Is it ADHD or are we expecting too much from young children?
A recent study has found that there is a “relative age effect” (RAE) on the diagnosis and prescription of medication for Attention Deficit Hyperactivity Disorder (ADHD) in children. The relative age effect refers to the impact of a child’s age relative to their peers within the same school year. In many educational systems, children born in the same year are grouped together in the same grade, resulting in potential age differences within the same class.
ADHD is characterized by difficulties with attention, hyperactivity, and impulsivity. The diagnosis and treatment of ADHD have been the subject of ongoing research and debate, particularly in relation to the relative age of children within their school year.
The study found that teachers tend to attribute signs of immaturity in children to ADHD or Autism Spectrum Disorder (ASD). The results show that the youngest students in a class, who have birth dates close to the school entry cut-off date, are more likely to be diagnosed with ADHD or given medication for it.
For this systematic review and meta-analysis, two separate searches were conducted to investigate the effect of relative age within a school year on symptoms, diagnosis, or medication for ADHD or ASD in participants up to 18 years of age. All observational studies were included, regardless of the dates conducted, if they reported on these measures in relation to the participants’ age within a school year, including their month of birth.
In the analysis of 32 studies, younger relative age was linked to higher rates of ADHD diagnosis and medication prescription. Younger children were about 38% more likely to be diagnosed with ADHD and 20% more likely to be prescribed medication compared to their peers. This trend was consistent across most studies, except for a few conducted in Denmark and Scotland.
The other two studies investigating Autism Spectrum Disorders found that children who were the youngest in their school year increased the likelihood of being diagnosed with ASD. One study also showed a significant drop in diagnosis rates from a high amonst students with a birthday in August (just before the cutoff) to September (just after the cutoff).
There are several potential explanations for this relative age effect. One theory is that younger children in the same grade may exhibit behaviors that are developmentally appropriate for their age but are mistakenly interpreted as symptoms of ADHD. Likewise, younger children may face challenges in meeting academic and behavioral expectations compared to their older classmates, leading to a higher likelihood of being referred for ADHD evaluation.
It’s important to note that the study’s findings do not imply that all, or even most ADHD diagnoses and medication prescriptions are unwarranted. ADHD is a legitimate neurodevelopmental disorder that can have significant impacts on a child’s academic performance, social interactions, and overall well-being. However, the study underscores the need for careful consideration of age-related factors when evaluating and treating children for ADHD.
Senior author Kapil Sayal, MSc, PhD, professor, School of Medicine at the University of Nottingham, said in a news release, “This review shows that adults involved in identifying or raising concerns over a child’s behavior—such as parents and teachers—may be inadvertently misattributing relative immaturity as symptoms of ADHD. The child’s age in relation to their classmates—their ‘relative’ age—needs to [be] considered when making this kind of diagnosis.”
The authors warn that the analysis has limitations, including potential overlaps in study populations, wide variability in assessment tools used in ADHD studies, potential publication bias, and lack of information on teacher training and experience in identifying ADHD symptoms and how long teachers have known the students.
Teachers are crucial in identifying ADHD symptoms in children. Research shows they may be more likely to identify ADHD symptoms in younger students compared to older ones. Lead study author Eleni Frisira, MBBS, from the University of Nottingham’s School of Medicine, hopes the study serves to underscore the importance of considering a child’s relative age in the classroom when ADHD is being considered.
The researchers’ findings begin to shed light on the complex connection between relative age and ADHD diagnosis and treatment in children. Hopefully, continued research and awareness in this area can contribute to more clarity in accurately identifying actual symptoms of ADHD in children, ensuring that those who genuinely require support receive timely and appropriate interventions.
Sources:
https://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder-what-you-need-to-know
https://en.wikipedia.org/wiki/Relative_age_effect
https://link.springer.com/article/10.1007/s00787-024-02459-x
https://www.psychiatry.org/patients-families/autism/what-is-autism-spectrum-disorder
https://www.eurekalert.org/news-releases/1047361