Looking on the Bright Side of Life
Introducing the Positive Mental Health Scale for Children and Adolescents (PMH-Kids)
Abstract
Abstract:Theoretical Background: Positive mental health is not simply the absence of a mental disorder. We need a better understanding of the development of mental health, particularly if we are to better understand prevention, remission, and relapse in the context of mental disorders. To date, no measurement tool exists that captures positive mental health for childhood and adolescence, building on a robust theory of positive mental health. Objective: This study develops a questionnaire to assess positive mental health in children and adolescents between 6 and 18 years of age, both in self-report and in external report, and analyzes its quality in a first small sample. Method: Based on established adult scales, we developed a new questionnaire. 83 children and adolescents aged 6 – 18 years (M = 11.89, SD = 3.0; 66 % female) and 77 parents completed the new questionnaire and other questionnaires assessing positive mental health and psychopathology. Results: The questionnaire showed a unidimensional factor structure as well as very good internal consistency and test-retest reliability. High positive correlations with self-efficacy and life satisfaction as well as high negative correlations with anxiety and depression confirmed the very good construct validity, both in child and parent ratings. Discussion and Conclusion: The PMH-Kids provides evidence of excellent psychometric quality in this first evaluation attempt. The questionnaire is comparable to its adult pendant, enabling researchers to assess positive mental health across the lifespan.
Zusammenfassung:Theoretischer Hintergrund: Positive psychische Gesundheit ist nicht nur die Abwesenheit von psychischen Störungen. Ein besseres Verständnis der Entwicklung von psychischer Gesundheit ist notwendig, um Prävention, Remission und Rezidive psychischer Störungen besser zu verstehen. Bislang liegt kein Messinstrument vor, das für das Kindes- und Jugendalter positive psychische Gesundheit erfasst. Fragestellung: Ziel der Studie ist die Entwicklung und erste Überprüfung der Gütekriterien eines Fragebogens zur Erfassung von positiver mentaler Gesundheit bei Kindern und Jugendlichen im Selbst- und Fremdbericht. Methode: Aufbauend auf Skalen aus dem Erwachsenenbereich wurde ein Fragebogen entwickelt. 83 Kinder und Jugendliche im Alter von 6 – 18 Jahren, sowie 77 Eltern füllten den Fragebogen, sowie Fragebögen zu positiver mentaler Gesundheit und Psychopathologie aus. Ergebnisse: Der Fragebogen zeigte eine eindimensionale Faktorenstruktur, sowie eine sehr gute interne Konsistenz und Test-Retest Reliabilität. Korrelationen mit Selbstwirksamkeit und Lebenszufriedenheit, sowie negative Korrelationen mit Angst und Depression zeigen im Eltern- und Kinderrating eine gute Konstruktvalidität. Diskussion und Schlussfolgerung: Die PMH-Kids zeigt in der Evaluation vergleichbare Ergebnisse wie die Erwachsenenversion. Damit kann erstmals positive psychische Gesundheit über die Lebensspanne erfasst werden.
Traditionally, mental health was defined by the absence of psychopathology or the absence of mental disorders (Keyes, 2005). However, the recent rise of positive psychology concepts in clinical psychology has made it clear that the absence of symptoms is not the same as the presence of positive mental health (Keyes & Lopez, 2002). Positive mental health (PMH) is now understood as an independent but correlated concept as important as psychopathology (Keyes & Lopez, 2002; Suldo & Shaffer, 2008) which builds on components of well-being and positive functioning in everyday life. Thus, PMH includes both hedonic (positive affect, life satisfaction) and eudaimonic concepts of well-being (“optimal human functioning and the endeavor to achieve meaningful goals in life,” Waterman, 2007). Following the tripartite model (Keyes, 2007), PMH refers to a conglomerate of emotional, social, and psychological well-being factors (Keyes & Lopez, 2002; Velten et al., 2022). It includes several subconcepts, such as self-efficacy, life satisfaction, self-acceptance, sense of coherence, optimism, and a social network of support (Lamers et al., 2012). Since its introduction, the concept of PMH has proved to be of great value in predicting the effects of prevention, treatment, and remission of mental disorders (Bieda et al., 2017; Brailovskaia et al., 2019; Trumpf et al., 2010).
