Girls from multilingual and immigrant families could be missing out on ADHD support - according to new research from the University of East Anglia.

ADHD is already known to be under-recognised in girls, whose symptoms are often less externally visible than those seen in boys.

But a major new study suggests that language and cultural factors could further delay diagnosis, causing girls to miss out on vital support during some of the most important years of their education.

The study involved more than 70,000 children in Norway from a large population-based cohort study.

But the team say their findings raise important questions for the UK – where around 5.1 million people in England and Wales speak a main language other than English.

A growing issue for the UK

Dr Maria Garraffa, from UEA's School of Health Sciences, said: “ADHD represents a substantial demand on UK health services, with an estimated 741,000 children and young people aged between five and 24 living with ADHD in England alone.

“But many children still go undiagnosed which can lead to struggles at school, poor mental health and problems with relationships.

“When children don’t receive a timely diagnosis, they miss out on targeted support, guidance, and treatment that can help them manage their symptoms.

“We wanted to better understand which children might be slipping through the net, particularly focusing on children from multi-lingual and immigrant families.

“We studied children in Norway and found that girls whose mothers spoke a language other than Norwegian were diagnosed with ADHD significantly later than other girls.

“This raises concerns that language, cultural and immigration-related factors may be creating barriers to timely diagnosis.

“Our work highlights the need to investigate whether similar inequalities exist in Britain, particularly among girls from culturally and linguistically diverse families.”

How the research happened

The study was led by Dr Köder at the University of Oslo in collaboration with UEA. The team analysed data from 70,102 children and linked parental reports of attention difficulties with official ADHD diagnoses recorded in Norway's healthcare system.

Dr Garraffa said: “We found that multilingual children were more likely to be rated by parents as having more attention difficulties than monolingual children. However, they were no more likely to receive an ADHD diagnosis.

“We then went on to look at the timing of diagnoses and found that girls whose mothers spoke a language other than Norwegian were diagnosed almost two-and-a-half years later than girls with Norwegian-speaking parents.

“Among families where the mother had a non-Norwegian language background, the gap between boys and girls stretched to almost five years,” she added.

Multiple barriers for ADHD girls

The findings suggest that some girls may face multiple barriers to having their symptoms recognised and assessed, potentially delaying access to treatment and support.

The team also found that some children from immigrant backgrounds were potentially being underdiagnosed - with ADHD diagnosis rates significantly lower among children whose mothers came from parts of North Africa, the Middle East, Southeast Asia, East Asia and Oceania than among children with Norwegian-born mothers.

“Our work doesn’t explain exactly why these disparities exist,” said Dr Garraffa. “But we believe that a combination of cultural, linguistic and healthcare-system factors may be involved.

“Some parents may be less familiar with ADHD or less likely to seek help because of concerns about stigma. Others may encounter difficulties navigating healthcare services or communicating concerns through language barriers.”

The researchers also suggest that commonly used assessment questionnaires may not work equally well across different cultural and linguistic groups. And they say that the implications are likely to extend beyond Norway.

Devastating consequences

Dr Garraffa said: “Although healthcare systems differ between countries, our work highlights a potential inequality that deserves closer examination in nations with increasingly diverse populations, including the UK.

“I would like to see more culturally sensitive assessment approaches to ensure that children from multilingual and immigrant families are not disadvantaged when seeking support for ADHD.

“Delayed diagnosis can have lasting consequences, affecting children's education, wellbeing and future opportunities long after symptoms first appear.”

This study was funded by the Research Council of Norway, as part of the AttCom project (the role of attention in communication) for which Dr Köder at the University of Oslo is the Principal Investigator.

‘The Impact of Multilingualism and Immigration Background on Attention Difficulties and ADHD Diagnoses: Findings from a Large Cohort Study in Norway’ is published in the Journal of Attention Disorders.