Self-reported mental health in school-aged children using the Dominic interactive questionnaire in the French Enabee 2022 study

Self-reported mental health in school-aged children using the Dominic interactive questionnaire in the French Enabee 2022 study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Self-reported mental health in school-aged children using the Dominic interactive questionnaire in the French Enabee 2022 study Louise Seconda, Viviane Kovess, Pascal Bessonneau, Damien Pognon, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4300080/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 May, 2025 Read the published version in European Child & Adolescent Psychiatry → Version 1 posted 10 You are reading this latest preprint version Abstract The COVID-19 pandemic highlighted the need to develop rigorous epidemiological monitoring of children’s mental health in France. The Dominic Interactive (DI) assesses children’s perceptions of their own mental health using illustrated questions, which reflect situations associated with symptoms of common disorders. Although many studies have used the DI, the last time its psychometric properties were assessed on school-aged children in France was in 2004. In the Enabee 2022 study, as part of a novel homonymous epidemiological monitoring project 15,206 child attending school in metropolitan France filled in the DI. Using data from Enabee 2022, the present study aimed to examine the psychometric properties of DI (internal consistency and factorial structure) and to assess the self-reported prevalence of mental health problems in children. The Cronbach alpha and Mc Donald’s Omega were acceptable for all DI subscales assessing a specific mental health disorder. The initial factor structure was confirmed for each subscale. Overall, 28.7% of the study sample had reported at least one probable mental health disorder. Phobias and separation anxiety disorder were the most frequent disorders (9.4% and 10.7%, respectively), especially among girls (13.6% and 12.6%). In contrast, although major depression was the least reported disorder (5.5%), it had the strongest correlations with other disorders. This study provides the first results for self-reported mental health in children within the framework of the novel French mental health surveillance system Enabee. Integrating the DI in this system assures that children’s self-reported symptoms can be taken into consideration when assessing their mental health. Child mental health self-evaluation psychometric properties and cross-sectional study Figures Figure 1 Figure 2 Figure 3 Introduction The importance of assessing the mental health of young children was reaffirmed in a 2015 meta-analysis which estimated that 12.4% of the children aged 6 to 11 years old had mental health disorders (1). A much more recent European meta-analysis reported a pooled mental health disorder prevalence rate of 15.5% in children aged to 5 to 18 years (2). This high prevalence underlines that child and adolescent mental health is a major public health issue (3), especially given that mental health disorders often impact child development and learning with potential repercussions in adulthood (3,4). Accordingly, providing reliable indicators of children’s mental health status – in particular for the most vulnerable – to stakeholders, is essential in order to adequately monitor the situation, especially during crises. These indicators are also essential to develop and evaluate adequate prevention programs. Moreover, they may also guide changes in healthcare policy. Child mental health estimates depend largely on the informant (5). To date, most epidemiological studies have solicited parents, teachers, and/or healthcare staff to describe the mental health of children. Few have involved self-reporting by children themselves. For example, in the Mental Health of Children and Young People survey in England (6), and in the Bella study in Germany (7,8), only adults (the parents and/or the teacher) reported the mental health of children younger than 11 years. These assessments are, by nature, subjective and partial. Parents’ perceptions of their child’s behavior may differ from that of a professional and might be influenced by their own mental health issues (9). Moreover, teachers mainly observe their pupils only in the school context. In order to improve the identification of mental health disorder symptoms in children - especially internalized symptoms which are usually under-reported by parents and teachers - any third-party assessment should be complemented by a self-reported assessment by the children themselves, as cross-referencing these various perspectives improves the evaluation (5). This requires the use of an adequate tool and an appropriate methodology (10). However, interviewing young children about their own mental health is a challenge since they have limited ability in reading, language comprehension, memory, concentration skills, abstract thinking, and self-reflection. Therefore, appropriate questionnaires that enable children to self-report their emotions and moods are essential (11,12). One such tool is the Dominic Interactive (DI), a computerized, pictorial self-administered questionnaire, designed for children aged 6–11 years old. Respondents self-report symptoms related to mental health disorders by responding ‘yes’ or ‘no’ to pictures illustrating situations that an avatar - which they choose - experiences (13). The questions illustrate real-world situations that refer to common abstract concepts of mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) for seven common disorders. The DI was developed in Quebec in 1999 (14,15); it was first used in both French and English-speaking children living in Montreal. Later, the tool was adapted for children living in France. Between 2000 and 2001, a study involving 403 French children demonstrated good acceptability of the DI among children in care and children in the general population as well as a good understanding of the questionnaire’s items (10). The prevalence of disorders identified by the DI in that study was significantly higher in the clinical population than in the general population (10). In a subsequent French study in 2004, the Cronbach alpha for each of the DI mental health disorder subscales, the distribution of scores for each DI subscale, and comorbidities, were all analyzed in a population of children (N=1274) living in the Provence-Alpes-Côte-D’Azur (South-Est) region (16). The Cronbach alphas of the various subscales were close to those measured in Quebec and 25.4% of children self-reported at least one probable mental disorder (16). The psychometric properties of the DI and correlations between disorder subscale scores have also been assessed in other countries (17–19). In particular, data collected in the School Children Mental Health in Europe (SCMHE) project were used to assess reliability, factor structure and measurement invariance for the DI in a sample of 8135 primary school children, aged 6–11 years old, in seven European countries (17,19). The McDonald omega for each disorder was good or high in all seven; furthermore, the factor structure of disorders related to the various subscales was confirmed for all seven. That study also showed cross-country test score invariance for five subscales and partial invariance for the DI’s two anxiety-related subscales. In terms of self-evaluation, 22.0% of the children involved had at least one mental disorder, with rates ranging from 16.4 % in the Netherlands to 27.9% in Turkey (20). In 2022, as part of a novel homonymous epidemiological project monitoring child mental health in France, the ‘National study on children’s well-being’ ( Etude nationale sur le bien-être des enfants ) Enabee 2022 - which included the DI - enrolled a random sample of 15,206 children living in metropolitan France. This large sample presented a unique opportunity to enhance our knowledge of the psychometric properties of the DI and to generate the first national estimates of self-reported child mental health. The objectives of the analysis described in this article were: i) to examine the internal consistency of each of the subscales of the DI and to confirm their factor structure on a large sample of elementary-school children living in metropolitan France. ii) to describe the symptom score distributions and the prevalence for each probable mental health disorder assessed using the DI. iii) to describe the correlations between symptoms scores and co-occurrences of probable disorders. Material and Methods 1. Study design Enabee is a repeated national cross-sectional study conducted in schools in France using self-administrated questionnaires. The protocol for the first edition, Enabee 2022 - which was conducted in the same year exclusively in metropolitan France (i.e., no French overseas territory was involved) - is described in detail elsewhere (21). Enabee 2022 aimed to establish a comprehensive set of indicators concerning children’s mental health from 3 to 11 years old. In France, elementary school for pupils aged 6-11 comprises five levels called CP, CE1, CE2, CM1, CM2, which correspond to 1 st to 5 th grades in the US system. As part of Enabee 2022, children from these five grades had to fill in a self-administered questionnaire which included the DI. 2. Data collection a) Procedure A probabilistic multistage stratified sampling plan was used to constitute the Enabee 2022 study sample. First, schools were randomly selected. Second, up to four classes per school were randomly selected. All pupils within each selected class were eligible. In schools with four classes or fewer, all classes were selected. School principals, teachers and parents received an information letter about the study. A school’s participation was contingent upon the agreement of the school principal; parents could disagree to their child’s participation. Children whose parents agreed to their participation could independently refuse to answer the questionnaire or to interrupt answering at any time. Data from the child questionnaire were collected during dedicated sessions held in participating schools between 2 May and 5 July 2022. Survey facilitators visited each class in pairs, equipped with a tablet and headphones for each participating child. During the answering sessions, children were first provided with general instructions explaining the purpose of the study and the rules. In particular, the survey facilitators emphasized that all answers would be confidential, and assured the children that there were no wrong answers. Children could ask questions before and during the session, but the survey facilitators were not allowed to interfere with the children’s answers. b) Child self-reported mental health using the DI Self-reported mental health was assessed using the DI (13). The original version of the DI comprised 91 questions related to the symptoms of seven common mental disorders observed in children as described in the DSM-5: attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), oppositional defiant disorder (ODD), specific phobias (SPh), separation anxiety disorder (SAD), generalized anxiety disorder (GAD), and major depressive disorder (MDD). Ten questions focus on the child’s strengths and competencies, unrelated to any of the seven disorders. Moreover, three components of ADHD can be distinguished: inattention, hyperactivity and impulsiveness; accordingly, DI items relative to ADHD can be separately analyzed (22). In order to improve the acceptability of the tool by school authorities, the steering committee of the Enabee 2022 study suggested to remove all 13 questions of the DI specifically related to CD. Accordingly, the study only investigated six of the DI’s seven mental health disorders. At the beginning of the DI, children were asked to choose an avatar from many options. The aim of proposing different avatars to choose from was to foster self-identification with the avatar finally chosen, with a view to improving the quality of the child’s answers. For all children, the chosen avatar was called Dominic (note: Dominic is a unisex name in France). A tutorial was provided to ensure that children understood how to answer the various questions asked. Each question had to be answered before proceeding to the next one. A short scene, illustrating the emotional and behavioral symptoms being described, accompanied each query. Children responded “yes” or “no” to the 78 questions in a variety of pictorial scenarios, according to whether they thought, felt, or acted like Dominic. Symptom scores were obtained by adding 1 point for each reported symptom of the evaluated disorder. For each disorder, thresholds were used to classify children into three groups: no disorder, possible disorder, probable disorder. These thresholds were based on the mean and standard deviations collected from the sample of 585 children living in Montreal in 1992 who were the first children to complete the DI in 1999 (15). Specifically, children whose number of reported symptoms was between one or two exclusive standard deviations above the mean in the Montreal sample were categorized as ‘possibly’ presenting a disorder; those with two standard deviations or more above the mean were categorized as ‘probably’ presenting a disorder. Generally, in epidemiological studies, the latter threshold is used to define the prevalence of mental health disorders (16,18,20). In the present analysis, (and all Enabee 2022 analyses), we followed suit in order to ensure comparison with other studies. c) Covariates We used data from the databases of the French Ministry of Education to collect the following information: child’s gender, grade (i.e., from 1 st to 5 th ), aged-related school type (i.e., elementary – 6 to 11 years old, primary – 3 to 11 years old), type of school (i.e., public or private under contract with the French Ministry of Education), and whether the participating schools were officially recognized as being located in a socially deprived ( Réseau d’éducation prioritaire , REP hereafter) or highly socially deprived (REP+ hereafter) area. The REP and REP+ programs are systems of educational support implemented in French public schools, aimed at addressing educational inequalities by providing additional resources and support to schools in socially deprived areas. 