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YOUNGER children are twice as likely to be prescribed medication for attention deficit hyperactivity disorder (ADHD) than their older classmates, suggesting that immature children are being mistakenly diagnosed with the disorder.
Research published in the MJA found that children aged 6–10 years in 2013 and born in June – the last month of the recommended school-year intake in Western Australia – were “about twice as likely to have received ADHD medication [in 2013] than those born in the first intake month (the previous July); the relative risks (RRs) were 1.93 for boys (95% confidence interval [CI], 1.53–2.38) and 2.11 for girls (95% CI, 1.57–2.53)”.
“For children aged 11–15 years [in 2013], the effect was less marked, but still significant (RR: boys, 1.26; 95% CI, 1.03–1.52; girls, 1.43; 95% CI, 1.15–1.76),” the researchers wrote.
The prescribing rate for the children in the study was 1.9%, comparable to a similar Taiwanese study (1.6%), but around half the rate of three US studies (4.5%, 5.8% and 3.6%), which also found late birth date effects in ADHD diagnoses.
Dr Jon Jureidini, a child psychiatrist and head of the University of Adelaide’s Paediatric Mental Health Training Unit, told MJA InSight that the prescribing rate was important.
“That’s what this study adds to the debate,” he said. “It shows that late birth date effects occur not only in high-prescribing districts, but also in low-prescribing districts where you would expect that [those diagnosed] would be so-called ‘real’ cases [of ADHD].
“What this shows is that included in the cohort [of children diagnosed with ADHD] appear to be immature kids.”
Lead author of the MJA study, former WA state member of parliament Dr Martin Whitely, told MJA InSight that a diagnosis of ADHD was “a dumber down label that does nothing to explain the causes of a child’s problem behaviours”.
“When kids are given amphetamines because they are less mature than their older classmates, you have to ask what happened to ‘first do no harm’? Accepting as an act of faith the hypothesis that ADHD is caused by a biochemical imbalance has benefits for everyone, except the child.
“It’s a great money earner for ADHD specialists, parents are told to stop looking for other causes of problem behaviours and teachers get a quiet, compliant class.”
One WA psychiatrist prescribed stimulants to 2074 patients in 2015.
“How much time is he spending with each patient and how often does he not diagnose ADHD?” Dr Whitely asked.
Dr Whitely said he hoped his co-authored research would be taken further.
“Other states, NSW for example, have greater flexibility in letting parents decide when their children start school – the question is, does that have a protective effect or does it make the ADHD late birth date effects worse when there’s a greater age range in the classroom?
Dr Christopher Pearson, a paediatrician with the Women’s and Children’s Hospital in Adelaide, and the author of a linked editorial in the MJA, told MJA InSight that children with problems such as high activity, impulsivity and poor control were getting diagnosed with ADHD “because a treatment is available”.
“But diagnosis is not that simple. We should not put labels on children unless it may be of benefit to the child.
“There is a lot of pressure to make the diagnosis [of ADHD]. Kids who don’t fit in a box and need help get diagnosed because there’s National Disability Insurance Scheme funding available.
“But we need to be very careful. It’s important that we keep in mind differential diagnoses – anxiety disorders, attachment disorders and autism spectrum disorders.”
In his editorial, Dr Pearson concluded that:
“Should we recommend medication, it should be viewed as a trial looking for clear evidence of benefit; and if side effects occur, they should not outweigh the benefits when we evaluate the response of the child. Finally, the period of treatment should be limited, and medication re-commenced only should there be evidence of clinical deterioration following its withdrawal.”
Professor Simon Clarke, from the Children’s Hospital at Westmead and the University of Sydney, said that putting young children, particularly boys, into classes with children up to 18 months older than them was a disaster waiting to happen.
“We used to say ‘beware the four-niners’,” Professor Clarke told MJA InSight.
“You can’t put boys who are 4 years and 9 months old in a class with girls who are 11 months older than them. It’s asking for trouble. They’re not emotionally or socially ready for school. They should be out playing.”
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I think the issue is that misdiagnosis can include kids who have ADHD and are told it’s something else. It would be good to look at the research directly and also look peer review and start seeking larger studies. I don’t think we should base any of this on anyone emotions and whether someone has had their child misdiagnosed and treated, especially since treatment hasn’t shown significant harm to most kids.
