDQ,

was higher for males than females. The

Figure 2. Prevalence of emotional and behavioral problems (only high scores on the brief

SDQ, only serious overall difficulties, both, and neither) among children aged 4–17 years:

United States, average annual estimates for 2001–2007

prevalence of serious overall difficulties

without high scores on the brief SDQ

was 3.9% among males and 2.2%

among females. The prevalence of

serious overall difficulties with high

scores on the brief SDQ also varied for

males and females (2.5% and 1.6%,

respectively).

The prevalence of emotional and

behavioral problems varied by race and

ethnicity and language of interview

among the three groups of children

identified by high scores on the brief

SDQ and serious overall difficulties

(Figure 5 and Table 3). Non-Hispanic

black children, compared with nonHispanic white children, had a higher

prevalence of only high scores on the

brief SDQ (3.0% and 2.0%,

respectively), but a similar prevalence of

only serious overall difficulties (3.5%

and 3.2%, respectively) and a similar

prevalence of both high scores on the

brief SDQ and serious overall

difficulties (2.2% for each group). In

contrast, Hispanic children with Spanish

language interviews, compared with

non-Hispanic white children, had a

similar prevalence of only high scores

on the brief SDQ (2.3% and 2.0%,

respectively), but a lower prevalence of

only serious overall difficulties (1.8%

and 3.2%, respectively) and a lower

prevalence of both high scores on the

brief SDQ and serious overall

difficulties (0.7% and 2.2%,

respectively).

The prevalence of emotional and

behavioral problems was approximately

twice as high among children in

mother-only families, compared with

two-parent families, regardless of the

category of problems (Figure 6 and

Table 3). Similarly, low family income

was associated with a higher prevalence

of emotional and behavioral problems

across all three categories of children

with problems (Figure 7 and Table 3).

The prevalence of high scores on the

brief SDQ ranged from 4.1% among

children with family income below

100% of the poverty level to 1.0%

among children in the most affluent

families (400% or more of the poverty

level). The prevalence of both high

scores on the brief SDQ and serious

overall difficulties also showed a similar
Page 6 National Health Statistics Reports n Number 48 n February 24, 2012

NOTES: Estimates based on household interviews of a sample of the civilian noninstitutionalized population. 

SDQ is Strengths and Difficulties Questionnaire. 

DATA SOURCE: CDC/NCHS, National Health Interview Survey. 

Percent 

0 2 4 

15–17 

11–14 

8–10 

4–7 

Both 

Only 

serious 

overall 

difficulties 

Only high 

scores on 

brief SDQ 

2.5 Years 

2.6 

2.6 

3.2 

3.4 

3.3 

1.1 

2.2 

2.4 

2.7 

2.0 

1.7 

Figure 3. Prevalence of three categories of emotional and behavioral problems among

children aged 4–17 years, by age group: United States, average annual estimates for

2001–2007

NOTES: Estimates based on household interviews of a sample of the civilian noninstitutionalized population. 

SDQ is Strengths and Difficulties Questionnaire. 

DATA SOURCE: CDC/NCHS, National Health Interview Survey. 

Percent 

0 2 4 

Both 

Only 

serious 

overall 

difficulties 

Only high 

scores on 

brief SDQ 

3.9 

2.2 

2.5 

1.6 

2.1 

2.3 

Female 

Male 

Figure 4. Prevalence of three categories of emotional and behavioral problems among

children aged 4–17 years, by sex: United States, average annual estimates for 2001–2007

discrepancy between children with

family income below 100% of the

poverty level and those with income

400% or more of the poverty level

(3.6% and 1.1%, respectively). The

prevalence of only serious overall

difficulties ranged from 3.7% to 2.5%

for poor children and the most affluent

children, respectively.

Children, who had Medicaid

coverage at the time of the interview,

compared with children with private

health insurance coverage, had a higher

prevalence of problems regardless of the

category of problems (Figure 8 and

Table 3). For example, the prevalence of

both high scores on the brief SDQ and

serious overall difficulties was 3.7%

among children covered by Medicaid

and 1.5% among children covered by

private insurance. Uninsured children,

compared with children with private

health insurance coverage, had a higher

prevalence of only high scores on the

brief SDQ (3.0% and 1.5%,

respectively). The prevalence of only

serious overall difficulties was similar

among uninsured children and children

with private health insurance coverage

(2.6% for each coverage group). The

prevalence of both high scores on the

brief SDQ and serious overall

difficulties was also similar among

uninsured children and children with

private health insurance coverage (1.8%

and 1.5%, respectively).

Adjusted risk of three

categories of emotional and

behavioral problems (only

high scores on the brief

SDQ, only serious overall

difficulties, and both)

Table 4 summarizes the results from

a multinomial logistic regression that

estimates the adjusted association of

selected characteristics and the risk of

emotional and behavioral problems as

indicated by: only high scores on the

brief SDQ, only serious overall

difficulties, and both. Family income

was associated with having only a high

score on the brief SDQ. Among children

whose family income was below 100%

of the poverty level, the risk of having

only a high score on the brief SDQ was

2.6 times the risk among children whose

family income was 400% or more of the

poverty level. Among children whose

family income was 100%–399% of the

poverty level, the risk of having only a

high score on the brief SDQ was

approximately twice the risk of children

whose family income was 400% or

more of the poverty level.

After adjustment for other

sociodemographic characteristics, the

risk factors associated with having only

serious overall difficulties included

being a male and having Medicaid
National Health Statistics Reports n Number 48 n February 24, 2012 Page 7

NOTES: Estimates based on household interviews of a sample of the civilian noninstitutionalized population. 

SDQ is Strengths and Difficulties Questionnaire. 

DATA SOURCE: CDC/NCHS, National Health Interview Survey. 

Percent 

0 2 4 

Both 

Only 

serious 

overall 

difficulties 

Only high 

scores on 

brief SDQ 

3.2 

3.5 

2.7 

1.8 

2.2 

2.2 

1.8 

0.7 

3.0 

2.7 

2.3 

2.0 

Hispanic 

(Spanish 

interview) 

Hispanic 

(English 

interview) 

Non-Hispanic 

black 

Non-Hispanic 

white 

Figure 5. Prevalence of three categories of emotional and behavioral problems among

children aged 4–17 years, by race and ethnicity and language of interview: United States,

average annual estimates for 2001–2007

NOTES: Estimates based on household interviews of a sample of the civilian noninstitutionalized population. 

