Psychometric properties of an Arabic translation of the 13-item short mood and feelings questionnaire- parent version (SMFQ-P) to screen for depression in children

Abstract

Background

Understanding the connection between parental wellbeing and its impact on childhood depression is crucial in order to develop targeted interventions and support systems that can mitigate potential long-term effects on mental health. This study focuses on examining the properties of an Arabic translation of a questionnaire called Short Mood and Feelings Questionnaire Parent Version (SMFQ-P) as a preliminary step toward validating a culturally relevant screening tool for childhood depression in Lebanon.

Methods

A total of 502 parents, recruited through a snowball method, took part in the survey with an age of 36.24 years (SD ± 8.29). Among them 74.5% were females 88.8% were married and 72.9% had completed university level education. The children’s mean age was 7.95 ± 1.14 years. The SMFQ-P was evaluated using confirmatory factor analysis (CFA), reliability measures, and correlations with parental distress using the Depression Anxiety Stress Scale-8 (DASS-8).

Results

Confirmatory factor analysis (CFA) demonstrated an excellent fit for the one-factor model of SMFQ-P scores (RMSEA = 0.059, 90% CI [0.049, 0.070]; SRMR = 0.034; CFI = 0.967; TLI = 0.960), with standardized factor loadings ranging from 0.58 to 0.82. Male parents reported more depression in their child than female parents (p = .016). Parental distress levels (r = .60, p < .001) correlated strongly with SMFQ-P scores, suggesting indirect concurrent validity.

Conclusion

The SMFQ-P shows promise as a screening tool for childhood depression, offering preliminary evidence of its reliability and validity in the Lebanese context. Limitations, including reliance on parent-reported distress and the lack of a direct child-report validation, should be addressed in future studies.

Introduction

Depression is a common and debilitating mood disorder that affects millions of people worldwide [1]. The diagnostic criteria for depressive disorders are consistent for both children and adults; however, in children, depression is influenced by their cognitive and developmental stage. In younger children, symptoms of depression may manifest as emotional disturbances, aggression, passivity, anxiety, behavioral issues, instability, restlessness, hyperactivity, social withdrawal, and various physical complaints, such as abdominal pain. Studies on children aged 3 to 6 with depression have revealed that their condition is often marked by intense guilt and severe fatigue [2]. The prevalence of depression in children is relatively low, with rates reported at 0.08% for those aged 3–5 years and 1.7% for children aged 6–11. However, a notable increase in prevalence occurs during the transition from childhood to adolescence. Among adolescents aged 12–17, the prevalence rises to 6.1% and 7.7%, as reported in studies [3].

Although studies on the prevalence of depression among Lebanese children are limited, juvenile depression is a significant issue. One study found that the 30-day prevalence of psychiatric disorders was 26.1% among adolescents in Beirut [4]. Another study that explored psychiatric disorders in the whole country found that 32.7% out of 1,517 children and adolescents screened positive for at least one psychiatric disorder [5]. In a study by Sfeir et al. [6], it was shown that aggression and depression (26%) as well as alexithymia (31,7%) appear to be more prevalent among Lebanese students compared to students around the world.

Early indications of depression in children are predictors of disorders such as major depressive disorder, anxiety and attention deficit hyperactivity disorder [7]. A study on health issues among youth also found connections between symptoms of depression and various psychopathologies including conduct disorder and narcissistic traits [8]. Hence, it is vital to diagnose these conditions for effective intervention in later chronic disorders [9].

Additionally, the dynamics within a family have an impact on a child’s wellbeing with parental depression affecting their children’s development [10]. Growing up in a stressful household environment may further increases the risk of children displaying mental health symptoms of anxiety [11]. Parental depression has been identified as a significant risk factor for the development of depression in children. Studies suggest that this association may be mediated by disruptions in parenting behaviors and exposure to family-level stressors [12]. Understanding the interplay between well-being and its effects on children is essential for developing targeted interventions and support systems to mitigate long-term consequences on the mental well-being of younger generations. Moreover, screening tools play a role in identifying these issues and providing access to professional support.