To effectively measure PMH with a brief, unidimensional person-centered questionnaire as described in the validation study by Lukat and colleagues (2016), Lutz, Heyn, Schmid, Sick & Steinl (1992, unpublished manuscript) developed the Positive Mental Health Scale. The questionnaire comprises 9 items covering a wide range of PMH components and combining internal factors (emotional and psychological well-being) and external factors (social support). The scale has proved to be a valid, reliable instrument to assess PMH in adults, which is sensitive to changes during treatment (Lukat et al., 2016). The scale was originally developed with 14 items (Trumpf, Vriends et al., 2010) and was shortened in the process to its final 9-item version (Lukat et al., 2016). It has been translated into several languages and proven valid in different cultures (Bieda et al., 2017; Velten et al., 2022). During the COVID-19 pandemic, the PMH scale was a useful tool to demonstrate the importance of both PMH and resilience in dealing with this crisis. Brailovskaia and Margraf (2020) found that participants with higher scores in PMH could cushion the negative effects of a lockdown better than participants with lower scores. Unfortunately, we have no comparable results for children and adolescents, although systematic reviews and empirical studies have demonstrated how the pandemic drastically influenced children’s and adolescents’ mental health (Holler et al., 2023; Newlove-Delgado et al., 2021; Panchal et al., 2023; Ravens-Sieberer et al., 2022; for an overview of the German-speaking countries, see Asbrand & Brinkmann, 2022). This research gap might result from a lack of psychometric instruments to measure PMH in children and adolescents. Most existing instruments for children focus on one concept of PMH, such as self-efficacy (e. g., SWE, Schwarzer & Jerusalem, 2003) or life satisfaction (e. g., ILK, Mattejat & Remschmidt, 2006). Further instruments try to measure well-being in combination with psychopathology with only few items (e. g., KIDS-SCREEN-10, Erhart et al., 2009; MHI-5, Rivera-Riquelme et al., 2019).
If we are to conduct further research on PMH in children and adolescents using a more holistic approach and to replicate results from adult research, we need a new instrument that includes broader concepts of well-being while using age-adequate wording. Thus, the Positive Mental Health Scale for Children and Adolescents (PMH-Kids) was developed by adapting the Positive Mental Health Scale (Lukat et al., 2016) for the ages between 6 and 18 years. As multi-informants are preferred when dealing with children and adolescents (e. g., Kraemer et al., 2003), we developed both a self-rating and a caregiver rating. The present study aimed to introduce the adapted version for children and adolescents and present validation data in a sample of healthy controls. We hypothesize that we can replicate both the excellent reliability and the one-dimensional factor structure of the adult version (Lukat et al., 2016). We further expect the PMH-Kids scale to correlate positively with self-efficacy and life satisfaction as well as negatively with anxiety and depression scores, thus confirming the convergent and divergent validity. Additionally, we hypothesize finding a consensus between the caregiver and the child version of the PMH-Kids.
Method
Participants
We advertised the present study through several channels, such as social media, friends, and coworkers. Additionally, we directly contacted the usual gathering points for children and adolescents, such as sports clubs, scouting groups, family education facilities, and music schools in several German cities, and asked them to invite their members to participate. The study was preregistered at AsPredicted (https://aspredicted.org/81G_R9L) and approved by the local Ethics Committee of the faculty of psychology, Ruhr University Bochum. Because of recruitment problems, we had to change the preregistered age range of 8 to 14 years to 6 to 18 years. We do not include a third PMH questionnaire examining positive mental health in the parent role; it will be part of another publication.
Eighty-three children and adolescents completed at least the PMH-Kids. The mean age was m = 11.89 (SD = 3.0, range 6 – 18 years). Twenty-nine (34 %) children were younger than 11 years, 42 (51 %) were 11 – 15 years of age, and 12 (15 %) adolescents were older than 15. Of these, n = 55 were female (n = 28 male). 21.7 % attended an elementary school, and the others attended various secondary schools in the German school system (49.4 % Gymnasium, 9.6 % Realschule, and 10.8 % Gesamtschule).