SDQ is Strengths and Difficulties Questionnaire. 

DATA SOURCE: CDC/NCHS, National Health Interview Survey. 

0 2.5 5 

Both 

Only 

serious 

overall 

difficulties 

Only high 

scores on 

brief SDQ 

4.4 

1.7 

3.4 

3.6 

2.6 

1.5 

Percent 

Two parents 

Mother only 

Figure 6. Prevalence of three categories of emotional and behavioral problems among

children aged 4–17 years, by family structure: United States, average annual estimates for

2001–2007

coverage. The risk factors associated a male, living in a mother-only family,
 

with having both high scores on the having a family income less than 400%
 

brief SDQ and serious overall of the poverty level, and having
 

difficulties included several Medicaid coverage.
 

sociodemographic characteristics: being
 

Ever diagnosed selected

developmental conditions

among children with and

without emotional and

behavioral problems

Among children with only high

scores on the brief SDQ, 21.3% had

ever been diagnosed with ADHD, 23.4%

with learning disability, and 2.0% with

intellectual disability (Figure 9 and

Table 5). Among children who had

serious overall difficulties, either with or

without high scores on the brief SDQ,

an even higher percentage of children

were reported to have ever been

diagnosed with ADHD, learning

disability, or intellectual disability

compared with children with only high

scores on the brief SDQ. Among

children with only serious overall

difficulties, 49.8% had ever been

diagnosed with ADHD, 44.9% with

learning disability, and 6.7% with

intellectual disability. Among children

with both high scores on the brief SDQ

and serious overall difficulties, 57.9%

had ever been diagnosed with ADHD,

49.1% with learning disability and 7.1%

with intellectual disability. A higher

prevalence of diagnosed developmental

conditions was found among children

with serious overall difficulties (either

with or without high scores on the brief

SDQ) compared with those with only

high scores on the brief SDQ. This

pattern was similar among both younger

(4–10 years) and older (11–17 years)

children.

Each specific diagnosed

developmental condition (ADHD,

learning disability, and intellectual

disability) was more prevalent among

children with problems compared with

children without problems (Figure 9 and

Table 5). Among children aged 4–17

years without problems (neither high

scores on the brief SDQ nor serious

overall difficulties), 4.6% had ever been

diagnosed with ADHD, 5.6% with

learning disability, and only 0.4% with

intellectual disability. Among children

without problems, the prevalence of

diagnosed conditions was generally

higher among older (11–17 years)
Page 8 National Health Statistics Reports n Number 48 n February 24, 2012

NOTES: Estimates based on household interviews of a sample of the civilian noninstitutionalized population. 

SDQ is Strengths and Difficulties Questionnaire. 

DATA SOURCE: CDC/NCHS, National Health Interview Survey. 

Percent 

0 2.5 5 

Both 

Only 

serious 

overall 

difficulties 

Only high 

scores on 

brief SDQ 

4.1 

2.8 

1.9 

1.0 

3.7 

3.7 

2.8 

2.5 

3.6 

2.3 

1.9 

1.1 

400% or more 

200%–399% 

100%–199% 

Below 100% 

Figure 7. Prevalence of three categories of emotional and behavioral problems among

children aged 4–17 years, by family income as a percent of poverty level: United States,

average annual estimates for 2001–2007

NOTES: Estimates based on household interviews of a sample of the civilian noninstitutionalized population. 

SDQ is Strengths and Difficulties Questionnaire. 

DATA SOURCE: CDC/NCHS, National Health Interview Survey. 

Percent 

0 2.5 5 

Both 

Only 

serious 

overall 

difficulties 

Only high 

scores on 

brief SDQ 

3.0 

1.5 

3.8 

2.6 

2.6 

4.7 

1.8 

1.5 

3.7 

Medicaid 

Private 

Uninsured 

Figure 8. Prevalence of three categories of emotional and behavioral problems among

children aged 4–17 years, by health insurance coverage: United States, average annual

estimates for 2001–2007

compared with younger (4–10 years)

children.

Use of educational and

health care services among

children with and without

emotional and behavioral

problems

Among children with only high

scores on the brief SDQ, 18.2% were

currently enrolled in special education,

16.9% had a parent who had talked to a

general doctor about the child’s mental

health problems, and 24.9% had a

parent who had consulted a mental

health professional (Figure 10 and

Table 6). Among children who had

serious overall difficulties either with or

without high SDQ scores, an even

higher percentage of children were

reported to be currently enrolled in

special education or had a parent who

had consulted a general doctor or mental

health professional about the child’s

mental health problems compared with

children with only high scores on the

brief SDQ. Among children with only

serious overall difficulties, 36.6% were

currently enrolled in special education,

32.0% had parents who had consulted

with a general doctor about the child’s

mental health problems, and 40.1% had

consulted with a mental health

professional. Among children with both

high scores on the brief SDQ and

serious overall difficulties, 40.8% were

currently enrolled in special education,

46.8% had parents who had consulted

with a general doctor about the child’s

mental health problems, and 58.5% had

consulted with a mental health

professional. Greater use of educational

and health care services was found

among children with serious overall

difficulties (either with or without high

scores on the brief SDQ) compared with

those with only high scores on the brief

SDQ. This pattern was similar among

both younger (4–10 years) and older

(11–17 years) children.

Use of educational and health care

services was less among children

without problems compared with

children with problems (Figure 10 and

Table 6). Among children aged 4–17

years without problems (neither high

scores on the brief SDQ nor serious

overall difficulties), 5.5% of children

were currently enrolled in special

education, 2.5% had a parent who had

consulted with a general doctor about

the child’s mental health problems, and

4.5% had a parent who had consulted a

mental health professional. Use of

educational and health care services was

less among children without problems

compared with children with problems

among younger (4–10 years) and older

(11–17 years) children.
National Health Statistics Reports n Number 48 n February 24, 2012 Page 9

NOTES: Estimates based on household interviews of a sample of the civilian noninstitutionalized population. 

SDQ is Strengths and Difficulties Questionnaire. ADHD is attention deficit hyperactivity disorder. 

DATA SOURCE: CDC/NCHS, National Health Interview Survey. 

