Mental health problems in a large representative sample of children and adolescents: Prevalence, associations with problematic substance use and psychometric properties of the Strengths and Difficulties Questionnaire

Lutz Wartberg; Rainer Thomasius; Nicolas Arnaud; Lutz Wartberg; Rainer Thomasius; Nicolas Arnaud

doi:10.3934/publichealth.2026042

AIMS Public Health

2026, Volume 13, Issue 3: 783-797. doi: 10.3934/publichealth.2026042

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Mental health problems in a large representative sample of children and adolescents: Prevalence, associations with problematic substance use and psychometric properties of the Strengths and Difficulties Questionnaire

1.
Department Psychology, Faculty of Human Sciences, MSH Medical School Hamburg, Hamburg, Germany
2.
German Center for Addiction Research in Childhood and Adolescence (DZSKJ), University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Received: 04 December 2025 Revised: 28 April 2026 Accepted: 27 May 2026 Published: 27 July 2026

Mental health problems are already widespread in childhood and adolescence. The Strengths and Difficulties Questionnaire (SDQ) is an internationally widely used instrument for assessing mental health problems and prosocial behavior in children and adolescents. Particularly, the Total Difficulties score (TDS) from the SDQ (calculated from the sum of all problem scales) is considered a good estimator for mental health problems. Heretofore, there are relatively few estimates for mental health problems based on representative samples that rely on self-assessments by children and adolescents. Although SDQ is frequently used internationally, the findings regarding its psychometric properties are inconsistent. So far, there are no results available from representative samples on the relationships between the TDS and various forms of problematic substance use. A representative sample of 4001 12–17-year-olds from Germany was examined using the SDQ with regard to mental health problems and established standardized instruments for problematic use of alcohol, cigarettes, and cannabis. We calculated relative frequencies, reliability coefficients (Cronbach's alpha and McDonald's omega), correlations, binary logistic regressions, and linear regression analyses. Furthermore, we conducted confirmatory factor analyses. Based on the TDS, 9.6% (95% confidence interval: 8.7%–10.5%) of the representative sample reported severe mental health problems. We observed reliability values for the five SDQ scales between 0.44 (peer problems) and 0.70 (emotional problems), as well as 0.74 and 0.75 for the TDS. In the different confirmatory factor analyses, no model showed a completely satisfactory fit to the data. In bivariate and multivariable analyses, consistent statistically significant associations were found between mental health problems (TDS) and problematic cigarette use and problematic cannabis use, whereas findings for problematic alcohol use were mixed. According to our results, a substantial proportion of German children and adolescents are affected by severe mental health problems, and problematic substance use is a possible source of this.
- mental health,
- mental disorder,
- psychopathology,
- prevalence,
- SDQ,
- reliability,
- factor structure,
- alcohol,
- tobacco,
- cannabis
Citation: Lutz Wartberg, Rainer Thomasius, Nicolas Arnaud. Mental health problems in a large representative sample of children and adolescents: Prevalence, associations with problematic substance use and psychometric properties of the Strengths and Difficulties Questionnaire[J]. AIMS Public Health, 2026, 13(3): 783-797. doi: 10.3934/publichealth.2026042

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Abstract

Mental health problems are already widespread in childhood and adolescence. The Strengths and Difficulties Questionnaire (SDQ) is an internationally widely used instrument for assessing mental health problems and prosocial behavior in children and adolescents. Particularly, the Total Difficulties score (TDS) from the SDQ (calculated from the sum of all problem scales) is considered a good estimator for mental health problems. Heretofore, there are relatively few estimates for mental health problems based on representative samples that rely on self-assessments by children and adolescents. Although SDQ is frequently used internationally, the findings regarding its psychometric properties are inconsistent. So far, there are no results available from representative samples on the relationships between the TDS and various forms of problematic substance use. A representative sample of 4001 12–17-year-olds from Germany was examined using the SDQ with regard to mental health problems and established standardized instruments for problematic use of alcohol, cigarettes, and cannabis. We calculated relative frequencies, reliability coefficients (Cronbach's alpha and McDonald's omega), correlations, binary logistic regressions, and linear regression analyses. Furthermore, we conducted confirmatory factor analyses. Based on the TDS, 9.6% (95% confidence interval: 8.7%–10.5%) of the representative sample reported severe mental health problems. We observed reliability values for the five SDQ scales between 0.44 (peer problems) and 0.70 (emotional problems), as well as 0.74 and 0.75 for the TDS. In the different confirmatory factor analyses, no model showed a completely satisfactory fit to the data. In bivariate and multivariable analyses, consistent statistically significant associations were found between mental health problems (TDS) and problematic cigarette use and problematic cannabis use, whereas findings for problematic alcohol use were mixed. According to our results, a substantial proportion of German children and adolescents are affected by severe mental health problems, and problematic substance use is a possible source of this.

Acknowledgments

This study (as part of the IMAC-Mind project) was funded by the German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF; Grant No.: 01GL1745A).
With the public-funded research project IMAC-Mind: Improving Mental Health and Reducing Addiction in Childhood and Adolescence through Mindfulness: Mechanisms, Prevention and Treatment (2017–2023; 01GL1745A; subproject TP0), the Federal Ministry of Education and Research (BMBF) contributes to improving the prevention and treatment of children and adolescents with substance use disorders and associated mental disorders. Project coordination was realized by the German Center of Addiction Research in Childhood and Adolescence at the University Medical Center Hamburg-Eppendorf. The consortium comprises seven projects in Germany. Principal Investigators are Rainer Thomasius (Coordinator, University Medical Center Hamburg-Eppendorf), Tobias Banaschewski, Herta Flor (Central Institute of Mental Health, Mannheim), Frauke Nees (Central Institute of Mental Health, Mannheim, and University Medical Center Schleswig Holstein, Kiel University), Johannes Kornhuber (Friedrich-Alexander-Universität Erlangen-Nürnberg), Michael Klein (Catholic University of Applied Sciences, Cologne), Olaf Reis (University Medicine of Rostock), Tanja Legenbauer (Ruhr-University Bochum), and Antonia Zapf (University Medical Center Hamburg-Eppendorf). Further members of the consortium are Nicolas Arnaud, Christiane Baldus, Anne Daubmann, Amra Hot, Sabrina Kunze, Kathrin Simon-Kutscher, Anna-Lena Schulz, Michael Supplieth (University Medical Center Hamburg-Eppendorf), Karina Jansone, Stella Guldner, Sabina Millenet, Maren Prignitz (Central Institute of Mental Health, Mannheim), Bernd Lenz, Peter Fasching, Matthias Beckmann, Verena Nadine Buchholz, Eva-Maria Siegmann, Anna Eichler, Jenny Gerlach, Christiane Mühle, Adriana Titzmann (Friedrich-Alexander University Erlangen-Nürnberg), Lina-Sophia Falkenberg, Daria Kunst (Catholic University of Applied Sciences, Cologne), Lucie Waedel, Katrin Bogumil (University Medicine of Rostock), Martin Holtmann, Regina Herdering, Carina Maria Huhn, Lea Kretschmar, and Laura Mokros (Ruhr-University Bochum). For detailed information, see www.IMAC-Mind.de.

Authors' contributions

Conceptualization, L.W.; methodology, L.W.; literature review L.W.; writing—original draft preparation, L.W.; review and editing, R.T. and N.A. All co-authors have read and agreed to the published version of the manuscript.

Conflict of interest

All authors declare no conflicts of interest in this paper.

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