N = 77 parents completed the PMH-Kids parent questionnaire. Of these, 87 % were mothers (n = 10 fathers). N = 36 children and N = 35 parents completed the second assessment 1 week later.
Design
After parents had given their informed consent, they received two links: one for the parent version of questionnaires and a second link for their children to fill out. The participants generated an individual code to combine the datasets. All questionnaires were processed online. After completing the first version, the participants were asked to be contacted for the second test to measure retest reliability a week later. If they agreed, they were invited to leave their email address at an additional survey to ensure anonymity. Families who had completed all (children and caregiver) questionnaires received a 10 € voucher.
Questionnaires
Development of thePositive Mental Health Scale for Children and Adolescents (PMH-Kids)
The PMH-Kids was developed as a 9-item instrument to assess positive mental health in children and adolescents aged 6 to 18, including self-rating and caregiver-rating versions. Items are rated on a 4-point Likert scale from 0 (do not agree) to 3 (totally agree). Based on the original Positive Mental Health Scale for adults (Lukat et al., 2016), we adapted the original 9 items using age-adequate wording. We changed the wording of some items in detail, whereas we kept others close to the adult version. To check whether children need the age-adequate wording, we added 5 items from the original long version, leading to 14 items.
We included children in the development of the questionnaire from an early stage. Before starting data collection, we showed the 14-item questionnaire to a boy aged 10 and a girl aged 8, who were available because they were participating in other research in the treatment center. We discussed all items regarding accessibility and wording following a semistructured protocol (talking about every single item, asking whether the children had problems understanding specific words, see Electronic Supplement 1). If the children rated individual words or phrases as incomprehensible, we discussed the items in the research team and changed them according to the children’s recommendations.
Data collection started with the 14-item version, during which we added questions asking about the comprehensibility of every single item. We used these to further shorten the questionnaire to 9 items, in accordance with the adult version of the PMH. Table 1 presents the reasons for the removal of 5 items. First, we removed 4 items because the participating children rated them incomprehensible (Table 1). The fifth excluded item was one that had originally belonged to the long form of the adult PMH scale (Lukat et al., 2016), which asked the degree to which the children and adolescents felt as having someone in their life who liked them. However, we excluded it to increase the comparability to the short adult PMH Scale (Lukat et al., 2016) and because factor analysis showed an inferior model fit if the item was included (see table in Electronic Supplement 2).
The 9 final items used in the PMH-Kids were specifically worded for children and adolescents; they were also the item versions rated the most comprehensible by the children and adolescents. The caregiver rating PMH-Kids was based entirely on the newly developed self-rating PMH-Kids, leading to a parallel version for caregivers (Table 2).
Additional Child Ratings
Children’s Life Satisfaction Inventory (ILK, Mattejat & Remschmidt, 2006)
The ILK is a German instrument to assess the quality of life in children and adolescents. It assesses quality of life in six domains: school, family, social contacts, personal interests, physical and mental health, and an overall assessment of quality of life. The questionnaire has proved to be reliable (α = .55–.76). In the present study, internal consistency was α = .88.
General Self-Efficacy Scale (WIRK-ALL, Schwarzer & Jerusalem, 2003)
This German self-efficacy scale is a 10-item questionnaire to assess self-efficacy in children and adolescents on a 4-point Likert scale (not true to always true). The internal consistency of the scale ranges between. α = .79 and α = .90 (Luszczynska et al., 2009). In the current study, internal consistency was α = .92.
Revised Child Anxiety and Depression Scale (RCADS, Chorpita, Moffitt, & Gray, 2005)
The RCADS (Chorpita et al., 2005) is a 47-item self-report questionnaire to assess anxiety and depressive symptoms in children and adolescents on a 4-point Likert scale (never to always). It measures anxiety on five subscales (separation anxiety disorder, social phobia, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder) as well as depression on one subscale. A total anxiety score can be calculated. This study used the German translation of the child-rated version (Grothus et al., 2023), which shows good psychometric properties (Cronbach’s α = .73–.96). Internal consistency in this sample was α = .97 for the anxiety subscale.