4.6 

21.3 

49.8 

57.9 

5.6 

23.4 

44.9 

49.4 

0.4 2.0 

6.0 7.1 8.5 

32.9 

66.0 

72.3 

0 

20 

40 

60 

80 

100 Only Both

serious 

overall 

difficulties 

Only high 

scores on 

brief SDQ 

Neither 

Any of the 

selected 

conditions 

Intellectual 

disability 

Learning 

disability 

ADHD 

Percent 

Figure 9. Selected developmental conditions among children aged 4–17 years, by

category of emotional and behavioral problems: United States, average annual estimates

for 2001–2007

NOTES: Estimates based on household interviews of a sample of the civilian noninstitutionalized population. 

SDQ is Strengths and Difficulties Questionnaire. 

DATA SOURCE: CDC/NCHS, National Health Interview Survey. 

5.5 

19.0 

36.6 

40.8 

2.5 

16.9 

32.0 

46.8 

4.5 

24.9 

40.1 

58.5 

10.2 

39.2 

65.4 

79.8 

0 

20 

40 

60 

80 

100 Only Both

serious 

overall 

difficulties 

Only high 

scores on 

brief SDQ 

Neither 

Any of the 

selected services 

Mental health 

professional 

General doctor 

for mental health 

Special 

education 

Percent 

Figure 10. Use of selected educational and health care services among children aged

4–17 years, by category of emotional and behavioral problems: United States, average

annual estimates for 2001–2007

Among the 7.4% of children identified

to have emotional and behavioral

problems by either of the two NHIS

measures, only 28% were identified by

both measures. Approximately 30% of

children were identified by only high

scores on the brief SDQ and 42% were

identified by only serious overall

difficulties. In addition to the lack of

concordance between the two measures

of emotional and behavioral problems,

there were significant differences in the

sociodemographic characteristics,

diagnosed developmental conditions,

and use of educational and health care

services among children with only high

scores on the brief SDQ, only serious

overall difficulties, and both high SDQ

scores and serious overall difficulties.

Results from the multivariate

analysis indicated that less affluent

children were more likely to have high

scores on the brief SDQ (either with or

without serious overall difficulties) than

more affluent children with family

income 400% or more of the poverty

level. However, there was no

relationship between family income and

the risk of having serious overall

difficulties. Males and children with

Medicaid coverage were more likely to

have serious overall difficulties (either

with or without high scores on the brief

SDQ) compared with females and

children with private health insurance

coverage at the time of the interview.

Additionally, the results of the

multivariate analysis revealed that, after

adjustment for other sociodemographic

characteristics, age and race and

ethnicity and language of interview were

not independently associated with any of

the categories of emotional and

behavioral problems.

Results related to diagnosed

developmental conditions showed that

children with serious overall difficulties

(either with or without high scores on

the brief SDQ) compared with children

with only high scores on the brief SDQ

were more likely to have a diagnosed

developmental condition (ADHD,

learning disability, or intellectual

disability). Children with serious overall

difficulties (either with or without high

scores on the brief SDQ) compared with

children with only high scores on the

Discussion

Among children aged 4–17 years,

the two measures of emotional and

behavioral problems indicated that a

relatively small percentage of children

had emotional and behavioral problems:

4.3% were identified by high scores on

the brief SDQ and 5.1% by serious

overall difficulties. Surprisingly, though,

these two measures of emotional and

behavioral problems in children did not

identify the same group of children.
Page 10 National Health Statistics Reports n Number 48 n February 24, 2012

brief SDQ were also more likely to have

used educational and health care

services. Among children with

emotional and behavioral problems, the

highest levels of service use were

reported for children with both high

scores on the brief SDQ and serious

overall difficulties.

The findings in this report are

similar to the results from several

previous studies using measures from

the SDQ, which also reported marked

differences in the diagnosed

developmental conditions and use of

mental health services between children

with and without emotional and

behavioral problems (8–10,12,13).

However, the current report also shows

significant differences among children

when high scores on the brief SDQ and

serious overall difficulties are used to

create three categories of emotional and

behavioral problems (only high scores

on the brief SDQ, only serious overall

difficulties, and both). While it is likely

that some of the variation observed in

the developmental conditions and

service use among the three groups of

children with problems reflect

differences in the specific diagnosable

mental health conditions of children in

each group, other factors may contribute

to this variation. Past studies have

shown that the duration and severity of

a child’s emotional and behavioral

symptoms as well as the level of family

burden reported by parents may

influence a parent’s recognition and

evaluation of a child’s emotional and

behavioral problems (13,14).

Although this report is unable to

explore potential explanations for the

differences in the number,

characteristics, conditions, and service

use of children in the three groups with

problems, the description of these

differences may be useful for analysts

who plan to use the measures from the

brief SDQ. For example, studies

focusing on the association between

measures of socioeconomic adversity

and emotional and behavioral problems

of children might consider how the

choice of a measure of problems could

influence the strength of these

relationships. Findings from the

2001–2007 NHIS show a stronger

negative association between family

income and only high scores on the

brief SDQ than between family income

and measures based on serious overall

difficulties. Similarly, studies focusing

on educational and health care services

among children with emotional and

behavioral problems also might evaluate

how the choice of a measure of

problems could affect estimates of

mental health service use (15). For

example, results from the 2001–2007

NHIS indicate lower levels of mental

health service use among children with

only high scores on the brief SDQ

compared with children with serious

overall difficulties (either with or

without high scores on the brief SDQ).

Strengths and limitations

The use of the SDQ to measure

emotional and behavioral problems in

children is a strength of the present

study. Research by Kessler and

colleagues has shown that the brief

version of the SDQ is a reliable and

valid instrument for screening

psychiatric disorders in adolescents (9).

Another strength of this report is the use

of a large nationally representative

sample that allowed the comparison of

three groups of children with emotional

and behavioral problems (those with

only high scores on the brief SDQ,

those with only serious overall

difficulties, and those with both).

Additionally, because the NHIS includes

a wide array of questions about

children’s sociodemographic

characteristics and use of educational

and health care services, it was possible

to describe the characteristics of

children with and without problems.

Among the limitations of this study

is the reliance on parents as the only

source of information about a child’s

emotional and behavioral problems. Past

research on the sensitivity and

specificity of different versions of SDQ

data have indicated greater validity and

reliability of estimates of emotional and

behavioral problems based on reports

from multiple informants including

parents, teachers, and, for some age

groups, children (16). Although research

by Kessler and others have determined

that high scores on the parent version of

the brief SDQ can be used to identify

adolescents aged 13–17 years with

serious emotional and behavioral

problems, additional research is needed

to validate high scores on the brief SDQ

as a useful measure of emotional and

behavioral problems of younger children

(9). Currently a study using data from

the NHIS is being conducted, with

support from SAMHSA, to determine

the range of scores for the parent

version of the brief SDQ that identifies

children with serious diagnosable mental

health disorders (17).