3. Study Sample As shown in Figure 1 , of a total of 554 primary/elementary schools randomly selected, 326 agreed to participate (participation rate 58.8%). Class participation rate was 93.5%, representing 19,725 children. The following children were not eligible to participate: those whose parents objected to the study, those whose parents did not receive information about the study at home, those who moved house, and those whose teacher considered that they were not able to properly complete the child questionnaire due to a disability or too poor a French linguistic level. For the statistical analysis, we further excluded children with incomplete DI and those with inconsistent responses. Finally, a total of 15,206 children were included in the final analysis. To enable statistical inference of the results, we calculated weights for the sample of children who fully completed the child questionnaire, taking into account the observed total non-response at each sampling stage (i.e., school, class, and individual). A calibration step was then performed using margins derived from the reference sample (children in 1 st to 5 th grade in public schools or private schools under contract) to ensure the study population could be compared with the reference sample in terms of the individual child’s gender, the type of school (public or private under contract), and grade (i.e., 1 st to 5 th grade). We subsequently applied a truncation step to avoid excessive dispersion of the weights. 4. Statistical analysis a) Descriptive analysis The statistical descriptive analysis described the main characteristics of the study population, taking into account the sampling design (i.e., weights, stratifications and sampling stage). b) Assessment of DI psychometric properties We first examined the ceiling and floor effects for each of the 78 questions in the DI. For each of the six mental health disorders examined, we estimated the internal consistency using Cronbach’s alpha and Mc Donald’s Omega. Cronbach alphas were also assessed for gender and for grade. To confirm the factorial structure, we reproduced Kuijpers’ approach by performing a categorical confirmatory factor analysis (CCFA) for each subscale (19). We used conventional limits for fit indices as follows: a CFI greater than 0.90 and an RMSEA less than 0.08 were considered acceptable while a CFI greater than 0.95 and an RMSEA less than 0.05 were considered good (23). R software was used to perform this assessment, specifically the survey (24) and EFAtool packages (25), to assess Cronbach alphas and Mc Donald Omegas with a categorical CFA, and the lavaan package for the CCFA (26). Weights were used for the analysis with the WLMSV estimator. It was not possible to specify a complex sampling plan with categorical data in the calculation of the McDonalds omega with the lavaan package. In contrast, we were able to specify a complex sampling plan for the calculation of Cronbach’s alpha. c) Prevalence assessment We computed the prevalence of ‘probable’ cases and their 95% confidence intervals (CI) for each ‘probable’ mental health disorder assessed by the DI. We also measured the percentages and their 95% CI for probable cases of the following four indicators: at least one probable internalizing disorder (i.e., MDD, SAD, GAD, or SPh), at least one probable externalizing disorder (i.e., ADHD or ODD), at least one probable mental health disorder (i.e., any one of the six studied), and at least one probable internalizing and one probable externalizing disorder. We also described the statistical distribution of each mental health disorders and each three components of ADHD (inattention, hyperactivity and impulsiveness) independently. We assessed prevalence according to gender, grade, and type of school (private school under contract or public school in an non-REP or REP+ area, public school located in REP area, public school located in REP+ area), and compared them using Pearson chi-square tests. Finally, we examined co-occurrences between each probable mental health disorder assessed by the DI and identified the most frequent associations. We computed the Pearson correlation of the sum of the item scores for each of the six diagnostic-specific subscales of the DI. These various statistical analyses were performed taking into account the sampling design of the study including non-response adjusted weights, strata and the finite population correction factor. They were performed using SAS Enterprise Guide version 7.11. 5. Ethical considerations The study was approved by the French authority for data protection ( Commission nationale informatique et libertés , CNIL, authorization demand n° 921423, deliberation DR-2022-009, 7 January 2022), as well as a French ethics committee ( Comité éthique et scientifique pour les recherches, les études et les évaluations dans le domaine de la santé , CESREES, decision of october 14, 2021, n° 5268850). The study also received approval from the French council for statistical information (CNIS, avis n° 85/H030) and the Committee of Public Statistics (n°2022_11193_DG75-L002). Results a) Study sample and characteristics The study sample was evenly distributed across all five grades (i.e., 1 st to 5 th ). Moreover, there were only small differences - for the variables investigated - between all children enrolled in public schools or in private schools under contract in metropolitan France and the sample of children participating in Enabee 2022 (Supplemental table 1). b) Psychometric properties of the DI used in the Enabee 2022 study 1) Ceiling and floor effects Of the 78 questions in the administered DI, only 7 displayed a ceiling or floor effect, meaning that a very large majority of the participants (i.e., > 90%) provided the same answer to a given question. Six of these were strengths and competencies questions (see above) while the seventh evaluated a SPh (see above), specifically a fear of cats. 2) Internal consistency of DI subscales The first columns in Table 1 show the Cronbach’s alpha and Mc Donald’s Omega of each subscale of mental health symptom assessed by the DI. Both coefficients were good (i.e., >0.7 and >0.8, respectively) for GAD, MDD, ADHD and ODD. Furthermore, the indicators of internal consistency for SPh and SAD were acceptable. The values of Mc Donald Omegas were consistent to the Cronbach alphas and were even higher for all subscales. The Cronbach alphas for girls and boys were nearly identical (less than 0.02 difference). The same was true for the lowest (1 st to 3rd) and highest (4 th and 5 th ) class grades. They differed slightly more for SPh between girls and boys (0.50 [0.49-0.52] vs 0.55 [0.53-0.57]), and for ODD between the lowest and highest school levels (0.73 [0.72-0.74] vs 0.77 [0.76-0.78]) (supplementary Table 2). Table 1: Cronbach’s alpha, Mc Donald’s Omega and Goodness-of-Fit Indices of the Six-Factor Structure of the Dominic Interactive (Enabee 2022 study, N=15,206) – Metropolitan France Internal consistency indicators Fit indices α # Ω * Chi 2 DF P CFI RMSEA Specific Phobias (SPh) 0.56 [0 .54-0.56] 0.72 [0.71-0.73] 1049.40 27 <0.0001 0.92 0.05 Separation anxiety disorders (SAD) 0.64 [0.63-0.64] 0.79 [0.79-0.80] 1349.78 20 <0.0001 0.93 0.07 Generalized anxiety disorders (GAD) 0.74 [0.74-0.75] 0.84 [0.84-0.85] 5064.98 90 <0.0001 0.90 0.06 Major depression disorder (MDD) 0.79 [0.78-0.79] 0.89 [0.89-0.89] 5951.94 170 <0.0001 0.93 0.05 Oppositional defiant disorder (ODD) 0.75 [0.74-0.75] 0.87 [0.87-0.88] 623.54 27 <0.0001 0.99 0.04 Attention-deficit/hyperactivity disorder (ADHD) 0.83 [0.82-0.83] 0.91 [0.91-0.91] 4041.69 152 <0.0001 0.97 0.04 # Cronbach’s alpha with 95%CI *Mc Donald’s Omega with 95%CI 3) Confirmatory factor analysis of DI subscales Table 1 shows acceptable to good fit measures, with CFI values ranging from 0.90 to 0.97 and RMSEA values ranging from 0.04 to 0.07, indicating that invariance was supported (23). The SAD and GAD scales had the highest RMSEA of the six subscales; nevertheless their values were acceptable. c) Distribution of DI symptom scores Figure 2 shows, for each of the six mental health disorders measured and the three components of ADHD (inattention, hyperactivity and impulsiveness) assessed, the symptom score distribution according to gender, the ninety-fifth percentiles of these distributions, and the thresholds defining the ‘probable mental health disorder’ group (13). Self-reported internalizing symptoms (i.e., MDD, SAD, GAD, or SPh) - except for SPh in boys - and inattention were distributed as a bell curve. While the distribution of self-reported ODD, hyperactivity and impulsiveness symptoms highlights that many children reported no symptoms for these disorders. For all six disorders, the ninety-fifth percentile was equal to the threshold for the probable mental health disorder category. We observed that the distributions of symptom scores between girls and boys were, for the most part, similar, except for the SPh symptoms score. d) Prevalence and co-occurrences of probable mental health symptoms Table 2 shows the weighted prevalence of probable mental health disorders in the Enabee 2022 study and the prevalence according to gender, type of school, and grade (i.e., 1 st to 5 th ). More children reported internalized symptoms than externalized symptoms; girls were more likely to report internalized symptoms compared to boys. The most commonly reported probable disorders were SAD and SPh (10.7% [10.1-11.4] and 9.4% [8.9-10.0], respectively). MDD was the least frequently reported disorder (5.5% [5.1-6.0]). We did not observe any significant difference between boys and girls who reported at least one probable internalizing disorder and one probable externalizing disorder (see above). The percentage of children who reported at least one probable internalizing disorder decreased as the grade increased, particularly for SAD (18.7% [17.3-20.3] for 1 st grade and 3.7% [3.0-4.5] for 5 th grade) and, to a lesser degree, for SPh and MDD. However, the percentages of girls and boys who reported ODD or ADHD symptoms were similar across all five grades (results not shown). Children in REP and REP+ areas were significantly more likely to have at least one probable mental health disorder. This was true for each of the six disorders assessed individually, for both girls and boys (results not shown). Among children reporting symptoms suggestive of at least one probable mental health disorder, the majority reported symptoms suggestive of only one disorder (60.7% [59.2-62.2]). Among the whole sample, only 5.4% [5.0-5.8] reported symptoms for three or more types of mental health disorder. Figure 3 shows that children predominantly reported SPh without any other type of probable disorder. In contrast, symptoms of MDD and GAD were mostly associated with two or more other types of probable disorders. Specifically, children who reported probable MDD also reported probable GAD and/or ADHD and children who reported probable GAD also reported probable SAD (results not show). The results from Figure 3 are consistent with the Pearson correlation coefficients between each symptom score reported in Table 3. All correlations were statistically significant. The strongest correlation was between symptoms for MDD and GAD, followed by the correlation between symptoms for MDD and ADHD. The calculation of MDD and ADHD prevalence were based on four similar DI items. MDD and GAD calculations were based on two similar DI items. Finally, symptoms for SPh were the least correlated with those of other disorders. Table 2: Weighted prevalence and CI 95% of probable mental health disorders in the study sample (total), and according to gender, grade (i.e., 1 st to 5 th ), and type of school (Enabee 2022 study. N=15206) - Metropolitan France; *REP and REP+ refer to a school located in a socially deprived area and in a highly socially deprived area, respectively. Gender Grade Type of school Total (N=15,206) Girls (N=7,436) Boys (N=7770) P 1 Grade 1 (N=2,890) (Mean age=6,9) Grade 2 (N=3,141) (Mean age=7,9) Grade 3 (N=3,099) (Mean age=8,9) Grade 4 (N=3228) (Mean age=9,9) Grade 5 (N=2,848) (Mean age=10,9) P 1 Private or public located outside REP/REP+ area* (N=12,474) Public located in REP area (N=1,549) Public located in REP+ area (N=1,183) P 1 Specific phobias (SPh) 9.4 [8.9-10.0] 13.6 [12.7-14.6] 5.4 [4.9-5.9] *** 12.0 [10.7-13.4] 10.2 [9.1-11.3] 9.8 [8.7-11.2] 8.3 [7.3-9.4] 6.9 [6.0-8.0] *** 8.7 [8.2-9.3] 13 [11.1-14.9] 14.0 [12.1-15.9] *** Generalized anxiety disorder (GAD) 7.8 [7.4-8.2] 9.9 [9.2-10.6] 5.8 [5.3-6.3] *** 8.1 [7.2-9.2] 9.7 [8.6-10.9] 8.0 [7.1-9.0] 7.1 [6.1-8.1] 6.1 [5.1-7.2] *** 7.4 [6.9-7.8] 9.9 [8.6-11.2] 10.5 [8.5-12.5] *** Separation anxiety disorder (SAD) 10.7 [10.1-11.4] 12.6 [11.7-13.6] 8.8 [8.2-9.5] *** 18.7 [17.3-20.3] 13.5 [12.2-15.0] 10.5 [9.4-11.6] 7.4 [6.4-8.5] 3.7 [3.0-4.5] *** 10.2 [9.5-10.9] 12.7 [11-14.5] 15.3 [12.7-17.8] *** Major depression disorder (MDD) 5.5 [5.1-6.0] 6.3 [5.7-6.9] 4.8 [4.3-5.4] ** 6.4 [5.5-7.5] 6.7 [5.8-7.7] 5.1 [4.3-6.1] 5.1 [4.4-6.0] 4.2 [3.5-5.1] ** 5.1 [4.6-5.5] 7.7 [6.2-9.1] 8.3 [6.4-10.2] *** Oppositional defiant disorder (ODD) 8.2 [7.7-8.7] 6.7 [6.1-7.3] 9.7 [9.0-10.4] *** 6.7 [5.8-7.7] 8.3 [7.3-9.4] 8.6 [7.6-9.6] 9.3 [8.3-10.3] 8.2 [7.7-8.7] * 7.8 [7.3-8.3] 10.2 [8.5-11.8] 11.6 [10.0-13.3] *** Attention-deficit/hyperactivity disorder (ADHD) 7.2 [6.8-7.7] 6.2 [5.7-6.8] 8.2 [7.6-9.0] *** 6.2 [5.4-7.2] 7.4 [6.5-8.5] 8.0 [7.0-9.2] 7.6 [6.7-8.6] 6.8 [5.8-8.0] 6.8 [6.3-7.3] 8.9 [7.6-10.2] 11.1 [9.0-13.2] *** At least one probable internalizing disorder 22.8 [22-23.7] 28.2 [27-29.4] 17.7 [16.7-18.7] *** 30.3 [28.5-32.1] 26.5 [24.8-28.4] 23.3 [21.8-24.9] 19.1 [17.5-20.8] 15.3 [14.0-16.7] *** 21.6 [20.7-22.5] 29.3 [26.9-31.7] 30.6 [27.4-33.8] *** At least one probable externalizing disorder 12.3 [11.7-13.0] 10.6 [9.9-11.4] 14 [13.2-14.9] *** 10.4 [9.3-11.6] 12.4 [11.2-13.7] 13.1 [11.8-14.5] 13.7 [12.5-14.9] 12.0 [10.7-13.6] ** 11.7 [11.0-12.4] 15.0 [13.2-16.8] 17.3 [15.0-19.6] *** At least one probable mental health disorder 28.7 [27.9-29.6] 32.0 [30.8-33.1] 25.6 [24.5-26.8] *** 33.7 [31.8-35.6] 31.1 [29.3-33.0] 29.9 [28.1-31.7] 26.7 [25-28.3] 22.6 [20.9-24.3] *** 27.4 [26.4-28.3] 36.1 [34.0-38.1] 37.4 [33.7-41.2] *** At least one probable internalizing and probable