Additional Child and Parent Rating
Short Mood and Feelings Questionnaire (SMFQ, Messer et al., 1995) Child and Parent Version
The SMFQ is a short, internationally established self- and parent-rating instrument to assess depressive symptoms in children and adolescents on a 3-point Likert scale (not true, sometimes, true). The 13-item questionnaire has shown excellent reliability (α = .85) and good screening quality (Messer et al., 1995). In the present study, internal consistency was α = .94 for the child and α = .92 for the parent version of the SMFQ.
The Strength and Difficulties Questionnaire (SDQ, Goodman, 2001)
The SDQ is an internationally established screening instrument for psychopathology for children aged 4 to 16 years. It consists of five subscales (emotional symptoms, peer problems, hyperactivity/inattention, conduct problems, and prosocial behavior). Each item is rated on a 3-point Likert scale from not true to certainly true. Two higher-order factors (externalizing symptoms and internalizing symptoms) and a total pathology score can be calculated. The German version showed good reliability (Cronbach’s α = .55–.77; Lohbeck et al., 2015). In the current study, the internal consistency of the internalizing subscale was α = .57, for the externalizing subscale α =.80, and for the prosocial subscale α =.83 for the child version. In the parent version, the internal consistency ranged between α =.72 and α = .85.
Additional Parent Ratings
Spence Child Anxiety Scale (SCAS, Spence, 1998)
The SCAS is an established instrument to measure anxiety in child and parent ratings on a 4-point Likert scale (never to always). The present study used the unpublished but already translated parent version of the SCAS because no German translation of the RCADS parent version was available. The questionnaire consists of 38 anxiety-related items, which measure six domains of anxiety (separation anxiety, social anxiety, obsessive-compulsive disorder, panic/agoraphobia, and generalized anxiety). The present version was adapted by using the German child version (Essau et al., 2002), which showed excellent psychometric properties in its validation (internal consistency Cronbach’s α = .92). In this study, the internal consistency of the parent version was α = .96.
Statistical Analysis
We tested factor structure, reliability, validity, and the association with the parent-rated version. To analyze the hypothesized factor structure, we conducted a confirmatory factor analysis using a unidimensional model in concordance with the adult PMH scale. We conducted another confirmatory factor analysis for the caregiver scale, also testing for a unidimensional model. We used standard SEM fit indices (CFI ≥ .95, TLI ≥ .95, not significant χ² test, RMSEA ≤. 06 and SRMR ≤ .08; see Hu & Bentler, 1999) to check model fit. For reliability analysis, we analyzed Mcdonald’s Omega. To test for convergent and divergent construct validity as well as associations with the parent version, we conducted Pearson correlations with Holm-adjusted p-values. To further analyze parent-child consensus, we drew and interpreted a Bland-Altman plot. We conducted all analyses using R Studio with the packages lavaan (Rossel, 2012), BlandAltmanLeh (Lehnert, 2015), and psych (Revelle, 2019) as well as IBM SPSS Statistics 24 (IBM Corp., 2016).
Results
Factor Structure
Child Version
We conducted a confirmatory factor analysis to analyze whether the PMH-Kids shares the same unidimensional factor structure of the adult version. The results showed an excellent model fit, χ²(27, 83) = 27.78 p = .42, CFI = 1.0, TLI = 1.0, RMSEA = .02, and SRMR =.06.
Parent Version
We also conducted a confirmatory factor analysis for the parallel parent version questionnaire. The results showed an almost acceptable model fit for the one-factor solution, χ²(27, 77) = 63.45 p < .001, CFI = .89, TLI = .86, RMSEA = .13 and SRMR = .07. Respecification using modification indices led to a similar model defining covariances between Item 5 (“child can fulfill its needs”) and Item 6 (“good physical and mental health”), as well as Item 5 (“child can fulfill its needs”) and Item 7 (“child handles challenges typical for its age”). That led to an excellent model fit with χ²(25, 77) = 31.96 p = .16, CFI = .98, TLI = .97, RMSEA = .06 and SRMR = .05.