Another limitation of this study is

the cross-sectional nature of the NHIS

that precludes the identification of

causal links between parent reports of

emotional and behavioral problems,

access to care, and a child’s use of

educational and health care services.

The brief version of the SDQ in the

NHIS also lacks information about the

severity and duration of the child’s

symptoms. The higher prevalence of

diagnosed conditions and higher level of

service use by children with both high

scores on the brief SDQ and serious

overall difficulties may indicate that

these children have more severe

conditions. Because the NHIS did not

include questions about the timing,

adequacy, or duration of child mental

health service use, these aspects of

service use could not be explored.

Finally, it should be noted that results

from the survey only describe children

in the noninstitutionalized population

and exclude children living in

psychiatric hospitals, juvenile justice

centers, and other institutions.

Conclusion

This report examines three measures

of emotional and behavioral problems

(only high scores on the brief SDQ,

only serious overall difficulties, and

both) using data from the 2001–2007

NHIS. The findings indicate that the

prevalence of emotional and behavioral

problems and the sociodemographic

characteristics, diagnosed developmental

conditions, and service use of children

with problems depend on the measure of

emotional and behavioral problems
National Health Statistics Reports

n Number 48n February 24, 2012	 Page 11

selected. Information about the

relationships between specific measures

of emotional and behavioral problems

and other aspects ofa child’s life may

be helpful in guiding the choice ofa

measure of emotional and behavioral

problems for future studies of child

mental health.

References

1.	 Merikangas KR, He JP, Brody D,

Fisher PW, Bourdon K, Koretz DS.

Prevalence and treatment of mental

disorders among U.S. children in the

2001–2004 NHANES. Pediatrics

125(1):75–81. 2010.

2.	 Merikangas KR, He JP, Burstein M,

Swanson SA, Avenevoli S, Cui L, et

al. Lifetime prevalence of mental

disorders in U.S. adolescents: Results

from the National Comorbidity

Survey Replication—Adolescent

Supplement (NCS–A).J Am Acad

Child Adolesc Psychiatry

49(10):980–89. 2010.

3.	 Breslau J, Lane M, Sampson N,

Kessler RC. Mental disorders and

subsequent educational attainment in a U.S. national sample. J Psychiatr

Res 42(9):708–16. 2008.

4.	 Currie J, Stabile M. Child mental

health and human capital

accumulation: The case of ADHD.J

Health Econ 25(6):1094–1118. 2006.

5.	 Fergusson DM, Horwood LJ, Ridder

EM. Show me the child at seven: the

consequences of conduct problems in

childhood for psychosocial

functioning in adulthood.J Child

Psychol Psychiatry 46(8):837–49.

2005.

6.	 Sayal K. Annotation: Pathways to

care for children with mental health

problems.J Child Psychol Psychiatry

47(7):649–59. 2006.

7.	 Deighton J, WolpertM (editors).

Mental health outcome measures for

children and young people. CAMHS

EBPU, University College London

(UCL) and the Anna Freud Centre.

2009. Available from: http://www.

ucl.ac.uk/clinical-psychology/EBPU/

publications/pub-files/Mental%20

Health%20Outcome%20Measures%

20for%20Children%20and%20Young

%20People.pdf.

8.	 Bourdon KH, Goodman R, Rae DS,

Simpson G, Koretz DS. The

Strengths and Difficulties

Questionnaire: U.S. normative data

and psychometric properties.J Am

Acad Child Adolesc Psychiatry

44(6):557–64. 2005.

9.	 Kessler RC, Gruber M, Sampson N.

Final report CDC contract 200–

2003–01054: Validation studies of

mental health indices in the National

Health Interview Survey (with

addendum). December 2006.

10. Simpson GA, Bloom B, Cohen RA,

Blumberg S, Bourdon KH. U.S.

children with emotional and

behavioral difficulties: Data from the

2001, 2002, and 2003 National

Health Interview Surveys. Advance

data from vital and health statistics;

no 360. Hyattsville, MD: National

Center for Health Statistics. 2005.

11.	 Research Triangle Institute.

SUDAAN Language Manual,

Release 10.0. Research Triangle

Park, NC: Research Triangle

Institute. 2008.

12. Federal Interagency Forum on Child

and Family Statistics. America’s

Children: Key National Indicators of

Well-Being, 2011. Washington, DC:

U.S. Government Printing Office.

2011.

13. Sayal K. The role of parental burden

in child mental service use:

Longitudinal study.J Am Acad Child

Adolesc Psychiatry 43(11):1328–33.

2004.

14. Angold A, Messer SC, Stangl D,

Farmer EMZ, Costello EJ, Burns BJ.

Perceived parental burden and

service use for child and adolescent

psychiatric disorders. AmJ Public

Health 88(1):75–80. 1998.

15. Kataoka SH, Zhang L, Wells KB.

Unmet need for mental health care

among U.S. children: Variation by

ethnicity and insurance status. AmJ

Psychiatry 159(2):1548–55. 2002.

16. Goodman R, Ford T, Simmons H,

Gatward R, Meltzer H. Using the

Strengths and Difficulties

Questionnaire (SDQ) to screen for

child psychiatric disorders ina

community sample. Int Rev

Psychiatry 15(1–2):166–72. 2003.

17. Proposed data collections submitted

for public comment and

recommendations. Federal Register.

Vol 74 no 175:46778–9. September

11, 2009.
Page 12 National Health Statistics Reports n Number 48 n February 24, 2012

Table 1. Prevalence estimates of high scores on the brief Strengths and Difficulties Questionnaire and serious overall difficulties among

children aged 4–17 years, by year: United States, 2001–2007

High scores Serious overall

Year on brief SDQ1 difficulties2

Percent (standard error)
 

2001 .................................................... 4.5 (0.3) 5.2 (0.3) 
 

2002 .................................................... 4.9 (0.3) 5.5 (0.3) 
 

2003 .................................................... 4.3 (0.3) 4.8 (0.3) 
 

2004 .................................................... 4.4 (0.3) 5.4 (0.3) 
 

2005 .................................................... 4.0 (0.2) 4.6 (0.3) 
 

2006 .................................................... 4.3 (0.3) 5.0 (0.3) 
 

2007 .................................................... 3.8 (0.3) 5.2 (0.4) 
 

1

Estimates include children with and without serious overall difficulties. Trend is statistically significant. SDQ is Strengths and Difficulties Questionnaire.
 2

Estimates include children with and without high scores on the brief SDQ. Trend is not statistically significant.
 

