Intended for healthcare professionals


Parental concerns about their child's emotions and behaviour and referral to specialist services: general population survey

BMJ 2005; 331 doi: (Published 15 December 2005) Cite this as: BMJ 2005;331:1435
  1. Tamsin Ford, MRC clinician scientist ({at},
  2. Kapil Sayal, senior lecturer1,
  3. Howard Meltzer, senior health analyst2,
  4. Robert Goodman, professor of brain and behaviour medicine1
  1. 1 King's College London, Institute of Psychiatry, Department of Child and Adolescent Psychiatry, London SE5 8AF
  2. 2 Office for National Statistics, London SW1V 2QQ
  1. Correspondence to: T
  • Accepted 16 August 2005


Childhood psychiatric disorders are common and are associated with heavy use of health services.1 Up to a third of children and adolescents attending primary care and paediatric outpatient departments have clinically significant psychopathology.2 3 Only a minority of these children reach specialist mental health services, partly because the presenting complaint is rarely psychological, so their disorders may not be recognised.2 4 Child mental health services may reject inappropriate referrals leading to frustration among referrers and families.

Although medical professionals often depend on parental concerns to identify affected children, we do not know how predictive they are. We used empirical data from the 1999 British child and adolescent mental health survey to examine how predictive parental perceptions of psychological difficulties were of psychiatric disorder and to provide simple strategies to aid clinicians in identifying children requiring referral.1

Participants, methods, and results

We used the child benefit register to select a nationally representative sample of 10 438 children aged 5-15 years from Great Britain. The Development and Well Being Assessment combined information from parents, teachers, and young people aged 11 and older to diagnose psychiatric disorders according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition.5 Parents completed the Strengths and Difficulties Questionnaire, which generates total difficulties and impact scores.6 The latter indicates the level of distress and related impairment in family life, peer relationships, academic functioning, and leisure activities.

Parents were also asked whether their child had “hyperactivity,” “behavioural problems,” and “emotional problems” and whether teachers had complained about the child's concentration, activity level, or impulsiveness. We cross tabulated parents responses to these questions with the presence of psychiatric disorder to elicit ways in which clinicians might assess which children require referral.

The negative predictive power and specificity of parental opinions were high, suggesting that clinicians can mostly be reassured by a lack of parental concern (table). About half of the children that parents were worried about had a psychiatric disorder; almost three quarters of parents reported problems in more than one area. Many of the children identified as having difficulties by parents will have significant problems even if they fall below the threshold for a psychiatric diagnosis. The Strengths and Difficulties Questionnaire total symptoms and impact scores were much higher in the “parent concerned but no diagnosis” group (n = 396) than the “no parental concern” group (n = 9477), (symptom score 13.9 (standard deviation 5.3) v 7.5 (4.9), t = 26, P < 0.001; impact score 0.9 (1.4) v 0.2 (0.7), t = 11, P < 0.001).

Accuracy of parental concerns about their child's emotions, behaviour, and activity level. Values are percentages (95% confidence intervals)

View this table:

Parents were most accurate at identifying conduct disorders, and those children reported to have behavioural problems were also most likely to have any sort of psychiatric disorder. However, nearly half of the children reported to have emotional problems or hyperactivity also had a psychiatric disorder. Parental reports of teacher concerns were more predictive of attention-deficit/hyperactivity disorder than parental concern alone; positive predictive power was particularly high when both the parent and teacher were concerned.


About half the children that parents are concerned about have a psychiatric disorder; others have subclinical levels of psychopathology. When parents are concerned about attention and activity, asking whether teachers are also concerned can help identify which children warrant referral to specialist services. Professionals should have a low threshold for enquiring about mental health issues in children as parents rarely raise these concerns.

What is already known on this topic

Children with psychiatric disorders rarely present themselves for treatment and are therefore dependent on the adults around them to identify their distress

What this study adds

If a parent reports concerns about their child's mental health, the child has a 50:50 chance of having a psychiatric disorder, and the predictive power of parental reports can be increased by asking about the level of concern at school; parental accuracy about the absence of significant problems is high

Although child mental health services are being expanded, they inevitably focus on children with the most severe levels of difficulty.4 Children with lesser, but still troubling, levels of psychopathology may benefit from self help approaches or contact with the voluntary sector. For example, includes information on books and websites related to child mental health in addition to online questionnaires and reports.


  • See Primary Care p 1451

  • Contributors TF conceived the idea and took the lead in the analysis and writing. She was involved in the planning and clinical rating of the Department of Health survey that provided the data for this analysis. RG supervised the analysis and contributed to the writing. He was involved in the planning and clinical rating of the Department of Health survey that provided the data and designed two of the instruments used to measure psychopathology. KS contributed to the conception, analysis, and writing up. HM contributed to the analysis and writing up of this manuscript and led the design, analysis, and writing up of the Department of Health survey that provided the data for this analysis. RG is guarantor.

  • Funding The Department of Health funded the original survey. TF was supported by a Wellcome Clinical Training Fellowship at the time that this work was completed. The Department of Health was involved in the design of the original survey but neither funder had any input to the secondary analysis presented here.

  • Competing interests RG and his family provide as a free public service.

  • Ethical approval The Institute of Psychiatry granted ethical approval for the clinical rating and secondary analysis of data from the British Child and Adolescent Mental Health Survey 1999 (reference 255/98).


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