Differential Parent and Teacher Reports of ADHD Symptoms According to the Child’s Country of Origin: A Quantitative Study From Denmark Exploring the Implication for Diagnosis

Abstract

Objective: This study aimed to investigate differences in parent- and teacher-reported ADHD symptoms according to the child’s country of origin. Method: We conducted a cross-sectional study of 4,207 nonimmigrant (Danish origin) and 233 immigrant (non-Danish origin) children including ratings of phenotypical ADHD symptoms on the Strengths and Difficulties Questionnaires. The association between ADHD symptoms and country of origin, separately for parents and teachers, was analyzed using multiple logistic regression. Results: Teachers reported similar numbers of ADHD symptoms for immigrant and nonimmigrant children (odds ratio [OR] = 0.95, confidence interval [CI] = [0.58, 1.54]), whereas immigrant parents were less likely than nonimmigrant parents to report ADHD symptoms (OR = 0.42, CI = [0.21, 0.84]). Conclusion: Immigrant parents were less likely than nonimmigrant parents to report ADHD symptoms, whereas the teachers reported similar amount of ADHD symptoms in the two groups of children. Our results emphasize the importance of paying attention to teacher reporting of ADHD symptoms when assessing immigrant children.

Keywords

attention deficit disorder with hyperactivity Strengths and Difficulties Questionnaire (SDQ)immigrants differences in report parent and teacher

There is a lower prevalence of diagnosed ADHD in children of immigrant compared with children of nonimmigrant parents in Europe and the United States.

However, the prevalence of ADHD symptoms has been found to be similar regardless of the children’s background.

Differences in report of ADHD symptoms between parents and teachers have been suggested.

We observed a lower report of ADHD symptoms by the parents of children with immigrant background compared with nonimmigrants.

Teacher reports of ADHD symptoms were similar regardless of the children’s background.

Lower frequency of parental reporting of ADHD symptoms may explain the lower prevalence of ADHD diagnoses among immigrant children and their lower use of related health care services.

Introduction

The prevalence of children diagnosed with and treated for ADHD has consistently been increasing during the last two decades (Polanczyk et al., 2014). ADHD is the most common diagnosed psychiatric disorder in childhood with a worldwide pooled prevalence of about 5% (Polanczyk et al., 2014). ADHD is characterized by maladaptive levels of inattention, impulsivity, and hyperactivity, which can negatively affect the individual’s daily life and well-being, especially in childhood but often also into adulthood (Erskine et al., 2016; Harpin, 2005). Several studies emphasize the importance of early diagnosis and treatment of ADHD to reduce the risk of, for example, social isolation, academic/occupational failure, criminal behavior, and substance use (Lichtenstein et al., 2012; Salmeron, 2009). The way to a diagnosis may however be complex due to multiple domains, informants, methods, settings, and cultural context (Stubbe, 2016). A significantly lower prevalence of ADHD diagnosis and medication use has been found in African American and Hispanic children compared with Caucasian children in the United States (Galera et al., 2014; Morgan et al., 2014; Pastor & Reuben, 2005; Singh et al., 2013). Similar results have been found in children of immigrant parents compared with nonimmigrant parents in Western Europe (Huss et al., 2008; Jablonska et al., 2020; Knopf et al., 2012; Wallach-Kildemoes et al., 2015; Wittkampf et al., 2010), although the prevalence of ADHD symptoms has been found to be similar (Huss et al., 2008; Rydell, 2010; Schlack et al., 2007; Zwirs et al., 2007). This could indicate an unclear association between ADHD diagnosis (and treatment) and ADHD symptoms in immigrant children. A study from the Netherlands found that the detection rate of ADHD in children was markedly lower among immigrant parents compared with nonimmigrants (Zwirs et al., 2006). In addition, there were larger differences between parent and teacher reports of ADHD symptoms in Sami children compared with other Norwegian children (Javo et al., 2009) and in immigrant children compared with nonimmigrant children in the United States (Takeda et al., 2020). Studies based on only teacher reports found similar or higher reports of ADHD symptoms in immigrant children than in nonimmigrant children (Crijnen et al., 2000; Sonuga-Barke et al., 1993). Teachers have the possibility to compare children’s social and behavioral functioning in the context of learning and interacting, irrespective of the individual child’s immigration status (Stubbe, 2016). Studies investigating differences in the reporting of ADHD symptoms in children with immigrant background compared with nonimmigrant background are sparse and inconclusive.