NOTES: Data are shown in Figure 1. See ‘‘Technical Notes’’ for definition of high scores on the brief SDQ and serious overall difficulties. Estimates are based on household interviews of a sample
 

of the civilian noninstitutionalized population.
 

DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2001–2007.
 

Table 2. Prevalence estimates of high scores on the brief Strengths and Difficulties Questionnaire and serious overall difficulties among

children aged 4–17 years, by selected characteristics: United States, average annual estimates for 2001–2007

Characteristic

High scores

on brief SDQ1

Serious overall

difficulties2

Percent (standard error)

Total ........................................... 4.3 (0.1) 5.1 (0.1)

Age (years)3

4–7 ...........................................

8–10...........................................

11–14 ..........................................

15–17 ..........................................

2.8 (0.2)

4.2 (0.2)

5.0 (0.2)

5.3 (0.2)

3.6 (0.2)

5.3 (0.2)

5.8 (0.2)

6.0 (0.3)

Sex

Male ..........................................

Female .........................................

4.8 (0.1)

3.7 (0.1)

6.3 (0.2)

3.8 (0.2)

Race and ethnicity, interview language4

Non-Hispanic white..................................

Non-Hispanic black..................................

Non-Hispanic other..................................

Hispanic, English ..................................

Hispanic, Spanish ..................................

4.2 (0.1)

5.2 (0.3)

3.8 (0.4)

4.6 (0.3)

3.0 (0.3)

5.4 (0.2)

5.7 (0.3)

4.7 (0.4)

4.5 (0.3)

2.5 (0.2)

Family structure

Two parent .......................................

Mother only ......................................

Other ..........................................

3.2 (0.1)

7.0 (0.3)

6.3 (0.4)

4.1 (0.1)

7.7 (0.3)

7.0 (0.5)

Family income as a percent of poverty level3

Below 100% ......................................

100%–199% ......................................

200%–399% ......................................

400% or more .....................................

7.6 (0.4)

5.1 (0.3)

3.9 (0.2)

2.1 (0.1)

7.3 (0.3)

6.0 (0.3)

4.7 (0.2)

3.5 (0.2)

Health insurance status at time of interview

Private5 .........................................

Medicaid6

........................................

Uninsured .......................................

3.1 (0.1)

7.5 (0.3)

4.8 (0.3)

4.0 (0.1)

8.3 (0.3)

4.3 (0.3)

1

Estimates include children with and without serious overall difficulties. SDQ is Strengths and Difficulties Questionnaire.
 2

Estimates include children with and without high scores on the brief SDQ.
 3

The test for trend for each outcome was significant (p <0.001).
 4

Language of interview for Hispanic children included English interviews conducted only in English, and Spanish interviews conducted only in Spanish or in Spanish and English.
 5

Private includes any private coverage and military insurance coverage.
 6

Medicaid includes only Medicaid, CHIP, Medicare, other state-sponsored insurance, or other government-sponsored insurance coverage.
 

NOTES: See ‘‘Technical Notes’’ for definitions of high scores on the brief SDQ, serious overall difficulties, and other characteristics. Estimates are based on household interviews of a sample of the
 

civilian noninstitutionalized population.
 

DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2001–2007.
 
National Health Statistics Reports n Number 48 n February 24, 2012 Page 13

Table 3. Prevalence estimates of three categories of emotional and behavioral problems (only high scores on the brief Strengths and

Difficulties Questionnaire, only serious overall difficulties, or both) among children aged 4–17 years, by selected characteristics:

United States, average annual estimates for 2001–2007

Category of emotional and behavioral problems

Only high

scores on Only serious

Characteristic brief SDQ1 overall difficulties Both2

Percent (standard error)

Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2 (0.1) 3.1 (0.1) 2.1 (0.1)

Age (years)3

4–7 .................................... 1.7 (0.1) 2.5 (0.2) 1.1 (0.1)

8–10 ................................... 2.0 (0.2) 3.2 (0.2) 2.2 (0.2)

11–14 ................................... 2.6 (0.2) 3.4 (0.2) 2.4 (0.2)

15–17................................... 2.6 (0.2) 3.3 (0.2) 2.7 (0.2)

Sex

Male ................................... 2.3 (0.1) 3.9 (0.1) 2.5 (0.1)

Female .................................. 2.1 (0.1) 2.2 (0.1) 1.6 (0.1)

Race and ethnicity, interview language4

Non-Hispanic white .......................... 2.0 (0.1) 3.2 (0.1) 2.2 (0.1)

Non-Hispanic black .......................... 3.0 (0.2) 3.5 (0.2) 2.2 (0.2)

Non-Hispanic other .......................... 1.9 (0.3) 2.8 (0.3) 2.0 (0.3)

Hispanic, English ........................... 2.7 (0.2) 2.7 (0.2) 1.8 (0.2)

Hispanic, Spanish ........................... 2.3 (0.2) 1.8 (0.2) 0.7 (0.1)

Family structure

Two parent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7 (0.1) 2.6 (0.1) 1.5 (0.1)

Mother only ............................... 3.6 (0.2) 4.4 (0.2) 3.4 (0.2)

Other ................................... 3.4 (0.3) 4.0 (0.3) 2.9 (0.3)

Family income as a

percent of poverty level3

Below 100%............................... 4.1 (0.3) 3.7 (0.2) 3.6 (0.2)

100%–199%............................... 2.8 (0.2) 3.7 (0.2) 2.3 (0.2)

200%–399%............................... 1.9 (0.1) 2.8 (0.1) 1.9 (0.1)

400% or more.............................. 1.0 (0.1) 2.5 (0.1) 1.1 (0.1)

Health insurance status

at time of interview

Private5

.................................. 1.5 (0.1) 2.6 (0.1) 1.5 (0.1)

Medicaid6 ................................ 3.8 (0.2) 4.7 (0.2) 3.7 (0.2)

Uninsured ................................ 3.0 (0.3) 2.6 (0.2) 1.8 (0.2)

1

SDQ is Strengths and Difficulties Questionnaire.
 2

Both refers to both high scores on the brief SDQ and serious overall difficulties.
 3

The test for trend for each outcome was significant (p <0.001).
 4

Language of interview for Hispanic children included English interviews conducted only in English, and Spanish interviews conducted only in Spanish or in Spanish and English.
 5

Private includes any private coverage and military insurance coverage.
 6

Medicaid includes only Medicaid, CHIP, Medicare, other state-sponsored insurance, or other government-sponsored insurance coverage.
 

