Immaturity in Young Children: Officially a Disease

I want to thank fellow member of Healthy Skepticism, Steindór J. Erlingsson, for alerting me to two articles in the relatively obscure jounal, the Journal of Health Economics, that both found nearly identical data about the diagnosis of ADHD in school children.  In the these articles, two different research groups (Evans, Morrill, &Parente, 29, 2010 657–673; Elder, 29 2010, 641–656) using four different data sets in different states came to the same conclusion.


They compared the rate of diagnoses of ADHD in the younger children in a particular grade with the rate of the diagnosis in the older children in the same grade.  This can be done using their birthdates.  When I was in school back in the stone age, the school year used to be divided into two semesters, with some children starting school in the middle of the year.  At that point, the first graders that started earlier would then be called A-1's while those that started later in the year would be called B-1's.  With this system, there was only a six month spread between the younger members of any particular class and the older ones.


Somewhere along the line someone decided to eliminate this system and have all the children born during a entire year - commencing on a certain "cut-off date" - start school at the same time.  This means that the youngest members of a grade school class can be up to a year younger than the oldest students.  Especially in the early grades, this undoubtedly means that the yonger children in a single class will be, on average, considerably less mature than the older ones.  In turn, this means that the average attention span and ability to sit still is likely to be considerably lower in the younger group.


In Elder's study, roughly 8.4 percent of children born in the month prior to their state’s cutoff date for kindergarten eligibility – who typically become the youngest and most developmentally immature children within a grade – were diagnosed with ADHD, compared to 5.1 percent of children born in the month immediately afterward. The study also found that the youngest children in fifth and eighth grades were nearly twice as likely as their older classmates to regularly use stimulants prescribed to treat ADHD!  The results of the second study were quite similar.


Translated into numbers nationwide, as Steindór summarized in his comment on my blog, this would mean that  between 900 thousand (Elder) and 1.1 million (Evans et al. 2010) of those children under age 18 in the US diagnosed with ADHD (at least 4.5 million) are misdiagnosed. 


Even this conclusion would presuppose that the older children were being correctly diagnosed, which is one hell of an assumption!  It is also quite possible, considering what this data means for the diagnosis itself,  that a lot of active and relatively inattentive or immature but otherwise normal kids in the older half of their classes are being labelled with a supposedly biogenetic disease. 


And these numbers do not take into account all the children who are misdiagnosed because they are in actuality distracted and jittery due to chaotic, neglectful or abusive home situations.  We're talking a lot of misdiagnosed children here.


If you don't believe the latter paragraph, consider a study by Strohschein,  (2007,  "Prevalence of methylphenidate use among Canadian children following parental divorce." Canadian Medical Association Journa,l 176(12), 1711-1714).  It showed that children of parents in the midst of getting a divorce were almost twice as likely to be put on Ritalin as children whose parents were staying together.  As we all know, people who have ADHD genes to pass to their kids are all genetically predisposed to get a divorce.  (For those readers who may be unfamiliar with concept of snarky sarcasm, that last sentence was a good example of it).


Indirect evidence that kids from bad environments, according to another study, are being mislabeled with biogenetic disorders is the fact that children in foster care in Texas are given heavy psychiatric medicines at a rate far greater than that seen for children not in foster care.   Does being placed in foster care also stem from having brain pathology?  Are headaches caused by a deficiency in the body of aspirin?

I write often, in this blog and in my book, about the misuse of legitimate psychiatric diagnoses to label and drug children who are really just acting out in response to social and family factors. Any journal article about "pediatric bipolar disorder" or ADHD that does not describe the methodology used to evaluate for and exclude acting-out or anxious children in the research subjects is automatically suspect in my mind. The docs who make these diagnosis are looking at extremely common behavior of children in certain contexts that could be easily be accounted for by family or other issues rather than by a biogenic disorder, yet are automatically jumping to the conclusion that a disease state exists.

ADHD has the longest history of any psychiatric disorder in terms of its basic validity being questioned - and not just by virulent antipsychiatry nut-jobs like Tom Cruise, but by many in the field as well as people in all walks of life. There may be children who do have brain pathology that causes symptoms of ADHD, but at the very least, the condition is obiously way over diagnosed.  I am hardly the only one around who thinks that.

When I trained in the 1970's, I recall that ADHD, which was called something different back then, was mostly described in children with dyslexia and other severe learning disabilities. Those kids just might have trouble staying focussed in class because of their disabilities. Interestingly, one rarely if ever hears about the role of dyslexia in ADHD any more.