The aim of this study was to investigate differences in parent and teacher reports of ADHD symptoms in children of immigrant parents, depending on the family’s country of origin, to examine explanations for the lower prevalence of ADHD in children of immigrant parents.

Materials and Methods

Study Design, Setting, and Population

We designed a cross-sectional study using information from the Strengths and Difficulties questionnaire (SDQ). Data were collected in March 2015 for children and adolescents (2–17 years) in a Danish municipality. For all children in the municipality, the Danish version of the SDQ (Niclasen et al., 2012) was electronically sent out to parents and teachers (to nursery teachers for children below 5 years of age and to the children themselves if they were above 11 years of age). Parents accessed and completed the SDQ at home through a safe and secure data exchange platform, whereas teachers completed the SDQ during working hours as a must-do assignment. Parental reports were available for 70% of the children, whereas teachers completed the questionnaire for 97% of the children. Data for 5,751 children with at least one SDQ report were included in the data set. If the teacher questionnaire was completed and the parent questionnaire was missing for a child above age 11 years, the child’s self-report questionnaire replaced the missing parent questionnaire. This procedure is in accordance with the SDQ algorithm, which is available on the SDQ homepage (http://www.sdqinfo.com/c8.html). We excluded 1,311 children for the following reasons: SDQ was available only from the teacher (n = 1,199), only from the parents (n = 52), only from the self-reporting child (n = 59), and missing age and sex for the child (n = 1). The final study population consisted of 4,440 children/adolescents with complete SDQ from both teachers and parents.

The sociodemographic characteristics of the study population were obtained from several Danish registers, including the Danish National Birth register and the Central Population Register. All live-born children and new residents in Denmark are assigned a unique civil personal registration number, which allows accurate linkage of data at the personal level between national registries (Pedersen, 2011).

Outcome

The SDQ is a well-documented multiinformant screening tool for emotional and behavioral problems in children and adolescents. The SDQ consists of 25 questions divided into five subscales/domains: emotional problems, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior. Each of these is rated as the sum score of five items. In addition, an impact supplement is provided from the parent and teacher reports. The supplement enquires about distress, burden, and impairment of the child in different settings (Goodman et al., 2000). Based on population scores on the hyperactivity/inattention subscale and the impact supplement from the United Kingdom, predictive algorithms were used to divide individuals into three groups: unlikely ADHD, possible ADHD, and probable ADHD (Goodman et al., 2000). In this study, children were dichotomized into experiencing ADHD symptoms (if classified with possible or probable ADHD) and not experiencing ADHD symptoms (if classified with unlikely ADHD).

Exposure

The country of origin classification was based on maternal grandparents’ place of birth. A child was classified as being nonimmigrant (Danish origin) if the mother’s mother was born in Denmark, and otherwise as immigrant (non-Danish origin). If the place of birth for the mother’s mother was missing, the mother’s father was used instead. If the place of birth for the mother’s father was missing too, the mother’s place of birth was used instead. It is important to notice that we use the term “immigrant” and “nonimmigrant” linked to Danish origin but the children and parents from both groups could still have been born in Denmark and could identify themselves as Danes.

Covariates

Based on prior research, we included the following variables as potential confounders: sex of the child; age on April 1, 2015 (categorized into: 2–5, 6–11, and 12–17 years); mother’s age on January 1, 2015 (categorized into: 17–34, 35–44, and 45+ years); disposable household income in 2014 (categorized into quartiles); length of education (categorized into: <10, 10–15, and >15 years); and family structure (categorized into: parents living together and parents separated, including single parents).