NOTES: Data shown in Figures 2–8. See ‘‘Technical Notes’’ for definitions of high scores on the brief SDQ, serious overall difficulties, and other characteristics. Estimates are based on household
 

interviews of a sample of the civilian noninstitutionalized population.
 

DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2001–2007.
 
Page 14 National Health Statistics Reports n Number 48 n February 24, 2012

Table 4. Adjusted risk ratios for three categories of emotional and behavioral problems (only high scores on the brief Strengths and

Difficulties Questionnaire, only serious overall difficulties, or both) among children aged 4–17 years by selected characteristics:

United States, average annual estimates for 2001–2007

Only high scores Only serious overall

on brief SDQ1 difficulties Both2

Characteristic Adj RR (95% CI)3,4 Adj RR (95% CI) Adj RR (95% CI)

Age (years)

4–7 .................................... 0.59 (0.27, 1.31) 0.70 (0.35, 1.41) 0.38 (0.12, 1.19)

8–10 ................................... 0.73 (0.36, 1.50) 0.92 (0.51, 1.66) 0.76 (0.37, 1.56)

11–14 .................................. 0.95 (0.52, 1.72) 1.02 (0.59, 1.75) 0.86 (0.44, 1.66)

15–17 .................................. 1.00 1.00 1.00

Sex

Male ................................... 1.12 (0.69, 1.82) 1.77 (1.23, 2.56) 1.59 (1.02, 2.47)

Female .................................. 1.00 1.00 1.00

Race and ethnicity, interview language5

Non-Hispanic black .......................... 0.89 (0.46, 1.70) 0.75 (0.39, 1.45) 0.52 (0.20, 1.33)

Non-Hispanic other .......................... 0.76 (0.31, 1.88) 0.83 (0.40, 1.72) 0.75 (0.32, 1.76)

Hispanic, English ............................ 0.99 (0.52, 1.86) 0.69 (0.34, 1.40) 0.57 (0.24, 1.35)

Hispanic, Spanish ........................... 0.69 (0.30. 1.56) 0.43 (0.14, 1.27) 0.18 (0.03, 1.27)

Non-Hispanic white .......................... 1.00 1.00 1.00

Family structure

Mother only ............................... 1.48 (0.94, 2.33) 1.50 (0.97, 2.30) 1.66 (1.04, 2.64)

Other ................................... 1.47 (0.85, 2.54) 1.31 (0.76, 2.27) 1.40 (0.79, 2.48)

Two parent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.00 1.00 1.00

Family income as a

percent of poverty level

Below 100%............................... 2.63 (1.69, 4.11) 1.01 (0.53, 1.93) 2.45 (1.49, 4.03)

100%–199%............................... 2.07 (1.28, 3.36) 1.17 (0.66, 2.08) 1.83 (1.06, 3.15)

200%–399%............................... 1.73 (1.07, 2.80) 1.06 (0.62, 1.81) 1.76 (1.07. 2.90)

400% or more.............................. 1.00 1.00 1.00

Health insurance status

at time of interview

Medicaid6 ................................ 1.60 (0.98, 2.61) 1.89 (1.27, 2.83) 2.08 (1.30, 3.31)

Uninsured ................................ 1.45 (0.85, 2.47) 1.12 (0.61, 2.04) 1.15 (0.58, 2.27)

Private7

.................................. 1.00 1.00 1.00

1

SDQ is Strengths and Difficulties Questionnaire.
 2

Both refers to both high scores on the brief SDQ and serious overall difficulties.
 3

Adj RR is adjusted risk ratio. The adj RRs associated with the categories of each sociodemographic variable are adjusted for all the other sociodemographic variables shown in the table.
 4

CI is confidence interval.
 5

Language of interview for Hispanic children included English interviews conducted only in English, and Spanish interviews conducted only in Spanish or in Spanish and English.
 6

Medicaid includes only Medicaid, CHIP, Medicare, other state-sponsored insurance, or other government-sponsored insurance coverage.
 7

Private includes any private coverage and military insurance coverage.
 

NOTES: See ‘‘Technical Notes’’ for definitions of high scores on the brief SDQ, serious overall difficulties, and other characteristics. Estimates are based on household interviews of a sample of the
 

civilian noninstitutionalized population.
 

DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2001–2007.
 
National Health Statistics Reports n Number 48 n February 24, 2012 Page 15

Table 5. Selected diagnosed developmental conditions among children aged 4–17 years, by age group and category of emotional and

behavioral problems: United States, average annual estimates for 2001–2007

Learning Intellectual Any of the selected

Category of emotional and behavioral problems ADHD1 disability disability conditions

All children Percent (standard error)

Neither2 ................................. 4.6 (0.1) 5.6 (0.1) 0.4 (0.0) 8.5 (0.1)

Only high scores on brief SDQ3................... 21.3 (1.5) 23.4 (1.5) 2.0 (0.5) 32.9 (1.6)

Only serious overall difficulties ................... 49.8 (1.4) 44.9 (1.5) 6.7 (0.8) 66.0 (1.3)

Both4 ................................... 57.9 (1.8) 49.1 (1.9) 7.1 (1.0) 72.3 (1.7)

4–10 years of age

Neither .................................. 3.1 (0.1) 4.1 (0.2) 0.3 (0.0) 6.2 (0.2)

Only high scores on brief SDQ ................... 20.3 (2.2) 21.8 (2.1) * 32.4 (2.5)

Only serious overall difficulities ................... 46.8 (2.1) 40.7 (2.2) 7.7 (1.4) 64.2 (2.0)

Both ................................... 62.2 (2.8) 45.3 (3.0) 7.8 (2.0) 75.5 (2.4)

11–17 years of age

Neither .................................. 6.2 (0.2) 7.1 (0.2) 0.4 (0.0) 10.7 (0.2)

Only high scores on brief SDQ ................... 21.9 (1.9) 24.4 (2.0) 1.7 (0.5) 33.2 (2.1)

Only serious overall difficulties ................... 52.1 (1.9) 48.2 (2.0) 6.0 (0.9) 67.5 (1.8)

Both ................................... 55.2 (2.4) 51.4 (2.4) 6.8 (1.1) 70.3 (2.2)

* Estimates have a relative standard error greater than 30% and do not meet standards of reliability or precision.
 1

ADHD is attention deficit hyperactivity disorder.
 2

Neither refers to neither high scores on the brief SDQ nor serious overall difficulties.
 3

SDQ is Strengths and Difficulties Questionnaire.
 4

Both refers to both high scores on the brief SDQ and serious overall difficulties.
 

