What Differentiates Children with ADHD Symptoms Who Do and Do Not Receive a Formal Diagnosis? Results from a Prospective Longitudinal Cohort Study


ADHD diagnoses are increasing worldwide, in patterns involving both overdiagnosis of some groups and underdiagnosis of others. The current study uses data from a national longitudinal study of Irish children (N = 8568) to examine the sociodemographic, clinical and psychological variables that differentiate children with high hyperactivity/inattention symptoms, who had and had not received a diagnosis of ADHD. Analysis identified no significant differences in the demographic characteristics or socio-emotional wellbeing of 9-year-olds with hyperactivity/inattention who had and who had not received a diagnosis of ADHD. However, by age 13, those who had held a diagnosis at 9 years showed more emotional and peer relationship problems, worse prosocial behaviour, and poorer self-concept. Further research is required to clarify the developmental pathways responsible for these effects.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 99

This is the net price. Taxes to be calculated in checkout.


  1. 1.

    Such a scenario may also occur in research contexts in double-blinded clinical trials, which further confounds the extent to which research on treatment outcomes can be generalised to draw conclusions about the outcomes of ADHD diagnosis.

  2. 2.

    Johnson et al.’s [49] study of children born preterm found that the more conservative procedure of requiring above-threshold scores in both (rather than either) teacher and parent reports reduced positive ADHD screens in a sample of from 34.2 to 9.6%. Similarly for this study, requiring a score of ≥ 9 in both teacher and parent SDQ reports would have reduced the sample of Undiagnosed ADHD to 81 (.9%) children. This would likely represent an overly conservative estimate of undiagnosed ADHD, given that the accepted prevalence of ADHD in the population is 5% [4] and the rate of existing clinical diagnosis in this sample was .8%.

  3. 3.

    They were not added to the Diagnosed ADHD group due to ambiguities caused by a change in question wording in GUI Wave 2, which queried the presence of “Emotional or behavioural disorders (e.g. ADHD/ADD)” instead of ADHD alone. This wording makes it impossible to establish whether these children held an ADHD diagnosis or another emotional or behavioural diagnosis. To preserve the clarity of the analysis, these ambiguous cases were dropped from any analysis involving Wave 2 data.

  4. 4.

    Unfortunately, since questions about medication were not asked of parents who did not report a mental health condition or disability, equivalent information is not available for the Undiagnosed ADHD group.

  5. 5.

    GUI did not ask those without a diagnosis whether their child was taking psychotropic medication, so it is not possible to determine whether some undiagnosed children were nevertheless undergoing pharmaceutical intervention. The lack of this data for the undiagnosed group also means it was not possible to include pharmaceutical treatment as a covariate in the analysis.


  1. 1.

    Schneider H, Eisenberg D (2006) Who receives a diagnosis of attention-deficit/hyperactivity disorder in the United States elementary school population? Pediatrics 117:e601–e609.

  2. 2.

    Taylor E (2017) Attention deficit hyperactivity disorder: overdiagnosed or diagnoses missed? Arch Dis Child 102:376–379.

  3. 3.

    Visser SN, Danielson ML, Bitsko RH et al (2014) Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011. J Am Acad Child Adolesc Psychiatry 53:34–46.e2.

  4. 4.

    Polanczyk GV, Willcutt EG, Salum GA et al (2014) ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis. Int J Epidemiol.

  5. 5.

    Ginsberg Y, Quintero J, Anand E et al (2014) Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature. Prim Care Companion CNS Disord.

  6. 6.

    Hamed AM, Kauer AJ, Stevens HE (2015) Why the diagnosis of attention deficit hyperactivity disorder matters. Front Psychiatry.

  7. 7.

    Sayal K, Prasad V, Daley D et al (2018) ADHD in children and young people: prevalence, care pathways, and service provision. Lancet Psychiatry 5:175–186.

  8. 8.

    Batstra L, Frances A (2012) Holding the line against diagnostic inflation in psychiatry. PPS 81:5–10.

  9. 9.

    Thomas R, Mitchell GK, Batstra L (2013) Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ 347:f6172.

  10. 10.

    Akinbami LJ, Liu X, Pastor PN, Reuben CA (2011) Attention deficit hyperactivity disorder among children aged 5–17 years in the United States, 1998–2009. National Center for Health Statistics, Hyattsville, MD

  11. 11.

    Boyle CA, Boulet S, Schieve LA et al (2011) Trends in the prevalence of developmental disabilities in US children, 1997-2008. Pediatrics 127:1034–1042.