Employing parental reports offers a more comprehensive understanding of adolescent depression. For instance, integrating parent observations provides a unique perspective on the presence and severity of symptoms [13]. Moreover, following Dougherty et al.’s (2008) review, parents as a source of information are especially useful in the case of pre-adolescent and younger children [14]. Several studies showed that multi-informant assessment, particularly parent reports, can contribute to a more comprehensive understanding of children’s mental health [13, 15]. Although studies have shown that there are usually discrepancies between parents and children’s reports on mental health, especially regarding internalizing problem behavior (e.g. somatic symptoms, depression, and anxiety), the use of parent reports allows for a more inclusive and comprehensive assessment of children’s mental health and in contexts where child-reporting practices may be less feasible [16, 17].

The efficacy and accessibility of the parent version of the short mood and feelings questionnaire (SMFQ)

Assessment of depressive symptoms and severity using rating scales may be considered cost-effective [18], and plenty of well-crafted measures based on parent-rating, and self-rating forms that screens for childhood depression were developed [19, 20]. The Beck Depression Inventory-II (BDI-II) [21], the Montgomery–Asberg Depression Rating Scale for youths (MADRS-Y) [22], the Adolescent Depression Rating Scale (ADRS) [23], the Revised Child Anxiety and Depression Scale (RCADS) – Major Depression Subscale [24], and the Reynolds Adolescent Depression Scale (RADS) [25] are all scales of adolescent depression that are available for use but are not free of cost. It has been debated that a small number of assessment tools are available free of charge, consequently restricting their accessibility and use [26]. Among the options available, the parent version of the Short Mood and Feelings Questionnaire (SMFQ-P) is a 13-item scale used for assessing childhood depression through the parents. It is designed to assess and screen core DSM-based depressive symptoms in individuals aged 6–17 years [27]. The superiority of SMFQ-P over other scales may stem from its brief design, which facilitates a concise, user-friendly, yet comprehensive assessment of children and adolescent depression. Additionally, the SMFQ-P allows for on-the-spot scoring and is available free of cost. This brief tool efficiently screens childhood depression, covering cognitive and affective aspects, along with components like focus difficulties, tiredness, and restlessness. The parent-report exhibit a unifactorial structure and strong psychometric qualities in community samples [27–29]. This underscores the effectiveness in identifying children at risk of developing depression and differentiating between clinical and non-clinical cases [26, 29, 30].

This tool has undergone cross-cultural adaptations for various populations, including Spain [28], New Zealand [31], Chinese [32], Brazilian-Portuguese [33], Norwegian [34], Serbian [35], and Bangladeshi [36]. Although parent versions of the Mood and Feelings Questionnaire (PMFQ) were translated to Arabic and effectively distinguished participants experiencing depression from those with other psychiatric disorders, the parent-report short version of this measurement (SMFQ-P) remains not validated for implementation among Arabic-speaking children [37].

The present study

The widespread impact of depression, especially among adolescents, highlights the need for screening tools that are reliable. In response to this urgency, this current study explores the psychometric properties of the Arabic-translated parent version Short Mood and Feelings Questionnaire (SMFQ-P) to address the necessity for a cost-effective and accessible instrument for assessing childhood depression in Lebanon. The compact design of the SMFQ-P not only addresses concerns about accessibility, but also introduces a more streamlined approach to evaluating childhood depression. This becomes particularly relevant in places like Lebanon where comprehensive assessment tools may be limited. The cost effectiveness of the SMFQ-P makes it practical and valuable for regions with resource constraints. Additionally, by assessing the properties of the SMFQ-P, this study contributes to the broader field of childhood depression while also offering specific insights into its usefulness in a culturally nuanced environment.

Moreover, evaluate only the parent measure in the context of childhood depression is supported by its ability to provide critical insights into a child’s behavior and emotional state that children themselves may struggle to articulate, particularly at younger ages. Research indicates that parents often observe symptoms such as irritability, changes in appetite, and withdrawal, which children might not recognize or report [38]. Moreover, parent reports are crucial for identifying depressive symptoms that manifest in contexts outside the child’s self-awareness, such as school or social interactions [39]. While child self-reports are valuable, younger children’s cognitive and emotional development may limit the reliability of their responses, making parent-reported measures an essential tool in accurately assessing childhood depression.

