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

Michael Fleming*, Ehsan E. Salim, Daniel F Mackay, Angela Henderson, Deborah Kinnear, David Clark, Albert King, James McLay, Sally-Ann Cooper, Jill P. Pell

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

28 Citations (Scopus)
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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.

Original languageEnglish
Article numbere1003290
Pages (from-to)e1003290
Number of pages24
JournalPLoS Medicine
Issue number10
Publication statusPublished - 13 Oct 2020

Bibliographical note

Data Availability:
All health data are owned by the Information Services Division of NHS National Services Scotland (, and all education data are owned by the ScotXed Unit, which is part of the Educational Analytical Services Division within the Learning and Justice Directorate of the Scottish Government ( Interested researchers may apply at these sites for data access.

The study was sponsored by Health Data Research UK ( (grant reference number MR/S003800/1) (MF) which is a joint investment led by the Medical Research Council, together with the National Institute for Health Research (England), the Chief Scientist Office (Scotland), Health and Care Research Wales, Health and Social Care Research and Development Division (Public Health Agency, Northern Ireland), the Engineering and Physical Sciences Research Council, the Economic and Social Research Council, the British Heart Foundation and Wellcome. There was additional funding from the Carnegie Trust for the Universities of Scotland (grant reference VAC007974) (EES) and an MRC Mental Health Data Pathfinder grant (grant reference MC_PC_17217) (MF, JPP, DK, SC).


  • children
  • ADHD
  • Schools
  • Depression
  • intellectual disability
  • Autism spectrum disorder
  • Labor and delivery
  • Scottish people


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