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Parents need high socioeconomic status to secure an ADHD diagnosis

Half of the children who exhibit typical ADHD behaviour at age seven have still not received the diagnosis that triggers the necessary help ten years later. A new study shows that a diagnosis is least probable for a girl who grows up in a disadvantaged area of rural Denmark with a single mother with low social status.

Overdiagnosis of ADHD in children and young people is a well-described problem, but hidden behind the many stories in the media about 'more and more diagnoses' is a story of inequality about how there may be too few receiving a diagnosis. At the same time, it is the story of a skewed Denmark.

More than half of Danish children who exhibit ADHD behaviour at the age of seven have not been diagnosed with ADHD once they reach the ages of 12 to 17. The potentially underdiagnosed young people share some common traits: they are girls and their mothers are low-skilled, earn less than average or are receiving public benefits – that is to say they have low socio-economic status.

"The probability of being girl and the probability of having low social status are 83 and 49 per cent higher respectively in the group of potentially underdiagnosed children when compared with the diagnosed. This applies even if a child has had well-known, serious symptoms of ADHD at age seven. If you also live in Western Jutland along the coast, then you really face a struggle, because it is here that the municipalities in Denmark with the fewest children with ADHD diagnoses nationally are found. The figures are very clear," says MSc and PhD Kathrine Bang Madsen.

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A diagnosis is needed to get help

Kathrine Bang Madsen is behind the new study that has, as part of her PhD dissertation, thus far resulted in three scientific articles. The latest was recently published in the journal European Child and Adolescent Psychiatry. Kathrine Bang Madsen stresses that it is certainly not the quest for more diagnoses that drives her research.

"But the diagnoses are not unimportant. A diagnosis from a specialist is the admission ticket to help in Denmark. Without a diagnosis, you will not get the often absolutely necessary medicine, and there is no psychoeducation, which is where the child learns the tools to live with his or her illness in everyday life. Neither is there any supportive teaching or parent training," says Kathrine Bang Madsen in her argument that potential underdiagnosis has significance for an already weak group.

Drawn from the birth cohort

The fundamental study result is based on data from the national birth cohort – which many parents know as the recurring questionnaire survey 'Better Health for Generations", in which parents of 51,527 children have answered questions about their child's strengths and difficulties at the age of seven. The parental replies have subsequently been coupled with data from the National Patient Registry, the Danish Psychiatric Central Register and the Register of Medicinal Product Statistics.

The research project was made possible because some of the questions in the parent questionnaire were taken from the internationally recognised 'Strength and Difficulties Questionnaire', which corresponds with strong indications of ADHD. The questions cover many parameters ranging from social and emotional to the child's tendencies towards anxiety and externalising or depressive behaviour. According to Kathrine Bang Madsen, the remarkable thing is that the potentially underdiagnosed group check the boxes on all parameters.

"A critical question could be: How can I postulate an underdiagnosis based on a questionnaire that parents have filled out, and indeed, I cannot do that. A diagnosis requires diagnostics. But all the professionals who have been presented for my data basis – including the assessors of my PhD project – have found it striking that the children have not subsequently appeared in the system with a diagnosis," says Kathrine Bang Madsen.

Fewest from West Jutland and most from North Zealand

In relation to geography, there is no discussion that the recognised disadvantaged area of western Jutland is the place in Denmark where the fewest children and adolescents are diagnosed with ADHD, and according to Kathrine Bang Madsen, there are additional differences which cannot be immediately explained – such as there are many diagnoses in the towns of Sønderborg and Tønder, but virtually none in Esbjerg.

Top scorer for ADHD diagnoses is northern Zealand, where there (generalising a little) are many people from the higher socioeconomic classes, which is also an indicator that parents with high socioeconomic status are required to get a diagnosis for their child.

The research results – more information

  • The study is a follow-up study with the use of cohort and register information.
  • The most important partners are Professor Carsten Obel and Professor Charlotte Ulrikka Rask, both from Aarhus University, as well as Professor Anette Kjær Ersbøl from the University of Southern Denmark.
  • The study is supported by Trygfonden. 
  • Direct links to the scientific articles:

https://www.ncbi.nlm.nih.gov/pubmed/28810815 (published August 2017)
https://www.ncbi.nlm.nih.gov/pubmed/28733915 (published July 2017)
https://www.ncbi.nlm.nih.gov/pubmed/26297014 (published August 2015)


PhD, MSc Kathrine Bang Madsen
Aarhus University, Department of Public Health
Email: kathrine.bang@ph.au.dk
Mobile: (+45) 2383 1745