Steven L. Pastyrnak, PhD, Division Chief, Pediatric Psychology
Helen DeVos Children's Hospital

A recent study from researchers at Notre Dame University suggests that children who are "young" for their grade, i.e., the child who turned 5 just before the cutoff for kindergarten, are more likely to be diagnosed with attention deficit hyperactivity disorder (ADHD) than children who are "older" for their grade, i.e., the child who turned 5 the March before kindergarten began.

The press release on this research from the university tries to link this study to high rates of ADHD, suggesting that such misdiagnosis may "at least in part" be driving the "epidemic" of ADHD.

I have to at least partially disagree with the notion of an epidemic of ADHD. I would agree that younger children may exhibit more immature behavior in comparison to their older peers. They may be more inattentive and restless and this may impact their classroom behavior. Whether they have ADHD, however, depends on far more than just classroom behavior. 

Recall that an ADHD diagnosis requires evidence of certain behaviors in the home, the community, and the classroom. Therefore, when evaluating ADHD, it is important to gather information from multiple sources.  Parents are the most important individuals to interview followed closely by teachers. Day care providers and extended family can also offer helpful information.  It is the consistency of symptoms across time and within multiple settings that should be considered when making an ADHD diagnosis. In addition, these symptoms must also cause some type of problem before a diagnosis is  considered.  

So if a child is more active than typical, but has no trouble making friends, is doing well at school, is behaving reasonably well at home, then that child probably doesn't qualify for an ADHD diagnosis. It is important that when pediatricians and other specialists evaluate children for ADHD, they do not rely only on teacher reports, nor do they rely on observations that may simply compare one child to another in the classroom. 

Bottom line: There must be evidence of certain behaviors linked to ADHD across multiple locations. If the child is having problems in the classroom only, other options may be available other than medication, such as placing the child closer to the teacher, allowing the child to move around more, or providing additional accommodations to keep the child on task. 

While I'm sure that some children are misdiagnosed with ADHD, my concern-and the concern of my peers-is that far more children are underdiagnosed. Kids may have a different problem such as a learning disability or anxiety that better explains the problems they are experiencing at home and/or school. This is particularly troubling given research demonstrating that children with ADHD who do not receive appropriate treatment are more likely to have functional problems later, including a higher risk of substance abuse and addiction.^1,2,3,4

Today, there are several validated checklists available to aid the community physician in diagnosing ADHD and very clear guidelines from the American Academy of Pediatrics on diagnosis and treatment. If you feel uncomfortable diagnosing and/or treating the condition, however, I suggest you refer, whether to a behavioral or developmental pediatrician, a child psychiatrist, or to a licensed psychologist  who specializes in pediatric mental health. 

How do you assess patients for ADHD in your practice? Click "Add Comment" below.)

Steven L. Pastyrnak, PhD, is the division chief of Pediatric Psychology at Helen DeVos Children's Hospital in Grand Rapids, Michigan.

1. Biederman J, Petty CR, Monuteaux MC, et al. Adult psychiatric outcomes of girls with attention deficit hyperactivity disorder: 11-year follow-up in a longitudinal case-control study. Am J Psychiatry. 2010;167(4):409-417.

2. Mannuzza S, Klein RG, Bessler A, et al. Adult psychiatric status of hyperactive boys grown up. Am J Psychiatry. 1998;155(4):493-498.

3. Wilens TE, Biederman J, Mick E. Does ADHD affect the course of substance abuse? Findings from a sample of adults with and without ADHD. Am J Addict. 1998;7(2):156-163. 

4.  Wilens TE, Adamson J, Monuteaux MC, et al. Effect of prior stimulant treatment for attention-deficit/hyperactivity disorder on subsequent risk for cigarette smoking and alcohol and drug use disorders in adolescents. Arch Pediatr Adolesc Med. 2008;162(10):916-921.