Evidence-based methods to identify behavioural problems among children are not regularly used within the Swedish Child healthcare. A new procedure was therefore introduced to assess children through parent- and preschool teacher reports using the Strengths and Difficulties Questionnaire (SDQ). This study aims to explore nurses', preschool teachers' and parents' perspectives of this new information sharing model. Using the grounded theory methodology, semi-structured interviews with nurses (n = 10) at child health clinics, preschool teachers (n = 13) and parents (n = 11) of 3-, 4- and 5-year-old children were collected and analysed between March 2014 and June 2014. The analysis was conducted using constant comparative method. The participants were sampled purposively within a larger trial in Sweden. Results indicate that all stakeholders shared a desire to have a complete picture of the child's health. The perceptions that explain why the stakeholders were in favour of the new procedure-the 'causal conditions' in a grounded theory model included: (1) Nurses thought that visits after 18-months were unsatisfactory, (2) Preschool teachers wanted to identify children with difficulties and (3) Parents viewed preschool teachers as being qualified to assess children. However, all stakeholders had doubts as to whether there was a reliable way to assess children's behaviour. Although nurses found the SDQ to be useful for their clinical evaluation, they noticed that not all parents chose to participate. Both teachers and parents acknowledged benefits of information sharing. However, the former had concerns about parental reactions to their assessments and the latter about how personal information was handled. The theoretical model developed describes that the causal conditions and current context of child healthcare in many respects endorse the introduction of information sharing. However, successful implementation requires considerable work to address barriers: the tension between normative thinking versus helping children with developmental problems for preschool teachers and dealing with privacy issues and inequity in participation for parents.

Background: The Strengths and Difficulties Questionnaire (SDQ), a valid and reliable instrument for measuring children's mental health, is available in parent- and teacher versions, making it an ideal tool for assessing behavioural and emotional problems in young children. However, few studies have evaluated inter-parent agreement on the SDQ, and in most studies on SDQ agreement, parent scores are either provided by only one parent or have been combined into one parent score. Furthermore, studies on SDQ inter-rater agreement usually only reflect degree of correlation, leaving the agreement between measurements unknown. The aim of the present study was therefore to examine both degree of correlation and agreement between parent and teacher SDQ reports, in a community sample of preschool-aged children in Sweden.

Methods: Data were obtained from the Children and Parents in Focus trial. The sample comprised 4,46 children 3-5-years-old. Mothers, fathers and preschool teachers completed the SDQ as part of the routine health check-ups at Child Health Centres. Inter-rater agreement was measured using Pearson correlation coefficient and intraclass correlation (ICC).

Results: Results revealed poor/fair agreement between parent and teacher ratings (ICC 0.25-0.54) and good/excellent agreement between mother and father ratings (ICC 0.66-0.76). The highest level of agreement between parents and teachers was found for the hyperactivity and peer problem subscales, whereas the strongest agreement between parents was found for the hyperactivity and conduct subscales.

Conclusions: Low inter-rater agreement between parent and teacher ratings suggests that information from both teachers and parents is important when using the SDQ as a method to identify mental health problems in preschool children. Although mothers and fathers each provide unique information about their child's behaviour, good inter-parent agreement indicates that a single parent informant may be sufficient and simplify data collection.

The Strengths and Difficulties Questionnaire (SDQ) is a widespread tool for assessing behavior problems in children and adolescents. Despite being investigated thoroughly concerning both validity and reliability, peer reviewed studies that provide norms, especially for preschool children, are lacking. This paper provides Swedish norms using data from a large community sample of children aged 3-5, based on mothers', fathers', and preschool teacher's ratings. Preschool teachers' ratings were generally lower than parents' ratings, which contradicts some previous studies. Differences between girls and boys were found, suggesting that boys display higher levels of behavior problems. Lower parental education and country of origin outside of Sweden were also associated with more difficulties. Cut-offs are presented for each age group, gender and rater category. Population-specific norms and percentile cut-offs provided in this study facilitate identifying children in need of interventions in paediatric care and enable cross-country comparisons of children's mental health problems. 

Background: A number of instruments for identifying mental health problems in children are available, but there is limited knowledge about how to successfully implement their use in routine practice. The Strengths and Difficulties Questionnaire (SDQ) is an instrument with sound psychometric properties. Because using multi-informant SDQs when assessing young children has been emphasized, parent- and preschool teacher reports on the SDQ were introduced at Child Health Clinics in a Swedish municipality. This paper aimed to describe a facilitation programme developed to support the introduction of SDQ in clinical practice and evaluate how nurses perceived the facilitation strategies used. Moreover, the dose (delivery) and reach (response rate and population coverage) of the questionnaires were assessed.

Methods: The mixed-methods process evaluation was guided by Moore et al.'s framework. Process data were excerpted from monitoring data, the trial database, research group documents, study materials, group interviews with nurses, and a survey on nurses' opinions and experiences of the screening method and the implementation process. Data were analysed using descriptive statistics and qualitative content analysis.

Results: Facilitation strategies used included: educational meetings, educational outreach visits, newsletters, facilitative administrative support, and adaptations made in procedures and materials when required. Although nurses described a variety of barriers at the organisational and individual level, they were in favour of using the SDQ in clinical practice and emphasised the importance of the facilitation strategies used for its implementation. While dose levels (77-91%) indicated that nurses essentially delivered the intervention as intended, parental response rates remained between 54 and 63% and population coverage at around 50%, throughout the intervention period.

Conclusion: The facilitation program was perceived to support the implementation of the SDQ at the yearly check-ups in the child healthcare setting, but further efforts are required to reach all families.