Reliability and Item Analysis
Child Version
The 9-item, unidimensional questionnaire showed very good internal consistency with McDonald’s ω = .85. All items showed discriminatory power > .30. The analyses of item difficulty showed almost all items in the acceptable range of .35 to .85 (Doran, 1976; Table 1). The analysis of skewness showed all items to be moderately skewed.
Parent Version
The parallel parent version also showed very good internal consistency with McDonald’s ω = .90. All items showed discriminatory power > .30. The analyses of item difficulty showed almost all items in the acceptable range of .35 to .85 (Doran, 1976; Table 2). All items were moderately skewed.
Convergent and Divergent Construct Validity
Child Version
For construct validity, we calculated Pearson correlations between the PMH-Kids and self-efficacy and life satisfaction for convergent validity and depression and anxiety symptoms for divergent validity (Table 3). The PMH-Kids score correlated significantly with self-efficacy (r = .57, p < .001), life satisfaction (r = .77, p < .001), and prosocial behavior (r = .25, p < .05). We found significant negative correlations with depressive symptoms (r = –.73, p < .001) and anxiety symptoms (r = –.71, p < .001), as well as the internalizing scales (r = –.74, p < .001) and the externalizing scales (r = –.41, p < .001) of the SDQ (Goodman et al., 2001).
Parent Version
PMH-Parent scores showed significant correlations with the internal (r = –.68, p < .001), external (r = –.29 , p = .012), and prosocial (r = .45, p <.001) scales of the SDQ (Goodman et al., 2001). Additionally, there were highly significant correlations between the PMH-Parent and the overall score of the SCAS parent version (r = –.59, p < .001) and each individual SCAS score (correlations between r = –.35 and r = –.62, all p < .003). Furthermore, correlations with the parent version of the SMFQ were significant (r = –.69, p < .001).
Retest Reliability and Child-Parent Agreement
Child Version
Pearson correlations between the PMH-Kids’ two different measurement points were significant, r = .85, p < .001, n = 36.
Parent Version
Pearson correlations between the PMH parent version at measurements points 1 and 2 were also highly significant, r = .91, p < .001, n = 35.
Child-Parent-Agreement
The Pearson correlations between PMH-Kids and PMH-Kids-P were significant, r = .41, p = .001. A descriptive comparison of mean scores (PMH-Kids M = 21.08; PMH-Kids-P M = 21.19) showed very similar ratings. We generated a Bland-Altman plot (Figure 1) which plots the relationship between the differences and means: The closer the data points are to 0, the better the agreement. The plot shows that almost all data points are within the acceptable threshold of +/– 2 SDs. Six data points show differences higher than the acceptable threshold. Four data pairs are below the threshold, which means that children rated their positive mental health lower than their parents. Two data pairs are above the threshold, revealing that, in these pairs, children rated their positive mental health higher than their parents did. The higher both parents and children rate positive mental health, the better the agreement. The median of the mean differences between child and parent ratings is 0.
Discussion
The present study introduced the PMH-Kids both as a self-report and caregiver report and described the development of this age-adapted scale. In an initial attempt to evaluate the questionnaire, factor structure and reliability, including retest reliability and validity, proved to be good to excellent for a small sample of 6- to 18-year-old children and adolescents. The PMH-Kids can therefore be used in nonclinical settings.
During the developmental process, we altered the items of the original PMH scale to make it more comprehensible and adequate for children and adolescents. Thus, the PMH Kids now differs slightly from the adult short version but is a comprehensible and adequate instrument for children and adolescents to measure positive mental health.
