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Difficulties with emotions, concentration, or behavior, past 6 months

Codes and Frequencies

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For sample children age 4 to 17, EMODIFF reports parents' responses to the question, "Overall, do you think that [child] has difficulties in any of the following areas: emotions, concentration, behavior, or being able to get along with other people?" Interviewers handed respondents a flashcard and asked them to select the appropriate response from the following choices: "No," "Yes, minor difficulties," "Yes, definite difficulties," "Yes, severe difficulties."

Use of EMODIFF with Other Variables 

The EMODIFF question was asked following a series of either 25 questions (for 2001 and 2003-2004, and 2019 forward) or 5 questions (for 2002, 2005-2007, and 2010-2018) designed to measure the child's difficulties in topic areas covering emotional symptoms, hyperactive behavior, conduct problems, and peer relationships. For these prior questions, the reference period was explicitly defined as the past 6 months. While the question wording for EMODIFF did not specify a time period, the Field Representative's Manuals for 2001 and 2003 forward stated, "If parents ask for the time period for this question, tell them it is also for the past six months." For 2010, in addition to EMODIFF, there is a separate question about children's mental health that specifically asks a yes or no question about whether the sample child had difficulties with emotions, concentration, behavior, or getting along with others during the past 6 months (EMODIFFYN).

As discussed in more detail below, EMODIFF was part of the Strengths and Difficulties Questionnaire Extended (SDQ-EX) which, according to the 2001 and 2003-2004 Manuals, was included "to monitor emotional and behavioral problems in children and the impact that these problems have on children's lives." More specifically, in these years, EMODIFF began a section of the SDQ-EX which the NHIS Survey Descriptions describe as "extended questions that provide information on the duration of a child's problem and the impact that problem has on the child and his/her family."

EMODIFF was also one of the six items comprising the brief version of the Strengths and Difficulties Questionnaire, which was included in the NHIS in 2002, 2005-2007, and 2010-2018. The purpose of the brief questionnaire was the same as for the extended questionnaire: "to monitor emotional and behavioral problems in children and the impact that these problems have on children's lives."

From 2008-2009, only the question for the variable EMODIFF was included in the Child Mental Health Brief Questionnaire section of the survey. The Field Representative's Manual for 2008 noted that all other SDQ questions were removed from the NHIS because of lack of funding.

Strengths and Difficulties Questionnaire Extended

EMODIFF is part of a set of 33 questions from the Strengths and Difficulties Questionnaire Extended (SDQ-EX) developed by Dr. Robert Goodman, Institute of Psychiatry, London, England.


As the Appendix on SDQ in the 2001 and 2003-2004 Codebook of the NHIS public use files explains:

The parent respondent version of the SDQ was added as a mental health supplement for children ages 4-17 as part of a collaborative agreement between NCHS and the National Institute of Mental Health (NIMH). The first part of the SDQ consists of 25 scale items... These items can be divided into five subscales measuring the following psychological attributes or dimensions:
  • emotional symptoms;
  • conduct problems;
  • hyperactive behavior;
  • peer relationships;
  • prosocial behavior.

EMODIFF was an element in the second part of the SDQ, which the same source describes as follows:

The second part of the SDQ, the extended questions...obtains additional information about the duration and impact of symptoms, which can be useful for determining psychiatric caseness.

More information on the SDQ-EX is available at This source describes the section of the SDQ-EX beginning with EMODIFF as the "Impact Supplement."

Calculating a Score for the SDQ-EX Impact Supplement

In the 2001 and 2003-2004 NHIS, if parents' response to EMODIFF was either "yes, minor difficulties," or "yes, definite difficulties," or "yes, severe difficulties," interviewers asked, "How long have these difficulties been present?" (DIFMOS). If the reported duration of these difficulties was one month or longer, interviewers asked further follow-up questions on how the difficulties had affected the child's life.


These follow-up questions were the basis of the following variables:

  • Difficulties upset or distress child (DIFUPSET)
  • Child's difficulties interfere with home life (DIFHOME)
  • Child's difficulties interfere with friendships (DIFFRIEND)
  • Child's difficulties interfere with classroom learning (DIFLEARN)
  • Child's difficulties interfere with leisure activities (DIFLEISURE)
DIFUPSET was based on the question, "Do the difficulties upset or distress your child?" The remaining four variables were based on query, "Do the difficulties interfere with your child's everyday life in the following areas: Home life? Friendships? Classroom learning? Leisure activities?"