externalizing disorder 6.4 [6.0-6.8] 6.8 [6.2-7.4] 6.0 [5.4-6.7] NA 7.0 [6.0-7.9] 7.8 [6.7-8.8] 6.5 [5.5-7.5] 6.1 [5.2-7.0] 4.7 [3.9-5.5] ** 5.9 [5.5-6.4] 8.3 [6.8-9.7] 10.5 [8.8-12.2] *** 1 Pearson chi-square tests (*** if p<0.001. ** if p<0.01 and * if p<0.05) Table 3: Pearson correlation of the scores of symptoms for the six mental health disorders investigated in the Dominic Interactive Questionnaire, and the number of shared DI questionnaire items (i.e., some response from the same item is used to calculate more than one mental health disorder) (Enabee 2022 study) - Metropolitan France Specific phobias (SPh) Separation anxiety (SAD) Generalized anxiety (GAD) Major depression (MDD) Oppositional defiant (ODD) ADHD Specific phobias (SPh) Correlation Shared items 1.00 0 Separation anxiety (SAD) Correlation Shared items 0.32 0 1.00 0 Generalized anxiety (GAD) Correlation Shared items 0.38 0 0.58 0 1.00 0 Major depression (MDD) Correlation Shared items 0.29 0 0.48 0 0.79 2 1.00 0 Oppositional defiant (ODD) Correlation Shared items 0.15 0 0.31 0 0.56 2 0.67 2 1.00 0 ADHD Correlation Shared items 0.21 0 0.35 0 0.62 2 0.75 4 0.62 0 1.00 0 Discussion The present study aimed to evaluate the internal structure of six of the seven mental health disorder subscales of the DI questionnaire implemented in a large national sample of children in metropolitan France in 2022, and to provide the prevalence of child self-reported probable mental health disorders using this questionnaire. The internal consistency coefficients (Cronbach’s alpha and Mc Donald’s Omega) of the six subscales were acceptable or good, for girls, boys, and the youngest respondents. The coefficient values were very close to those measured in other samples (14,16–19). As previously observed, internal consistency indicators were lower for SPh. One possible explanation for this is the multidimensional structure of the SPh score which assesses various types of phobias: a fear of animals (insects, dogs, cats, and spiders), as well as environmental (thunderstorms and heights), situational (elevators or long corridors) and other types (e.g., persons in costumes) of phobia (27). The Mc Donald Omegas were consistent with the Cronbach alphas; however, the former showed better consistency for all subscales. The results for the factorial structure for each of the six subscales showed acceptable fit indices. For each subscale model, the CFI was above 0.9 while the RMSEA was below 0.08 (23). Therefore, we confirmed the factorial structure and the internal consistence of the six DI subscales based on the Enabee 2022 study sample. The distributions of the six mental health disorder symptom scores we obtained were very similar to those reported in 2004 in a sample of children living in the South-East region of France (16). In our study, most children did not mention any or mentioned very few ODD symptoms, while for MDD, GAD, and SAD, the majority of children mentioned a few symptoms, resulting in an almost bell curve distribution. For ADHD, we observed differences for the three types of symptoms. Specifically, symptoms of inattention were more frequent, whereas very few children mentioned symptoms of hyperactivity and impulsiveness. One possible explanation for this is that symptoms for these two components of ADHD are either less noticeable to the children themselves (28) or more difficult to admit; further studies are needed to clarify this. We also observed a difference in the distribution of SPh scores between girls and boys, reflecting previous work elsewhere (16). Young boys were much more likely to mention no or one phobia, while girls were more likely to mention more than one phobia. The overall distribution of symptoms, in particular regarding gender differences, remained relatively stable between the 2004 study and Enabee 2022. However, it is important to note that the geographical areas involved were different in the two studies. Our results also show that for the six mental health disorders investigated, the ninety-fifth percentile was equal to the threshold for the ‘probable’ mental health disorder category. More specifically, at least 5% of children fell into the category of ‘likely have a disorder’. This result is consistent with studies using other psychometric tools than the DI, which choose 5% as the threshold value for the ‘probable’ category. Our findings also showed that the prevalence values in the Enabee 2022 sample were higher than those reported in the South-East region in France in 2004 (e.g., 28.7% vs. 25.4% reported at least one probable disorder) (16). Furthermore, our values were inside the range of prevalence values observed for SPh, SAD, and MDD in a study of seven European countries in 2010, and above the ranges observed in that study for GAD, ADHD, and ODD (between 2.4% and 6.7%, between 1.6% and 5.6%, and between 1.8% and 5.8%, respectively) (20). The Enabee 2022 study protocol was very similar to those of the 2004 French study and the 2010 European study, especially the DI component. However, the differences in geographical locations with our study limit our ability to make an in-depth exploration of the increase of child-reported mental health symptoms in France since 2004. The higher prevalence of internalized disorders among girls and the higher prevalence of externalized disorders among boys in our study reflect previous findings (16,20,27). Additionally, we found that younger children were more likely to report an internalized disorder. More specifically, the prevalence of SPh and SAD drastically decreased with increasing grade. Our finding that children aged 6 to 8 years were more likely to report an internalizing disorder reflects findings in most European studies using the DI to date (16,20,27). We also observed that children in socially deprived (i.e., REP, see above) and in highly socially deprived (REP+) areas were more likely to report a mental health disorder, reflecting previous findings (16,20). Finally, the use of the DI in Enabee 2022 highlighted co-occurrence between externalized (ODD and ADHD) and internalized symptoms (MDD and GAD). The proportion of children who reported at least one internalizing disorder and one externalizing disorder was 6.4% [6.0-6.8]. Therefore, the DI might be particularly useful to highlight internalizing symptoms that may mask externalizing disorders or that can provoke unease. It might also be useful to address sensitive topics, such as suicide (10,16). This study provides the first description of self-reported mental health of children aged 6 to 11 years living in France. The strengths of our work lie in its large sample size as well as its good representativeness of French children aged 6 to 11 years in France, reflecting the diversity of living conditions of children in the country. Moreover, our data are very recent and could be particularly useful to highlight internalizing symptoms that remain hidden in studies that do not consider children’s points of view. Enabee 2022 also has limitations, which must be considered when interpreting our results. First, the school participation rate was only 58.8%. Nevertheless, one must consider the challenging post COVID-19 pandemic context for schools in 2022. Indeed, several principals cited pandemic-related difficult as the reason not to participate. In this regard, the participation rate can be considered relatively high. Parents’ refusal is a separate issue, and the non-involvement of children whose parents refused to participate or children who were absent on the day of the study sessions (almost 13% of those eligible) may potentially have introduced selection bias in the prevalence assessment. However, the sophisticated sampling design (survey weights, stratification, sampling stages) used, should have limited any such bias. It should also be noted that the DI does not provide a clinical diagnosis. It does not assess the frequency, duration or impact of mental health symptoms on the child’s life; these are three required dimensions for a DSM-5 diagnosis. Finally, it would be interesting to reexamine the calibration the DI thresholds using results from a clinical study. One could also integrate parents’, teachers’, and children’s points of view with the DI and compare it with a mental health evaluation by a clinician, in the context of improving mental health evaluation and better assessing mental health care needs. Despite this shortcoming, the DI is a very valuable tool in epidemiological studies, in particular to explore changes in mental health disorder prevalence in children over time and to identify associated determinants. To conclude, this study highlighted that children aged 6 to 11 years were able to self-report their mental health symptoms using the DI. This robust instrument could be used in additional large-scale epidemiological studies in children to explore their mental health. Declarations Acknowledgements The authors are most grateful to all the participants (children, teachers, and parents), school principals, and health and educational staff who contributed to the successful implementation of Enabee 2022. We also thank the scientific advisory board and the project steering committee for their advice and for supporting the study, as well as all the stakeholders and representatives from the health, family and education sectors who were involved in the consultation group. Finally, we would like to thank CGI Business Consulting for their help in project management, Eclectic Expérience for their help in stakeholder involvement, the IPSOS Observer institute for implementing the data collection, and Jude Sweeney for his careful copyediting of the manuscript. References Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. 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Primary School Children’s Self-Reports of Attention Deficit Hyperactivity Disorder-Related Symptoms and Their Associations With Subjective and Objective Measures of Attention Deficit Hyperactivity Disorder. Front Hum Neurosci. 2022;16:806047. Additional Declarations No competing interests reported. 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16:08:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1326561,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4300080/v1/27c62563-cd83-41dc-b00f-18285131303d.pdf"},{"id":56016610,"identity":"b9238a00-2555-442c-a28f-22819e0d4353","added_by":"auto","created_at":"2024-05-07 15:21:45","extension":"pdf","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":600609,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementalmaterial.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4300080/v1/ad236a6460641415872cc89a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Self-reported mental health in school-aged children using the Dominic interactive questionnaire in the French Enabee 2022 study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe importance of assessing the mental health of young children was reaffirmed in a 2015 meta-analysis which estimated that 12.4% of the children aged 6 to 11 years old had mental health disorders\u0026nbsp;(1). A much more recent European meta-analysis reported a pooled mental health disorder prevalence rate of 15.5%\u0026nbsp;in children aged to 5 to 18 years \u0026nbsp;(2). This high prevalence underlines that child and adolescent mental health is a major public health issue\u0026nbsp;(3), especially given that mental health disorders often impact child development and learning with potential repercussions in adulthood\u0026nbsp;(3,4). Accordingly, providing reliable indicators of children’s mental health status – in particular for the most vulnerable – to stakeholders, is essential in order to adequately monitor the situation, especially during crises. These indicators are also essential to develop and evaluate adequate prevention programs. Moreover, they may also guide changes in healthcare policy.\u003c/p\u003e\n\u003cp\u003eChild mental health estimates depend largely on the informant\u0026nbsp;(5). To date, most epidemiological studies have solicited parents, teachers, and/or healthcare staff to describe the mental health of children. Few have involved self-reporting by children themselves. For example, in the Mental Health of Children and Young People survey in England\u0026nbsp;(6), and in the Bella study in Germany\u0026nbsp;(7,8), only adults (the parents and/or the teacher) reported the mental health of children younger than 11 years. These assessments are, by nature, subjective and partial. Parents’ perceptions of their child’s behavior may differ from that of a professional and might be influenced by their own mental health issues\u0026nbsp;(9). Moreover, teachers mainly observe their pupils only in the school context. In order to improve the identification of mental health disorder symptoms in children - especially internalized symptoms which are usually under-reported by parents and teachers - any third-party assessment should be complemented by a self-reported assessment by the children themselves, as cross-referencing these various perspectives improves the evaluation\u0026nbsp;(5). This requires the use of an adequate tool and an appropriate methodology\u0026nbsp;(10).\u003c/p\u003e\n\u003cp\u003eHowever, interviewing young children about their own mental health is a challenge since they have limited ability in reading, language comprehension, memory, concentration skills, abstract thinking, and self-reflection. Therefore, appropriate questionnaires that enable children to self-report their emotions and moods are essential\u0026nbsp;(11,12). One such tool is the Dominic Interactive (DI), a computerized, pictorial self-administered questionnaire, designed for children aged 6–11 years old. Respondents self-report symptoms related to mental health disorders by\u0026nbsp;responding ‘yes’ or ‘no’ to pictures illustrating situations that an avatar - which they choose - \u0026nbsp;experiences\u0026nbsp;(13). The questions illustrate real-world situations that refer to common abstract concepts of mental disorders based on the\u0026nbsp;\u003cem\u003eDiagnostic and Statistical Manual of Mental Disorders, fifth\u003c/em\u003e\u003cem\u003e\u0026nbsp;edition\u003c/em\u003e (DSM-5) for seven common disorders.