Statistical Analysis

The distribution of characteristics was reported using numbers and percentages according to exposure category (immigrant vs. nonimmigrant children). Chi-square tests were conducted to examine whether the distribution of each variable was independent of exposure. Multiple logistic regression models were performed to investigate the association between ADHD symptoms and country of origin. Information from the parent and the teacher reports was used separately. Sensitivity analyses were performed to investigate the impact on the association when categorizing possible and probable ADHD from ADHD symptoms and to investigate the impact on the association when missing parental reports were replaced by available self-reports completed by the children. Due to an interaction between sex and exposure, subanalyses for boys and girls were conducted separately. All estimates were reported as odds ratio (OR) with 95% confidence interval (CI) and were adjusted for sex, age, and disposable household income. The sensitivity analyses also adjusted for family structure, but this did not change the results significantly (results not shown). All analyses were performed using Stata software, version 11 (Stata Corporation, College Station, TX, USA), on a secure platform hosted by Statistics Denmark.

Ethical Approval

The study was approved by the Danish Data Protection Agency. According to Danish legislation, informed consent and ethical approval is not required from the national or regional Committee on Health Research Ethics for register-based studies in Denmark.

Results

A total of 4,440 children were included in this study. Of these, 233 (5.25%) were classified as being immigrant. Table 1 shows the characteristics of the study population according to exposure status (immigrants vs. nonimmigrants). In both groups, we found a larger number of boys, of children aged 12 to 17 years, of mothers aged 35 to 44 years, and of parents living together. The most important differences between parents of the two groups were that parents of immigrant children generally had lower disposable income and lower education level. Still, the educational level may not reflect the actual distribution as missing data were more frequently seen for immigrant parents.

Table 1.

Background Characteristics of Children and Their Parents According to Migration Status.

	NonimmigrantsN = 4,207	ImmigrantsN = 233	p value^a
	N (%)	N (%)	p value^a
Sex of the child
Boy	2,136 (50.7)	119 (51.1)	.918
Girl	2,073 (49.3)	114 (48.9)
Age of the child (years)
2–5	728 (17.3)	49 (21.0)	.208
6–11	1,705 (40.5)	83 (35.6)
12–17	1,774 (42.2)	101 (43.4)
Age of the mother (years)
17–34	814 (19.4)	51 (21.9)	<.001
35–44	2,478 (58.9)	134 (57.5)
45+	886 (21.1)	41 (17.6)
Missing	29 (0.7)	7 (3.0)
Maternal years of education
1–10	620 (15.0)	16 (6.9)	<.001
11–14	1,943 (46.0)	69 (29.6)
15+	1,641 (39.0)	70 (30.0)
Missing	3 (0.1)	78 (33.5)
Paternal years of education
1–10	844 (20.1)	18 (7.7)	<.001
11–14	2,152 (51.2)	84 (36.1)
15+	1,152 (27.4)	63 (27.0)
Missing	59 (1.4)	68 (29.2)
Disposable household income
1st quartile (low)	936 (22.2)	96 (41.2)	<.001
2nd quartile	975 (23.2)	60 (25.8)
3rd quartile	997 (23.7)	35 (15.0)
4th quartile (high)	1,008 (24.0)	23 (9.9)
Missing	291 (6.9)	29 (8.2)
Family structure
Parents living together	3,415 (81.2)	191 (82.0)	<.001
Parents not living together	759 (18.0)	35 (15.0)
Missing	33 (0.8)	7 (3.0)

Note. Children with parent and teacher report available.

p value for chi-square test.

Table 2 shows the association between migration status and ADHD symptoms for all children combined and for boys and girls separately based on either teacher- or parent-reported SDQ. A total of 339 children (8.2%; 13.0% boys and 3.8% girls) were reported by the teachers to have ADHD symptoms, while the corresponding number was 304 (7.4%; 9.0% boys and 5.9% of girls) when based on parental reports. No association was found between migration status and teacher reporting of ADHD symptoms (adjusted OR = 0.95, 95% CI = [0.58, 1.54]). However, immigrant children were less likely than nonimmigrants to have parental reporting of ADHD symptoms (adjusted OR = 0.42, 95% CI = [0.21, 0.84]).

Table 2.

Crude and Adjusted OR and 95% CI Between Migration Status and ADHD Symptoms Reported Separately by the Teacher and the Parents.

