The conundrum between maturity and ADHD

A recent Canadian study showed that the youngest children in each grade (born in the earliest month of the Canadian grade cutoff: December) were 30% more likely to be diagnosed with ADHD than the oldest children (born in January). For girls, who overall have a lower incidence of ADHD, the difference was even more pronounced: 70%.

Interestingly, the overall rate of ADHD diagnosis in the sampling of children from this Canadian study (900,000 children) was 6.9% for boys and 2.2% for girls. Rates of diagnosis here in the United States are much higher, creeping up on 10% of all children.

What does all of this mean? Well, you can look at this data many different ways, depending on your point of view and feelings about ADHD, but it stresses to me what seems to be common sense: many factors play into our expectations of what normal behavior should be.  It is often the school which prompts parents to have their child evaluated for attention problems and this comes from a comparison to other children in the class. A six year old may be significantly less mature or able to stay on task than a seven year old. Likewise, boys tend to have more trouble with the expectations of the school environment than girls in the younger grades.

Both of these groups, boys, and the younger ones in class are diagnosed and treated for ADHD at higher rates. I have ambivalent feelings on the matter. Medications are not without their side effects but most parents see an improvement in behavior with minimal negative effects. If these compounds work, if they create better students, what difference does it make what groups have higher rates of diagnosis and treatment?

I don’t know if it makes any difference, provided the medications are safe and effective. There is still, however, some part of me that questions the introduction of a medication to a mind that is still maturing, unless it is absolutely necessary. Is there a “natural process” for the creation of self control in the brain? Are we creating a reliance on an artificial substance, or missing some environmental piece of the puzzle, like sleep? I simply do not know.

Most clinicians and experts would argue ADHD is like any other organic disease. You do not choose not to treat diabetes. If that is the right way of looking at it, I think this study tells us we need to be more careful about how we choose who is selected for this diagnosis, at the very least.

Matthew Toohey is a pediatrician who blogs at The Pediatrician Next Door.

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  • broadthinking

    What’s not said: today’s “teach to the test” curriculum has taken much of the hands-on joy out of learning. Creative teaching on the part of teachers, and creative thinking on the part of kids, has given way to endless worksheets focused on improving standardized test scores. Boredom can be the cause of increased inattention.  I’ve seen what my fourth grader has to sit through – it wouldn’t hold my attention either. And yes, it has been suggested to us that he be tested for ADHD.

    • http://twitter.com/Dr_Toohey Matthew Toohey MD

      I wholeheartedly agree. I think we need to start considering our expectations of children and work within the bounds of what they can realistically do before we tell parents they have an organic problem in their minds.

  • http://twitter.com/SurvivingADs Surviving ADs

    “….however, some part of me that questions the introduction of a medication to a mind that is still maturing….”

    Doctor, don’t let your conscience get in the way of writing ADHD prescriptions for children who may simply be distractable because of their age!

  • http://www.facebook.com/jonathan.marcus.ca Jonathan Marcus

    I’m a family doctor in Toronto.

    ADHD is not like any other organic disease such as diabetes.  We do not know the pathophysiology if any.  There is no blood test, etc. to rule it in or out.  It’s diagnosis is subjectively arrived at by a series of criteria which were determined by committee.  The symptoms on the milder end blend into normal human behaviour.  I think we need to be very careful in the diagnosis and treatment and have great humility…. ADHD is a provisional diagnosis that may be supplanted by others as we learn more and diagnostic criteria change over time.

    • http://twitter.com/Dr_Toohey Matthew Toohey MD

      Jonathan,
      You make a point that I try to bring up with all families who come to me with concerns about attention or distractibility: the spectrum of normal human behavior. I strongly feel, as I think many other people do, that psychiatric diagnoses blend into what we call ‘normal’ on a gradient. I’m not sure we will ever be able to draw that line in the sand and say one person has a disease state and one doesn’t. That’s what makes these issues so difficult, and why I feel we should honor the idea of ‘do no harm,’ by erring on the side of NOT medicating when the situation is ambiguous. 

      • http://profile.yahoo.com/N5ET6XIC4NYV4NTCOZ62LKLGPQ Frank

        I often explained to my patients that like height, the ability to pay attention is distributed along a bell shaped curve – some kids have long attention spans (tall), some have short attention spans (short stature) and most are in-between.  Is it really a disease to be at one end of the spectrum (assuming there is no organic or emotional cause)?  Who decides what is abnormal?  Is it the bottom 3?, 5?, 10%, 25%??? Partly, it depends on what is expected (or needed) to be learned in the educational system.  That has changed a lot since the old days when most kids grew up to be farmers, laborers, and housewives.

  • Payne Hertz

    I’m glad to see someone is questioning the high prevalence of ADHD diagnoses in kids today.  There is something extremely wrong in a society where 25 percent of children are on some kind of regular medication for ADHD and other over-diagnosed “disorders.” Are we raising a generation of kids who are drugged into oblivion whenever they show any signs of individuality or deviating from the norm?

    There is something  warped and frightening about the way children today are expected to behave as impassive and compliant myrmidons at all times lest they be drugged up (or imprisoned).

    As America becomes increasingly authoritarian, I think we can expect a lot more psychopathologizing of normal childhood behavior. Concurrent with this there is the rise of “zero tolerance” policies in schools where kids are subjected to draconian punishments for things like setting off firecrackers or wrestling.

    Psychologist Bruce Levine has an interesting take on this that strikes me as spot on:

    http://www.madinamerica.com/2012/02/why-anti-authoritarians-are-diagnosed-as-mentally-ill/

    “Albert Einstein, as a youth, would have likely received an ADHD
    diagnosis, and maybe an ODD one as well. Albert didn’t pay attention to
    his teachers, failed his college entrance examinations twice, and had
    difficulty holding jobs. However, Einstein biographer Ronald Clark (Einstein: The Life and Times)
    asserts that Albert’s problems did not stem from attention deficits but
    rather from his hatred of authoritarian, Prussian discipline in his
    schools.”

  • bojimbo26

    A long article to say ” don’t make love during certain calender months ” .

  • http://twitter.com/Dr_Toohey Matthew Toohey MD

    Many great minds did not do well with the structured environment of school, Einstein being one great example. This is not to give every child without self control a free pass to torture teachers but more to say that our idea of how a ‘good’ student should develop needs evaluation. Do we catch those rare sparks or try our best to extinguish them? I think that must be a very difficult job for teachers today, where demands very structured in terms of ‘success.’

  • http://twitter.com/lizditz Liz Ditz

    There’s another issue you didn’t address, Dr. Toohey:  developmentally inappropriate curriculum beginning in preschool.  Handwriting in preschool?  Standardized testing?  No time for play?   See the 2009 report from The Alliance for Childhood by Edward Miller and Joan Almon, “Crisis in the Kindergarten”

    • http://twitter.com/Dr_Toohey Matthew Toohey MD

      It took me several days between patients to read through the PDF you suggested. I’d have to say I agree completely. Over and over again, we see our manipulations and best intentions lead us in the wrong direction.

       I think the expectations in the early grades are not consistent with what nature presents to us in a 5 or 6 year old child and how they interact with the world (particularly boys). An author named Jonah Lehrer was on the Colbert Report (I love that show) this week talking about creativity and how it comes during periods of relaxation and downtime. I know that a combination of hard work and ‘nonthinking’ activities like hiking, cooking and gardening make me more productive than hard work alone. This need for less structured, more creative, more physical time is important for me, and I would think even more so for children. Thank you for the resource!