Tuesday, March 20, 2012

Immaturity Officially a Disease: You Saw It Here First

The kid in red is in the same grade and classroom as the other four

In my post of September 20, 2010, Immaturity in YoungChildren: Officially a Disease, I described two studies published in a very obscure journal, 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. 

In one, 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.  

Now, a year and a half later, another study, published in a more widely read journal and reported widely in the news, came up with the exact same conclusion.  (“Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children” by Richard L. Morrow, et. al., Canadian Medical Association Journal, published on line March 5, 2012). 

In a cohort study (a study of a group of individuals with something in common followed over time) of more than 900,000 Canadian children, researchers found that boys born in the month of December (the cutoff birth date for entry to school in British Columbia) were 30% more likely to be diagnosed with ADHD than boys in their grade who were born the previous January.
This number was even more dramatic in the girls, with those born in December 70% more likely to be diagnosed with ADHD than girls born in January.
In addition, both boys and girls were at a significantly higher risk of being prescribed an ADHD treatment medication if they were born in the later month than in the earlier one.
 "It could be that a lack of maturity in the youngest kids in the class is being misinterpreted as symptoms of a behavioral disorder," said lead author Richard L. Morrow.  

Could be?  About about “is?”
Some of these behaviors could include not being able to sit still, not being able to focus and listen to the teacher, or not following through on a task, he added.

"You wouldn't expect a 6- and 9-year-old to behave the same way, but we're often putting a 6- and 7-year-old in the same class. And we're learning that you can't expect the same behaviors from them," he added. "We would like to avoid medicalizing a normal range of childhood behaviors."  No sh*t!

This problem has been complicated recently by the fad of "redshirting" children for kindergarten: overachieving parents purposely starting them at age six rather than five in order to give them a competitive advantage academically over their classmates.  Now children in the same class may be as much as two years apart in age.
The study authors went on to  note that potential harms of overtreatment in children include increased risk for cardiovascular events, as well as effects on growth, sleep, and appetite.  There was no mention of the harm of making this diagnosis and using these potentially toxic medication instead of investigating and addressing possible psychosocial reasons for “hyperactivity” such as a chaotic family environment or abusive and/or inconsistent parenting practices.
This brings up the issue of the risk to the heart and the rest of the cardiovascular system posed by stimulant use.  There have been several studies recently published that have been reported in both the medical and lay media that claim that this risk is minimal.  

This is in an interesting contrast to the publicity about an article, published this week in BMJ Open (the online version of the British Medical Journal)  that purported to show that the use of sleeping pills increases the risk of dying from all causes by a factor of 4 over just two and a half years.  Sleeping pills are generally regarded as far less dangerous and less likely to be abused than stimulants.  The FDA categorizes benzos as "Schedule IV" (lower likelihood of abuse) and stimulants as "Schedule II" (most likely to be abused short of the illegal "Schedule I" drugs).
That study about sleeping pills seemed to me to be a bit hard to believe, especially since epidemiological studies are notoriously unreliable.  But even if the numbers are valid, the fact that the risk of death from all causes increases most likely means that there is  some other characteristic, or a bunch more characteristics, of the population of people who are prescribed sleepers that are not characteristic of other populations. Those additional factors might explain the findings.
As for stimulants, in the February, 2012 issue of the American Journal of Psychiatry, there is an article on methylphenidate (Ritalin and its variations) and risk of heart problems in adults. Using a large medication database, researchers matched about 44000 methylphenidate (MPH) users and about 176,000 controls. 

They looked at main the incidence of a cardiac event defined as a myocardial infarction, stroke, ventricular arrhythmia, or sudden death. They found a 117% increased risk - or over double the risk – in the Ritalin group. After adjustment for some potential confounding factors, the risk was still 84% higher.
The news stories about the study on the benzo’s seemed to be meant to scare people out of using them, while the stories about increased risk in stimulant users seemed to be meant to reassure people about using them.  Of course, both of these studies described relative risk and not absolute risk (See my post from November 2, 2011).   

This means that  “double the risk” means the risk might go from, say, a tenth of a percent to two tenths of percent.  Double a very small risk is still a very small risk.  The absolute risk in this example would have gone up just one tenth of one percent.  Still, if millions of people are getting the prescriptions, this increased risk can still turn out to apply to a sizeable number of people.

