Neurodevelopmental multimorbidity and educational outcomes of Scottish schoolchildren: A population-based record linkage cohort study

Autoři: Michael Fleming aff001;  Ehsan E. Salim aff001;  Daniel F. Mackay aff001;  Angela Henderson aff001;  Deborah Kinnear aff001;  David Clark aff002;  Albert King aff003;  James S. McLay aff004;  Sally-Ann Cooper aff001;  Jill P. Pell aff001
Působiště autorů: Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom aff001;  Information Services Division, Edinburgh, United Kingdom aff002;  ScotXed, Scottish Government, Edinburgh, United Kingdom aff003;  Department of Child Health, University of Aberdeen, Aberdeen, United Kingdom aff004
Vyšlo v časopise: Neurodevelopmental multimorbidity and educational outcomes of Scottish schoolchildren: A population-based record linkage cohort study. PLoS Med 17(10): e32767. doi:10.1371/journal.pmed.1003290
Kategorie: Research Article



Neurodevelopmental conditions commonly coexist in children, but compared to adults, childhood multimorbidity attracts less attention in research and clinical practice. We previously reported that children treated for attention deficit hyperactivity disorder (ADHD) and depression have more school absences and exclusions, additional support needs, poorer attainment, and increased unemployment. They are also more likely to have coexisting conditions, including autism and intellectual disability. We investigated prevalence of neurodevelopmental multimorbidity (≥2 conditions) among Scottish schoolchildren and their educational outcomes compared to peers.

Methods and findings

We retrospectively linked 6 Scotland-wide databases to analyse 766,244 children (390,290 [50.9%] boys; 375,954 [49.1%] girls) aged 4 to 19 years (mean = 10.9) attending Scottish schools between 2009 and 2013. Children were distributed across all deprivation quintiles (most to least deprived: 22.7%, 20.1%, 19.3%, 19.5%, 18.4%). The majority (96.2%) were white ethnicity. We ascertained autism spectrum disorder (ASD) and intellectual disabilities from records of additional support needs and ADHD and depression through relevant encashed prescriptions. We identified neurodevelopmental multimorbidity (≥2 of these conditions) in 4,789 (0.6%) children, with ASD and intellectual disability the most common combination. On adjusting for sociodemographic (sex, age, ethnicity, deprivation) and maternity (maternal age, maternal smoking, sex-gestation–specific birth weight centile, gestational age, 5-minute Apgar score, mode of delivery, parity) factors, multimorbidity was associated with increased school absenteeism and exclusion, unemployment, and poorer exam attainment. Significant dose relationships were evident between number of conditions (0, 1, ≥2) and the last 3 outcomes. Compared to children with no conditions, children with 1 condition, and children with 2 or more conditions, had more absenteeism (1 condition adjusted incidence rate ratio [IRR] 1.28, 95% CI 1.27–1.30, p < 0.001 and 2 or more conditions adjusted IRR 1.23, 95% CI 1.20–1.28, p < 0.001), greater exclusion (adjusted IRR 2.37, 95% CI 2.25–2.48, p < 0.001 and adjusted IRR 3.04, 95% CI 2.74–3.38, p < 0.001), poorer attainment (adjusted odds ratio [OR] 3.92, 95% CI 3.63–4.23, p < 0.001 and adjusted OR 12.07, 95% CI 9.15–15.94, p < 0.001), and increased unemployment (adjusted OR 1.57, 95% CI 1.49–1.66, p < 0.001 and adjusted OR 2.11, 95% CI 1.83–2.45, p < 0.001). Associations remained after further adjustment for comorbid physical conditions and additional support needs. Coexisting depression was the strongest driver of absenteeism and coexisting ADHD the strongest driver of exclusion. Absence of formal primary care diagnoses was a limitation since ascertaining depression and ADHD from prescriptions omitted affected children receiving alternative or no treatment and some antidepressants can be prescribed for other indications.


Structuring clinical practice and training around single conditions may disadvantage children with neurodevelopmental multimorbidity, who we observed had significantly poorer educational outcomes compared to children with 1 condition and no conditions.

Klíčová slova:

ADHD – Autism spectrum disorder – Depression – Children – Labor and delivery – Schools – Intellectual disability – Scottish people


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