	ADHD symptoms reported by the teacher				ADHD symptoms reported by the parents
	No symptomsn (%)	Symptomsn (%)	Crude OR[95% CI]	Adjusted OR^a [95% CI]	No symptomsn (%)	Symptomsn (%)	Crude OR[95% CI]	Adjusted OR^a [95% CI]
All children
Nonimmigrants	3,597 (91.9)	319 (8.1)	1 (ref)	1 (ref)	3,621 (92.5)	295 (7.5)	1 (ref)	1 (ref)
Immigrants	194 (90.7)	20 (9.3)	1.16 [0.72, 1.87]	0.95 [0.58, 1.54]	205 (95.8)	9 (4.2)	0.54 [0.27, 1.06]	0.42 [0.21, 0.84]
Boys only
Nonimmigrants	1,731 (87.4)	249 (12.6)	1 (ref)	1 (ref)	1,801 (91.0)	179 (9.0)	1 (ref)	1 (ref)
Immigrants	102 (90.3)	11 (9.7)	0.75 [0.40, 1.41]	0.64 [0.34, 1.29]	108 (95.6)	5 (4.4)	0.47 [0.19, 1.16]	0.39 [0.15, 0.97]
Girls only
Nonimmigrants	1,866 (96.4)	70 (3.6)	1 (ref)	1 (ref)	1,820 (94.0)	116 (6.0)	1 (ref)	1 (ref)
Immigrants	92 (91.1)	9 (8.9)	2.60 [1.26, 5.38]	1.99 [0.95, 4.15]	97 (96.0)	4 (4.0)	0.65 [0.23, 1.79]	0.48 [0.17, 1.33]

Note. These analyses excluded children with missing data for sex, age, and disposable household income. OR = odds ratio; CI = confidence interval; SDQ = Strengths and Difficulties Questionnaires.

Adjusted for sex, age, and disposable household income.

Furthermore, analyses stratified by sex showed similar associations for boys and girls in the parental reporting of ADHD symptoms; immigrants were less likely to report ADHD symptoms. However, compared with nonimmigrant children, teachers were generally less likely to report ADHD symptoms for immigrant boys (adjusted OR = 0.64, 95% CI = [0.34, 1.29]) and more likely to report ADHD symptoms for immigrant girls (adjusted OR = 1.99, 95% CI = [0.95, 4.15]). Nevertheless, these estimates are based on few individuals and are not significant.

We performed a sensitivity analysis for probable ADHD only, which showed the same pattern of differences in the reporting by parents and teachers (results not shown).

We also performed a sensitivity analysis of the child self-reports, which showed that immigrant children were less likely to have parental reporting of ADHD symptoms than nonimmigrants (results not shown). This trend was similar to the estimated differences in the parental reporting presented in Table 2. Due to small sample sizes and wide confidence intervals, the results from the sensitivity analysis are not shown.

Discussion

Principal Findings

Teachers reported similar amounts of ADHD symptoms independently of migration status. Conversely, immigrant parents reported fewer ADHD symptoms than nonimmigrants did. Overall, teachers reported slightly more ADHD symptoms than parents did. Furthermore, we found different results for boys and girls when using the teacher-based reporting of ADHD symptoms. However, the number of cases was too small to show statistically reliable results. We found a weak trend of teachers reporting fewer symptoms for immigrant boys compared with nonimmigrants, and teachers were twice as likely to report ADHD symptoms for immigrant girls than nonimmigrants.

Comparison With Existing Literature

Studies of ADHD behavior among children of different country of origin have been sparse and inconclusive, depending on the use of measurements tools, ethnic groups, and type of informants. Consistent with the results of the present study, studies from Holland found similar teacher reports of externalizing behavior and ADHD symptoms in Turkish immigrants compared with nonimmigrants (Crijnen et al., 2000; Stevens et al., 2003). In addition, studies have reported higher prevalence of teacher-reported ADHD symptoms in immigrants compared with nonimmigrants. For example, higher prevalence of teacher-rated ADHD symptoms were found for Moroccan adolescents compared with Turkish and Dutch adolescents in Holland (Stevens et al., 2003), and higher prevalence of teacher-reported ADHD symptoms was seen for Asian immigrant children compared with English children (Sonuga-Barke et al., 1993). Studies with parental reports of ADHD symptoms found that Moroccan and Surinamese parents were less likely to detect ADHD than Dutch parents (Zwirs et al., 2006). These results are in line with the associations found in our study. Furthermore, a study comparing teacher and parent reports of ADHD symptoms found a higher discrepancy between parent and teacher reports for immigrant children than for nonimmigrant children in the USA (Takeda et al., 2020). In addition, Javo et al. (2009) found a higher discrepancy between parent and teacher reports of problems that needed attention for the minority of Sami children than for Norwegian children. The discrepancies between parent and teacher reports for ethnic minority groups were primarily due to lower parental symptom reports in ethnic minority groups, which is consistent with the findings in the present study (Javo et al., 2009; Takeda et al., 2020).