Physicians will not be able to see the increased risk in their clinical experience.  As Nassir Ghaemi says,They don't happen in 10-20% of patients in our practice; they happen in 1-2% (or 0.1-0.2%), and so, the average clinician, faced with a welter of patients, doesn't make the causal connection.”

The question should be, what are the risks versus the benefits from taking the medication.  For sleeping pills, for instance, one might want to know if there is a much larger increased risk of death for people who are sleep deprived.  For example, before the practice was stopped, medical interns would routinely work 36 hour shifts.  Fatal accidents on the car trip from the hospital back home were not all that unusual.

Then there is the whole question of other, non-pharmacological treatments, which is relevant for both the use of sedatives and stimulants.  Of course, they do not work for everyone either.

An editorial in the same issue of the American Journal of Psychiatry as the study of Ritalin in adults sounded reassuring about stimulant use.  Based on that study, I’m not so reassured.  


  1. This sounds really similar to that book "Outliers". A study was done in Canada (where hockey is a big thing), and pro hockey players tended to be born in the early months of the year. And they realized that it's because, by the time the scouts show up looking for young, new, hockey players, the older boys in their age group were more likely to be noticed by the scouts. They would receive lots of extra training and eventually become pros. Like if your kid was in hockey for 7 year olds, but he was born in January and the other 7 year olds were born in December, he would have almost a year on them, so he would be bigger, stronger, and probably a better player. As a result, he would be singled out as a star even though it really had more to do with his age than anything else. It was a good book. You should read it.

    There was another thing I thought was interesting. I think it was on wikipedia. I was reading about homeschooling and there was a study done in the 70s that basically stated that we actually start kids in school at too young an age. According to the study, the average kid doesn't have the kind of mastery of etiquette that would be necessary for public school until they are between the ages of 8-10. So there are some kids who are settled down enough by 8 to be a productive student...but what about the people who do not blossom until they are 10?

    Personally, if I ever have kids, I might just homeschool them until they hit middle school or high school. IMO, I think I could probably give them a better education when they are little than a public school could. I've heard homeschooling is usually way more effective than traditional schools no matter what the grade.

  2. Outliers, Malcolm Gladwell, a best seller, (actually four best sellers under his belt)! His formula or algorithim for holding children back and then trying to justify it - quite revolting. I personally think the parents should be held back and let the children grow through trial and error and does not need to be dictated to any parent with a caring heart and brain. Hold your children in your arms and read and count with them - my mother can still teach a dog to read! Just kidding, but as far as back as I can remember, she would comfort the less fortunate, rock crack babies, teach ABCs and make learning inclusive and wonderful. This should be our focus and expectation from a country given and blessed with so much. Wonderful and insightful post, as usual.

  3. About the risks of stimulants in adults and children and sleeping medications --

    As you've noticed, there's spin in both reports. In minimizing the danger to children of psychiatric drugs, you may discern the hands of pharma and the new child-drugging faction of medicine. They'll deny to their last breath that their practices are harming children. We'll have to see the bodies first.

    The warnings about sleeping medications may be coming out of the wave of public health concern about burgeoning abuse of prescription drugs.

    All of this activity is politically and economically motivated, though not necessarily by the same groups at the same time.

    However, one thing you can take to the bank is that chronic treatment with any kind of drug is going to have some kind of deleterious effect, amplified by the drug combinations so many people are taking now. Drugs of any type should be minimized. Doctors should be very reluctant to add anything to anyone's drug burden.

    The question is not how to balance risks of chronic sleeping medication vs the health danger of insomnia but how to balance the risks of chronic medication in combination with all the other medications the person is taking and the person's other health risks.

    All non-drug alternatives should be thoroughly exhausted before chronic medication is prescribed for any condition.

    David Healy's new book Pharmageddon is about just this, the wages of chronic medication cocktails across a large swath of the population. We are entering an unprecedented era, driven by pharma sales, where many people are chronically overmedicated and their health damaged as a result. He proposes the term "pharmacosis" for this hidden epidemic of iatrogenic harm.

  4. Speaking of which:

    One can see this as a turf war among medical specialties, each insisting getting their drugs into the patient takes priority over the others.

    Perhaps overmedication is performing the necessary function of decreasing the surplus population, as Scrooge would say.