# Early warning signs and comorbidities of attention deficit hyperactivity disorder in children in Western China: a multicenter, cross-sectional study

## TL;DR

This study finds that ADHD in children in rural western China is underdiagnosed and linked to comorbidities like behavioral issues and sleep problems.

## Contribution

The study identifies early warning signs and comorbidities of ADHD in rural Chinese children, emphasizing the need for better screening.

## Key findings

- Only 3.25% of children at risk for ADHD received a diagnosis or treatment.
- ADHD risk was strongly associated with abnormal behavior and daytime sleepiness.
- Family conflict and parental anxiety were consistently linked to ADHD risk in children aged 6–15.

## Abstract

This study aimed to investigate the prevalence of attention-deficit/hyperactivity disorder (ADHD) and its association with common comorbidities among children in rural western China, to improve early recognition of ADHD in children by identifying early signs.

A cross-sectional study was conducted with children aged 6–18 in rural schools across three provinces in western China. ADHD symptoms were assessed through caregiver-reported questionnaires utilizing the Swanson, Nolan, and Pelham Questionnaire-IV (SNAP-IV), without the involvement of clinical diagnosis. Propensity score matching and conditional logistic regression were used to analyze associations between ADHD risk and comorbidities while controlling for potential confounders.

2.07% of children were at risk for ADHD, with only 3.25% of them receiving a diagnosis or treatment. The risk of ADHD was significantly associated with the presence of family disharmony, sleep disorders, behavioral abnormalities, and parental anxiety and depression. After matching, the strongest associations were found with abnormal behavior (OR = 6.467, P < 0.001) and daytime sleepiness (OR = 1.128, P < 0.001). Age-stratified analysis revealed that family conflict, daytime sleepiness, abnormal behavior, and parental anxiety symptoms were consistently associated with higher ADHD risk in children aged 6–15 years.

In this cross-sectional study, the low diagnosis and treatment rates for ADHD in rural western China highlight significant gaps in recognition and intervention. Children at risk for ADHD was associated with various comorbidities, particularly behavioral abnormalities and daytime sleepiness, suggesting that screening for ADHD should be incorporated into assessments of children presenting with these comorbidities, especially in regions with low ADHD awareness.

The online version contains supplementary material available at 10.1186/s12889-025-26014-8.