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe DI was developed in Quebec in 1999\u0026nbsp;(14,15); it\u0026nbsp;was first used in both French and English-speaking children living in Montreal. Later, the tool was adapted for children living in France. Between 2000 and 2001, a study involving 403 French children demonstrated good acceptability of the DI among children in care and children in the general population as well as a good understanding of the questionnaire’s items\u0026nbsp;(10). The prevalence of disorders identified by the DI in that study was significantly higher in the clinical population than in the general population\u0026nbsp;(10). In a subsequent French study in 2004, the Cronbach alpha for each of the DI mental health disorder subscales, the distribution of scores for each DI subscale, and comorbidities, were all analyzed in a population of children (N=1274) living in the Provence-Alpes-Côte-D’Azur (South-Est) region\u0026nbsp;(16). The Cronbach alphas of the various subscales were close to those measured in Quebec and 25.4% of children self-reported at least one probable mental disorder\u0026nbsp;(16). The psychometric properties of the DI and correlations between disorder subscale scores have also been assessed in other countries\u0026nbsp;(17–19). In particular, data collected in the School Children Mental Health in Europe (SCMHE) project were used to assess reliability, factor structure and measurement invariance for the DI in a sample of 8135 primary school children, aged 6–11 years old, in seven European countries\u0026nbsp;(17,19). The McDonald omega for each disorder was good or high in all seven; furthermore, the factor structure of disorders related to the various subscales was confirmed for all seven. That study also showed cross-country test score invariance for five subscales and partial invariance for the DI’s two anxiety-related subscales. In terms of self-evaluation, 22.0% of the children involved had at least one mental disorder, with rates ranging from 16.4 % in the Netherlands to 27.9% in Turkey\u0026nbsp;(20).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn 2022, as part of a novel homonymous epidemiological project monitoring child mental health in France, the ‘National study on children’s well-being’ (\u003cem\u003eEtude nationale sur le bien-être des enfants\u003c/em\u003e)\u0026nbsp;Enabee 2022\u0026nbsp;- which included the DI -\u0026nbsp;enrolled a random sample of 15,206 children living in metropolitan France. This large sample presented a unique opportunity to enhance our knowledge of the psychometric properties of the DI and to generate the first national estimates of self-reported child mental health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe objectives of the analysis described in this article were:\u003c/p\u003e\n\u003cp\u003ei) to examine the internal consistency of each of the subscales of the DI and to confirm their factor structure on a large sample of elementary-school children living in metropolitan France.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eii) to describe the symptom score distributions and the prevalence for each probable mental health disorder assessed using the DI.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eiii) to describe the correlations between symptoms scores and co-occurrences of probable disorders.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003e1. Study design\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEnabee is a repeated national cross-sectional study conducted in schools in France using self-administrated questionnaires. The protocol for the first edition, Enabee 2022 - which was conducted in the same year exclusively in metropolitan France (i.e., no French overseas territory was involved) - is described in detail elsewhere\u0026nbsp;(21). Enabee 2022 aimed to establish a comprehensive set of indicators concerning children\u0026rsquo;s mental health from 3 to 11 years old. In France, elementary school for pupils aged 6-11 comprises five levels called CP, CE1, CE2, CM1, CM2, which correspond to 1\u003csup\u003est\u003c/sup\u003e to 5\u003csup\u003eth\u003c/sup\u003e grades in the US system. As part of Enabee 2022, children from these five grades had to fill in a self-administered questionnaire which included the DI.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. Data collection\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ea) Procedure\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA probabilistic multistage stratified sampling plan was used to constitute the Enabee 2022 study sample.\u0026nbsp;First, schools were randomly selected. \u0026nbsp;Second, up to four classes per school were randomly selected. All pupils within each selected class were eligible. In schools with four classes or fewer, all classes were selected. School principals, teachers and parents received an information letter about the study. A school\u0026rsquo;s participation was contingent upon the agreement of the school principal; parents could disagree to their child\u0026rsquo;s participation. Children whose parents agreed to their participation could independently refuse to answer the questionnaire or to interrupt answering at any time. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData from the child questionnaire were collected during dedicated sessions held in participating schools between 2 May and 5 July 2022. Survey facilitators visited each class in pairs, equipped with a tablet and headphones for each participating child.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring the answering sessions, children were first provided with general instructions explaining the purpose of the study and the rules. In particular, the survey facilitators emphasized that all answers would be confidential, and assured the children that there were no wrong answers. Children could ask questions before and during the session, but the survey facilitators were not allowed to interfere with the children\u0026rsquo;s answers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eb) Child self-reported mental health using the DI\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSelf-reported mental health was assessed using the DI\u0026nbsp;(13). The original version of the DI comprised 91 questions related to the symptoms of seven common mental disorders observed in children as described in the DSM-5: attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), oppositional defiant disorder (ODD), specific phobias (SPh), separation anxiety disorder (SAD), generalized anxiety disorder (GAD), and major depressive disorder (MDD). Ten questions focus on the child\u0026rsquo;s strengths and competencies, unrelated to any of the seven disorders. Moreover, three components of ADHD can be distinguished: inattention, hyperactivity and impulsiveness; \u0026nbsp;accordingly, DI items relative to ADHD can be separately analyzed\u0026nbsp;(22). In order to improve the acceptability of the tool by school authorities, the steering committee of the Enabee 2022 study suggested to remove all 13 questions of the DI specifically related to CD. Accordingly, the study only investigated six of the DI\u0026rsquo;s seven mental health disorders.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt the beginning of the DI, children were asked to choose an avatar from many options. The aim of proposing different avatars to choose from was to foster self-identification with the avatar finally chosen, with a view to improving the quality of the child\u0026rsquo;s answers. For all children, the chosen avatar was called Dominic (note: Dominic is a unisex name in France). A tutorial was provided to ensure that children understood how to answer the various questions asked. Each question had to be answered before proceeding to the next one. A short scene, illustrating the emotional and behavioral symptoms being described, accompanied each query. Children responded \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo; to the 78 questions in a variety of pictorial scenarios, according to whether they thought, felt, or acted like Dominic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSymptom scores were obtained by adding 1 point for each reported symptom of the evaluated disorder. For each disorder, thresholds were used to classify children into three groups: no disorder, possible disorder, probable disorder. These thresholds were based on the mean and standard deviations collected from the sample of 585 children living in Montreal in 1992 who were the first children to complete the DI in 1999\u0026nbsp;(15). Specifically, children whose number of reported symptoms was between one or two exclusive standard deviations above the mean in the Montreal sample were categorized as \u0026lsquo;possibly\u0026rsquo; presenting a disorder; those with two standard deviations or more above the mean were categorized as \u0026lsquo;probably\u0026rsquo; presenting a disorder.\u0026nbsp;Generally, in epidemiological studies, the latter threshold is used to define the prevalence of mental health disorders\u0026nbsp;(16,18,20). In the present analysis, (and all Enabee 2022 analyses), we followed suit in order to ensure comparison with other studies.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ec) Covariates\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe used data from the databases of the French Ministry of Education to collect the following information: child\u0026rsquo;s gender, grade (i.e., from 1\u003csup\u003est\u003c/sup\u003e to 5\u003csup\u003eth\u003c/sup\u003e), aged-related school type (i.e., elementary \u0026ndash; 6 to 11 years old, primary \u0026ndash; 3 to 11 years old), type of school (i.e., public or private under contract with the French Ministry of Education), and whether the participating schools were officially recognized as being located in a socially deprived (\u003cem\u003eR\u0026eacute;seau d\u0026rsquo;\u0026eacute;ducation prioritaire\u003c/em\u003e, REP hereafter) or highly socially deprived (REP+ hereafter) area. The REP and REP+ programs are systems of educational support implemented in French public schools, aimed at addressing educational inequalities by providing additional resources and support to schools in socially deprived areas.\u003c/p\u003e\n\u003ch3\u003e3.\tStudy Sample \u003c/h3\u003e\n\u003cp\u003eAs shown in \u003cstrong\u003eFigure 1\u003c/strong\u003e, of a total of 554 primary/elementary schools randomly selected, 326 agreed to participate (participation rate 58.8%). Class participation rate was 93.5%, representing 19,725 children. The following children were not eligible to participate: those whose parents objected to the study, those whose parents did not receive information about the study at home, those who moved house, and those whose teacher considered that they were not able to properly complete the child questionnaire due to a disability or too poor a French linguistic level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the statistical analysis, we further excluded children with incomplete DI and those with inconsistent responses. Finally, a total of 15,206 children were included in the final analysis.\u003c/p\u003e\n\u003cp\u003eTo enable statistical inference of the results, we calculated weights for the sample of children who fully completed the child questionnaire, taking into account the observed total non-response at each sampling stage (i.e., school, class, and individual). A calibration step was then performed using margins derived from the reference sample (children in 1\u003csup\u003est\u003c/sup\u003e\u0026nbsp; to 5\u003csup\u003eth\u003c/sup\u003e grade in public schools or private schools under contract) to ensure the study population could be compared with the reference sample in terms of the individual child’s gender, the type of school (public or private under contract), and grade (i.e., 1\u003csup\u003est\u003c/sup\u003e to 5\u003csup\u003eth\u003c/sup\u003e grade). We subsequently applied a truncation step to avoid excessive dispersion of the weights.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e4.\tStatistical analysis\u003c/h3\u003e\n\u003cp\u003e\u003cem\u003ea) Descriptive analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe statistical descriptive analysis described the main characteristics of the study population, taking into account the sampling design (i.e., weights, stratifications and sampling stage).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eb) Assessment of DI psychometric properties\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe first examined the ceiling and floor effects for each of the 78 questions in the DI. For each of the six mental health disorders examined, we estimated the internal consistency using Cronbach\u0026rsquo;s alpha and Mc Donald\u0026rsquo;s Omega. Cronbach alphas were also assessed for gender and for grade. To confirm the factorial structure, we reproduced Kuijpers\u0026rsquo; approach by performing a categorical confirmatory factor analysis (CCFA) for each subscale\u0026nbsp;(19). We used conventional limits for fit indices as follows: a CFI greater than 0.90 and an RMSEA less than 0.08 were considered acceptable while a CFI greater than 0.95 and an RMSEA less than 0.05 were considered good\u0026nbsp;(23).\u003c/p\u003e\n\u003cp\u003eR software was used to perform this assessment, specifically the survey\u0026nbsp;(24)\u0026nbsp;and EFAtool packages\u0026nbsp;(25), to assess Cronbach alphas and Mc Donald Omegas with a categorical CFA, and the lavaan package for the CCFA\u0026nbsp;(26). Weights were used for the analysis with the WLMSV estimator. It was not possible to specify a complex sampling plan with categorical data in the calculation of the McDonalds omega with the lavaan package. In contrast, we were able to specify a complex sampling plan for the calculation of Cronbach\u0026rsquo;s alpha.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ec) Prevalence assessment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe computed the prevalence of \u0026lsquo;probable\u0026rsquo; cases and their 95% confidence intervals (CI) for each \u0026lsquo;probable\u0026rsquo; mental health disorder assessed by the DI. We also measured the percentages and their 95% CI for probable cases of the following four indicators: at least one probable internalizing disorder (i.e., MDD, SAD, GAD, or SPh), at least one probable externalizing disorder (i.e., ADHD or ODD), at least one probable mental health disorder (i.e., any one of the six studied), and at least one probable internalizing \u003cem\u003eand\u003c/em\u003e one probable externalizing disorder.