European Child & Adolescent Psychiatry

, Volume 28, Issue 5, pp 625–633 | Cite as

The predictive validity of the Strengths and Difficulties Questionnaire for child attention-deficit/hyperactivity disorder

  • Kristin Romvig OvergaardEmail author
  • Kathrine Bang Madsen
  • Beate Oerbeck
  • Svein Friis
  • Carsten Obel
Original Contribution


We need accurate screening measures for attention-deficit/hyperactivity disorder (ADHD) to ensure that children with the disorder are referred for assessment without raising concern for children with normal behaviour. The Strengths and Difficulties Questionnaire (SDQ) provides hyperactivity–inattention (HI), conduct, emotional and peer problem subscales and impact scores that may be used for screening. The aim of the study was to investigate the predictive validity of the Danish version of the parent SDQ HI subscale at the child age of 7 years for subsequent clinically diagnosed ADHD (age 8–15 years). Participants were part of the Danish National Birth Cohort (N = 51,096), and children with ADHD were identified through the Danish National Health registries (n = 943). Receiver operating characteristic analysis showed that the screening accuracy for the HI scores was good (area under the curve = .84). With Cox multivariate regression analysis, we found that SDQ HI subscale scores ≥ 7 with impact gave a nearly 14-fold [hazard ratio (HR) = 13.59] increased risk for ADHD, while conduct and emotional problems indicated low risk (HRs of 1.62 and 1.67, respectively). For the HI subscale to be a sensitive measure for ADHD, a low cutoff (4) was needed, but gave many false screening positives (PPV = .02). Although the diagnostic accuracy of the parent version of the SDQ HI subscale for predicting ADHD was good, our results question the feasibility of screening the general child population for ADHD with only the parent SDQ HI subscale.


ADHD SDQ Cohort study Patient registries 



The Danish National Research Foundation established the Danish Epidemiology Science Centre, which initiated and created the Danish National Birth Cohort. The cohort is also a result of a major grant from the Danish National Research Foundation. Additional support for the Danish National Birth Cohort was obtained from the Pharmacy Foundation, the Egmont Foundation, the March of Dimes Birth Defects Foundation, the Augustinus Foundation, and the Health Foundation.

Compliance with ethical standards

Conflict of interest

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Professor emeritus Svein Friis has received an honorarium as a data consultant for RAND Corporation for a project sponsored by the Janssen-Cilag pharmaceutical company.