This study contributes to the broader field of childhood depression by offering preliminary insights into the SMFQ-P’s applicability in an Arabic-speaking population. While the study evaluates the tool’s linguistic and psychometric properties, it does not incorporate extensive cultural adaptation beyond translation. This limitation underscores the need for future research to assess its applicability across diverse Arabic-speaking contexts. Moreover, this study acknowledges the importance of multi-informant approaches in evaluating childhood mental health but focuses solely on the parent-report version of the SMFQ due to its logistical feasibility and clinical utility in this population.

Therefore, in this study, we aimed to investigate the psychometric properties of the SMFQ-P in its Arabic translation. We postulated the following hypotheses regarding the Arabic SMFQ-P: (1) it will exhibit strong uni-structural validity, (2) it will demonstrate reliable internal consistency, (3) its structure will remain invariant between boys and girls (as reported by the parents), and (4) it will show satisfactory convergent and concurrent validity as indicated by substantial relationships with parental assessments of their own depression, anxiety, and stress.

Methods

Procedures

During November 2023, data for this cross-sectional study was collected through an online Form link. The research team invited people to complete the survey; those who agreed were requested to share the link with others, following the snowball sampling technique. Inclusion criteria comprised being an adult who resides in and is a citizen of Lebanon. Exclusions encompassed individuals declining to complete the questionnaire. The survey was conducted anonymously and participation was voluntary and without compensation.

Translation procedure

Prior to utilization in the current study, the SMFQ-P scale underwent translation for adaptation for the Arabic language and cultural context. The translation aimed to attain semantic equivalence between the original measures and their Arabic counterparts, adhering to international recommendations [40]. A Lebanese translator, unaffiliated with the study, independently translated the English version into Arabic. Following that, a Lebanese psychologist, proficient in English, translated the Arabic version back into English. To ensure accuracy, a committee of experts, comprising two psychiatrists, one psychologist, and the research team, compared the original and translated English versions, identifying and correcting any inconsistencies [41]. Following this, a pilot study involving 30 participants was conducted to validate the clarity of all questions. No modifications were made after the completion of the pilot study.

Measures

Short Mood and Feelings Questionnaire- Parent Report Version (SMFQ-P) [27] is a brief questionnaire consisting of 13 questions. Its purpose is to assess signs of depression, in individuals based on observations from their parents. The items mainly focus on affective and cognitive symptoms. Parents rate their children’s behavior and feelings over the past two weeks using a 3-point Likert scale (0 = not true; 1 = sometimes; 2 = true). To calculate the SMFQ-P score, all the responses are added up resulting in a score ranging from 0 to 39. Higher scores indicate depressive symptoms in the child or adolescent.

Depression Anxiety Stress Scale (DASS-8) [42] is designed to provide a more concise evaluation of symptoms related to depression, anxiety and stress. It consists of 8 items divided into three subscales: depression (3 items), anxiety (3 items), and stress (2 items). Participants rate the extent to which they have experienced each symptom during the week using a 4-point Likert scale (0 = Not applicable all, to me 3 = Very applicable or most of the time). Higher scores equate to a higher level of symptom affirmation.

Analytic strategy

There were no missing responses in the dataset. To examine the factor structure of the SMFQ-P, we conducted a Confirmatory Factor Analysis using the data from the total sample via SPSS AMOS v.29 software. A minimum sample varying between 39 and 260 participants was deemed necessary to conduct a confirmatory factor analysis following a recommendation between 3 and 20 times the number of the scale’s variables [43]. Our intention was to test the original model of the scale. Parameter estimates were obtained using the maximum likelihood method. Calculated fit indices were the Steiger-Lind root mean square error of approximation (RMSEA), the Tucker-Lewis Index (TLI) and the comparative fit index (CFI). Values ≤ 0.08 for RMSEA, and 0.95 for CFI and TLI indicate good fit of the model to the data [44]. Multivariate normality was not verified at first (Critical ratio > 5; Bollen-Stine p = .018); therefore, we performed non-parametric bootstrapping procedure (available in AMOS).

To examine gender invariance of SMFQ-P scores, we conducted multi-group CFA [45] using the total sample. Measurement invariance was assessed at the configural, metric, and scalar levels [46]. We accepted ΔCFI ≤ 0.010 and ΔRMSEA ≤ 0.015 or ΔSRMR ≤ 0.010 as evidence of invariance [45]. Comparison between males and females was done using the Student t-test only if scalar or partial scalar invariance.