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe also described the statistical distribution of each mental health disorders and each three components of ADHD (inattention, hyperactivity and impulsiveness) independently.\u003c/p\u003e\n\u003cp\u003eWe assessed prevalence according to gender, grade, and type of school (private school under contract or public school in an non-REP or REP+ area, public school located in REP area, public school located in REP+ area), and compared them using Pearson chi-square tests.\u003c/p\u003e\n\u003cp\u003eFinally, we examined co-occurrences between each probable mental health disorder assessed by the DI and identified the most frequent associations. We computed the Pearson correlation of the sum of the item scores for each of the six diagnostic-specific subscales of the DI.\u003c/p\u003e\n\u003cp\u003eThese various statistical analyses were performed taking into account the sampling design of the study including non-response adjusted weights, strata and the finite population correction factor. They were performed using SAS Enterprise Guide version 7.11.\u003c/p\u003e\n\u003ch3\u003e5.\tEthical considerations\u003c/h3\u003e\n\u003cp\u003eThe study was approved by the French authority for data protection (\u003cem\u003eCommission nationale informatique et libert\u0026eacute;s\u003c/em\u003e, CNIL, authorization demand n\u0026deg; 921423, deliberation DR-2022-009, 7 January 2022), as well as a French ethics committee (\u003cem\u003eComit\u0026eacute; \u0026eacute;thique et scientifique pour les recherches, les \u0026eacute;tudes et les \u0026eacute;valuations dans le domaine de la sant\u0026eacute;\u003c/em\u003e, CESREES, decision of october 14, 2021, n\u0026deg; 5268850). The study also received approval from the French council for statistical information (CNIS, avis n\u0026deg; 85/H030) and the Committee of Public Statistics (n\u0026deg;2022_11193_DG75-L002).\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003ea) Study sample and characteristics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study sample was evenly distributed across all five grades (i.e., 1\u003csup\u003est\u003c/sup\u003e to 5\u003csup\u003eth\u003c/sup\u003e). Moreover, there were only small differences - for the variables investigated - between all children enrolled in public schools or in private schools under contract in metropolitan France and the sample of children participating in Enabee 2022 (Supplemental table 1).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eb) Psychometric properties of the DI used in the Enabee 2022 study\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e1) Ceiling and floor effects\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eOf the 78 questions in the administered DI, only 7 displayed a ceiling or floor effect, meaning that a very large majority of the participants (i.e., \u0026gt; 90%) provided the same answer to a given question. Six of these were strengths and competencies questions (see above) while the seventh evaluated a SPh (see above), specifically a fear of cats.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e2) Internal consistency of DI subscales\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe first columns in \u003cstrong\u003eTable 1\u003c/strong\u003e show the Cronbach\u0026rsquo;s alpha and Mc Donald\u0026rsquo;s Omega of each subscale of mental health symptom assessed by the DI. Both coefficients were good (i.e., \u0026gt;0.7 and \u0026gt;0.8, respectively) for GAD, MDD, ADHD and ODD. Furthermore, the indicators of internal consistency for SPh and SAD were acceptable. The values of Mc Donald Omegas were consistent to the Cronbach alphas and were even higher for all subscales. The Cronbach alphas for girls and boys were nearly identical (less than 0.02 difference). The same was true for the lowest (1\u003csup\u003est\u003c/sup\u003e to 3rd) and highest (4\u003csup\u003eth\u003c/sup\u003e and 5\u003csup\u003eth\u003c/sup\u003e) class grades. They differed slightly more for SPh between girls and boys (0.50 [0.49-0.52] vs 0.55 [0.53-0.57]), and for ODD between the lowest and highest school levels (0.73 [0.72-0.74] vs 0.77 [0.76-0.78]) (supplementary Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: Cronbach\u0026rsquo;s alpha, Mc Donald\u0026rsquo;s Omega and Goodness-of-Fit Indices of the Six-Factor Structure of the Dominic Interactive (Enabee 2022 study, N=15,206) \u0026ndash; Metropolitan France\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"747\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.664879356568363%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.605898123324394%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eInternal consistency indicators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.729222520107236%\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eFit indices\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.664879356568363%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.364611260053618%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026alpha;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e#\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.241286863270776%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026Omega;\u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eChi\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCFI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRMSEA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.664879356568363%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecific Phobias (SPh)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.364611260053618%\" valign=\"top\"\u003e\n \u003cp\u003e0.56 [0 .54-0.56]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.241286863270776%\" valign=\"top\"\u003e\n \u003cp\u003e0.72 [0.71-0.73]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e1049.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.664879356568363%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeparation anxiety disorders (SAD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.364611260053618%\" valign=\"top\"\u003e\n \u003cp\u003e0.64 [0.63-0.64]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.241286863270776%\" valign=\"top\"\u003e\n \u003cp\u003e0.79 [0.79-0.80]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e1349.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.664879356568363%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneralized anxiety disorders (GAD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.364611260053618%\" valign=\"top\"\u003e\n \u003cp\u003e0.74 [0.74-0.75]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.241286863270776%\" valign=\"top\"\u003e\n \u003cp\u003e0.84 [0.84-0.85]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e5064.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.664879356568363%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMajor depression disorder (MDD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.364611260053618%\" valign=\"top\"\u003e\n \u003cp\u003e0.79 [0.78-0.79]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.241286863270776%\" valign=\"top\"\u003e\n \u003cp\u003e0.89 [0.89-0.89]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e5951.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.664879356568363%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOppositional defiant disorder (ODD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.364611260053618%\" valign=\"top\"\u003e\n \u003cp\u003e0.75 [0.74-0.75]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.241286863270776%\" valign=\"top\"\u003e\n \u003cp\u003e0.87 [0.87-0.88]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e623.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.664879356568363%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttention-deficit/hyperactivity disorder (ADHD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.364611260053618%\" valign=\"top\"\u003e\n \u003cp\u003e0.83 [0.82-0.83]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.241286863270776%\" valign=\"top\"\u003e\n \u003cp\u003e0.91 [0.91-0.91]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e4041.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.093833780160858%\" valign=\"top\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e# Cronbach\u0026rsquo;s alpha with 95%CI\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e*Mc Donald\u0026rsquo;s Omega with 95%CI\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e3) Confirmatory factor analysis of DI subscales\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e shows acceptable to good fit measures, with CFI values ranging from 0.90 to 0.97 and RMSEA values ranging from 0.04 to 0.07, indicating that invariance was supported (23). The SAD and GAD scales had the highest RMSEA of the six subscales; nevertheless their values were acceptable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003ec) Distribution of DI symptom scores\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2\u003c/strong\u003e shows, for each of the six mental health disorders measured and the three components of ADHD (inattention, hyperactivity and impulsiveness) assessed, the symptom score distribution according to gender, the ninety-fifth percentiles of these distributions, and the thresholds defining the \u0026lsquo;probable mental health disorder\u0026rsquo; group (13).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSelf-reported internalizing symptoms (i.e., MDD, SAD, GAD, or SPh) - except for SPh in boys - and inattention were distributed as a bell curve. While the distribution of self-reported ODD, hyperactivity and impulsiveness symptoms highlights that many children reported no symptoms for these disorders. For all six disorders, the ninety-fifth percentile was equal to the threshold for the probable mental health disorder category. We observed that the distributions of symptom scores between girls and boys were, for the most part, similar, except for the SPh symptoms score.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ed) Prevalence and co-occurrences of probable mental health symptoms\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e shows the weighted prevalence of probable mental health disorders in the Enabee 2022 study and the prevalence according to gender, type of school, and grade (i.e., 1\u003csup\u003est\u003c/sup\u003e to 5\u003csup\u003eth\u003c/sup\u003e). More children reported internalized symptoms than externalized symptoms; girls were more likely to report internalized symptoms compared to boys. The most commonly reported probable disorders were SAD and SPh (10.7% [10.1-11.4] and 9.4% [8.9-10.0], respectively). MDD was the least frequently reported disorder (5.5% [5.1-6.0]). We did not observe any significant difference between boys and girls who reported at least one probable internalizing disorder \u003cem\u003eand\u003c/em\u003e one probable externalizing disorder (see above). The percentage of children who reported at least one probable internalizing disorder decreased as the grade increased, particularly for SAD (18.7% [17.3-20.3] for 1\u003csup\u003est\u003c/sup\u003e grade and 3.7% [3.0-4.5] for 5\u003csup\u003eth\u003c/sup\u003e grade) and, to a lesser degree, for SPh and MDD. However, the percentages of girls and boys who reported ODD or ADHD symptoms were similar across all five grades (results not shown). Children in REP and REP+ areas were significantly more likely to have at least one probable mental health disorder. This was true for each of the six disorders assessed individually, for both girls and boys (results not shown). Among children reporting symptoms suggestive of at least one probable mental health disorder, the majority reported symptoms suggestive of only one disorder (60.7% [59.2-62.2]). Among the whole sample, only 5.4% [5.0-5.8] reported symptoms for three or more types of mental health disorder.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 3\u003c/strong\u003e shows that children predominantly reported SPh without any other type of probable disorder. In contrast, symptoms of MDD and GAD were mostly associated with two or more other types of probable disorders. Specifically, children who reported probable MDD also reported probable GAD and/or ADHD and children who reported probable GAD also reported probable SAD (results not show). The results from Figure 3 are consistent with the Pearson correlation coefficients between each symptom score reported in Table 3. All correlations were statistically significant. The strongest correlation was between symptoms for MDD and GAD, followed by the correlation between symptoms for MDD and ADHD. The calculation of MDD and ADHD prevalence were based on four similar DI items. \u0026nbsp;MDD and GAD calculations were based on two similar DI items. Finally, symptoms for SPh were the least correlated with those of other disorders.\u003c/p\u003e\n\u003cp\u003eTable 2: Weighted prevalence and CI 95% of probable mental health disorders in the study sample (total), and according to gender, grade (i.e., 1\u003csup\u003est\u003c/sup\u003e to 5\u003csup\u003eth\u003c/sup\u003e), and type of school (Enabee 2022 study. N=15206) - Metropolitan France; *REP and REP+ refer to a school located in a socially deprived area and in a highly socially deprived area, respectively.