  12. 12.

    Danielson ML, Bitsko RH, Ghandour RM et al (2018) Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. J Clin Child Adolesc Psychol 47:199–212.

  13. 13.

    Conrad P, Bergey MR (2014) The impending globalization of ADHD: notes on the expansion and growth of a medicalized disorder. Soc Sci Med 122:31–43.

  14. 14.

    Scheffler RM, Hinshaw SP, Modrek S, Levine P (2007) The global market for ADHD medications. Health Aff (Millwood) 26:450–457.

  15. 15.

    Bruchmüller K, Margraf J, Schneider S (2012) Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis. J Consult Clin Psychol 80:128–138.

  16. 16.

    Quinn PO, Madhoo M (2014) A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. Prim Care Companion CNS Disord.

  17. 17.

    Chen M-H, Lan W-H, Bai Y-M et al (2016) Influence of relative age on diagnosis and treatment of attention-deficit hyperactivity disorder in Taiwanese children. J Pediatr 172:162–167.e1.

  18. 18.

    Elder TE (2010) The importance of relative standards in ADHD diagnoses: evidence based on exact birth dates. J Health Econ 29:641–656.

  19. 19.

    Evans WN, Morrill MS, Parente ST (2010) Measuring inappropriate medical diagnosis and treatment in survey data: the case of ADHD among school-age children. J Health Econ 29:657–673.

  20. 20.

    Halldner L, Tillander A, Lundholm C et al (2014) Relative immaturity and ADHD: findings from nationwide registers, parent- and self-reports. J Child Psychol Psychiatry 55:897–904.

  21. 21.

    Hoshen MB, Benis A, Keyes KM, Zoëga H (2016) Stimulant use for ADHD and relative age in class among children in Israel. Pharmacoepidemiol Drug Saf 25:652–660.

  22. 22.

    Morrow RL, Garland EJ, Wright JM et al (2012) Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children. CMAJ 184:755–762.

  23. 23.

    Sayal K, Chudal R, Hinkka-Yli-Salomäki S et al (2017) Relative age within the school year and diagnosis of attention-deficit hyperactivity disorder: a nationwide population-based study. The Lancet Psychiatry 4:868–875.

  24. 24.

    Whitely M, Lester L, Phillimore J, Robinson S (2017) Influence of birth month on the probability of Western Australian children being treated for ADHD. Med J Aust 206:85.

  25. 25.

    Zoëga H, Valdimarsdóttir UA, Hernández-Díaz S (2012) Age, academic performance, and stimulant prescribing for ADHD: a nationwide cohort study. Pediatrics 130:1012–1018.

  26. 26.

    Health Service Exeecutive (2014) Fifth annual child & adolescent mental health service report. Health Service Exeecutive, Dublin

  27. 27.

    Adamis D, Tatlow-Golden M, Gavin B, McNicholas F (2018) General practitioners’ (GP) attitudes and knowledge about attention deficit hyperactivity disorder (ADHD) in Ireland. Ir J Med Sci.

  28. 28.

    O’Connor C, Kadianaki I, Maunder K, McNicholas F (2018) How does psychiatric diagnosis affect young people’s sense of self and social identity? A systematic review and synthesis of the qualitative literature. Soc Sci Med 212:94–119.

  29. 29.

    Cheung KKW, Wong ICK, Ip P et al (2015) Experiences of adolescents and young adults with ADHD in Hong Kong: treatment services and clinical management. BMC Psychiatry.

  30. 30.

    Cooper P, Shea T (1998) Pupils’ perceptions of AD/HD. Emot Behav Diffic 3:36–48.

  31. 31.

    Honkasilta J, Vehmas S, Vehkakoski T (2016) Self-pathologizing, self-condemning, self-liberating: youths’ accounts of their ADHD-related behavior. Soc Sci Med 150:248–255.

  32. 32.

    Kendall J, Hatton D, Beckett A, Leo M (2003) Children’s accounts of attention-deficit/hyperactivity disorder. Adv Nurs Sci 26:114–130

  33. 33.

    Singh I (2011) A disorder of anger and aggression: children’s perspectives on attention deficit/hyperactivity disorder in the UK. Soc Sci Med 73:889–896.

  34. 34.

    Travell C, Visser J (2006) ‘ADHD does bad stuff to you’: young people’s and parents’ experiences and perceptions of attention deficit hyperactivity disorder (ADHD). Emot Behav Diffic 11:205–216.

