The influence of factors at the structural, community, family and child level

During the past decade, there has been an increasing focus on under-identification of children with mental health problems. Studies have shown that only about 20-25% of children with mental health problems are in contact with specialist mental health services and barriers at different levels have been identified. Despite that Attention Deficit Hyperactivity Disorder (ADHD) is the most commonly diagnosed child psychiatric disorder, under-diagnosis and under-identification still exist. Among other, this is reflected in the large geographical variation in the prevalence of ADHD diagnoses both between and within countries (http://mindhood.au.dk/research/understanding-mental-health/geographic-variation-in-the-prevalence-of-adhd/). When these large variations are considered it becomes evident that factors besides the child’s ADHD symptoms may be important for the identification and assessment of the child.

In the model, inspired by Dahlgren and Whitehead’s model of the main determinants of health, factors that influence the pathway to an ADHD diagnosis are presented. In the model, each level interplays with the other levels, and the factors are interdependent. The mechanisms involved in the pathway to an ADHD diagnosis are probably complex and diverse. The structural level constitutes the overall frame and administrative level and includes factors such as availability of diagnostic services and treatment. In our studies we found that the incidence of ADHD was higher in densely populated areas with greater diagnostic resources available and conversely, that the incidence of ADHD was lower in less populated areas with lesser resources available. The next layer in the model represents the social and community networks; these constitute the influence of school, primary healthcare for children and neighbourhood on the identification of children with ADHD. Finally, the family and child level is represented in the model in which different characteristics of both the parents and the child may influence the help-seeking behaviour of the family. Our studies suggest that place of residence, maternal socioeconomic status and mental health, child gender and symptoms are all factors that might affect the probability of a child being referred for diagnostic assessment and receiving an ADHD diagnosis.

Figure 1. Model of influential of factors at different levels for a child receiving an ADHD diagnosis (figure adapted from Dahlgren and Whitehead: Dahlgren, G. and M. Whitehead, Policies and strategies to promote social equity in health, 1991, Institute for Future Studies: Stockholm)

This project was part of a PhD dissertation finalized in June 2017 (defense is expected in September 2017)