Wider determinants and inequalities

Autistic people and people with ADHD may be more likely to experience determinants of poor mental health, in domains such as housing, employment and education.
Autistic people and people with ADHD can face stigma and discrimination around these conditions, which is associated with poor mental wellbeing:
- Stigma around ADHD is associated with poorer life satisfaction and mental wellbeing; as well as poorer adherence to ADHD medication (Mueller et al., 2012).
- Stigma around autism is associated with poorer wellbeing and quality of life, and greater levels of psychological distress, for autistic people and their families (Turnock, Langley and Jones, 2022).
- Stigma around autism can be experienced differently depending on other factors, such as ethnicity, gender and religion (Turnock, Langley and Jones, 2022), with autistic people reporting poor understanding of how different aspects of their identity can intersect (APPGA, 2019).
Following a ‘neurodiversity paradigm’ promotes the acceptance of autism and ADHD and focuses attention on ending stigma and changing wider factors (such as unemployment) that impact of mental health of autistic people and people with ADHD (Pellicano and den Houting, 2022).

Wider determinants of health

The conditions in which we ‘are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life’ are central to our mental health (World Health Organisation, 2022). The following table summarises data around wider determinants of health for people with ADHD and autistic people; and highlights the need for improvements in services and systems to better meet the needs of neurodivergent people. The links in the list below are to earlier sections of the mental health needs assessment, which provide more detail about how these factors are important to mental health.

Socioeconomic deprivation

One study found that the rates of ADHD in children were twice as high in the most deprived areas of England, compared to the least deprived areas (Prasad et al., 2018). Reasons for this trend are unclear.

Poverty and financial insecurity

One large study involving English school children found that autism diagnoses were more likely among pupils eligible for free school meals, eligibility for which is based on family income (Roman-Urrestarazu et al., 2021b).

Housing, homelessness and environmental justice

There is evidence that neurodivergent people (including people with ADHD and autistic people) are more likely to become homeless and can face barriers to accessing housing support (Blood et al., 2023). A recent audit of the needs of people experiencing homelessness in Cambridgeshire and Peterborough found that (Hertzberg, 2024):

11% reported having been diagnosed with autism
26% reported having a learning disability
19% reported having been diagnosed with ADHD/ADD.

Education and life-long learning

Autistic pupils are likely to have poorer experiences in school than their non-autistic peers. National surveys show that:

Only 26% of autistic pupils feel happy at school (National Autistic Society, 2023);
Half of autistic pupils feel that their teachers do not know how to support them and fewer than 50% of teachers feel confident in supporting autistic children (All Party Parliamentary Group on Autism, 2017)
Autistic pupils are twice as likely to be excluded from school than pupils who do not have SEND (Guldberg et al., 2022).
Young autistic people, particularly those from low-income families and from ethnic minority backgrounds, are less likely to begin post-secondary education or enter employment after secondary school (Crane, Adams, et al., 2019).

Children and young people with ADHD face similar challenges in education: one study of primary school-age children with ADHD found that this group is more likely to fall below expected attainment in school and have unauthorised absences; and report feeling less happy in school than their peers (May et al., 2021); and untreated ADHD is associated with lower academic performance (Arnold et al., 2020).

There is ongoing work in Cambridgeshire and Peterborough as part of Partnerships for Inclusion of Neurodiversity in Schools (PINS) to make schools more inclusive for every child (Pinpoint, 2023).

Crime, safety and violence

The prevalence of ADHD and autism amongst people in prison may be substantially higher than in the general population, with estimates ranging from 20 to 50% (Criminal Justice Joint Inspection, 2022).

Autistic people and people with ADHD are also more likely to experience bullying, violence and abuse. A meta-analysis found that people with ADHD are more likely to experience intimate partner violence and sexual violence than those who do not have ADHD (Arrondo et al., 2023). Autistic people are more likely to report experiences of bullying, child abuse and sexual violence than non-autistic people, with around half of autistic people having been bullied and 40% having experienced sexual abuse (Trundle et al., 2023).

Community wellbeing

Autistic people report much lower levels of life satisfaction than the general population, with one survey finding that autistic people are 8 times more likely to feel ‘often’ or ‘always’ lonely (NAS, 2021). Mental ill-health has a substantial impact on quality of life for autistic people (Oakley et al., 2021).

There is evidence that both children and adults with ADHD have poorer quality of life than the general population, and that this relationship may partially explained by the increased rates of anxiety and depression in these groups (Yang et al., 2013).

