Kindergarten enrollment dates affect ADHD diagnosis rates | Hacker News Reader

Kindergarten enrollment dates affect ADHD diagnosis rates

news.ncsu.edu

56 pointsblasdel61 comments

Well, considering the criteria used to diagnose ADHD, pretty much any kid who fails to be in exact lockstep with the rest of his/her class runs the risk of being forced into conformity with psychoactive drugs. Below are the currently official criteria (from http://www.neurosurvival.ca/ClinicalAssistant/scales/dsm_IV/...; note that these criteria are the ONLY means of diagnosis). I think personally I failed more than half the things on the list back when I was 6; thank Goodness they didn't have ADHD diagnostics back then.

-Fails to pay close attention to details or makes careless errors in schoolwork, work or other activities

-Has trouble keeping attention on tasks or play

-Doesn't appear to listen when being told something

-Neither follows through on instructions nor completes chores, schoolwork, or jobs

-Has trouble organizing activities and tasks

-Dislikes or avoids tasks that involve sustained mental effort (homework, schoolwork)

-Loses materials needed for activities (assignments, books, pencils, tools, toys)

-Easily distracted by extraneous stimuli

-Forgetful

-Squirms in seat or fidgets

-Inappropriately leaves seat

-Inappropriately runs or climbs

-Has trouble quietly playing or engaging in leisure activity

-Appears driven or "on the go"

-Talks excessively

-Answers questions before they have been completely asked

-Has trouble or awaiting turn

-Interrupts or intrudes on others

This just sounds like a normal 6 year old to me.

Yes. Specifically, a normal 6 year old boy.

I'm a woman and I'm pretty sure I was like this when I was in kindergarten, as were most of my friends. I would be kind of concerned to meet a 6 year old girl who never acted this way.

You left out some qualifiers, though:

- "Persisting for at least 6 months to a degree that is maladaptive and immature..."

- "The disorder impairs school, social or occupational functioning."

While all kids are going to exhibit many/most of the items on the list, most don't do so in a maladaptive way that's immature relative to their peers and that impairs their function. So while I'm certain there are inappropriate diagnoses of ADHD (perhaps disproportionately many, I don't know), I don't find the list you posted to be an indictment of the DSM-IV criteria.

> - "Persisting for at least 6 months to a degree that is maladaptive and immature..."

> - "The disorder impairs school, social or occupational functioning."

Which is pretty much the definition of typical little boys until recently. Read "The Ransom of Red Chief" http://www.eastoftheweb.com/short-stories/UBooks/RanRed.shtm... for what was once considered typical. Today, that kid would be drugged into submission.

Which is pretty much the definition of typical little boys until recently.

No, it's not. Typical members of an age group are by definition not immature relative to the average member of their age group. Thus they can't be maladaptively impaired in their functioning due to immaturity.

> Typical members of an age group are by definition not immature relative to the average member of their age group.

I think the argument is: "what happens to the average of a distribution when you throw out one tail?"

Yes, so - how does this make a difference? These qualifiers are subjective and add nothing on top of the diagnosis criteria above.

"persists for 6 months" - so you don't get Ritalin for the first tree you climb. Good.

"maladaptive and immature" = the "out-of-lockstep" factor I mentioned in my comment

"The disorder impairs school, social or occupational functioning" = you keep doing these things even though teachers and parents get annoyed at you.

It's hard to be "guilty" of doing the things in the list repeatedly, without also fulfilling the qualifiers.

After you start to hit many items on that list, though, some people box you in and hear impairment without objective evidence of it. I was seen by a counselor a few times for a witches brew of issues, mostly synonymous with being shy. She gave me the usual battery and picked up on my pervasive disorganization -- loses pencils, check, routinely avoids doing homework, check, not looking intimidating counselor in eye, check. She became convinced, quote, I would have no academic success without addressing my ADD. My mother explained that I had had straight As for my entire life and she wrote that off to "unusually good coping skills for his ADD"

I have one or two friends whose lives were very improved by medication, but the use of this diagnosis to label and crowd control scares me. And once you get it, that is the scarlet A. God bless my mother for keeping it out of my record. Otherwise, every paper I delivered late would have been because I was ADD. Bored in pre algebra because I had already solved systems of equations in two variables? ADD. Prefer reading books to group work? ADD.

In the old days, naughty kids would get a spanking, and shy kids would be lectured by parents. These days, society has decided to go "Clockwork Orange" on such crimes instead, and the seed of nonconformity is chemically suppressed in the brain.