The Scoring Guide at the website provides guidance on how responses for these five variables "can be summed to generate an impact score that ranges from 0 to 10 for the parent-completed version." Under these guidelines, the responses "not at all" and "a little" are given a score of 0; a response of "a medium amount" is given a score of 1; and a response of "a great deal" is given a score of 2. For each of these variables, a score of 0 implies the least impact from the child's difficulty, and a score of 2 implies the greatest impact from the child's difficulty. If the scores for these five variables are summed, the total ranges from 0 to 10, with 0 implying the least impact from the child's difficulties and 10 implying the greatest impact from the child's difficulties.

If parents responded "no" to the opening question about whether the child had difficulties with emotions, concentration, behavior, or getting along with others (EMODIFF), none of these five questions were asked. In such cases, when parents "are not asked to complete the questions on resultant distress or impairment," the Scoring Guide states, "the impact score is automatically scored zero." The same is true when parents reported difficulty in these areas that lasted less than 1 month (and thereby avoided these follow-up questions on "resultant distress or impairment").

The five variables that can be summed to create a total "impact score" receive codes in IPUMS NHIS that facilitate this scoring process. Responses that should receive a score of 0 in the scoring process--namely, "not at all" or "a little"--receive a code of 0 in the first digit. In addition, sample children with no reported difficulties (in EMODIFF) or with no difficulties lasting one month or longer (in DIFMOS) also receive a code of 0 in the first digit in these five variables. (The three different categories, "No difficulty for greater than or equal to 1 month," "not at all," and "a little" can still be distinguished from each other by the respective values of 0, 1, and 2 in the second digit.) The response "a medium amount," which should receive a score of 1, receives a code of 1 in the first digit (and a code of 0 in the second digit). The response "a great deal," which should receive a score of 2, receives a code of 2 in the first digit (and a code of 0 in the second digit). Cases which should be excluded from this summing of scores--that is, not in universe cases consisting of persons other than sample children age 4-17, and cases with a response of "unknown"--all receive a code of 9 in the first digit (with the second digit distinguishing between those not in the variable universe and unknowns.)

Put succinctly, to calculate an "impact score" for the child's difficulties, researchers should 1) exclude cases beginning with a code of 9; 2) group together other categories that share a common first digit; 3) sum the scores across the five variables, using only the first digit of the codes for each variable. The result will range from 0 to 10.

The Scoring Guide at provides the following guideline for interpreting these results:

Although the impact scores can be used as continuous variables, it is sometimes convenient to classify them as normal, borderline, or abnormal: a total impact score of 2 or more is abnormal; a score of 1 is borderline; and a score of 0 is normal.

Individual Elements of the SDQ-EX Impact Supplement


Some researchers may prefer to use only some of the "impact" variables (DIFUPSET, DIFHOME, DIFFRIEND, DIFLEARN, and DIFLEISURE) discussed in the previous section, or to avoid combining their values in a single "impact score." The same is true for EMODIFF (which reports whether the child had difficulties with emotions, concentration, behavior, or getting along with others) and DIFMOS (which reports the duration of such difficulties, if present). DIFBURDEN (which reports parents' answers to the question, "Do the difficulties put a burden on you or the family as a whole?") focuses on the effect of difficulties on family members other than the child. DIFBURDEN is thus excluded from the calculation of an "impact score" for the child, described in the previous section.

In the abbreviated version of the SDQ, which was part of the NHIS in 2002, 2005-2007, and 2010-2018. EMODIFF was the only element of the "impact supplement" from the SDQ-EX included in the survey. For 2008 forward, EMODIFF is the only element of the SDQ questionnaire included in the National Health Interview Survey.


In terms of universe, question wording, and codes, this variable is completely comparable over time with the exception of the NHIS questionnaire redesign introduced in 2019. However, responses to the question may have been shaped by the series of questions preceding EMODIFF in the survey. In the 2001, 2003, 2004, and 2019 forward surveys, which included the extended version of the SDQ, EMODIFF was preceded by 25 questions dealing with specific problems related to emotions, concentration, conduct, and peer relationships. In the surveys for 2002, 2005-2007, and 2010-2018, which included an abbreviated version of the SDQ, EMODIFF was preceded by just 5 such specific questions. In 2008-2009 forward, EMODIFF was the only question on the child's emotional and behavioral problems taken from the SDQ. Researchers should thus exercise caution in comparing results across these three periods.

The NHIS questionnaire was substantially redesigned in 2019 to introduce a different data collection structure and new content. For more information on changes in terminology, universes, and data collection methods beginning in 2019, please see the user note.


  • 2001-2018: Sample children age 4 to 17.
  • 2019 2022: Sample children age 4 to 17.


  • 2001-2019, 2022