Inequalities in mental health

Some populations face inequalities in mental health: they are at a higher risk of experiencing poor mental health; of being underserved by mental health services and requiring targeted support to ensure that their needs are met.
National research shows that some people autistic people and people with ADHD are more likely to experience poorer outcomes, including having contact with the criminal justice system, spending time in inpatient mental health settings, and experiencing homelessness. People with ADHD are also more likely to experience accidents and injuries (Brunkhorst-Kanaan et al., 2021).
There are also inequalities in access to ADHD and autism assessments, and support services (Wallace-Watkin, Sigafoos and Waddington, 2023). For example:
- Children whose first language is not English are less likely to have an autism diagnosis or autism-related support through an Education, Health and Care Plan (Roman-Urrestarazu et al., 2021b).
- One study found that children whose mothers had educational qualifications at A-Level or higher were twice as likely to have a recorded autism diagnosis, compared to those whose mothers has lower levels of educational qualifications (Kelly et al., 2019).

Deprivation

National data suggests that people living in more deprived areas are more likely to have been diagnosed with autism: in 2018, around 1 in 100 people living the most deprived quintiles in England had an autism diagnosis, compared to 1 in 170 of people in the least deprived areas (O’Nions et al., 2023). Similarly, national studies show that there are higher rates of ADHD diagnosis in more deprived areas (Hire et al., 2018).

Ethnicity

National research suggests children of ‘white heritage’ are 50% more likely to receive an autism diagnosis compared to children of ‘Asian heritages’ (Longfield, 2024). Another large national study found that, compared to White pupils, the autism diagnosis rates and access to support from EHCPs (Education, Health and Care Plans) were highest in Black pupils and lowest in Roma/Irish Traveller pupils (Roman-Urrestarazu et al., 2021b).

Some research indicates that families from Black, Asian and minority ethnic groups with autistic children can face barriers when trying to access an autism diagnosis and when getting support from services and within their local community. Families suggest that this can happen due to a range of reasons, including a lack of knowledge around autism, historic negative experiences of healthcare services and a lack of cultural competency within health and education services (Slade, 2014).

Some UK research suggests that there is no difference in the prevalence of ADHD symptoms among adults (NHS Digital, 2014). However, international research suggests that children from minoritised ethnic groups are less likely to be diagnosed with ADHD and prescribed ADHD medication than their peers (Slobodin and Masalha, 2020). Some studies also suggest that children from minoritised ethnic groups can face prejudice in the perception of behaviour and ability (Slobodin and Masalha, 2020).

Gender

Around 1 in 80 boys and men in the UK had been diagnosed with autism in 2018, compared to 1 in 280 girls and women (O’Nions et al., 2023). Boys are more likely to be diagnosed with autism and are almost 5 times as likely to have an EHCP, compared to girls (Roman-Urrestarazu et al., 2021b). Autistic women and girls may be more likely to have their autism ‘missed’, for a range of reasons (Lockwood Estrin et al., 2021). There is also some research suggesting that there are higher rates of undiagnosed autism amongst transgender and gender-diverse people (Ward, 2019).

NICE guidelines highlight that ADHD is more commonly diagnosed in boys than girls, but that differences in presentation (boys present more often with disruptive behaviour and are more likely to have conduct disorder; whilst girls are more likely to have the inattentive subtype of ADHD) may contribute to these differences (NICE, 2023).

LGBTQ+

Autism and ADHD are more common amongst trans and gender diverse individuals, both ‘marginalized groups where the currently available support and understanding is inadequate’ (Warrier et al., 2020).

Care experienced

Around 3% of ‘looked after’ children in England are recorded as having autism, however this is likely to be an underestimate of true figures (Parsons et al., 2019). Some studies suggest that ADHD is more common among ‘looked after’ children than the general population, but that these findings should be interpreted cautiously (Heady et al., 2022).

Disability/long-term physical health conditions

The strong bidirectional relationship between physical and mental health is likely to contribute to higher rates of mental ill-health amongst autistic people and people with ADHD, although there is limited research looking into co-morbidity in these populations.

Reviews show that some physical health conditions are more common in autistic people than the general population, including sleep problems, epilepsy, and autoimmune conditions (Rydzewska, Dunn and Cooper, 2021), and that autistic people can face a range of barriers to accessing physical healthcare (Mason et al., 2019; Walsh et al., 2020).
There is less research into the physical health needs of people with ADHD, although a recent review identified an increased risk of obesity, asthma and sleep disorders associated with ADHD (Instanes et al., 2018). Chronic pain may be more common among people with ADHD (Battison et al., 2023).

Severe multiple disadvantage

Severe multiple disadvantage (SMD) is a term used to describe people experiencing a combination of mental ill health, homelessness, substance use, domestic abuse, and/or offending (Harland et al., 2022). Some groups argue that neurodivergence should be considered as an aspect of SMD, as people can be disadvantaged because of a lack of support around neurodivergence. Examples include (Revolving Doors, 2022):

Substance use to ‘mask’ neurodivergent behaviours.
The behaviour of neurodivergent people is often misinterpreted, potentially making them more likely to be arrested.
Neurodiverse conditions often go unrecognised and/or are not always considered as part of mitigating circumstances within the criminal justice system.

Additional resources

References

The references for this section can be accessed here.