A Dutch study found slightly higher prevalence of ADHD among Dutch children compared with non-Dutch children. This study was based on SDQ teacher and parent reports and SDQ self-reports. The result could be due to lower reporting of symptoms (from parents and self-reports) in non-Dutch children (Zwirs et al., 2007). Consistent with these findings, our study showed that the overall prevalence of ADHD symptoms did not differ markedly across the child’s country of origin, at least according to the teachers. The possibility to compare children in the same context may qualify the teacher reporting of ADHD symptoms based on the schools cultural setting (Goodman et al., 2000). The observed differences between parent-based and teacher-based reports of ADHD symptoms could thus be due to perceptual differences rather than actual differences in the behavior of the children.

The lower parental reporting of ADHD symptoms in immigrant children compared with nonimmigrants in this Danish study could be related to the structure of the impact supplement in the parent version of the SDQ. The questions in the impact supplement gather information on the child’s behavior at home and in school. Some studies have suggested that the parent–teacher communication about children of immigrants is not as satisfactory as the communication about nonimmigrant children (Turney & Kao, 2009; Vera et al., 2012). If there is a lack of communication between parents and teachers, immigrant parents may not be aware of their child’s behavioral problems at school, and they would thus be less likely to report symptoms related to this domain. Other explanations could be that the parental perceptions or beliefs about their child’s behavior may differ according to country of origin. A study found that Caucasian American parents were more likely to rate the mental health of their adolescents as worse compared with African American and Hispanic parents. The study suggested that different cultures often have varying thresholds for differentiating normal from abnormal behavior (Roberts et al., 2005). Furthermore, research has found that a significant number of immigrant parents are concerned about psychiatric diagnoses, such as ADHD, which may cause negative attitudes toward those being diagnosed (Eiraldi et al., 2006). Fear of stigmatization of their child may also influence the parents’ decision to report ADHD symptoms or abnormal behavior, especially parents with limited knowledge about ADHD and its treatment (Eiraldi et al., 2006). In addition, parental identification of child problem behavior was found to be a predictor for use of mental health services (Sayal et al., 2002), which makes the lower reporting of ADHD symptoms among immigrant parents problematic for diagnosis and treatment.

Strengths and Limitations

The major strength of this study is the high participation rate of children with 77% eligible reports from a municipality with more than 41,000 citizens. Second, the parent and teacher reports of ADHD symptoms for the children were gathered within the same month. This increases the reliability of the report for each child, as it limits the risk of recall bias and is likely to reflect the true and actual behavior. Third, the personal identification number enabled linking of register data about the children’s country of origin, age, parental educational level, disposable house income, and family structure. Finally, the SDQ has previously shown to be a useful screening instrument for identifying children at high risk of ADHD (Rimvall et al., 2014). However, due to the low sensitivity, the measurement tool cannot stand alone as a diagnostic instrument, but it is reliable indicator of ADHD symptoms in children (Rimvall et al., 2014).