I was diagnosed with ADHD, and while these criteria might have led to the testing, the actual testing was relatively scientific. There was a several hour battery of tests where my scores were compared against average. Most of the tests were relatively boring, like a computer screen would show letters, and you were supposed to hit the space bar for every character except Xs. People with ADHD performance at that task degrades much more quickly over time vs people without. There were also tests where people would employ different memory strategies to do them, and people with ADHD tend to use particularly poor ones. The doctor would read a list of 12 words, and you were supposed to recite it back. Then he'd tell you what words you missed, and you'd try to say the whole list again. Most people can get the whole list in 3-4 tries.

They also did an IQ test and the scores on all the ADHD tests were compared to what would be expected for my IQ. I performed at sub tenth percentile on many memory tasks, but my IQ was substantially hire than tenth percentile.

Just including multiple-choice questions doesn't make a test scientific. It's easy to fail all of those tasks if you simply see no point in them and keep wishing you were outside, climbing a tree instead.

Nice.

The first study I've heard of of it's type and it confirms the anecdotal evidence I've been reading about for years!

Hope there are a few more studies like this around so doctors sit up and pay attention (pun unintended).

Who's going to the first to mention Gladwell's Outliers? Oh wait, I just did.

What logically follows is that ADHD meds make you bad at hockey

Had to chuckle at that one. I was thinking it also gave you frizzy hair.

Actually, it might be that doctors are quite accurate with diagnosing ADHD. The problem is that the sample of kids that they even get to examine is already biased - they may be the younger ones, in which parents or teachers just observed immaturity (which is probably uncorrelated to ADHD). Just a guess - maybe the paper addresses this issue.

Let's nip this in the butt before people actually think this is correct. This study confirms ONLY (edit: [redacted]) that development is affected by what kids do with themselves. (Duuuuuh.) It does NOT erase the fact that there are real, empirical differences between the brains of kids with and without ADHD. For example, it doesn't erase the fact that kids with ADHD do have demonstrably abnormal cerebral myelination.

ADHD is actually one of the most researched areas of Pediatric Psychiatry, so before everyone jumps on the Starbucks MD bandwagon, at least do the research. I don't want to be overly rude about this, and I apologize if I am, but it's hard to have patience for intellectual whack-a-mole.

I don't think the article or the parent comment make any claim that ADHD is not a real disorder.

What the study is saying is that children who are relatively young compared to their peers are diagnosed with ADHD at a higher rate because their teachers report them acting in ways "consistent with ADHD" more often than their peers. The physicians use these reports as part of their evidence when making a diagnosis. The explanation is that these children are probably just less mature due to relative age. Their ADHD diagnosis rate is higher than the other group of children, who are essentially the exact same age, but relatively old compared to their classmates.

Since the author of the parent comment expected other users to pick up what "anecdotal" evidence he was talking about, I took it to mean what it typically means.

I know what the study is saying. I wasn't responding directly to it.

I was talking about over diagnosis which is anecdotally an issue and is the conclusion the authors of this study drew.

My mistake then. I apologize.

How many kids are diagnosed with ADHD due to some objective measurement of their bodies?

No, it's "do you have problems with X or more of the following list items" + the physician's judgment.

The study does not contradict what you're saying.

Most American babies are born around August and September:

http://abcnews.go.com/Health/Science/story?id=945911

Which happens to be the cut off date for Kindergarten in many states.

http://users.stargate.net/~cokids/kindergarten_cut-off_dates...

Since most children are born in Aug/September, you'd probably have the most premature births around then too right?

Premature children are 70% more likely to have ADHD:

http://www.medicalnewstoday.com/articles/44574.php

Could it be that a lot of premature children happen to come right before the early/mid September deadline at the peak of the "birthing season"?

If the relationship between ADHD and prematurity is correct, these children would face a double whammy...being young for their grade and ADHD.

That's very insightful, but it's my guess is that it's not as salient as one would think. Scientists (at least in the lab) will typically use a number of metrics to measure ADHD, most notably cerebral myelination. ADHD tends to involve improper development in this regard (i.e., the brain does NOT myelinate as fast as one would expect). Since the authors posit that younger children may simply be less mature, my suspicion is that they are talking about this. And the obvious thing to do would be to correct for what you talk about (in fact, it's hard to see how they could get into a journal and not do so).

Implicit in the study seems to be the assumption that the development of ADHD would occur irrespective of developmental context. It could be that always being the least mature person in one's class helps cause ADHD-like behaviors (e.g., your peer group's conversation is less interesting, so you act up or become easily distracted).