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1107\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.567811934900542%\" rowspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.69620253164557%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"16.00361663652803%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.14466546112116%\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.587703435804702%\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of school\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.501547987616099%\"\u003e\n \u003cp\u003eTotal (N=15,206)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.533539731682146%\"\u003e\n \u003cp\u003eGirls (N=7,436)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.8431372549019605%\"\u003e\n \u003cp\u003eBoys (N=7770)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.889576883384933%\"\u003e\n \u003cp\u003eP\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.803921568627452%\"\u003e\n \u003cp\u003eGrade 1\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(N=2,890)\u003c/p\u003e\n \u003cp\u003e(Mean age=6,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.700722394220847%\"\u003e\n \u003cp\u003eGrade 2\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(N=3,141)\u003c/p\u003e\n \u003cp\u003e(Mean age=7,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.8431372549019605%\"\u003e\n \u003cp\u003eGrade 3\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(N=3,099)\u003c/p\u003e\n \u003cp\u003e(Mean age=8,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.8431372549019605%\"\u003e\n \u003cp\u003eGrade 4\u003c/p\u003e\n \u003cp\u003e(N=3228)\u003c/p\u003e\n \u003cp\u003e(Mean age=9,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.8431372549019605%\"\u003e\n \u003cp\u003eGrade 5\u003c/p\u003e\n \u003cp\u003e(N=2,848)\u003c/p\u003e\n \u003cp\u003e(Mean age=10,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.889576883384933%\"\u003e\n \u003cp\u003eP\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.700722394220847%\"\u003e\n \u003cp\u003ePrivate or public located outside REP/REP+ area* (N=12,474)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.771929824561404%\"\u003e\n \u003cp\u003ePublic located in REP area (N=1,549)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.8431372549019605%\"\u003e\n \u003cp\u003ePublic located in REP+ area (N=1,183)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.3735810113519094%\"\u003e\n \u003cp\u003eP\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.6191950464396285%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.545126353790614%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecific phobias (SPh)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.6859205776173285%\"\u003e\n \u003cp\u003e9.4 [8.9-10.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.588447653429603%\"\u003e\n \u003cp\u003e13.6 [12.7-14.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e5.4 [4.9-5.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.574007220216606%\"\u003e\n \u003cp\u003e12.0 [10.7-13.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e10.2 [9.1-11.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e9.8 [8.7-11.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e8.3 [7.3-9.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e6.9 [6.0-8.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e8.7 [8.2-9.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.671480144404332%\"\u003e\n \u003cp\u003e13 [11.1-14.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e14.0 [12.1-15.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.0758122743682312%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5415162454873647%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.545126353790614%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneralized anxiety disorder (GAD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.6859205776173285%\"\u003e\n \u003cp\u003e7.8 [7.4-8.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.588447653429603%\"\u003e\n \u003cp\u003e9.9 [9.2-10.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e5.8 [5.3-6.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.574007220216606%\"\u003e\n \u003cp\u003e8.1 [7.2-9.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e9.7 [8.6-10.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e8.0 [7.1-9.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e7.1 [6.1-8.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e6.1 [5.1-7.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e7.4 [6.9-7.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.671480144404332%\"\u003e\n \u003cp\u003e9.9 [8.6-11.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e10.5 [8.5-12.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.0758122743682312%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5415162454873647%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.545126353790614%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeparation anxiety disorder (SAD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.6859205776173285%\"\u003e\n \u003cp\u003e10.7 [10.1-11.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.588447653429603%\"\u003e\n \u003cp\u003e12.6 [11.7-13.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e8.8 [8.2-9.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.574007220216606%\"\u003e\n \u003cp\u003e18.7 [17.3-20.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e13.5 [12.2-15.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e10.5 [9.4-11.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e7.4 [6.4-8.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e3.7 [3.0-4.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e10.2 [9.5-10.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.671480144404332%\"\u003e\n \u003cp\u003e12.7 [11-14.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e15.3 [12.7-17.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.0758122743682312%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5415162454873647%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.545126353790614%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMajor depression disorder (MDD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.6859205776173285%\"\u003e\n \u003cp\u003e5.5 [5.1-6.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.588447653429603%\"\u003e\n \u003cp\u003e6.3 [5.7-6.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e4.8 [4.3-5.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.574007220216606%\"\u003e\n \u003cp\u003e6.4 [5.5-7.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e6.7 [5.8-7.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e5.1 [4.3-6.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e5.1 [4.4-6.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e4.2 [3.5-5.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e5.1 [4.6-5.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.671480144404332%\"\u003e\n \u003cp\u003e7.7 [6.2-9.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e8.3 [6.4-10.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.0758122743682312%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5415162454873647%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.545126353790614%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOppositional defiant disorder (ODD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.6859205776173285%\"\u003e\n \u003cp\u003e8.2 [7.7-8.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.588447653429603%\"\u003e\n \u003cp\u003e6.7 [6.1-7.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e9.7 [9.0-10.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.574007220216606%\"\u003e\n \u003cp\u003e6.7 [5.8-7.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e8.3 [7.3-9.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e8.6 [7.6-9.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e9.3 [8.3-10.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e8.2 [7.7-8.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e7.8 [7.3-8.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.671480144404332%\"\u003e\n \u003cp\u003e10.2 [8.5-11.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e11.6 [10.0-13.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.0758122743682312%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5415162454873647%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.545126353790614%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttention-deficit/hyperactivity disorder (ADHD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.6859205776173285%\"\u003e\n \u003cp\u003e7.2 [6.8-7.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.588447653429603%\"\u003e\n \u003cp\u003e6.2 [5.7-6.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e8.2 [7.6-9.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.574007220216606%\"\u003e\n \u003cp\u003e6.2 [5.4-7.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e7.4 [6.5-8.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e8.0 [7.0-9.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e7.6 [6.7-8.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e6.8 [5.8-8.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e6.8 [6.3-7.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.671480144404332%\"\u003e\n \u003cp\u003e8.9 [7.6-10.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e11.1 [9.0-13.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.0758122743682312%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5415162454873647%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.545126353790614%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAt least one probable internalizing disorder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.6859205776173285%\"\u003e\n \u003cp\u003e22.8 [22-23.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.588447653429603%\"\u003e\n \u003cp\u003e28.2 [27-29.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e17.7 [16.7-18.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.574007220216606%\"\u003e\n \u003cp\u003e30.3 [28.5-32.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e26.5 [24.8-28.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e23.3 [21.8-24.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e19.1 [17.5-20.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e15.3 [14.0-16.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e21.6 [20.7-22.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.671480144404332%\"\u003e\n \u003cp\u003e29.3 [26.9-31.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e30.6 [27.4-33.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.0758122743682312%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5415162454873647%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.545126353790614%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAt least one probable externalizing disorder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.6859205776173285%\"\u003e\n \u003cp\u003e12.3 [11.7-13.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.588447653429603%\"\u003e\n \u003cp\u003e10.6 [9.9-11.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e14 [13.2-14.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.574007220216606%\"\u003e\n \u003cp\u003e10.4 [9.3-11.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e12.4 [11.2-13.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e13.1 [11.8-14.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e13.7 [12.5-14.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e12.0 [10.7-13.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e11.7 [11.0-12.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.671480144404332%\"\u003e\n \u003cp\u003e15.0 [13.2-16.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e17.3 [15.0-19.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.0758122743682312%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5415162454873647%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.545126353790614%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAt least one probable mental health disorder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.6859205776173285%\"\u003e\n \u003cp\u003e28.7 [27.9-29.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.588447653429603%\"\u003e\n \u003cp\u003e32.0 [30.8-33.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e25.6 [24.5-26.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.574007220216606%\"\u003e\n \u003cp\u003e33.7 [31.8-35.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e31.1 [29.3-33.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e29.9 [28.1-31.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e26.7 [25-28.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e22.6 [20.9-24.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e27.4 [26.4-28.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.671480144404332%\"\u003e\n \u003cp\u003e36.1 [34.0-38.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e37.4 [33.7-41.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.0758122743682312%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5415162454873647%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.545126353790614%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAt least one probable internalizing \u003cem\u003eand\u003c/em\u003e probable externalizing disorder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.6859205776173285%\"\u003e\n \u003cp\u003e6.4 [6.0-6.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.588447653429603%\"\u003e\n \u003cp\u003e6.8 [6.2-7.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e6.0 [5.4-6.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.574007220216606%\"\u003e\n \u003cp\u003e7.0 [6.0-7.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e7.8 [6.7-8.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e6.5 [5.5-7.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e6.1 [5.2-7.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e4.7 [3.9-5.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.527075812274368%\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.483754512635379%\"\u003e\n \u003cp\u003e5.9 [5.5-6.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.671480144404332%\"\u003e\n \u003cp\u003e8.3 [6.8-9.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.859205776173285%\"\u003e\n \u003cp\u003e10.5 [8.8-12.