NOTES: Data are shown in Figure 9. See ‘‘Technical Notes’’ for definitions of high scores on the brief SDQ, serious overall difficulties, and selected diagnosed developmental conditions. Estimates

are based on household interviews of a sample of the civilian noninstitutionalized population.

DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2001–2007.

Table 6. Use of selected educational and health care services among children aged 4–17 years, by age group and category of emotional

and behavioral problems: United States, average annual estimates for 2001–2007

General doctor Mental health

Special for mental professional Any of the

education health (past (past 12 selected

Category of emotional and behavioral problems (current) 12 months) months) services

All children Percent (standard error)

Neither1 ................................. 5.5 (0.1) 2.5 (0.1) 4.5 (0.1) 10.2 (0.2)

Only high scores on brief SDQ2................... 18.2 (1.4) 16.9 (1.3) 24.9 (1.5) 39.2 (1.7)

Only serious overall difficulities ................... 36.6 (1.4) 32.0 (1.4) 40.1 (1.5) 65.4 (1.4)

Both3 ................................... 40.8 (1.9) 46.8 (1.9) 58.5 (1.9) 79.8 (1.4)

4–10 years of age

Neither .................................. 5.3 (0.2) 2.6 (0.1) 3.8 (0.1) 9.4 (0.2)

Only high scores on brief SDQ ................... 17.0 (2.0) 18.2 (2.2) 23.6 (2.3) 36.9 (2.6)

Only serious overall difficulities ................... 37.8 (2.1) 35.5 (2.1) 37.6 (2.1) 67.1 (2.0)

Both ................................... 41.5 (3.1) 48.2 (3.1) 54.4 (3.1) 80.0 (2.2)

11–17 years of age

Neither .................................. 5.6 (0.2) 2.5 (0.1) 5.2 (0.2) 10.9 (0.2)

Only high scores on brief SDQ ................... 19.0 (1.9) 15.9 (1.6) 25.8 (2.0) 40.7 (2.3)

Only serious overall difficulties ................... 35.6 (1.9) 29.2 (1.8) 42.2 (2.0) 64.1 (1.9)

Both ................................... 40.3 (2.3) 45.9 (2.4) 61.0 (2.4) 79.7 (1.8)

1

Neither refers to neither high scores on the brief SDQ nor serious overall difficulties.
 2

SDQ is Strengths and Difficulties Questionnaire.
 3

Both refers to both high scores on the brief SDQ and serious overall difficulties.
 

NOTES: Data are shown in Figure 10. See ‘‘Technical Notes’’ for definitions of high scores on the brief SDQ, serious overall difficulties, and selected educational and health care services.
 

Estimates are based on household interviews of a sample of the civilian noninstitutionalized population.
 

DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2001–2007.
 
Page 16 National Health Statistics Reports n Number 48 n February 24, 2012

Technical Notes

Sample design

The National Health Interview

Survey (NHIS) is a cross-sectional

household interview survey of the U.S.

civilian noninstitutionalized population.

Data are collected continuously

throughout the year in all 50 states and

the District of Columbia. The NHIS

uses a multistage, clustered sample

design to produce national estimates for

a variety of health indicators. Some

health and demographic information is

collected for all household members.

Additional detailed health-related

information is collected for one

randomly selected child (the ‘‘sample

child’’) in each family that includes

children 0–17 years. Information about

the sample child is provided by an adult,

usually a parent, who is knowledgeable

about the child’s health. Interviews are

conducted in the home by field staff

from the U.S. Census Bureau using a

computer-assisted personal interview

(CAPI), with telephone interviewing

permitted for follow-up, if necessary.

Starting in 2006, the sample design

included Asian children and adults in

the oversampling of populations in the

NHIS; in 2001–2005, only households

with black and Hispanic children and

adults were oversampled. A detailed

description of the NHIS sample design

and the survey questionnaires are

available from: http://www.cdc.gov/nchs/

nhis/quest_data_related_1997_forward.

htm.

Item nonresponse

Between 2001 and 2007, item

nonresponse for each of the

demographic indicators for children

aged 4–17 years shown in this report

was generally less than 1%, with the

exception of poverty status, which is

based on detailed family income as

ascertained in the family component of

the questionnaire. Because the item

nonresponse for the poverty status

variable for children aged 4–17 years

was relatively high (22%–31% between

1997 and 2007), family income data

were imputed for families with missing

values (Schenker N, Raghunathan TE,

Chiu P, Makuc DM, Zhang G, and

Cohen AJ. Multiple imputation of

family income and personal earnings in

the NHIS: Methods and examples.

Available from: http://www.cdc.gov/

nchs/data/nhis/tecdoc.pdf). Item

nonresponse for the indicators of

emotional and behavioral problems, use

of special education services, and use of

health care services was 1% or less. The

denominators for statistics shown in the

tables exclude children with unknown

information.

Tests of significance

Statistical tests performed to assess

significance of differences in the

estimates were two-tailed with no

adjustments for multiple comparisons.

The test statistic used to determine

statistical significance of differences

between two percentages was

|Xa – Xb

| .

y(S 2 + Sb

2

)

Z =

a

where Xa and Xb are the two

percentages being compared, and Sa and

Sb are the standard errors of those

percentages. The critical value used for

two-sided tests at the 0.05 level of

significance was 1.96.

Definitions of terms

Demographic and socioeconomic

terms

Age—The age recorded for each

child is the age at his or her last

birthday.

Family income as a percentage of

the poverty level—Poverty level is based

on family income and family size and

composition using the U.S. Census

Bureau’s poverty thresholds.

Family structure—A mother-only

family refers to a family in which a

mother, but not a father, is a household

member. A two-parent family refers to a

family in which both a mother and

father are household members.