  35. 35.

    Krueger M, Kendall J (2001) Descriptions of self: an exploratory study of adolescents with ADHD. J Child Adolesc Psychiatr Nurs 14:61–72.

  36. 36.

    Hallberg U, Klingberg G, Setsaa W, Moller A (2010) Hiding parts of one’s self from others—a grounded theory study on teenagers diagnosed with ADHD. Scand J Disabil Res 12:211–220.

  37. 37.

    MTA Cooperative Group (2004) National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: changes in effectiveness and growth after the end of treatment. Pediatrics 113:762–769

  38. 38.

    Shaw M, Hodgkins P, Caci H et al (2012) A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment. BMC Med 10:99.

  39. 39.

    Storebø OJ, Ramstad E, Krogh HB et al (2015) Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). Cochrane Database Syst Rev.

  40. 40.

    Sonuga-Barke EJS, Brandeis D, Cortese S et al (2013) Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatry 170:275–289.

  41. 41.

    Zwi M, Jones H, Thorgaard C et al (2011) Parent training interventions for attention deficit hyperactivity disorder (ADHD) in children aged 5 to 18 years. Cochrane Database Syst Rev.

  42. 42.

    Arnold LE, Hodgkins P, Caci H et al (2015) Effect of treatment modality on long-term outcomes in attention-deficit/hyperactivity disorder: a systematic review. PLoS ONE 10:e0116407.

  43. 43.

    Harpin V, Mazzone L, Raynaud JP et al (2016) Long-term outcomes of ADHD: a systematic review of self-esteem and social function. J Atten Disord 20:295–305.

  44. 44.

    Fischer M, Barkley RA, Fletcher KE, Smallish L (1993) The adolescent outcome of hyperactive children: predictors of psychiatric, academic, social, and emotional adjustment. J Am Acad Child Adolesc Psychiatry 32:324–332.

  45. 45.

    Sayal K, Goodman R, Ford T (2006) Barriers to the identification of children with attention deficit/hyperactivity disorder. J Child Psychol Psychiatry 47:744–750.

  46. 46.

    Rey JM, Sawyer MG (2003) Are psychostimulant drugs being used appropriately to treat child and adolescent disorders? Br J Psychiatry 182:284–286.

  47. 47.

    Able SL, Johnston JA, Adler LA, Swindle RW (2007) Functional and psychosocial impairment in adults with undiagnosed ADHD. Psychol Med 37:97–107.

  48. 48.

    Thornton M, Williams J, McCrory C et al (2016) Growing up in Ireland National Longitudinal Study of children: design, instrumentation and procedures for the child cohort at wave two (13 years). Department of Children and Youth Affairs, Dublin

  49. 49.

    Johnson S, Hollis C, Marlow N et al (2014) Screening for childhood mental health disorders using the strengths and difficulties questionnaire: the validity of multi-informant reports. Dev Med Child Neurol 56:453–459.

  50. 50.

    Goodman R, Ford T, Simmons H et al (2000) Using the strengths and difficulties questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. Br J Psychiatry 177:534–539

  51. 51.

    Goodman R, Renfrew D, Mullick M (2000) Predicting type of psychiatric disorder from strengths and difficulties questionnaire (SDQ) scores in child mental health clinics in London and Dhaka. Eur Child Adolesc Psychiatry 9:129–134.

  52. 52.

    Russell G, Rodgers LR, Ford T (2013) The strengths and difficulties questionnaire as a predictor of parent-reported diagnosis of autism spectrum disorder and attention deficit hyperactivity disorder. PLoS ONE 8:e80247.

  53. 53.

    van Dulmen MHM, Egeland B (2011) Analyzing multiple informant data on child and adolescent behavior problems: predictive validity and comparison of aggregation procedures. Int J Behav Dev 35:84–92.

  54. 54.

    Silva TBF, Osório FL, Loureiro SR (2015) SDQ: discriminative validity and diagnostic potential. Front Psychol.

  55. 55.

    Faul F, Erdfelder E, Lang A-G, Buchner A (2007) G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39:175–191

  56. 56.

    Goodman R (1997) The strengths and difficulties questionnaire: a research note. J Child Psychol Psychiatry 38:581–586.

  57. 57.

    Piers EV, Herzberg DS (2007) Piers-Harris children’s self-concept scale–manual, 2nd edn. Western Psychological Services, Los Angeles, CA

  58. 58.

