Approximately 15% of adolescents experience a mental health disorder, accounting for a significant proportion of the global burden of illness. Moreover, the rates of diagnosed mental and behavioural disorders in adolescents have risen significantly over recent years. The prevalence of poor mental health in Pacific Island populations remains poorly defined, particularly during the period of adolescence which represents a sensitive period for the development of mental health disorders. In the present study, a survey of mental health in adolescents in the Cook Islands was undertaken using the Strengths and Difficulties Questionnaire (SDQ). Fifty-seven adolescents (aged 13-14 years) representing three schools across the Cook Islands completed the self-report SDQ. A large proportion of students presented with total SDQ scores that well exceeded those mapped against the expected band prevalence with 38% of adolescents having total difficulties scores in the High-Very High category versus an expected banding for these categories at 10%. This study has highlighted a current significant mental health burden in Cook Island adolescents and identified an urgent need to develop scaffolded resources to support these students, their families, the schools and wider community.