A population-based study of nearly 300,000 Swedish compulsory school pupils reveals that academic achievement significantly alters the observed socio-demographic patterns in Attention-Deficit/Hyperactivity Disorder (ADHD) diagnosis. Published in Child and Adolescent Psychiatry and Mental Health, the research indicates that when differences in school grades are taken into account, the gender gap in ADHD diagnosis narrows by approximately two-thirds, while the socioeconomic gradient reverses direction. The study, conducted by Björn Högberg, utilized linked national registers to examine how socio-demographic differences in diagnosis change when academic performance is held constant.
The investigation focused on 296,380 pupils who graduated from the final year of Swedish compulsory school, known as grade 9, between 2015 and 2017. This cross-sectional design allowed researchers to link individual-level data from several administrative registers, including the National Patient Register, the Prescribed Drugs Register, and school pupil registers. By using the personal identification numbers assigned to all Swedish residents, the study ensured a comprehensive population-based sample. The overall prevalence of diagnosed ADHD in this cohort was 5.62%, with diagnosis defined by specialist ICD-10 codes or the dispensation of ADHD medication in the year prior to or during graduation.
Before adjusting for academic achievement, the data mirrored well-documented international patterns: boys had a higher probability of ADHD diagnosis than girls, and pupils with lower socioeconomic status (SES) were diagnosed more frequently than those with higher SES. Additionally, native-born pupils had substantially higher diagnostic rates than immigrant pupils. However, when the researchers adjusted for academic achievement, measured by compulsory school-leaving grades, these patterns shifted dramatically. The excess odds of diagnosis among boys were strongly reduced, and the socioeconomic gradient reversed, with pupils having tertiary-educated parents showing the highest probability of diagnosis.
The reversal of the socioeconomic gradient is a particularly notable finding. In models not adjusted for achievement, pupils with less highly educated parents had higher odds of ADHD diagnosis. Yet, when academic performance was accounted for, the highest odds were observed among children of tertiary-educated parents. The study notes that higher-SES parents often have greater health literacy and educational aspirations, which may lead to compensatory strategies such as pursuing special educational support or psychiatric evaluation.
In contrast, the differences between native-born and immigrant pupils persisted and even widened slightly after adjustment for academic achievement. Immigrant pupils, particularly those from first-generation immigrant families, continued to have lower odds of ADHD diagnosis compared to native pupils, even when comparing students with similar levels of academic performance. This persistence may indicate barriers to accessing psychiatric services, such as language difficulties, lower familiarity with the Swedish school and healthcare system, or stigma. It may also reflect differential detection by parents or teachers, who might have differing expectations or understandings of mental health symptoms among children with migration backgrounds.
The study also explored the impact of diagnostic timing on the gender gap. When accounting for the fact that girls are typically diagnosed later than boys, the gender gap not only narrowed but reversed in some supplementary analyses. After adjusting for both academic achievement and earlier diagnostic history, girls had higher odds of diagnosis than boys. In adolescence, previously undiagnosed girls may have a higher probability of receiving a diagnosis at a given level of academic achievement, possibly because academic underachievement is less normative among girls and thus more likely to be interpreted as reflecting an underlying disability.
The researchers employed logistic regression models to estimate the associations between socio-demographic characteristics and ADHD diagnosis, with and without adjustment for academic achievement. The models included covariates for graduation year, pupil age, and birth month to account for temporal trends and relative age effects. The odds ratios were transformed into marginal effects and predicted probabilities to allow for a clearer interpretation of the differences in diagnostic risk. The results were robust to several supplementary analyses, including those that defined ADHD diagnosis solely using data from the National Patient Register and those that adjusted for concurrent internalizing and externalizing disorders.
Limitations of the study include the lack of direct data on ADHD symptoms in the population registers, meaning that academic achievement serves as a proxy for symptom severity rather than a direct measure. The cross-sectional design also prevents the disentangling of causal relationships between achievement and diagnosis, as the two may have influenced each other over time. Furthermore, the National Patient Register may underreport diagnoses from private healthcare providers, potentially leading to an underestimation of prevalence among groups with greater access to private care. The broad categorization of migration background also masks within-group heterogeneity in terms of language and culture.
Despite these limitations, the study provides valuable insights into the mechanisms underlying socio-demographic differences in ADHD diagnosis. It highlights the need to consider academic achievement when interpreting these patterns and suggests that some groups may face barriers to diagnosis even when their level of academic impairment is comparable to that of more frequently diagnosed groups. The findings have implications for policy and practice, underscoring the need to ensure equitable access to diagnostic services and healthcare for all children, regardless of their social and demographic characteristics.
Future research should utilize longitudinal data to track the emergence and development of these socio-demographic differences and the role of academic achievement in shaping them. Such studies could follow the full diagnostic process, from initial detection of difficulties through referral to clinical assessment and diagnosis, to illuminate at which stage socio-demographic differences arise. Additionally, studies with access to data on ADHD symptoms could investigate whether similar patterns emerge when symptom severity is held constant, helping to distinguish between differential referral practices and socio-demographic differences in the composition of low-achieving pupils. Cross-country comparisons could also reveal whether the patterns observed in Sweden are specific to its institutional context or generalizable to other settings.
By identifying the role of academic achievement in shaping these differences, the research offers a nuanced perspective on the disparities in ADHD diagnosis. It calls for a more comprehensive approach to understanding and addressing these disparities, one that considers the interplay between academic functioning, referral processes, and diagnostic practices.
By addressing the barriers that prevent certain groups from accessing diagnosis, healthcare providers and schools can work together to ensure that struggling children are identified and supported, regardless of their gender, socioeconomic status, or migration background.
The research underscores the complexity of ADHD diagnosis and the importance of considering multiple factors when interpreting diagnostic rates. By integrating academic performance into the analysis of ADHD diagnosis, the study provides a more accurate picture of the socio-demographic patterns in this common neurodevelopmental condition.
Subject of Research: Socio-demographic differences in ADHD diagnosis among Swedish school pupils adjusted for academic achievement
Article Title: Academic achievement and socio-demographic differences in ADHD diagnosis: a population-based study of Swedish compulsory school pupils
Article References: Högberg, B. (2026). Academic achievement and socio-demographic differences in ADHD diagnosis: a population-based study of Swedish compulsory school pupils. Child and Adolescent Psychiatry and Mental Health, 20(1), Article 133. https://doi.org/10.1186/s13034-026-01176-4
Image Credits: AI Generated
DOI: 10.1186/s13034-026-01176-4
Keywords: ADHD diagnosis, academic achievement, socio-demographic disparities, Swedish education, population-based study, gender gap, socioeconomic status, immigrant pupils, child psychiatry, school grades, Academic, achievement
News Source: Ophelia Keating. (November 7, 2026). Swedish Study Links ADHD Diagnosis Gaps to School Grades. Scienmag.