The study also has several limitations. First, the number of immigrant children was low due to high levels of missing parental reports and low proportions of immigrants in the municipality. All immigrants were defined as being non-Danish, and the country of origin classification was if possible based on the maternal grandmother’s place of birth. The immigrant population is ethnically and culturally highly heterogeneous, ranging from highly educated immigrants from Europe or other countries to war or political refugees with psychological stress and low educational level. Due to the large number of missing reports from parents born outside Denmark, our results are mainly based on second and third generation of immigrants, and the findings may thus not be generalizable to the first generation. Nevertheless, as the effects of being a second- or third-generation immigrant are assumed to have less cultural impact than the effects of being a first-generation immigrant, the association for the first generation (with parents born outside Denmark) are expected to be at least the same or even stronger. Second, children and parents from the immigrant group could still have been born in Denmark and could identify themselves as Danes. Characterization of ethnicity based solely on country of origin may hold a risk of limiting the validity, as voluntary self-definition of ethnicity is considered a gold standard today (and not place of birth) although this measure also implies problems (Norredam, 2011). Third, the SDQ was only administered in Danish and electronically distributed; this procedure may explain the markedly lower reporting rate from immigrant parents. Moreover, it may have excluded reports from parents who are the least assimilated and less likely to report ADHD symptoms. This might have resulted in an underestimation of differences in the investigated associations. In addition, immigrant parents who report ADHD behavior may be challenged in the Danish language, which carries the risk that they may not report reliably. However, the extent to which the associations are underestimated or overestimated remains unclear. In future studies, translated and validated SDQ versions in other languages could be attached to the Danish SDQ or be available for non-Danish speakers. Fourth, cut-off values were based on British samples. Although these have not yet been validated in a Danish sample, they have been used in Danish studies for several years. A study suggests that it is reasonable to apply the British predictive algorithm for ADHD in a Nordic population (Heiervang et al., 2008). In addition, the SDQ cut-off points for ADHD symptoms were set between unlikely and possible/probable according to predictions for ADHD (Rimvall et al., 2014). This categorization includes children with minor ADHD symptoms (possible) who are less likely to have ADHD than children with symptoms predicting probable ADHD. The performed sensitivity analysis based on only probable ADHD showed same patterns. Therefore, this does not seem to have influenced the association. Fifth, the feasibility of using the SDQ as an ADHD prediction tool for parents and teachers separately can be discussed, as ADHD symptoms can be present in multiple contexts. In addition, the reporting of ADHD symptoms made by teachers in the SDQ may be affected by the child’s country of origin or sex. A study found that English teachers’ assessment of Asian children were biased compared with observational measurements (Sonuga-Barke et al., 1993). Moreover, according to the SDQ algorithm, a missing parental report should be replaced by the child’s self-report (from a certain age), but a sensitivity analysis of the self-reports showed similar patterns as the analysis based on the parents’ reports. Therefore, this does not seem to have influenced the association. Sixth, due to the considerable amount of missing information on educational level for immigrant parents, the observed educational level in this study was less likely to reflect the real distribution for this group. For this reason, we decided not to adjust for educational level. However, disposable household income, which is positively correlated with educational level, was used to adjust for the socioeconomic effects. Finally, the study population was based on a sample from a municipality with a low prevalence of immigration compared with the national prevalence in Denmark (Danmarks Statistik, n.d.). Thus, our findings might not represent national level. Nevertheless, the trend of higher discrepancy between parent and teacher reports for immigrant children could be assumed to be even stronger in geographical areas with higher prevalence of immigrants. A Swedish study found that the higher the proportion of residents born outside Sweden, the lower the proportion of children using ADHD medication (Jablonska et al., 2020).

Conclusion, Implications, and Future Research

We found that teachers reported similar numbers of ADHD symptoms for immigrant and nonimmigrant children. In contrast, immigrant parents reported fewer ADHD symptoms for their children compared with nonimmigrants. These findings may partly explain the observed lower diagnostic and treatment rates among children of immigrants in western countries.

Future studies—especially qualitative ones—should examine the mechanisms underlying the lower parental reporting of ADHD behavior in immigrant children. Further knowledge may contribute to more targeted health interventions aimed at ensuring equal ADHD treatment and opportunities for immigrants.

Footnotes

Acknowledgements

The authors owe a special thanks to Katrine Svendsen, data manager and project assistant at the Department of Public Health, Aarhus University, Denmark.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Kathrine Bang Madsen

Oleguer Plana-Ripoll

Author Biographies

Armin Sahuric is a Master student in Public Health at Aarhus University.

Lena Hohwü is a postdoc at the Department of Public Health, Aarhus University.

Kathrine Bang Madsen is a postdoc at the National Centre for Register-based Research, Aarhus University.

Astrid Fyrstenborg Christensen is a Master student in Public Health at Aarhus University.

Maria Vandborg Snestrup is a Master student in Public Health at Aarhus University.

Carsten Obel is a professor of Child Mental Health at the Department of Public Health, Aarhus University.

Oleguer Plana-Ripoll is a postdoc at the National Centre for Register-based Research, Aarhus University.

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