Monday, September 20, 2010

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.


  1. As we all know, people who have ADHD genes to pass to their kids are all genetically predisposed to get a divorce.

    Well ... they may be more likely to, at least?

    Is that really so far-fetched? I suspect the total picture may be a complex mixture of factors.

  2. Hi Holmegm,

    Yes, actually I do believe that it is far fetched, and let me tell you why. While there may be some genetic influence on one's choice of mate because of assortative mating, the neuroscientists I read (like molecular biologist John Medina) say that there is a general consensus that no genes or group of genes codes for any complex human behavior - such as whether or not your marriage ends in divorce.

    It seems to me far more likely that the explanation is that the children of divorcing parents are on average more likely to be stressed out and to act out.

  3. Dr. Allen,

    Like other psychiatric "illnesses," "ADHD" is a collection of symptoms...

    Dr. Mary Ann Block provides some Congressional testimony on the subject of ADHD diagnosis, amphetamine use, and integrative (non-drug) options that are both safer and more effective than amphetamines -

    For any parent who is concerned about the use of psychiatric drugs with their child, and any good parent should be!.... Here are some links that may help for integrative approaches to mental wellness -


  4. Thank you for writing this post. In my native Iceland (population 310k) there has in recent months been some debate about ADHD and the potential abuse of the stimulant drugs used to treat it. What is interesting about this "debate" is that nobody discusses the elephant in the room:

    Despite an ADHD prevalence similar to the US, the use of stimulant drugs in Finland is not only vanishingly small in comparison to the US, but smaller than in the other Nordic countries. Stimulant use is 22 times higher in Iceland, 8 times higher in Norway, 3 times higher in Sweden, and twice as high in Denmark as it is in Finland, despite the fact that use in Finland has increased by more than an order of magnitude between 1999 and 2005. (1)

    It is not only in stimulant prescription to children and adolescents that Iceland holds the European record (in per capita terms), as the same applies to antidepressants (actually the world record) and antipsychotics(2). The physicians who have participated in the ADHD "debate", defending the drug use, have never discussed these facts, not even the ones who have written scientific papers about this dreadful situation.

    Last spring I wrote an article about this issue in Iceland's leading newspaper but it did not spur any public discussion, but I know that it had some impact behind the scene. The papers you discuss in your blog post have now given me an opportunity to address this issue again in a newspaper article, which is awaiting publication. My hope is that it will start a debate about the real issue, i.e. the overprescription of psychotrophic drugs to children and adolescents in Iceland (the same actually applies to adults!).

    (1) Leon Eisenberg1 and Myron Belfer, "Prerequisites for global child and adolescent
    mental health", Journal of Child Psychology and Psychiatry 50:1-2 (2009), pp 26–35, p. 31.
    (2) Helga Zoëga et al., "Psychotropic drug use among Icelandic children: A nationwide population based study", Journal of Child and Adolescent Psychopharmacology. December 2009, 19(6): 757-764.