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Development or Diagnosis?

Where the need for active engagement meets ADHD.

This blog is the first in a series on attention-deficit/hyperactivity disorder (ADHD) and youth development. Read part two: Asking the Hard Questions about ADHD and part three: Strong Relationships are Crucial in Treating ADHD.

Photo by freestocks dot org
Source: Photo by freestocks dot org

A recent study published in the New England Journal of Medicine found that younger children in their class were more likely to be diagnosed with attention-deficit/hyperactivity disorder (ADHD) than their older peers. In states that required kindergarteners to be 5 years old by a September 1 cut-off date, children who recently turned 5 in August were more likely to be diagnosed with ADHD than their September-born peers, who were nearly a year older. This finding is concerning, but not surprising. Often students’ behavior in school, specifically their “misbehavior” (stemming from difficulties with self-regulation, particularly around movement and speech), is interpreted as symptoms of ADHD. As a result, these children are diagnosed and are prescribed stimulants (sometimes as early as ages 3 and 4 or younger) when in fact the real issue is immaturity, not disorder. This can put a child onto a pathway of diagnosis, low expectations, and treatments, which can all have negative outcomes despite the positive aspirations and motivations of parents, teachers, and clinicians.

The scope of the issue can be seen in the numbers. There has been a significant increase of diagnoses just within the past two decades. Between 2014 and 2016, 10.6 percent of children aged 5-17 years old and 12.4 percent of children aged 10-17 years old were diagnosed with ADHD, up from 6.5 percent and 7.6 percent respectively from 1997-1999 (Centers for Disease Control, 2017). The median ages of diagnosis for moderate and severe ADHD are 6 and 4 (!) (National Institute of Mental Health, 2017). With about 56.6 million students in U.S. elementary and secondary schools as of the fall of 2018 (National Center for Education Statistics), that means between 5 and 7 million children in our school system are currently diagnosed with ADHD or “deserve” such a diagnosis. And of those children diagnosed with ADHD, according to the CDC, 62 percent are taking medication, with 18 percent of those children as young as 2-5 years old.

That said, there is no doubt that there are many cases where medication does incredible good. We have the great advancements of modern medicine to thank for having that capacity to help children who truly need it. I have personally seen almost miraculous changes, where children start concentrating, calming their behaviors, become strong learners and start receiving positive feedback instead of constant criticism. The medication can also reduce symptoms sufficiently so that actual productive development can occur with the support of peers and adults.

However, this study shows that we need to rethink the threshold we use to decide when kids are put on medication. Before that step, we need to explore other avenues, including a reduction of over-stimulation in the classroom environment and changing criteria on when children should start school (rather than using birth month). If these issues are left unaddressed, children will continue to face long-term use of medications beginning earlier and earlier in life. If people tell you that they can diagnose the difference between a stunted system in a 3, 4, 5, 6 or even 7-year-old from a child with a biologically-based impulse and ADHD, they are not admitting the limitations of our present knowledge base.

I am focusing on this topic because this issue gets to the heart of the tension between development and diagnosis. The study highlighted in New England Journal of Medicine provides evidence for time and maturation being important potential contributors to a medical, diagnostic approach where youth in the same cohort who have had time to mature and self-regulate are viewed as less disordered. Although it is clear that prescriptions for children can be beneficial in specific cases, the millions of students that have been put on ADHD medications represents a sloppy practice. A study showing that mere months can make a difference in ADHD diagnosis rates should give all of us pause and show us the importance of being patient with children as they develop.

Even when a pediatrician, child psychiatrist or child psychologist makes an ADHD diagnosis, medication should only be a portion of the treatment plan, which according to CDC treatment guidelines, includes behavior therapy for children and their parents and school accommodations and interventions. Unfortunately, as many as 30 percent of children diagnosed with ADHD are being treated with medication alone (CDC Data and Statistics about ADHD). In my next blog post on this topic, I will focus on what family members of a child diagnosed with ADHD should ask their child’s pediatrician, teacher, and other important adults in their lives to make sure their child receives the right accommodations and interventions to thrive.