Composite reliability in both subsamples was assessed using McDonald’s ω and Cronbach’s alpha, with values greater than 0.70 reflecting adequate composite reliability. Normality of the SMFQ-P score was verified since the skewness and kurtosis values for each item of the scale varied between − 1 and + 1 [47]. To assess concurrent validity, Pearson test was used to correlate SMFQ-P scores with DASS-8 subscales scores using the total sample.

Results

Sociodemographic characteristics of the participants

Five hundred two parents filled the survey, with a mean age of 36.24 ± 8.29 years, 74.5% females, 88.8% married, and 72.9% with a university level of education. The mean and standard deviation of the scores were as follows: SMFQ (6.42 ± 6.10), DASS depression (2.81 ± 2.34), DASS anxiety (2.87 ± 2.39) and DASS stress (2.33 ± 1.64). The children’s mean age was 7.95 ± 1.14 years, with the SMFQ scores not differing by child’s age (Table 1).

Table 1.

SMFQ-P scores according to the child’s age

Age (years)	Mean ± SD	p	Effect size
		0.475	0.005
7	6.21 ± 6.00
8	6.32 ± 5.78
9	6.18 ± 6.13
10	7.39 ± 6.78

SMFQ-P = Short Mood and Feelings Questionnaire- Parent Report Version

Confirmatory factor analysis of the SMFQ-P scale

CFA indicated that fit of the one-factor model of SMFQ-P scores was excellent: RMSEA = 0.059 (90% CI 0.049, 0.070), SRMR = 0.034, CFI = 0.967, TLI = 0.960. The standardized estimates of factor loadings were all adequate (Table 2). Internal reliability was excellent (ω = 0.93; α = 0.93). The AVE value was acceptable = 0.51.

Table 2.

Standardized estimates of factor loadings of the SMFQ-P items

Item	Loading factor
1- S/he felt miserable or unhappy	0.70
2- S/he didn’t enjoy anything at all	0.65
3- S/he felt so tired that s/he just sat around and did nothing	0.65
4- S/he was very restless	0.71
5- S/he felt s/he was no good anymore	0.74
6- S/he cried a lot	0.58
7- S/he found it hard to think properly or concentrate	0.67
8- S/he hated him/herself	0.82
9- S/he felt s/he was a bad person	0.79
10- S/he felt lonely	0.70
11- S/he thought nobody really loved him/her	0.76
12- S/he thought s/he could never be as good as other kids	0.75
13- S/he felt s/he did everything wrong	0.69

Gender invariance

Indices suggested that configural, metric, and scalar invariance was supported across gender (Table 3). Male parents reported more depression in their child than female parents (7.64 ± 6.82 vs. 6.00 ± 5.79; p = .016; Cohen’s d = 0.270).

Table 3.

Measurement invariance across fathers and mothers in the total sample

Model	CFI	RMSEA	SRMR	Model Comparison	ΔCFI	ΔRMSEA	ΔSRMR
Model 1: Gender
Fathers	0.947	0.082	0.049
Mothers	0.961	0.062	0.038
Configural	0.956	0.048	0.049
Metric	0.953	0.047	0.057	Configural vs. metric	0.003	0.001	0.008
Scalar	0.951	0.047	0.056	Metric vs. scalar	0.002	< 0.001	0.001

Note. CFI = Comparative fit index; RMSEA = Steiger-Lind root mean square error of approximation; SRMR = Standardised root mean square residual

Concurrent validity

Higher depression (r = .60; p < .001), anxiety (r = .60; p < .001), and stress (r = .45; p < .001) in parents were significantly associated with higher SMFQ-P scores reported in their children.

Discussion

The Confirmatory Factor Analysis (CFA) demonstrates that the one factor model of the SMFQ- P fits well, and the latter is in alignment with previous studies [28, 33]. The factor loadings and internal reliability provides preliminary evidence on the scale’s validity. The standardized factor loadings, for each item were satisfactory ranging from 0.58 to 0.82. This indicates that the SMFQ-P is a scale aligning adequately with its structure. Moreover, when measuring internal reliability using McDonald’s ω and Cronbach’s alpha, we obtained values (ω = 0.93; α = 0.93) suggesting reliability and consistency with studies conducted on children and adolescents in other countries like Brazil (α = 0.87; [33]), United States (α = 0.84–0.87; [27, 29]), Australia (α = 0.89; [48]), Norway (α = 0.83; [49]), and Spain (α = 0.87; [28]). This indicates that the SMFQ-P consistently measures the intended construct making it suitable for assessing symptoms in children.