Indeed, the whole study is predicated on ADHD being entirely genetic.

Moral of the story:

Being a kid = ADHD.

Parents need to stop resorting to "parenting in a pill" for their own inadequacies, or pressure by society to "act" on their child being precisely that.

That's not to say that ADHD doesn't exist or some-such nonsense, but I believe this study at least is going somewhat in the right direction to prevent overzealous diagnosis.

As someone already stated (and with whom I definitely agree) - the test set is already biased for a large percentage based on age.

Not to mention the pressure that is allowed by teachers. I myself was suddenly diagnosed after ONE of my teachers decided I was too active and made an enormous fuss about it. Took the meds for a couple of weeks, lost ~10 pounds (I'm already a stick), and told them to bugger off.

Doctors are actually very careful not to be overzealous in diagnosis. To meet the criteria for a real diagnosis, the symptoms must be "excessive, long-term, and pervasive".

Similarly, not everyone with "blues" is clinically depressed, and not everyone with unexplained weight loss has cancer... the folk estimates of the prevalence of these conditions are way overblown.

A while ago I wrote this:

http://jacquesmattheij.com/content/adhd-ritalin-and-evolutio...

It's how I feel about the whole ADHD thing and the industry surrounding it.

An alternate theory based on the same information (and I'd be interested in others' opinions on this):

Younger kids have different stresses on them than older kids in the same grade. You don't often hear of the youngest in a class bullying the oldest. The increase in ADHD diagnoses could also be because they may be more ADHD prone, and not just because of age.

I just think we need to lose the focus on medication for ADHD. For some: absolutely. For most: hell no, they just need to learn to manage it. Many of the most productive people were clearly ADHD, but managed it to at least some degree.

>Morrill explains that the study shows that children born just after the kindergarten cutoff date were 25 percent less likely to be diagnosed as having ADHD than children born just before the cutoff date.

Anyone care to explain what is "kindergarten cutoff date" ?

EDIT: nevermind, found explanation via google(http://users.stargate.net/~cokids/kindergarten_cut-off_dates...)

Generally kids who are 5 years old (if I'm not mistaken) are in Kindergarten. Some kids start Kindergarten at 4 because their birthday is later in the year. However there is a cut-off date (probably in November or December) and students born after that cut-off date are enrolled in next years Kindergarten class.

So if the cut-off date is December 1st, kids born on December 1st will start Kindergarten a year earlier than kids born on December 2nd.

The title is somewhat misleading -- it's not like Kindergarten causes ADHD. The key observation is that if you grab any group of young kids with an age spread of a full year, "younger children may be mistakenly diagnosed as having ADHD, when in fact they are simply less mature." You cannot just pretend they're all at the same stage of development.

You see a similar effect in sports (where again, older kids in the group will have a big advantage).

That's not quite it either. The reason Kindergarten is important is because it's examining kids among their peers. Kids who are on average 6 months younger than their peers are more likely to be diagnosed with ADHD.

Yeah, but the Kindergarten cutoff mechanism is irrelevant -- the point is that if you group young kids by some system that's aligned with the calender year rather than their actual age, they're not really peers. You'd get the same effect if you group them by what year they were born in (i.e. used January 1st as the cutoff date).

You are correct that these traits would apply to any arbitrary group of young children with a one year age spread. Kindergarten is an ideal such group, not only because it encompasses a one year spread of young children, but also because it is a group that is being observed for signs of ADHD.

But yeah, I'm not trying to say that the title isn't misleading - there is a correlation between Kindergarten enrollment dates and ADHD diagnosis and that's it. The article makes this pretty clear but the title does not.

Luckily, ADHD is still unknown here (Italy, and as far as i know also in the rest of europe, UK excluded), i wonder what will happen when the gullible public will discover its existence. ADHD treatments could become even more popular than homeoteraphy.

EDIT: Report about ADHD awareness in Europe: http://www.adhs-deutschland.de/pdf/pdf0007.pdf

EDIT2: Why the downvotes?

Where is "here"? Afaik (but I'm no expert), the diagnosis is used in large parts of Europe (even if some countries use other acronyms). The Swedes even came up with their own version of ADHD, called DAMP:

http://en.wikipedia.org/wiki/Deficits_in_Attention,_Motor_co...