  1. 1.
    Thapar A, Cooper M (2016) Attention deficit hyperactivity disorder. Lancet 387(10024):1240–1250. CrossRefGoogle Scholar
  2. 2.
    American Psychiatric Association (APA) (2013) Diagnostic and statistical manual of mental disorders: DSM-5. APA, Washington, DCCrossRefGoogle Scholar
  3. 3.
    Polanczyk G, Rohde LA (2007) Epidemiology of attention-deficit/hyperactivity disorder across the lifespan. Curr Opin Psychiatry 20(4):386–392. CrossRefGoogle Scholar
  4. 4.
    Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA (2015) Annual research review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry 56(3):345–365. CrossRefGoogle Scholar
  5. 5.
    Kraut AA, Langner I, Lindemann C et al (2013) Comorbidities in ADHD children treated with methylphenidate: a database study. BMC Psychiatry 13:11. CrossRefGoogle Scholar
  6. 6.
    Ghanizadeh A (2009) Psychiatric comorbidity differences in clinic-referred children and adolescents with ADHD according to the subtypes and gender. J Child Neurol 24(6):679–684. CrossRefGoogle Scholar
  7. 7.
    Steinhausen HC, Novik TS, Baldursson G et al (2006) Co-existing psychiatric problems in ADHD in the ADORE cohort. Eur Child Adolesc Psychiatry 15(Suppl 1):I25–I29. CrossRefGoogle Scholar
  8. 8.
    Pliszka SR (2003) Psychiatric comorbidities in children with attention deficit hyperactivity disorder: implications for management. Paediatr Drugs 5(11):741–750. CrossRefGoogle Scholar
  9. 9.
    Chorozoglou M, Smith E, Koerting J, Thompson MJ, Sayal K, Sonuga-Barke EJ (2015) Preschool hyperactivity is associated with long-term economic burden: evidence from a longitudinal health economic analysis of costs incurred across childhood, adolescence and young adulthood. J Child Psychol Psychiatry 56(9):966–975. CrossRefGoogle Scholar
  10. 10.
    Dalsgaard S, Ostergaard SD, Leckman JF, Mortensen PB, Pedersen MG (2015) Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study. Lancet 385(9983):2190–2196. CrossRefGoogle Scholar
  11. 11.
    Dalsgaard S, Leckman JF, Mortensen PB, Nielsen HS, Simonsen M (2015) Effect of drugs on the risk of injuries in children with attention deficit hyperactivity disorder: a prospective cohort study. Lancet Psychiatry 2(8):702–709. CrossRefGoogle Scholar
  12. 12.
    Erskine HE, Norman RE, Ferrari AJ et al (2016) Long-term outcomes of attention-deficit/hyperactivity disorder and conduct disorder: a systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry 55(10):841–850. CrossRefGoogle Scholar
  13. 13.
    Lee HJ, Cho S, Shin MS (2008) Supporting diagnosis of attention-deficit hyperactive disorder with novelty detection. Artif Intell Med 42(3):199–212. CrossRefGoogle Scholar
  14. 14.
    Becker A, Woerner W, Hasselhorn M, Banaschewski T, Rothenberger A (2004) Validation of the parent and teacher SDQ in a clinical sample. Eur Child Adolesc Psychiatry 13(Suppl 2):ii11–ii16. Google Scholar
  15. 15.
    Carballo JJ, Rodriguez-Blanco L, Garcia-Nieto R, Baca-Garcia E (2014) Screening for the ADHD phenotype using the Strengths and Difficulties Questionnaire in a clinical sample of newly referred children and adolescents. J Atten Disord. Google Scholar
  16. 16.
    Stone LL, Otten R, Engels RC, Vermulst AA, Janssens JM (2010) Psychometric properties of the parent and teacher versions of the strengths and difficulties questionnaire for 4- to 12-year-olds: a review. Clin Child Fam Psychol Rev 13(3):254–274. CrossRefGoogle Scholar
  17. 17.
    Algorta GP, Dodd AL, Stringaris A, Youngstrom EA (2016) Diagnostic efficiency of the SDQ for parents to identify ADHD in the UK: a ROC analysis. Eur Child Adolesc Psychiatry 25(9):949–957. CrossRefGoogle Scholar
  18. 18.
    Goodman R (2001) Psychometric properties of the Strengths and Difficulties Questionnaire. J Am Acad Child Adolesc Psychiatry 40(11):1337–1345. CrossRefGoogle Scholar
  19. 19.
    Sheldrick RC, Garfinkel D (2017) Is a positive developmental-behavioral screening score sufficient to justify referral? A review of evidence and theory. Acad Pediatr 17(5):464–470. CrossRefGoogle Scholar
  20. 20.
    Ullebo AK, Posserud MB, Heiervang E, Gillberg C, Obel C (2011) Screening for the attention deficit hyperactivity disorder phenotype using the Strength and Difficulties Questionnaire. Eur Child Adolesc Psychiatry 20(9):451–458. CrossRefGoogle Scholar
  21. 21.
    Cuffe SP, Moore CG, McKeown R (2009) ADHD and health services utilization in the National Health Interview Survey. J Atten Disord 12(4):330–340. CrossRefGoogle Scholar
  22. 22.
    Dopfner M, Breuer D, Wille N, Erhart M, Ravens-Sieberer U, BELLA Study Group (2008) How often do children meet ICD-10/DSM-IV criteria of attention deficit-/hyperactivity disorder and hyperkinetic disorder? Parent-based prevalence rates in a national sample—results of the BELLA study. Eur Child Adolesc Psychiatry 17(Suppl 1):59–70. CrossRefGoogle Scholar
  23. 23.
    Hawes DJ, Dadds MR (2004) Australian data and psychometric properties of the Strengths and Difficulties Questionnaire. Aust NZ J Psychiatry 38(8):644–651. CrossRefGoogle Scholar
  24. 24.
    Croft S, Stride C, Maughan B, Rowe R (2015) Validity of the Strengths and Difficulties Questionnaire in preschool-aged children. Pediatrics 135(5):e1210–e1219. CrossRefGoogle Scholar
  25. 25.
    Rimvall MK, Elberling H, Rask CU, Helenius D, Skovgaard AM, Jeppesen P (2014) Predicting ADHD in school age when using the Strengths and Difficulties Questionnaire in preschool age: a longitudinal general population study, CCC2000. Eur Child Adolesc Psychiatry 23(11):1051–1060. CrossRefGoogle Scholar