Factor structure revealed a unidimensional structure for both self-report and caregiver report, making the PMH-Kids brief and easy to interpret. The discriminant validity was moderately high with internal symptoms (depressive symptoms, anxiety symptoms), and moderate with external symptoms. Convergent validity with prosociality was weak but significant for children and moderate for parents. The results indicate a good fit for measuring positive mental health. Internal consistencies, excellent retest reliabilities for the parent report, and good retest-reliabilities for the self-report suggest that the scale is stable over time. Thus, in its first evaluation, the PMH-Kids is comparable to the excellent psychometric properties of the adult version of the PMH Scale (Lukat et al., 2016). Additionally, we examined parent-child agreement. The correlation and the Bland-Altman plot showed acceptable agreement between the two measures. Nonetheless, six data points in the plot lay beyond the acceptable threshold, which is in line with other measures of quality of life (Rajmil et al., 2013), which also shows slight disagreement. Despite the small sample size, the dataset included young children and adolescents and could depict children from many school forms. The present version of the PMH-Kids scales measured only PMH in children and adolescents 6+ years, though PMH may also be a relevant construct for younger children. Future research could therefore also take into account a younger sample. First findings on a newly developed parent-report version of the PMH for children between 3 and 7 years of age by Marks et al. (2023) showed good internal consistency (α = .82).
One clear limitation of the present study was the small sample size. To increase the sample size, we took several actions: repeated announcements in different social media channels, personal phone calls to several institutions hosting youths in different cities, a 10 € voucher for every dyad completing the questionnaires, calls to various schools, and repeated announcements in the authors’ private circles. Nevertheless, many institutions reported very high family stress because of the COVID-19 pandemic (see Asbrand & Brinkmann, 2022). Additionally, many children and adolescents reported being interested in participating but unable to obtain parental consent because of their parents not finding the time. This is supported by the fact that 54 % of parents who started the assessment quit after an average time of 4 minutes. The mean total completion time for adults was 23.5 minutes. So, it is rather probable that the fatigue from participating in online studies during and after the COVID-19 pandemic might be responsible, although online fatigue so far is mostly described in an academic or teaching setting (e. g., Bonanomi et al., 2021). Because of the recruitment problems, we decided to include adolescents up to 18 years. Some German translations of the questionnaires used (e. g., the SDQ) are validated only for children up to 16 years. In contrast, the original questionnaire can also be used in adolescents 16+ (Bøe et al., 2016; Vugteveen et al., 2022), so we decided to keep the data in the set to not further reduce the already small sample size. Nonetheless, the results must be interpreted with caution. Future studies should invite participants to the lab to fill out the questionnaire or find other ways, such as creating outreach concepts to bring research to the daily life of families.
The present study is a first important step toward validation. Further validation should occur in future studies, including a larger convenience sample with different age groups to measure invariance, clinical samples to measure potential differences regarding diagnoses, and sensitivity for change during treatment.
Although the underlying structure of the new PMH-KIDS is comparable to that of the adult version, future studies should explore whether other PMH constructs might be equally important for children and adolescents. As children age, they tend to spend more and more time with peers than with family members, and maintaining positive close relationships with peers is highly important for adolescents (Rutter et al., 1979). However, we had to exclude our proposed item focusing on positive social interactions during this study because of insufficient model fit. Nonetheless, future research should include peer relationships in the analysis of PMH, especially in this age group, in a larger sample.
Nonetheless, the present study already shows very promising first data suggesting the direct implementation of the PMH-Kids in research and clinical application. The PMH-Kids can be used as a brief, unidimensional measure in research, prevention, and therapy to measure and promote positive mental health in children and adolescents. It enables researchers to expand their research on positive mental health towards children and adolescents and to replicate important results from adult research. Positive mental health has been identified as a predictor of academic achievement in elementary schools (O’Connor et al., 2019) and was furthermore associated with indicators of career progression for adolescents of 15 – 16 years of age and taking on citizenship responsibilities over a decade later (O’Connor et al., 2017). The study provides some first indications of the role PMH might have on child, youth, and adult development, though further research is needed to understand and promote PMH even better. The PMH-Kids may be a useful tool to support these undertakings.
In sum, the PMH-Kids demonstrated initial promising results in a small sample. It proved to be a reliable and valid instrument but should be further investigated in larger samples, including clinical subgroups, and tested regarding its sensitivity to therapeutic change. Introducing the PMH-Kids may lead to more research and a larger therapeutic focus on positive mental health in children and adolescents.
Electronic Supplementary Materials
The electronic supplementary material is available with the online version of the article at https://doi.org/10.1026/0942-5403/a000439
We would like to thank all the children, parents, and teachers who supported this research.
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