12 December 2018

Could starting school young lead to false diagnosis of ADHD?

Research suggests that particularly in the early grades, age gaps can make a big difference to pupils' behaviour.

Does being the youngest in the class up your child's odds of being erroneously diagnosed with attention deficit hyperactivity disorder (ADHD)?

It might. New research suggests these kids appear to be about 30% more likely to receive a diagnosis of ADHD. However, it probably doesn't change a child's actual risk of developing ADHD.

Overdiagnosis of ADHD

So if your child was an August baby and your school district has a 1 September birth date cutoff for school admissions, your child will be one of the youngest in class. And, particularly in the early grades, those age gaps can make a big difference in behaviour, researchers said.

"Physicians should take into account a child's age relative to their peers. Behaviour that is normal for a child's age may appear anomalous when compared to older peers," explained study author Timothy Layton, an assistant professor of health care policy at Harvard Medical School.

The consequences from not factoring in age might be overdiagnosis and overtreatment of the disorder, according to Layton. He noted that kids born in August (in areas with a September birthday cutoff) were also more likely to be given medication for ADHD symptoms.

ADHD is a neurodevelopmental disorder that's common in children, but it may not always last into adulthood, according to the US Centers for Disease Control and Prevention. Kids with ADHD may have trouble controlling their behaviour, may act impulsively and may be overly active, the CDC says.

ADHD rates have been rising sharply among America's youth. Over the past two decades, the rate of ADHD jumped from 6% to 10%, according to a recent study from the University of Iowa.

No single test for ADHD

In children between ages two and five, the rate of ADHD diagnosis went up by 50% between 2007 and 2012, according to background information from the study. In 2016, more than 5% of US children were being treated with medication for ADHD.

There's no single test that can diagnose ADHD, the CDC says. Instead, doctors must rely on a medical exam, along with information from parents, teachers and, sometimes, the child. Doctors have to rule out other disorders that can cause symptoms similar to ADHD.

To see how a child's birth date might affect the risk of being diagnosed with ADHD, the researchers reviewed data from a large insurance database with information on more than 400 000 youngsters from 50 states. The kids were born between 2007 and 2009, and followed through 2015.

In states that had a September 1 cut-off date for starting preschool, the researchers found that 85 out of 10 000 August-born youngsters were diagnosed with ADHD. For those born in September, the ADHD rate was 64 per 10 000 kids.

When the researchers looked at treatment for ADHD, they found that 53 out of 10 000 children born in August were getting ADHD medication, compared to 40 out of 10 000 kids born in September.

Nicely designed study

Layton said these findings would likely hold true in districts that had other cutoff dates for starting school. For example, in a school with a 1 December birthday cutoff for school entry, kids born in November would probably be more likely to receive an ADHD diagnosis than kids born in December.

Dr Andrew Adesman, chief of developmental and behavioural paediatrics at Cohen Children's Medical Center in New Hyde Park, New York, said, "This nicely designed study has confirmed what several other investigators have likewise demonstrated — that the youngest children within a grade are more likely to be diagnosed with ADHD than are the oldest children in that same grade."

Adesman, who was not part of the study, said that if the researchers looked at kids closer in age in the same grade, say, just a few months apart, the differences would likely be smaller.

He said this study suggests that parents of kids who are young for their grade who have ADHD symptoms may want to consider having their child repeat a grade. This might give a child time to mature, so he or she will behave more appropriately in school.

The findings were published in the New England Journal of Medicine.

Image credit: iStock


Ask the Expert

ADHD Expert

Dr Renata Schoeman has been in full-time private practice as a general psychiatrist (child, adolescent and adult psychiatry) since 2008, currently based in Oude Westhof (Bellville). Renata also holds appointments as senior lecturer in Leadership (USB) and as a virtual faculty member of USB Executive Development’s Neuroleadership programme. She serves on the advisory boards of various pharmaceutical companies, as a director of the Psychiatric Management Group (PsychMG) and is the co-convenor of the South African Society of Psychiatrist (SASOP) special interest group for adult ADHD, and co-founder of the Goldilocks and The Bear Foundation ( She is passionate about corporate mental health awareness and uses her neuroscience background to assist leaders in equipping them to become balanced, healthy and dynamic leaders that take their own and their team’s emotional, intellectual, social health and physical needs into account. Renata is academically active and enjoys research and collaborative work, has published in many peer-reviewed journals, and has presented at local and international congresses. She is regularly invited to present at conferences and to engage with the media. During her post-graduate studies, she trained at Harvard, Boston in neurocognition and neuroimaging. Her awards include, amongst others, the Young Minds in Psychiatry award from the American Psychiatric Association, the Discovery Foundation Fellowship award, a Thuthuka award from the NRF, and a MRC Fellowship. She also received the Top MBA student award and the Director’s award from USB for 2015. She was a finalist for the Businesswomen’s Association of South Africa’s Businesswoman of the Year Award for 2016, and received the Excellence in Media Work award from SASOP during 2016.

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