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.0758122743682312%\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5415162454873647%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003cem\u003e\u0026nbsp;Pearson chi-square tests (*** if p\u0026lt;0.001. ** if p\u0026lt;0.01 and * if p\u0026lt;0.05)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 3: Pearson correlation of the scores of symptoms for the six mental health disorders investigated in the Dominic Interactive Questionnaire, \u0026nbsp;and the number of shared DI questionnaire items \u0026nbsp;(i.e., some response from the same item is \u0026nbsp;used to calculate more than one mental health disorder) (Enabee 2022 study) - Metropolitan France\u003c/p\u003e\n\u003ctable\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99.55pt;border-top: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-right: none;background: white;padding: 0in 3.5pt;height: 30.75pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82.15pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 3.5pt;height: 30.75pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:43.15pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;background:white;padding:0in 3.5pt 0in 3.5pt;height:30.75pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eSpecific\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003ephobias (SPh)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.75pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;background:white;padding:0in 3.5pt 0in 3.5pt;height:30.75pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eSeparation anxiety (SAD)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.9pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;background:white;padding:0in 3.5pt 0in 3.5pt;height:30.75pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eGeneralized anxiety (GAD)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.85pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;background:white;padding:0in 3.5pt 0in 3.5pt;height:30.75pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eMajor depression (MDD)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:65.75pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;background:white;padding:0in 3.5pt 0in 3.5pt;height:30.75pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eOppositional defiant (ODD)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.7pt;border:solid windowtext 1.0pt;border-left: none;background:white;padding:0in 3.5pt 0in 3.5pt;height:30.75pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eADHD\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99.55pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eSpecific phobias (SPh)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82.15pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eCorrelation\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eShared items\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:43.15pt;border:none;background:#D9D9D9;padding:0in 3.5pt 0in 3.5pt;height:30.0pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e1.00\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.75pt;border: none;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70.9pt;border: none;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border: none;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 65.75pt;border: none;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:99.55pt;border:none;border-left:solid windowtext 1.0pt;background:white;padding:0in 3.5pt 0in 3.5pt;height:30.0pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eSeparation anxiety (SAD)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:82.15pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 3.5pt 0in 3.5pt;height:30.0pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eCorrelation\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eShared items\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43.15pt;border: none;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0.32\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.75pt;border: none;background: rgb(217, 217, 217);padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e1.00\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.9pt;border: none;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border: none;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 65.75pt;border: none;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:99.55pt;border:none;border-left:solid windowtext 1.0pt;background:white;padding:0in 3.5pt 0in 3.5pt;height:30.0pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eGeneralized anxiety (GAD)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:82.15pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 3.5pt 0in 3.5pt;height:30.0pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eCorrelation\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eShared items\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43.15pt;border: none;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0.38\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.75pt;border: none;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0.58\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.9pt;border: none;background: rgb(217, 217, 217);padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e1.00\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border: none;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 65.75pt;border: none;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;background: white;padding: 0in 3.5pt;height: 30pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:99.55pt;border:none;border-left:solid windowtext 1.0pt;background:white;padding:0in 3.5pt 0in 3.5pt;height:15.0pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eMajor depression (MDD)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:82.15pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 3.5pt 0in 3.5pt;height:15.0pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eCorrelation\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eShared items\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43.15pt;border: none;background: white;padding: 0in 3.5pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0.29\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.75pt;border: none;background: white;padding: 0in 3.5pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0.48\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.9pt;border: none;background: white;padding: 0in 3.5pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0.79\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border: none;background: rgb(217, 217, 217);padding: 0in 3.5pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e1.00\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65.75pt;border: none;background: white;padding: 0in 3.5pt;height: 15pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;background: white;padding: 0in 3.5pt;height: 15pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:99.55pt;border:none;border-left:solid windowtext 1.0pt;background:white;padding:0in 3.5pt 0in 3.5pt;height:15.0pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eOppositional defiant (ODD)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:82.15pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 3.5pt 0in 3.5pt;height:15.0pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eCorrelation\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eShared items\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43.15pt;border: none;background: white;padding: 0in 3.5pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0.15\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.75pt;border: none;background: white;padding: 0in 3.5pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0.31\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.9pt;border: none;background: white;padding: 0in 3.5pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0.56\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border: none;background: white;padding: 0in 3.5pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0.67\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65.75pt;border: none;background: rgb(217, 217, 217);padding: 0in 3.5pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e1.00\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;background: white;padding: 0in 3.5pt;height: 15pt;vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:99.55pt;border-top:none;border-left:solid windowtext 1.0pt;border-bottom:solid windowtext 1.0pt;border-right:none;background: white;padding:0in 3.5pt 0in 3.5pt;height:15.75pt;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003eADHD\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:82.15pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 3.5pt 0in 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\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e1.00\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size:15px;color:black;\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study aimed to evaluate the internal structure of six of the seven mental health disorder subscales of the DI questionnaire implemented in a large national sample of children in metropolitan France in 2022, and to provide the prevalence of child self-reported probable mental health disorders using this questionnaire.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe internal consistency coefficients (Cronbach’s alpha and Mc Donald’s Omega) of the six subscales were acceptable or good, for girls, boys, and the youngest respondents. The coefficient values were very close to those measured in other samples\u0026nbsp;(14,16–19). As previously observed, internal consistency indicators were lower for SPh. One possible explanation for this is the multidimensional structure of the SPh score which assesses various types of phobias: a fear of animals (insects, dogs, cats, and spiders), as well as environmental (thunderstorms and heights), situational (elevators or long corridors) and other types (e.g., persons in costumes) of phobia\u0026nbsp;(27). The Mc Donald Omegas were consistent with the Cronbach alphas; however, the former showed better consistency for all subscales.\u003c/p\u003e\n\u003cp\u003eThe results for the factorial structure for each of the six subscales showed acceptable fit indices. For each subscale model, the CFI was above 0.9 while the RMSEA was below 0.08\u0026nbsp;(23). Therefore, we confirmed the factorial structure and the internal consistence of the six DI subscales based on the Enabee 2022 study sample.\u003c/p\u003e\n\u003cp\u003eThe distributions of the six mental health disorder symptom scores we obtained were very similar to those reported in 2004 in a sample of children living in the South-East region of France\u0026nbsp;(16). In our study, most children did not mention any or mentioned very few ODD symptoms, while for MDD, GAD, and SAD, the majority of children mentioned a few symptoms, resulting in an almost bell curve distribution. For ADHD, we observed differences for the three types of symptoms. Specifically, symptoms of inattention were more frequent, whereas very few children mentioned symptoms of hyperactivity and impulsiveness. One possible explanation for this is that symptoms for these two components of ADHD are either less noticeable to the children themselves\u0026nbsp;(28)\u0026nbsp;or more difficult to admit; \u0026nbsp;further studies are needed to clarify this. We also observed a difference in the distribution of SPh scores between girls and boys, reflecting previous work elsewhere\u0026nbsp;(16). Young boys were much more likely to mention no or one phobia, while girls were more likely to mention more than one phobia. The overall distribution of symptoms, in particular regarding gender differences, remained relatively stable between the 2004 study and Enabee 2022.\u0026nbsp;However, it is important to note that the geographical areas involved were different in the two studies.\u003c/p\u003e\n\u003cp\u003eOur results also show that for the six mental health disorders investigated, the ninety-fifth percentile was equal to the threshold for the ‘probable’ mental health disorder category. More specifically, at least 5% of children fell into the category of ‘likely have a disorder’. This result is consistent with studies using other psychometric tools than the DI, which choose 5% as the threshold value for the ‘probable’ category.\u003c/p\u003e\n\u003cp\u003eOur findings also showed that the prevalence values in the Enabee 2022 sample were higher than those reported in the South-East region in France in 2004 (e.g., 28.7% vs. 25.4% \u0026nbsp;reported at least one probable disorder)\u0026nbsp;(16). Furthermore, our values were inside the range of prevalence values observed for SPh, SAD, and MDD in a study of seven European countries in 2010, and above the ranges observed in that study for GAD, ADHD, and ODD (between 2.4% and 6.7%, between 1.6% and 5.6%, and between 1.8% and 5.8%, respectively)\u0026nbsp;(20). The Enabee 2022 study protocol was very similar to those of the 2004 French study and the 2010 European study, especially the DI component. However, the differences in geographical locations with our study limit our ability to make an in-depth exploration of the increase of child-reported mental health symptoms in France since 2004.\u003c/p\u003e\n\u003cp\u003eThe higher prevalence of internalized disorders among girls and the higher prevalence of externalized disorders among boys in our study reflect previous findings\u0026nbsp;(16,20,27). Additionally, we found that younger children were more likely to report an internalized disorder. More specifically, the prevalence of SPh and SAD drastically decreased with increasing grade. Our finding that children aged 6 to 8 years were more likely to report an internalizing disorder reflects findings in most European studies using the DI to date\u0026nbsp;(16,20,27). We also observed that children in socially deprived (i.e., REP, see above) and in highly socially deprived (REP+) areas were more likely to report a mental health disorder, reflecting previous findings\u0026nbsp;(16,20).\u003c/p\u003e\n\u003cp\u003eFinally, the use of the DI in Enabee 2022 highlighted co-occurrence between externalized (ODD and ADHD) and internalized symptoms (MDD and GAD). The proportion of children who reported at least one internalizing disorder \u003cem\u003eand\u003c/em\u003e one externalizing disorder was 6.4% [6.0-6.8]. Therefore, the DI might be particularly useful to highlight internalizing symptoms that may mask externalizing disorders or that can provoke unease. It might also be useful to address sensitive topics, such as suicide\u0026nbsp;(10,16).