Does a fidgety, distractible, and disruptive youngster have attention deficit hyperactivity disorder? Or is the behavior just an example of the emotional ups and downs of young childhood?
A recent highly-publicized study in Taiwan has renewed interest in this question. Its findings—and the results of similar studies conducted in other countries—lend credence to the idea that immaturity may be driving some diagnoses and subsequent medication for ADHD, a disorder linked to inattention, impulsive behavior and excessive activity. Several other studies have had similar results. We’ll talk about the findings here, and offer some takeaway tips for educators and parents.
Linking ADHD to Relative Age
In Taiwan, the cutoff age for school entry is Aug. 31. (Compulsory education begins at age 6, but children can enroll in preschool at age 4.) Children born in August would typically be the youngest children in their class. Children born in September, on the other hand, would be the oldest.
The study, Influence of Relative Age on Diagnosis and Treatment of Attention-Deficit Hyperactivity Disorder in Taiwanese Children, published March 10 in the Journal of Pediatrics, looked at more than 378,000 children ages 4 to 17, between 1997 and 2011. Researchers found that 4.5 percent of boys born in August—the young ones—were diagnosed with ADHD, and 3.3 percent were taking medication for it. In contrast, among boys born in September—children who would be the oldest of their grade-level peers—2.8 percent were diagnosed with ADHD and 1.9 percent were taking medication.
Among girls, the same pattern held but the overall rates of diagnosis were much lower. The study found that 1.2 percent of August-born girls were diagnosed with ADHD and 0.8 percent were taking medication; among September-born girls, 0.7 percent were diagnosed with ADHD and 0.5 percent were medicated for it.
As the researchers examined births through the year, they found that the closer that children were to the school enrollment cut-off age, the more likely they were to be diagnosed with ADHD. The pattern was true for preschool and elementary-school children, but not adolescents. The researchers think overall age and maturity could be behind this difference.
Other research has come to the same conclusion, including studies conducted in the United States, Canada, Iceland and Sweden. Interestingly, the pattern did not hold true in among children in Denmark, according to one study. In Denmark, children generally start school in the year they turn 7. Researchers in the Denmark study suggest that the difference may be that many Danish families—about 40 percent, in this study— hold their children out from formal education if they are born late in the calendar year.
The ADHD Diagnosis Takeaway for Educators and Parent
Whatever the causes for ADHD, it’s on the rise in the United States. About 7.8 percent of children ages 4-17 were diagnosed with ADHD in 2003, but by 2011 that had risen to 11 percent—about 6.4 million kids.
A valid diagnosis of ADHD should be made after examining how a child behaves at school, at home, and with his or her peers, said David Anderson, the senior director of the ADHD and Behavior Disorders Center at the New York-based Child Mind Institute. The behavior has to be occurring in more than one context, and these studies suggest that careful diagnosis is not happening everywhere, he said.
But parents need not fear an evaluation, Anderson said. They should look for practitioners who are as willing to consider other explanations as they are to “rule in” ADHD, he said. That health-care provider should also be willing to explain the evidence base behind any treatment, Anderson stressed.
And because school is such an important part of a full evaluation process, teachers need to be prepared to offer their assessment. This ADHD checklist from the Centers from Disease Control and Prevention offers an sample of behaviors to be aware of.
And finally, ADHD does not always require medication. “Parents are expecting that we’re going to tell them they must pursue medication,” he said. But “we can engage in a number of environmentally based interventions in order to help support that child’s function.”
Behavioral therapy is the preferred first step for children under age 6, according to the American Academy of Pediatrics, and parents often feel more comfortable with therapy than with medication for young children, Anderson said.
The Centers for Disease Control and Prevention says several parent training programs are effective for children with ADHD and disruptive behaviors in general, including Triple P (Positive Parenting Program) and the Incredible Years parenting program. What these programs all have in common is that they want the adults in a child’s life to reinforce positive behaviors.
In school, an intervention program such as a Daily Report Card can be an effective way to consistently reward children for positive classroom behavior.
These concepts are so much easier to think about conceptually than they are to actually apply,” Anderson said. “It requires going against basic human behavior, which is noticing the behaviors that frustrate us.” But “catching children being good” can be remarkably effective, he said.
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