Keeping Relative Age Effects and ADHD Care in Context.

Abstract

* Abbreviations: ADHD — : attention-deficit/hyperactivity disorder DSM-5 — : Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition RAE — : relative age effect The diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) requires discerning clinical judgment and deliberate shared decision-making between parents, teachers, and other engaged caregivers. ADHD is widely accepted as a neurodevelopmental disorder that emerges early in life and has life span implications for many. The functional impairment associated with ADHD is significant, and the available treatments, including medication, can be effective at improving educational, behavioral, and social-emotional functioning. Missing or delaying the diagnosis of ADHD can lead to unnecessary suffering and poor adaptation for children.1 Similarly, overdiagnosing and overprescribing to children who are misidentified as having ADHD brings many serious adverse consequences, including medication side effects such as sleep disturbance, appetite suppression, and cardiovascular system impacts as well as negative psychosocial sequelae of being misdiagnosed with a behavioral health disorder. In this issue of Pediatrics , Vuori et al,2 using a national registry from Finland, report on the relative age effect (RAE) associated with ADHD diagnoses in which the youngest children in a classroom are at the higher risk of being diagnosed with ADHD and being prescribed medications compared with older classmates. This study builds on the findings of Sayal et al3 and others, which document that a younger relative age increases the risk of being diagnosed with ADHD. Support for the RAE has grown in the literature, and a significant body of evidence documents similar observations of 6the RAE worldwide.4 Many may interpret the findings of relative age impacts on rates of diagnosis of ADHD and medication use as reflecting teacher biases rather than a true presence of the disorder in some younger children. From this perspective, the finding suggests that teachers are more likely to initiate a diagnostic process for less mature children who may exhibit more problematic behavior in the classroom than slightly older … Address correspondence to Eric M. Butter, PhD, Department of Pediatric Psychology and Neuropsychology, Nationwide Children’s Hospital, 700 Children’s Drive, JWest Building 3rd Floor, Columbus, OH 43205. E-mail: eric.butter{at}nationwidechildrens.org