What a difference a day makes, especially if it is the birthday of a child. New research suggests that the month in which a child is born can affect the likelihood of being diagnosed with Attention Deficit Hyperactivity Disorder (ADHD).
The New England Journal of Medicine (NEJM) published a report noting that ADHD rates are significantly higher among children who are the youngest in their class. This stoked the long-running discussion - among pediatricians and parents - about the potential for misdiagnosis of this condition.
In 25 years of practice, Dr. Jennifer Gruen, the founding partner of Village Pediatrics in Westport, Connecticut, has seen her share of children who exhibit the symptoms of ADHD but in fact are suffering from another disorder. She explained.
“ADHD is a diagnosis of a specific pattern of the inability to pay attention and focus,” Dr. Gruen said. “In addition, it includes hyperactivity and impulsivity. It is important to note that it interferes with the child’s daily function and development in at least two or more settings.
“This means that if a child is manifesting signs of hyperactivity and has the inability for focus at school, but when they are home they are perfectly functional, to the clinician this should suggest that there may not be true diagnosis of ADHD. It could be something in the school setting.”
The Importance of the Month of Birth
"I was very interested in this study because in Connecticut we have a January 1st cut-off for first grade," Dr. Gruen said. “This means we allow children who are as young as 4 years to enter kindergarten. Professionally, I believe this is too young because schools have progressively increased their demands and expectations for children."
“Most states have the traditional September 1st cut-off date and my belief is that younger children (born between September and December) should be held back from first grade due to their social and emotional states. Even if the child is an academic ‘superstar’ at a young age, if he or she is socially immature they can have behavior problems. I don’t worry about the academic as much as the social consequences of early kindergarten entrance.
“The conclusions of this research are interesting, but there are so many confounding variables that have to do with the diagnosis of ADHD, that I believe we need to ‘drill down’ into these numbers to get more accurate information.”
Is ADHD Overdiagnosed or Underdiagnosed?
“Many people say the this condition is overdiagnosed,” Dr. Gruen said. “In some cases, we’re putting kids on medications when they are merely exhibiting normal behaviors. As is often the case, there is some truth and some falsity to these claims.
“On the one hand, particularly in parts of the country where there is not good access to pediatric psychiatrists or even pediatricians, it is challenging for a general practitioner to make this diagnosis. This often results in an overdiagnosis of ADHD and we are using medications without proof that the condition exists. It is much more preferable to put children into counseling or therapy and take the time to do a full analysis in order to ascertain what is really going on.
“On the other hand, there can also be underdiagnosis of this condition in the areas with a dearth of pediatric services because, even though the child may be struggling with behavioral problems, the reasons may be misunderstood.
“This NEJM article is relying on age and prescription data for its conclusions. It doesn’t share information on whether these children were from rural, urban or suburban areas and this is germane to any conclusions that might be drawn. There is little disagreement that this condition is often misdiagnosed. This can occur because the symptoms underlying ADHD are found in a lot of other conditions as well.
“Physical conditions are more clear-cut to diagnose. For example, if a child comes into our office complaining of a sore throat, we take a look at the throat, feel his or her glands and then do a ‘strep test.’ This information can be compiled very easily and we can determine if they have strep throat.
“When we are diagnosing a mental condition, we are relying on symptom reports from parents, teachers and other caregivers. This can be tricky. We must first understand where the information is coming from. Is it coming from parents or teachers and that may be biased for any reason? For example, if the parent is overwhelmed, with multiple jobs, too many responsibilities and inadequate childcare and their child who is misbehaving, they urgently want to have the child behave properly.
"I have also experienced situations where the child is exhibiting some of the symptoms of ADHD but was really just very anxious. If the clinician is not adept at ‘weeding out’ all of the little issues that might suggest this condition, it can certainly be misdiagnosed. It is not an easy diagnosis to make."
“I have been practicing pediatric medicine for more than 25 years and when I was in residency, I can’t remember a single course or training on the diagnosis of ADHD. I have had to train myself by reading and studying my patients. I believe the pediatric residences are now doing a better job of training young doctors about this condition but we’re not psychiatrists.
“As long as there is this ‘gap’ between access to good psychiatric care, the pediatricians are going to do the best they can but we’re not perfect. We may be misdiagnosing ADHD.”
How Can a Pediatrician More Accurately Diagnose ADHD?
“In our practice, we use the services of CHADIS,” Dr. Gruen said. “Their surveys allow us to collect patient-generated data that can be used to make clinical decisions. We use their ‘Vanderbilt’ scale and we have parents, teachers and other caregivers complete these surveys about the child. This helps us hone in on what symptoms the child might have.
“CHADIS then scores these surveys for the practice. This helps the practitioner determine whether the child might have ADHD, anxiety, depression or other conditions.
“One of the first things a pediatrician should do is to become familiar with these scales and surveys, since this is where the information about these conditions is gathered. The second action for pediatrician to take is to educate themselves on ADHD."
“There are many good websites that a practitioner can visit and learn more about this condition. One of my favorites is CHADD.org. This site has some excellent resources for diagnosing this condition. There is another good site and magazine - ADDitudemag.com - which is also a good source of current best practices for this condition. The Academy of Pediatrics also has several good books on the condition. One of my favorites is “Caring for Children with ADHD.”
"I also talk to a lot of other pediatricians about this subject, one of whom I met through PCC. Dr. Kristen Stuppy writes about ADHD and other pediatric subjects in her very informative blog - Quest for Health KC.com. Subscribing to this blog would be a great way to keep up on this condition.”
The Role of an EHR in Diagnosing ADHD
“PCC allows pediatricians to create their own protocols for treating this condition,” Dr. Gruen said. “When I decided to use the PCC EHR, I used some existing ADHD protocols that other PCC clients had created. With their technical help, I built in all of the criteria that I wanted for diagnosing this condition and have it available on our practice EHR. This allowed my practice partners, who might not see as many ADHD patients as I have, to go into the PCC protocol and step by step go through the diagnosis."
“With our EHR, we have an initial evaluation (based on a questionnaire) and a follow-up protocol. In the initial evaluation, it prompts the clinician about family history, sleep and diet habits of the child and any prior diagnosis of developmental issues.
“The technical diagnosis of ADHD comes from the DSM 5, a manual that lays out how various mental health issues are diagnosed. There are specific criteria that must be met in order to qualify for a diagnosis of this condition.
"PCC EHR allows me to have a very customized and consistent protocol for diagnosis. Plus, it helps to uncover any other mental or development issues that may not be ADHD but still require treatment."