  26. 26.
    Olsen J, Melbye M, Olsen SF et al (2001) The Danish National Birth Cohort—its background, structure and aim. Scand J Public Health 29(4):300–307. CrossRefGoogle Scholar
  27. 27.
    Andersen TF, Madsen M, Jorgensen J, Mellemkjoer L, Olsen JH (1999) The Danish National Hospital Register. A valuable source of data for modern health sciences. Dan Med Bull 46(3):263–268Google Scholar
  28. 28.
    Munk-Jorgensen P, Mortensen PB (1997) The Danish Psychiatric Central Register. Dan Med Bull 44(1):82–84Google Scholar
  29. 29.
    Kildemoes HW, Sorensen HT, Hallas J (2011) The Danish National Prescription Registry. Scand J Public Health 39(7 Suppl):38–41. CrossRefGoogle Scholar
  30. 30.
    World Health Organization (WHO) (1990) International classification of diseases and related health problems (ICD-10), 10th edn. WHO, GenevaGoogle Scholar
  31. 31.
    Goodman R (1999) The extended version of the Strengths and Difficulties Questionnaire as a guide to child psychiatric caseness and consequent burden. J Child Psychol Psychiatry 40(5):791–799CrossRefGoogle Scholar
  32. 32.
    Niclasen J, Teasdale TW, Andersen AM, Skovgaard AM, Elberling H, Obel C (2012) Psychometric properties of the Danish Strength and Difficulties Questionnaire: the SDQ assessed for more than 70,000 raters in four different cohorts. PLoS One 7(2):e32025. CrossRefGoogle Scholar
  33. 33.
    Niclasen J, Skovgaard AM, Andersen AM, Somhovd MJ, Obel C (2013) A confirmatory approach to examining the factor structure of the Strengths and Difficulties Questionnaire (SDQ): a large scale cohort study. J Abnorm Child Psychol 41(3):355–365. CrossRefGoogle Scholar
  34. 34.
    Nohr EA, Bech BH, Vaeth M, Rasmussen KM, Henriksen TB, Olsen J (2007) Obesity, gestational weight gain and preterm birth: a study within the Danish National Birth Cohort. Paediatr Perinat Epidemiol 21(1):5–14. CrossRefGoogle Scholar
  35. 35.
    Swets JA (1988) Measuring the accuracy of diagnostic systems. Science 240(4857):1285–1293CrossRefGoogle Scholar
  36. 36.
    McGee S (2002) Simplifying likelihood ratios. J Gen Intern Med 17(8):646–649CrossRefGoogle Scholar
  37. 37.
    Youngstrom EA (2014) A primer on receiver operating characteristic analysis and diagnostic efficiency statistics for pediatric psychology: we are ready to ROC. J Pediatr Psychol 39(2):204–221. CrossRefGoogle Scholar
  38. 38.
    Youngstrom E, Meyers O, Youngstrom JK, Calabrese JR, Findling RL (2006) Comparing the effects of sampling designs on the diagnostic accuracy of eight promising screening algorithms for pediatric bipolar disorder. Biol Psychiatry 60(9):1013–1019. CrossRefGoogle Scholar
  39. 39.
    Rettew DC, Lynch AD, Achenbach TM, Dumenci L, Ivanova MY (2009) Meta-analyses of agreement between diagnoses made from clinical evaluations and standardized diagnostic interviews. Int J Methods Psychiatr Res 18(3):169–184. CrossRefGoogle Scholar
  40. 40.
    Oerbeck B, Overgaard KR, Pripp AH, Reichborn-Kjennerud T, Aase H, Zeiner P (2017) Early predictors of ADHD: evidence from a prospective birth cohort. J Atten Disord. Google Scholar
  41. 41.
    Hamre Sveen T, Berg-Nielsen TS, Lydersen S, Wichstrom L (2016) Screening for persistent psychopathology in 4-year-old children. Pediatrics 138(4):e20151648. CrossRefGoogle Scholar
  42. 42.
    Jacobsen TN, Nohr EA, Frydenberg M (2010) Selection by socioeconomic factors into the Danish National Birth Cohort. Eur J Epidemiol 25(5):349–355. CrossRefGoogle Scholar
  43. 43.
    Madsen KB, Hohwu L, Zhu JL, Olsen J, Obel C (2017) Social selection in cohort studies and later representation of childhood psychiatric diagnoses: the Danish National Birth Cohort. Scand J Public Health. Google Scholar
  44. 44.
    Madsen KB, Ersboll AK, Olsen J, Parner E, Obel C (2015) Geographic analysis of the variation in the incidence of ADHD in a country with free access to healthcare: a Danish cohort study. Int J Health Geogr 14:24. CrossRefGoogle Scholar
  45. 45.
    Mohr-Jensen C, Koch SV, Lauritsen BM, Steinhausen H-C (2016) The validity and reliability of the diagnosis of hyperkinetic disorders in the Danish Psychiatric Central Research Registry. Eur Psychiatry 35:16–24. CrossRefGoogle Scholar
  46. 46.
    Oerbeck B et al (2017) ADHD, comorbid disorders and psychosocial functioning: how representative is a child cohort study? Findings from a national patient registry. BMC Psychiatry 17(1):23. CrossRefGoogle Scholar
  47. 47.
    Overgaard KR, Oerbeck B, Friis S, Pripp AH, Biele G, Aase H, Zeiner P (2018) Attention-deficit/hyperactivity disorder in preschoolers—the accuracy of a short screener. J Am Acad Child Adolesc Psychiatry 57(6):428–435. CrossRefGoogle Scholar
  48. 48.
    Posserud MB, Ullebo AK, Plessen KJ, Stormark KM, Gillberg C, Lundervold AJ (2014) Influence of assessment instrument on ADHD diagnosis. Eur Child Adolesc Psychiatry 23(4):197–205. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Kristin Romvig Overgaard
    • 1
    Email author
  • Kathrine Bang Madsen
    • 2
  • Beate Oerbeck
    • 1
  • Svein Friis
    • 1
    • 3
  • Carsten Obel
    • 2
  1. 1.Division of Mental Health and AddictionOslo University HospitalOsloNorway
  2. 2.Department of Public HealthAarhus UniversityAarhusDenmark
  3. 3.Institute of Clinical MedicineUniversity of OsloOsloNorway

Personalised recommendations