So, we can cry hypocrisy all we want, but we need to address the fact that there is a well know anti-medication community in Psychology as well as other fields, but particularly in regards to psychology. Which means, it does little to fixate on hypocrisy and focus more on the concern as how the diagnosis strategy can be improved and see what happens. And addressing the authors own bias and yet, I rarely see people who take issue with prescribing stimulants quite solidly done research that peer reviews a study they quote. This concerns me.
With this said, I don’t see evidence that people aren’t allowed to express a view that differs, but that people are concerned about how the public will respond to hearing such views since it took a long time to get parents to take mental health serious when it came to kids. There was a time people thought you could beat kids into behaving well, practically anytime they thought necessary, only to realise later that the child actually had a legitimate issue. The desire is to protect present and future kids from this kind of thinking resurging and challenging people who interact with kids regularly to consider that we should logically assess a child behaviour before assuming punishment will fix them and maybe consider there is something else we should looking for. We need to keep in mind that there are people on both side who simply want to help kids.
Overall, I think Alison makes a good point, from what I’ve seen studies wise, treatment of ADHD is rather a small percentage compared to diagnosis. So, it seems many kids who are diagnosed aren’t being treated.
Why is it that likely all here who criticise the authors of the article have not had their own child misdiagnosed and wrongfully put on amphetamines? And why is it that the critics here do not declare their own bias towards diagnosing ADHD? Hypocrites who do harm.
The authors both have an appalling history of ad hominem attacks and bias. What’s good for the goose is good for the gander. Why are they not approaching autism, anxiety disorders/OCD and childhood depression? These all have similar epidemiology trends, they share with ADHD increased recognition over the last 30 years. Why do they not declare their profound bias. Any serious research considers the null hypothesis. As for howled down, try supporting those with ADHD and see what happens – stigma is profound.
Recent unbiased Australian government driven research shows around 7% of Australian kids have ADHD national Survey of Mental Health of Children and Adolescents “comparison of the three disorders included in both the 1998 and 2013-14 surveys suggests that overall prevalence has remained relatively stable, with modest declines in prevalence of ADHD and conduct disorder and a modest increase in the prevalence of major depressive disorder.” https://www.health.gov.au/internet/main/publishing.nsf/Content/9DA8CA21306FE6EDCA257E2700016945/$File/child2.pdf
Only 13% of Australian kids with ADHD receive stimulants and full diagnostic fidelity of those children who do get medicine is around 80 %. Large bodies of research show they are both safe and one of the most effective treatments we have (one which recent research shows normalises brain development Rappaport et al 2016). Diagnosis and treatment saves lives and prevents injury (Chang et al 2015). I am much more concerned about stigma, under diagnosis and under treatment.
The sustained ad hominem attacks against the research authors really needs to stop. They are consistently reporting on over-medication of kids diagnosed with ADHD because there is amply evidence that there is mass over-medication.
It should be obvious to anyone who reads the ADHD literature, or any critique of the evolution of the DSM (including by its past chief editors) that ADHD is massively over-diagnosed, and the reasons why should be obvious to anyone who understands how Big Pharma pushes the medicalisation of variants of normalcy, and to anyone who understand education and how NDIS funding encourages/skews diagnoses.
Here, the findings are the findings. Assuming the replicated findings in multiple countries are correct (that younger kids in their respective early grades are significantly more likely to be diagnosed with ADHD), they alone are damning evidence of over-diagnosing — the alternative, that every year, younger kids are 1.5-2x more likely to actually HAVE ADHD, is preposterous.
Finally a comprehensive reply to this appalling propaganda
http://www.smh.com.au/comment/scientists-lurid-claims-about-adhd-do-parents-no-good-20170131-gu2ajh.html
Interesting the discrepancy between the comments section and the poll results. Clearly many doctors share the concern about over diagnosis and the associated use of amphetamine like medications in children. However they are also concerned about being howled down for daring to express a view.
Medical students are taught that one cannot make the diagnosis before 5 years of age
It is very worrying that practitioners are both making a diagnosis which may be labelling a child & prescribing stimulants before this age.
Andrew Nielsen – repeating a year – or starting school a year later – works for some children, but not all, regardless of ADHD or any other learning difficulty/difference. If a bright or gifted kid is held back a year, their situation might well get worse. If they are ready to start school with their age group peers and excel even though 11 months younger than the oldest in their class, why put them through the torture of holding them back? If they have ADHD, they will still have ADHD if held back a year. This strategy is more likely to cause frustration, a lack of focus and disengagement with education, if the bright kid already knows the content.