    Angold A, Costello EJ, Messer SC, Pickles A (1995) Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. Int J Methods Psychiatr Res 5:237–249

  59. 59.

    Batzle CS, Weyandt LL, Janusis GM, DeVietti TL (2010) Potential impact of ADHD with stimulant medication label on teacher expectations. J Atten Disord 14:157–166.

  60. 60.

    Canu WH, Newman ML, Morrow TL, Pope DLW (2008) Social appraisal of adult ADHD stigma and influences of the beholder’s big five personality traits. J Atten Disord 11:700–710.

  61. 61.

    Chew BL, Jensen SA, Rosén LA (2009) College students’ attitudes toward their ADHD peers. J Atten Disord 13:271–276.

  62. 62.

    Harris MJ, Milich R, Corbitt EM et al (1992) Self-fulfilling effects of stigmatizing information on children’s social interactions. J Pers Soc Psychol 63:41–50.

  63. 63.

    O’Driscoll C, Heary C, Hennessy E, McKeague L (2012) Explicit and implicit stigma towards peers with mental health problems in childhood and adolescence. J Child Psychol Psychiatry 53:1054–1062.

  64. 64.

    Ohan JL, Visser TAW, Moss RG, Allen NB (2013) Parents’ stigmatizing attitudes toward psychiatric labels for ADHD and depression. Psychiatr Serv 64:1270–1273.

  65. 65.

    Walker JS, Coleman D, Lee J et al (2008) Children’s stigmatization of childhood depression and ADHD: magnitude and demographic variation in a national sample. J Am Acad Child Adolesc Psychiatry 47:912–920.

  66. 66.

    Ohan JL, Visser TAW, Strain MC, Allen L (2011) Teachers’ and education students’ perceptions of and reactions to children with and without the diagnostic label “ADHD”. J Sch Psychol 49:81–105.

  67. 67.

    Ford T, Goodman R, Meltzer H (2003) The British child and adolescent mental health survey 1999: the prevalence of DSM-IV disorders. J Am Acad Child Adolesc Psychiatry 42:1203–1211.

  68. 68.

    Kvist AP, Nielsen HS, Simonsen M (2013) The importance of children’s ADHD for parents’ relationship stability and labor supply. Soc Sci Med 88:30–38.

  69. 69.

    Meltzer H, Gatward R, Goodman R, Ford T (2000) Mental health of children and adolescents in Great Britain. The Stationery Office, London

  70. 70.

    Bagwell CL, Molina BSG, Pelham WE, Hoza B (2001) Attention-deficit hyperactivity disorder and problems in peer relations: predictions from childhood to adolescence. J Am Acad Child Adolesc Psychiatry 40:1285–1292.

  71. 71.

    Barkley RA, Fischer M, Smallish L, Fletcher K (2006) Young adult outcome of hyperactive children: adaptive functioning in major life activities. J Am Acad Child Adolesc Psychiatry 45:192–202.

  72. 72.

    Young S, Chadwick O, Heptinstall E et al (2005) The adolescent outcome of hyperactive girls. Eur Child Adolesc Psychiatry 14:245–253.

  73. 73.

    Mikami AY, Hinshaw SP, Lee SS, Mullin BC (2008) Relationships between social information processing and aggression among adolescent girls with and without ADHD. J Youth Adolesc 37:761–771.

  74. 74.

    Mehta N, Clement S, Marcus E et al (2015) Evidence for effective interventions to reduce mental health-related stigma and discrimination in the medium and long term: systematic review. Br J Psychiatry 207:377–384.

  75. 75.

    Thornicroft G, Mehta N, Clement S et al (2016) Evidence for effective interventions to reduce mental-health-related stigma and discrimination. Lancet 387:123–1132

Download references

Author information

Correspondence to Cliodhna O’Connor.

Ethics declarations

Conflicts of interest

The authors declare that they have no conflicts of interest.

Ethical Approval

The GUI study was conducted in accordance with the 1964 Helsinki Declaration and its later amendments and received ethical approval from the Irish Health Research Board’s Research Ethics Committee. Informed consent was obtained from all participants.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

O’Connor, C., McNicholas, F. What Differentiates Children with ADHD Symptoms Who Do and Do Not Receive a Formal Diagnosis? Results from a Prospective Longitudinal Cohort Study. Child Psychiatry Hum Dev 51, 138–150 (2020) doi:10.1007/s10578-019-00917-1

Download citation


  • ADHD
  • Diagnosis
  • Longitudinal
  • Ireland
  • Child wellbeing