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study provides\u0026nbsp;the first description of self-reported mental health of children aged 6 to 11 years living in France. The strengths of our work lie in its large sample size as well as its good representativeness of French children aged 6 to 11 years in France, reflecting the diversity of living conditions of children in the country. Moreover, our data are very recent and could be particularly useful to highlight internalizing symptoms\u0026nbsp;that remain hidden in studies that do not consider children’s points of view. Enabee 2022 also has limitations, which must be considered when interpreting our results. First, the school participation rate was only 58.8%. Nevertheless, one must consider the challenging post COVID-19 pandemic context for schools in 2022. Indeed, several principals cited pandemic-related difficult as the reason not to participate. In this regard, the participation rate can be considered relatively high. Parents’ refusal is a separate issue, and the non-involvement of children whose parents refused to participate or children who were absent on the day of the study sessions (almost 13% of those eligible) may potentially have introduced selection bias in the prevalence assessment. However, the sophisticated sampling design (survey weights, stratification, sampling stages) used, should have limited any such bias. It should also be noted that the DI does not provide a clinical diagnosis. It does not assess the frequency, duration or impact of mental health symptoms on the child’s life; these are three required dimensions for a DSM-5 diagnosis. Finally, it would be interesting to reexamine the calibration the DI thresholds using results from a clinical study. One could also integrate parents’, teachers’, and children’s points of view with the DI and compare it with a mental health evaluation by a clinician, in the context of improving mental health evaluation and better assessing mental health care needs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite this shortcoming, the DI is a very valuable tool in epidemiological studies, in particular to explore changes in mental health disorder prevalence in children over time and to identify associated determinants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo conclude, this study highlighted that children aged 6 to 11 years were able to self-report their mental health symptoms using the DI. This robust instrument could be used in additional large-scale epidemiological studies in children to explore their mental health. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are most grateful to all the participants (children, teachers, and parents), school principals, and health and educational staff who contributed to the successful implementation of Enabee 2022. We also thank the scientific advisory board and the project steering committee for their advice and for supporting the study, as well as all the stakeholders and representatives from the health, family and education sectors who were involved in the consultation group. Finally, we would like to thank CGI Business Consulting for their help in project management, Eclectic Expérience for their help in stakeholder involvement, the IPSOS Observer institute for implementing the data collection, and Jude Sweeney for his careful copyediting of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePolanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry. 2015 Mar;56(3):345\u0026ndash;65. \u003c/li\u003e\n\u003cli\u003eSacco R, Camilleri N, Eberhardt J, Umla-Runge K, Newbury-Birch D. A systematic review and meta-analysis on the prevalence of mental disorders among children and adolescents in Europe. Eur Child Adolesc Psychiatry [Internet]. 2022 Dec 30 [cited 2023 Oct 30]; Available from: https://link.springer.com/10.1007/s00787-022-02131-2\u003c/li\u003e\n\u003cli\u003ePatel V, Flisher AJ, Hetrick S, McGorry P. Mental health of young people: a global public-health challenge. The Lancet. 2007 Apr 14;369(9569):1302\u0026ndash;13. \u003c/li\u003e\n\u003cli\u003eSellers R, Warne N, Pickles A, Maughan B, Thapar A, Collishaw S. Cross-cohort change in adolescent outcomes for children with mental health problems. J Child Psychol Psychiatry. 2019;60(7):813\u0026ndash;21. \u003c/li\u003e\n\u003cli\u003eAchenbach TM. As Others See Us: Clinical and Research Implications of Cross-Informant Correlations for Psychopathology. Curr Dir Psychol Sci. 2006 Apr 1;15(2):94\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eFord T, Vizard T, Sadler K, McManus S, Goodman A, Merad S, et al. Data Resource Profile: Mental Health of Children and Young People (MHCYP) Surveys. Int J Epidemiol. 2020 Apr 1;49(2):363\u0026ndash;364g. \u003c/li\u003e\n\u003cli\u003eOtto C, Reiss F, Voss C, W\u0026uuml;stner A, Meyrose AK, H\u0026ouml;lling H, et al. Mental health and well-being from childhood to adulthood: design, methods and results of the 11-year follow-up of the BELLA study. Eur Child Adolesc Psychiatry. 2021 Oct;30(10):1559\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eRavens-Sieberer U, Otto C, Kriston L, Rothenberger A, D\u0026ouml;pfner M, Herpertz-Dahlmann B, et al. The longitudinal BELLA study: design, methods and first results on the course of mental health problems. Eur Child Adolesc Psychiatry. 2015 Jun;24(6):651\u0026ndash;63. \u003c/li\u003e\n\u003cli\u003eBajeux E, Klemanski DH, Husky M, Leray E, Chan Chee C, Shojaei T, et al. Factors Associated with Parent\u0026ndash;Child Discrepancies in Reports of Mental Health Disorders in Young Children. Child Psychiatry Hum Dev. 2018 Dec 1;49(6):1003\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eChan Chee C, Kovess V, Valla JP, All\u0026egrave;s-Jardel M, Gras-Vincendon A, Martin C, et al. Validation d\u0026rsquo;un questionnaire interactif sur la sant\u0026eacute; mentale des enfants de 6 \u0026agrave; 11 ans. Ann M\u0026eacute;d-Psychol Rev Psychiatr. 2003 Aug 1;161(6):439\u0026ndash;45. \u003c/li\u003e\n\u003cli\u003eIalongo NS, Edelsohn G, Kellam SG. A Further Look at the Prognostic Power of Young Children\u0026rsquo;s Reports of Depressed Mood and Feelings. Child Dev. 2001;72(3):736\u0026ndash;47. \u003c/li\u003e\n\u003cli\u003eRebok G, Riley A, Forrest C, Starfield B, Green B, Robertson J, et al. Elementary school-aged children\u0026rsquo;s reports of their health: A cognitive interviewing study. Qual Life Res. 2001 Jan 1;10(1):59\u0026ndash;70. \u003c/li\u003e\n\u003cli\u003eValla JP, Bergeron L, Smolla N. The Dominic-R: a pictorial interview for 6- to 11-year-old children. 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Reliability and construct validity of a child self-report instrument: The Dominic Interactive. Eur J Psychol Assess. 2014;30(1):40\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eKovess-Masfety V, Yan G, Yin H, Sun L, Hou X, Li M, et al. Chinese version of Dominic Interactive \u0026ndash; A self-report video game for assessing mental health in young children. Front Psychiatry [Internet]. 2023 [cited 2023 Aug 1];14. Available from: https://www.frontiersin.org/articles/10.3389/fpsyt.2023.1149970\u003c/li\u003e\n\u003cli\u003eKuijpers RCWM, Otten R, Vermulst AA, Bitfoi A, Goelitz D, Ko\u0026ccedil; C, et al. Reliability, Factor Structure, and Measurement Invariance of the Dominic Interactive Across European Countries: Cross-Country Utility of a Child Mental Health Self-Report. Psychol Assess. 2016 May;28(5):539\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003eHusky MM, Boyd A, Bitfoi A, Carta MG, Chan-Chee C, Goelitz D, et al. Self-reported mental health in children ages 6-12 years across eight European countries. Eur Child Adolesc Psychiatry. 2018 Jun;27(6):785\u0026ndash;95. \u003c/li\u003e\n\u003cli\u003eMotreff Y, Marillier M, Saoudi A, Verdot C, Seconda L, Pognon D, et al. Implementation of a novel epidemiological surveillance system for children\u0026rsquo;s mental health and well-being in France: the national \u0026lsquo;Enabee\u0026rsquo; cross-sectional study protocol (Preprint) [Internet]. JMIR Public Health and Surveillance; 2024 Feb [cited 2024 Feb 29]. Available from: http://preprints.jmir.org/preprint/57584\u003c/li\u003e\n\u003cli\u003eDominic [Internet]. [cited 2023 Nov 22]. Available from: https://dominic-interactive.net/shop/intro\u003c/li\u003e\n\u003cli\u003eMarsh HW, Hau KT, Wen Z. In Search of Golden Rules: Comment on Hypothesis-Testing Approaches to Setting Cutoff Values for Fit Indexes and Dangers in Overgeneralizing Hu and Bentler\u0026rsquo;s (1999) Findings. Struct Equ Model Multidiscip J. 2004 Jul;11(3):320\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eLumley T. Survey: analysis of complex survey samples. R package version 4.2. 2023. \u003c/li\u003e\n\u003cli\u003eSteiner MD, Grieder SG. EFAtools: An R package with fast and flexible implementations of exploratory factor analysis tools. J Open Source Softw. 2020;5(53):2521. \u003c/li\u003e\n\u003cli\u003eRosseel Y. lavaan: An R Package for Structural Equation Modeling. J Stat Softw. 2012 May 24;48:1\u0026ndash;36. \u003c/li\u003e\n\u003cli\u003eHusky MM, Bitfoi A, Chan-Chee C, Carta MG, Goelitz D, Ko\u0026ccedil; C, et al. Self-reported fears and mental health in elementary school children across Europe. Eur Child Adolesc Psychiatry. 2022 Dec 1;31(12):1909\u0026ndash;19. \u003c/li\u003e\n\u003cli\u003eSlobodin O, Davidovitch M. Primary School Children\u0026rsquo;s Self-Reports of Attention Deficit Hyperactivity Disorder-Related Symptoms and Their Associations With Subjective and Objective Measures of Attention Deficit Hyperactivity Disorder. Front Hum Neurosci. 2022;16:806047. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-child-and-adolescent-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ecap","sideBox":"Learn more about [European Child \u0026 Adolescent Psychiatry](http://link.springer.com/journal/787)","snPcode":"787","submissionUrl":"https://submission.nature.com/new-submission/787/3","title":"European Child \u0026 Adolescent Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Child mental health, self-evaluation, psychometric properties, and cross-sectional study ","lastPublishedDoi":"10.21203/rs.3.rs-4300080/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4300080/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe COVID-19 pandemic highlighted the need to develop rigorous epidemiological monitoring of children’s mental health in France. The Dominic Interactive (DI) assesses children’s perceptions of their own mental health using illustrated questions, which reflect situations associated with symptoms of common disorders. Although many studies have used the DI, the last time its psychometric properties were assessed on school-aged children in France was in 2004. In the Enabee 2022 study, as part of a novel homonymous epidemiological monitoring project 15,206 child attending school in metropolitan France filled in the DI.\u003c/p\u003e\n\u003cp\u003eUsing data from Enabee 2022, the present study aimed to examine the psychometric properties of DI (internal consistency and factorial structure) and to assess the self-reported prevalence of mental health problems in children.\u003c/p\u003e\n\u003cp\u003eThe Cronbach alpha and Mc Donald’s Omega were acceptable for all DI subscales assessing a specific mental health disorder. The initial factor structure was confirmed for each subscale. Overall, 28.7% of the study sample had reported at least one probable mental health disorder. Phobias and separation anxiety disorder were the most frequent disorders (9.4% and 10.7%, respectively), especially among girls (13.6% and 12.6%). In contrast, although major depression was the least reported disorder (5.5%), it had the strongest correlations with other disorders.\u003c/p\u003e\n\u003cp\u003eThis study provides the first results for self-reported mental health in children within the framework of the novel French mental health surveillance system Enabee. Integrating the DI in this system assures that children’s self-reported symptoms can be taken into consideration when assessing their mental health.\u003c/p\u003e","manuscriptTitle":"Self-reported mental health in school-aged children using the Dominic interactive questionnaire in the French Enabee 2022 study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-07 15:21:40","doi":"10.21203/rs.3.rs-4300080/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-11T07:59:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-10T19:49:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225359103284168621972623200168766225734","date":"2024-08-10T18:43:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-11T19:07:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181011988064954335570531856086580073844","date":"2024-05-10T08:05:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65269638023014270498418444215696578442","date":"2024-05-07T13:01:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-23T09:43:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-22T03:44:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-22T03:44:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Child \u0026 Adolescent Psychiatry","date":"2024-04-21T09:06:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-child-and-adolescent-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ecap","sideBox":"Learn more about [European Child \u0026 Adolescent Psychiatry](http://link.springer.com/journal/787)","snPcode":"787","submissionUrl":"https://submission.nature.com/new-submission/787/3","title":"European Child \u0026 Adolescent Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"e97c16a7-849e-4c92-8913-633151666548","owner":[],"postedDate":"May 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-19T16:03:53+00:00","versionOfRecord":{"articleIdentity":"rs-4300080","link":"https://doi.org/10.1007/s00787-025-02728-3","journal":{"identity":"european-child-and-adolescent-psychiatry","isVorOnly":false,"title":"European Child \u0026 Adolescent Psychiatry"},"publishedOn":"2025-05-17 15:57:35","publishedOnDateReadable":"May 17th, 2025"},"versionCreatedAt":"2024-05-07 15:21:40","video":"","vorDoi":"10.1007/s00787-025-02728-3","vorDoiUrl":"https://doi.org/10.1007/s00787-025-02728-3","workflowStages":[]},"version":"v1","identity":"rs-4300080","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4300080","identity":"rs-4300080","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}