The first author is notoriously against ADHD, even denying that it exists. He has very strong personal views from his teaching experience, but he does not appear to have anything other than very one-dimensional views on diagnosis and stimulant prescription and I suspect that he cherry-picks evidence to support his views. He lacks knowledge about the different types of ADHD and individual variations in behaviour. He also makes life very much more difficult for individuals with ADHD and health professionals who specialise in this area, by questioning the existence of the disorder, and using language such as ‘dumbing down’ and psychiatric. ADHD is a neuro-developmental condition, not a mental or psychiatric illness. Whitely is doing his best to ensure that children and adults with ADHD continue to be misunderstood by the community, and continue to to be denied the supports and adjustments that they need in education and the workplace. Discrimination and stigma are very common and these authors are enabling this to continue.
The fact that the paper was written by a campaigner really does kill its credibility. On the other hand, the findings are not new at all. There is even a dose response, seen when the children are assessed by month of birth. It seems that repeating a year should be given as a treatment option. Which makes sense for ADHD anyway.
In life, in general, if someone makes a criticism of anything at all, I listen and then ask them ‘what is your alternative proposition’. On the frightful truth of sending a 4 year 8 month old boy into a Reception class, the alternative propositions are deafeningly silent. The press is deafeningly silent.
It is worth noting that the Education Department bean counters consider that children who did one and a half years of Reception were being ‘baby sat’ free for 6 months, and that teaching them for 13 years insted of 13.5 years trims 3.8% off the cost of those children’s public education.\
Furthermore the poor child who has the misfortune to be born in July is up for 13 years of potential misery, always being immature relative to the others, smaller, the last to be picked for sport, a struggler on the concepts of calculus, never in the ‘in group’, and so on.
Dr Pearson’s comment is not quite true or perhaps misquoted. Children with ADHD are not generally eligible for NDIS funding. I have many times seen the same social immaturity resulting in bogus diagnoses of ASD, which does attract funding, and is one of the main problems behind the total blowout of NDIS costs.
JUREDINI AND WHITELY SHOULD ATTACH DECLARATION OF BIAS TO ANY PUBLICATION. SURELY THE ESSENCE OF THIS DIAGNOSIS IS THAT IT IS NOTABLE FROM EARLY PRIMARY SCHOOL, THIS IS CERTAINLY WHAT EVERY ADULT PATIENT WHO GETS THE DIAGNOSIS TELLS ME. THE RATE OF PRESCRIPTION IN YOUNGER KIDS COULD BE INTERPRETED AS A TRIUMPH FOR EARLY DETECTION.
I think that the interesting take away here is re: school readiness. Unfortunately, it also drives the constant media coverage about the over-diagnosis of ADHD, which is continuously reported upon as if it were a black/white issue – and drives in kids a shame around having ADHD, and a sense it will not be taken seriously. Much like people sometimes feel re: Depression. I say this as an adult who has grown up with ADHD (diagnosed age 10), and kept it a secret because I feel ashamed – and because i know what the community perception of it is.
It is important not to over-interpret these figures; a diagnosis of ADHD and treatment with stimulant medication are not the same as not all children with ADHD are prescribed medication. These prescription rates are far less than the 11% estimated prevalence of ADHD in Australian children.
I would suggest that children with ADHD who are younger when they start school are not being inappropriately diagnosed, but might just be starting to take medication at a slightly earlier age than they would have if they had been able wait a few months and then start school with a younger age cohort.
I am so disappointed that the MJA published this article. I can’t see any benefit to it other than driving media coverage. The info isn’t new, there is no scientific evidence included to show that kids have actually been misdiagnosed and the lead authoris a well known anti-med campaigner with no psychiatric or scientific qualifications. This is an opinion piece for a newspaper, not a report for a journal.
Jon seems to be consistently anti anything prescribing to a degree, but he has a valid point about the overuse of stimulants. My experience is that Paediatricians tend to rely on Psychologists or Nurses to run the check lists for the DSM criteria for them, but many ignore the section in the criteria that asks that other causes of the same symptoms. In particular, apart from the obvious immaturity factor, strong family histories of Bipolar Disorder get ignored.
I knew before I opened the link that this article was going to be driven by Dr Jon Jureidini. He is consistently anti stimulant prescribing. Surely this means he should not be taken seriously by the medical science community. Agendas should not drive research.