Health insurance coverage—NHIS

respondents were asked about the health

insurance coverage of the child at the

time of the interview. Respondents

reported whether the child was covered

by private insurance (obtained through

the employer or workplace, purchased

directly, or through a local or

community program), military coverage

(including VA, TRICARE, or CHAMPVA), a state-sponsored health plan,

another government program, Medicare,

Children’s Health Insurance Program

(CHIP), Indian Health Service (IHS), or

any single service plans. This

information was used to form a health

insurance hierarchy, which consisted of

three mutually exclusive categories. In

this report, children with more than one

type of health insurance were assigned

to the first appropriate category in the

following hierarchy: private (this

category also includes military

coverage), Medicaid (this category also

includes CHIP, Medicare, a statesponsored health plan, or another

government program) and uninsured

(this category also includes children

who are only covered by IHS or only

have single service plans).

Hispanic or Latino ethnicity—

Hispanic or Latino ethnicity includes

children of Mexican, Puerto Rican,

Cuban, Central and South American, or

Spanish origins. Children of Hispanic or

Latino ethnicity may be of any race.

Race and ethnicity—Race is defined

as the reported race or races of children

and ethnicity as the reported origin of

children, Hispanic or non-Hispanic. The

reporting of race and ethnicity conform

to the 1997 Office of Management and

Budget Race and Ethnic Standards for

Statistical Statistics and Administrative

Reporting. In this report, three

categories are shown: non-Hispanic

white, non-Hispanic black, and Hispanic

of any race. Other racial categories,

including a multiple-race category, are

not shown due to the small number of

sample children in these categories.

Language of interview for Hispanic

children—Spanish language interviews

were conducted in Spanish or in Spanish

and English. English language

interviews were conducted in English.

Terms related to measures of

emotional and behavioral

problems

Brief Strengths and Difficulties

Questionnaire (SDQ)—The Strengths
National Health Statistics Reports

n Number 48n February 24, 2012 Page 17

and Difficulties Questionnaire (SDQ),

developed and copyrighted by Robert

Goodman, isa screening tool for

identifying emotional and behavioral

difficulties in children. The brief SDQ

includes five questions about the child’s

symptoms related to conduct problems,

hyperactivity-inattention, emotional

symptoms, and peer problems. The brief

SDQ also includesa single question

about the severity of the child’s overall

difficulties. The parent was asked the

following questions: ‘‘I am going to

reada list of items that describe

children. For each item, please tell me if

it has been: not true, somewhat true, or

certainly true for (sample child) during

the past6 months. [Sample child]: 1) Is

generally well behaved, usually does

what adults request, 2) has many

worries, or often seems worried, 3) is

often unhappy, depressed, or tearful, 4)

gets along better with adults than with

other children/youth, and 5) has good

attention span, sees chores or homework

through to the end.’’ Responses to these

questions in the SDQ were coded 0=

‘‘not true,’’ 1= ‘‘somewhat true,’’ and 2=

‘‘certainly true.’’ Responses to all

questions were scored 0, 1, 2, so thata

higher score indicated higher risk of

emotional and behavioral problems.

High scores on the brief SDQ—

High scores on the brief SDQ were

defined asa score of6 or more based

on parent’s responses to five questions

about the child’s symptoms related to

conduct problems, hyperactivityinattention, emotional symptoms, and

peer problems.

Serious overall difficulties—A

parent report of overall difficulties was

based on responses to the following

question: ‘‘Overall, do you think that

[sample child] has any difficulties in

one or more of the following areas:

emotions, concentration, behavior, or

being able to get along with other

people?’’ Response options were 1)

‘‘no’’; 2) ‘‘yes, minor difficulties’’; 3)

‘‘yes, definite difficulties’’; and 4) ‘‘yes,

severe difficulties.’’ Children whose

parents responded ‘‘yes, definite

difficulties’’ or ‘‘yes, severe difficulties’’

were defined as having serious overall

difficulties.

Terms related to health conditions

Attention deficit hyperactivity

disorder (ADHD)—A parent report ofa

diagnosis of attention deficit

hyperactivity disorder bya doctor or

health professional.

Intellectual disability—A parent

report ofa diagnosis of mental

retardation or other developmental delay

bya doctor or health professional.

Learning disability—A parent report

ofa diagnosis of learning disability bya

representative froma school or health

professional.

Terms related to use of health

care and educational services

Contact witha general doctor about

child’s emotional or behavioral

problem—Contact witha general doctor

was based ona question that asked

whether respondents, during the past 12

months, had seen or talked toa general

doctor because of an emotional or

behavioral problem that the sample child

had.

Contact witha mental health

professional—Contact witha mental

health professional was based ona

question that asked whether respondents,

during the past 12 months, had seen or

talked toa mental health care provider

about the sample child’s health. The

providers includeda psychiatrist,

psychologist, psychiatric nurse, or

clinical social worker.

Special education—Special

education was based ona question that

asked respondent if the child currently

received special education services.
U.S. DEPARTMENT OF

HEALTH & HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

3311 Toledo Road

Hyattsville, MD 20782

FIRST CLASS MAIL
 

POSTAGE & FEES PAID
 

CDC/NCHS
 

PERMIT NO. G-284
 

OFFICIAL BUSINESS

PENALTY FOR PRIVATE USE, $300

National Health Statistics Reports n Number 48 n February 24, 2012

Suggested citation

Pastor PN, Reuben CA, Duran CR. Identifying

emotional and behavioral problems in children

aged 4–17 years: United States, 2001–2007.

National health statisitcs reports; no 48.

Hyattsville, MD: National Center for Health

Statistics. 2012.

Copyright information

All material appearing in this report is in the

public domain and may be reproduced or

copied without permission; citation as to

source, however, is appreciated.

National Center for Health Statistics

Edward J. Sondik, Ph.D., Director
 

Jennifer H. Madans, Ph.D., Associate Director
 

for Science
 

Division of Health and Nutrition
 

Examination Surveys
 

Clifford L. Johnson, M.S.P.H., Director

For free e-mail updates on NCHS publication releases, subscribe online at: http://www.cdc.gov/nchs/govdelivery.htm.
 

For questions or general information about NCHS: Tel: 1–800–232–4636 • E-mail: cdcinfo@cdc.gov • Internet: http://www.cdc.gov/nchs
 

DHHS Publication No. (PHS) 2012–1250 • CS229055