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Psychiatric Times
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According to research, symptoms of ADHD are more often overlooked or diagnosed later in children with higher cognitive ability, physical activity, or social skills.
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SPECIAL REPORT: CHILD AND ADOLESCENT PSYCHIATRY
Symptoms of attention-deficit/hyperactivity disorder (ADHD) are more often overlooked or diagnosed later in children with higher cognitive ability, physical activity, or social skills, according to findings of a large population cohort study of factors that contribute to diagnosis timing.1
Delayed or missed diagnosis of ADHD was also more likely in youth with fewer behavioral, emotional, peer, and conduct issues. In addition, sex-stratified analysis suggests that the higher prevalence of ADHD in male patients partly reflects sex bias in diagnosis, with higher rates of missed and late diagnoses in female patients.
“Overall, our findings suggest that children may have their ADHD missed, or diagnosed later if they are not particularly disruptive, are more cognitively able, and have better prosocial skills,” said Isabella Barclay, PhD candidate, Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, and colleagues.
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Detecting ADHD Symptoms in an Undiagnosed Cohort
Barclay et al identified a cohort of 9991 individuals (43.69% female) from the Millennium Cohort Study,2 a United Kingdom–based population study that defined clinician-diagnosed ADHD by parent report and the presence of undiagnosed symptoms consistent with ADHD by parent-reported questionnaires.
The investigators compared characteristics of individuals with ADHD who were diagnosed earlier in childhood (5 or 7 years) with those diagnosed later (11 or 14 years), as well as of those who received a diagnosis at any age, compared with those with probable but unrecognized ADHD.
In addition to parent-reported clinician diagnosis, the presence of probable but undiagnosed ADHD symptoms was drawn from the Strengths and Difficulties Questionnaire (SDQ)-hyperactivity subscale, which includes hyperactive-impulsive and inattentive symptoms, completed by parents at the child’s age of 5, 7, 11, and 14 years. An SDQ Impact (Supplement) score of 2 to 10 was considered consistent with experiencing impact from ADHD symptoms.
Children with high SDQ-hyperactivity scores reflecting impact at either age 5 or 7 years were considered to have probable ADHD regardless of whether a clinical diagnosis had been made. Children were considered not to have ADHD if they had no or low symptoms (score < 7) on the SDQ-hyperactivity scale and their parents confirmed an absence of clinician diagnosis at all time points.
Individual characteristics were drawn from a range of parent-reported instruments, including the SDQ for conduct and emotional problems, peer relationships, and prosocial skills, at ages 5 and 7 years. The Child Social and Behavioral Questionnaire, adapted from the Adaptive Social Behavior Inventory, provided a measure of emotional dysregulation at ages 5 and 7 years. Physical activity was gauged from parent report of the number of days per week of involvement with a club, class, sport, or other physical activity. Cognitive ability was drawn from the British Ability Scale measure at age 5 years.
Unrecognized, Undiagnosed, Untreated
Barclay et al report finding children are more likely to receive an earlier diagnosis if they experience more emotional and behavioral difficulties, greater emotional dysregulation, lower cognitive ability, and poorer prosocial skills. They also cite previous studies that suggest that the impact of difficulties on others around the child, as well as comorbidity, predict referral to specialist services.
“Indeed, in our study, the final comparison comparing recognized ADHD to unrecognized ADHD with higher reported levels of impact, the only differing factor was an increased likelihood of an autism diagnosis in the recognized group,” Barclay and colleagues reported.
“Evidently, children with symptoms and impact might benefit from an ADHD assessment, and this finding suggests that the burden of multiple difficulties may increase likelihood of contact with specialist services,” they said.
The investigators found the ratio of unrecognized ADHD to be higher in female patients in both the earlier (4.2:1) and later (3.7:1) recognized groups compared with the unrecognized group (1.6:1). The only factor indicating a sex difference was emotional dysregulation, with male patients with an ADHD diagnosis more likely to have a higher score of emotional dysregulation than male patients with unrecognized ADHD, but without that difference in female patients.
“Emotional dysregulation is gaining recognition as a key aspect of ADHD symptomatology, despite not being included in diagnostic criteria,” the investigators observed. “If included in the criteria, females may be more likely to be recognized, as post hoc analysis revealed that females with both recognized and unrecognized ADHD were more likely to have higher levels of emotional dysregulation than females with no ADHD.”
Undiagnosed ADHD is untreated ADHD, the investigators emphasize, and is likely to undermine development, particularly in the academic and social domains. “This highlights the need to assess for the possibility of ADHD, regardless of academic and social abilities, if children are displaying symptoms, especially if they also have functional impact,” said Barclay et al.
Dr Bender reports on medical innovations and advances in practice and edits presentations for news and professional education publications. He previously taught and mentored pharmacy and medical students, and he provided and managed pharmacy care and drug information services.
References
1. Barclay I, Sayal K, Ford T, et al. Investigating the reasons behind a later or missed diagnosis of attention-deficit/hyperactivity disorder in young people: a population cohort study. JCPP Advances. 2024:e12301.
2. Joshi H, Fitzsimons E. The Millennium Cohort Study: the making of a multi-purpose resource for social science and policy. Longit Life Course Stud. 2016;7(4).
