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Child mental health: is it in crisis?
Child mental health: is it in crisis?

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2.2 Lily’s parents seek help

Read the next part of Lily’s case study.

Case study: Lily

Fortunately, Lily’s parents recognise that they need help, and they take Lily to see her family doctor/general practitioner (GP). During her appointment Lily starts to cry and she discusses her worries. Lily’s doctor asks her to complete a Strengths and Difficulties Questionnaire and notices her very high scores in terms of emotional symptoms. The GP explains that Lily’s issues could be understood by Figure 1.

The figure consists of an overarching theme, depicted in the middle, stated as ‘Fears about being in danger’. These fears are compounded by learning experiences which visually surround the over-arching theme: ‘Stay away from fears to cope’ leads to (as indicted by an arrow) ‘What other people do to make Lily less scared’, which in turn leads again to (as indicated by another arrow) ‘Stay away from fears to cope’ (i.e. there is a cycle of fears).
Figure 1 Lily’s fear–avoidance cycle (adapted from Siddaway, Wood and Cartwright-Hatton, 2014)

In Lily’s case the ‘learning experiences’ revolve around her developing the firm belief that she cannot cope leaving home to attend school, and that school is a risky and unsafe place away from home and her loved ones. Being at home is where she feels she ‘needs’ to be, given her fears of what could happen to her parents (i.e. fears about them being in danger). While staying away from her fears (i.e. school, where she is at a distance from her mother) appears to help her cope or manage, it becomes a cycle whereby her avoidance maintains her anxious feelings. These anxious feelings are then (inadvertently) supported by her parents who unintentionally reinforce her avoidance by presenting in-person school attendance as optional and reducing their demands of her to make her feel less scared. Lily may then come to view herself as someone that cannot cope when outside her home, further reinforcing her anxiety levels.

In the case study above the Strengths and Difficulties Questionnaire (SDQ) was mentioned. You may be unfamiliar with what this. Developed by Professor Robert Goodman, the SDQ is a well-tested assessment of mental health. It moves beyond merely highlighting issues, exploring strengths as well. Additionally, parents and young people report that the SDQ is quick to complete, and that the questions it asks are meaningful, simple and unambiguous (Stasiak et al., 2012). It is designed to assess children and young people aged between 4 and 17 years old and is usually completed by a parent/guardian or teacher. You will the explore the SDQ in more detail in the next activity.

Activity 3 Critiquing the strengths and difficulties questionnaire

Timing: Allow about 1 hour

Spend some time familiarising yourself with the questions (also known as items) in the Strengths and Difficulties Questionnaire (SDQ). Then, answer the four questions that follow:

Strengths and Difficulties Questionnaire

For each item, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain or the item seems daft! Please give your answers on the basis of the child’s behaviour over the last six months or this school year.

Child’s Name .................................................


Date of Birth....................................................

Not True Somewhat True Certainly true
Considerate of other people’s feelings    
Restless, overactive, cannot stay still for long    
Often complains of headaches, stomach-aches or sickness    
Shares readily with other children (treats, toys, pencils etc.)    
Often has temper tantrums or hot tempers    
Rather solitary, tends to play alone    
Generally obedient, usually does what adults request    
Many worries, often seems worried    
Helpful if someone is hurt, upset or feeling ill    
Constantly fidgeting or squirming    
Has at least one good friend    
Often fights with other children or bullies them    
Often unhappy, down-hearted or tearful    
Generally liked by other children    
Easily distracted, concentration wanders    
Nervous or clingy in new situations, easily loses confidence    
Kind to younger children    
Often lies or cheats    
Picked on or bullied by other children    
Often volunteers to help others (parents, teachers, other children)    
Thinks things out before acting    
Steals from home, school or elsewhere    
Gets on better with adults than with other children    
Many fears, easily scared    
Sees tasks through to the end, good attention span    

Date ...........................................................................

Parent/Teacher/Other (please specify:)

Signature ...........................................................................

Thank you very much for your help

Source: © Robert Goodman, 2005

  1. What are your initial impressions of the assessment?
  2. Reflect on a time when you were an adolescent (approximately between the ages of 11 and 17 years old) what 3 (or more) items were ‘certainly true’ of you (attempt to pick at least one that is not obviously a ‘positive’ or strength)?
  3. Was it hard to recall the items that were ‘certainly true’ or was it challenging to think of your difficulties when younger?
  4. There are 25 items in the SDQ, of which 5 are ‘strengths’. Which do you think are the five strengths-based items?
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Thinking about the items, especially those that focus on issues or difficulties, can be challenging emotionally. Plus, it can be hard to think about how you would have been as a young person retrospectively, after several years have passed. It is also common for people completing self-report questionnaires like the SDQ to comment that it is difficult to decide which response is the most accurate when only three possible responses are available (i.e. ‘not true’, ‘somewhat true’ and ‘certainly true’).

The strengths, known as the prosocial scale in the SDQ (i.e. traits that show an orientation towards the welfare of others), are ‘I try to be nice to other people. I care about their feelings’; ‘I usually share with others (food, games, pens, etc.)’; ‘I am helpful if someone is hurt, upset or feeling ill’; ‘I am kind to younger children’; and ‘I often volunteer to help others (parents, teachers, children) (Goodman, Meltzer and Bailey, 1998). The four other scales are all difficulties (or deficit) focused, and they are the hyperactivity scale, emotional symptoms scale, conduct problems scale and peer problems scale (Goodman, Meltzer and Bailey, 1998).