Sorry, updated. What i meant is that the general public still usually ignores (confirmed in the linked report, can't attest its accuracy, btw) the existence of this disorder and so i expect that the number of diagnosed cases is still quite small at the moment. What i fear is that with more awareness, more inept parents will find in the ADHD an easy way to explain what is only the result of their educational ineptitude. And sadly, it seems clear that this disorder can easily be misdiagnosed.

You are probably being downvoted because you are making the claim that ADHD is not a real disorder and that treatment for it is comparable to homeopathy.

You are right, maybe i should have stated what i meant more clearly and in a different way, i'm not claiming that. See my other comment below.

I claim: ADHD is not a real disorder and that treatment for it is comparable to homeopathy.

The treatment for ADHD is Adderall. Regardless of if ADHD is real or not, Adderall is nothing like any Homeopathy treatment.

http://en.wikipedia.org/wiki/Adderall#Performance-enhancing_...

This is not necessarily a crazy claim to make.

Mental differences are objective, but mental disorders are culturally relative.

This doesn't diminish the mental pain that such a difference can cause in a specific culture, but it's not absolute. It's more of a round peg / square hole kind of thing.

They did a similar study about sports expertise. Being born at the wrong time makes you less likely to become a sports star, because the kids who are nominally your "peers" are physically superior, and it creates the perception that you are not as skilled. Pretty rough deal.

I believe RadioLab touched upon this in their recent podcast "Secrets of Success". My memory is a bit fuzzy on the details, but IIRC they interviewed someone who noticed that most hockey teams were made up of players that were born in the first few months of the year.

I guess parents can turbocharge their kids's future by holding them back a year, so they'll be the biggest, strongest, and most mature kids in the class.

Here's a link to the authors' presentation:

http://www.academyhealth.org/files/2010/saturday/morrill.pdf

Wasn't something like that Malcolm Gladwell's theory for the prevalence of top Canadian hockey players born in the early months of the year?

Malcolm just rehashed something than any coach or school teacher can tell you: the smarter, stronger kids are the older.

Interestingly, that was one of the parts where he had some sort of numbers listed so it seems a little unfair to accuse him of rehashing anecdotal evidence. Not that he's shy about using anecdotal evidence.

This doesn't prove anything at all. It simply proves that school makes you more likely to be diagnosed with ADHD, which is hardly shocking. However, the idea that this implies that kids are getting misdiagnosed is a non sequiter. How do you know that this isn't a sign that kids aren't getting the medical attention they need until they get to school.

And VC's are accused of being lemmings...looks like doctors get to share that label.

ADHD isn't about age, it is about amygdala sensitivity and compensating behavioral habits, like shying away, avoiding eye contacts and playing alone with/in own imagination.

Yes, that's why the study can use age to measure inappropriate diagnosis.

Age is a wrong explanation.

This is kind a little off topic but I have a question for you.

I am in the middle of being diagnosed with ADHD (I'm 30). It was actually HN that prompted me to take action, but that's another story which I can expand on if anyone is interested.

I haven't read much about ADHD being linked to shyness and introversion, although I certainly haven't done enough research. But it describes me very well, could you possibly say a little more or point me to some resources? Everything I've read talks about impulsiveness and extroversion. I would guess that shyness and introversion are learned reactions to the impulsiveness.

I'm not a guru, but I have my own experience, which matches resent publicly accepted studies.

http://www.amazon.com/Emotional-Intelligence-Matter-More-Tha... is a good starting point.

I think everyone involved (I'm with Asperger's) should study the topic, to be able to understand (and then make a corrections to) one's own behavior, instead of believing what other people (including doctors) are saying.

I've heard good things about that book, I probably should get a copy.

I didn't word my question very well. I was wondering where you got your examples. None of the ADHD info I've read says anything about shyness or eye contact. A child playing by themselves would seem to be the exact opposite of the popular notion of what a kid with ADHD is like (assuming that they weren't totally spaced out to the world around them, which you didn't mention).

I'm just interested because that's me. I'm shy, I have minor problems with eye contact (more like I just have problems relating to new people) and I spent a large chunk of my childhood playing by myself with Legos and Transformers. That last bit was one of the reasons my parents said they didn't think I could have ADHD. "But you used to amuse yourself for hours by yourself. You certainly were paying attention to THAT."

There's an inattentive type[1] of ADHD that doesn't connote hyperactivity or impulsivity.

Mood, anxiety, and personality disorders also frequently occur along with ADHD[2].

[1]: http://www.webmd.com/add-adhd/guide/types-of-adhd

[2]: http://www.mayoclinic.com/health/adult-adhd/DS01161/DSECTION...

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