Although our research shows that there are variations in SMFQ-P scores between genders with male parents reporting more than female parents, this finding diverts from previous studies, where one study have reported no gender differences [28], while another revealed that females scored higher than males [34], as stated and assessed by the parents. It is possible that cultural variations in the way depressive symptoms are expressed across cultures or differences in reporting styles between males and females could explain this inconsistency [50, 51]. To gain an understanding, further investigations should explore the nuanced aspects of gender-related disparities in childhood depression symptoms.

The study’s findings show substantial correlation between SMFQ-P and parental DASS-8, indicating a connection between parental mental health and children’s depressive symptoms. The positive correlations indicate that higher SMFQ-P scores correspond to increased levels of depression, anxiety and stress symptoms in parents. While this suggests that the SMFQ-P captures aspects of childhood depression, this finding primarily reflects the relationship between parental psychological distress and their perceptions of their children’s mental health. The results also align with other studies that state throughout their findings the association between depression, anxiety and stress among parents and an increase possibility of children experiencing symptoms of depression [10, 52, 53]. One possible explanation for this connection could be the interaction between parents’ psychological distress and their children’s psychological health. When parents experience levels of depression, anxiety or stress it may affect the psychological state of their children. Changes in parenting behaviors such as decreased involvement and heightened stress are some factors that might contribute to an increased likelihood of childhood depression [54].

Clinical implications

The scale demonstrates preliminary effectiveness in identifying depression symptoms offering a tool with potential for early detection and intervention. Timely mental health support remains crucial for children at risk of depression aligning with efforts to prioritize health among young populations. Clinician in Lebanon can incorporate the SMFQ-P into their assessments as a part of a broader, comprehensive approach to addressing and identifying childhood depression, ensuring its use is well informed by further validation studies.

Limitations

The snowball sampling method followed in the recruitment of participants predisposes us to a selection bias, especially that the refusal rate is unknown. Additionally, information was self-reported by participants, predisposing us to an information bias. Moreover, since data collection was a one-time occurrence, we cannot draw conclusions about the scales ability to predict outcomes or how symptoms of childhood depression may change over time. It would be worthwhile for research to explore how cultural factors influence the manifestation of symptoms. Additionally, conducting studies that compare the Short Mood and Feelings Questionnaire Parent Version (SMFQ-P) with established scales could provide a comprehensive understanding of its strengths and weaknesses. Furthermore, investigating variations in symptoms between genders could contribute to our understanding of this complex interplay. Another limitation is that there might be a chance of differential information bias, which can affect the accuracy of the responses regarding mood and feelings. Finally, the absence of a child-reported measure is a notable limitation, as it restricts the ability to capture the child’s subjective experiences and perspectives, potentially leading to a less comprehensive understanding of their emotional state. The absence of an independent assessment of validity is another limitation; the high correlations found between scores might be due to a reporter bias. However, although the above limitations, the study aims to provide insights into the mental health of children in Lebanon, while acknowledging the challenges associated with the specific tool used for data collection.

Conclusion

The SMFQ-P proves to be a reliable, valid, and cost-effective tool for assessing symptoms related to childhood depression. Using reliable mental health screening instruments facilitates swift estimation by researchers of the prevalence and intensity of mental health symptoms, assists in timely interventions and psychological support, and provides a sustainable method for monitoring and assessing mental health symptoms amidst economic crises and other humanitarian disasters. To evaluate the practical effectiveness of the Arabic SMFQ-P and to further enhance the data on its construct validity, future studies should assess the measure in diverse contexts and among specific populations.

Author contributions

FFR, SO and SH designed the study; AN drafted the manuscript and collected the data; SH carried out the analysis and interpreted the results; SEK, FS and MD collected the data; DM reviewed the paper for intellectual content; all authors reviewed the final manuscript and gave their consent.

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The study protocol was approved by the ethics committee of the School of Pharmacy at the Lebanese International University (2023ERC-127-LIUSOP). Participants were asked to get their parents’ approval before filling the survey; an electronic informed consent was considered obtained from each participant when submitting the online form. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.