School readiness impaired in preschoolers with ADHD symptoms
July 22, 2019
Science Daily/Stanford Medicine
Preschoolers with symptoms of attention-deficit hyperactivity disorder are much less likely than other children their age to be ready for school, new research from the Stanford University School of Medicine has found.
The study, which will be published online July 21 in Pediatrics, is among the first to comprehensively examine school readiness in young children with ADHD. Several previous studies have addressed academic difficulties in school-aged children with ADHD, but few studies have investigated whether these children start school behind their peers.
"We were pretty surprised at the proportion of kids within the ADHD group who were not school-ready," said the study's senior author, Irene Loe, MD, assistant professor of pediatrics. Seventy-nine percent of children with ADHD had impaired school readiness compared with 13 percent of children in a control group, the study found. "It's a really high number," Loe said.
The study's lead author is Hannah Perrin, MD, who was a fellow in developmental and behavioral pediatrics at Stanford when the research was done.
The main symptoms of ADHD -- inattention, hyperactivity and impulsivity -- can be normal in toddlers, and these behaviors sometimes persist into the preschool years even in children who will not ultimately meet the diagnostic criteria for ADHD. This makes the disorder difficult to diagnose in preschoolers. "A lot of these kids are not identified until they're really having a lot of trouble in the school setting," Loe said.
The study included 93 children, all of whom were 4 or 5 years old. Nearly all had attended or were currently enrolled in preschool, and some were enrolled in kindergarten. The ADHD group included 45 children who previously had been diagnosed with the disorder or were identified by their parents as having significant levels of ADHD symptoms. The comparison group consisted of 48 children without ADHD. The researchers tested all the children to confirm their levels of ADHD symptoms.
The researchers conducted tests and administered parent questionnaires to measure five areas of the children's functioning: physical well-being and motor development; social and emotional development; approaches to learning; language development; and cognition and general knowledge. "Approaches to learning" included measures of executive function, which is a person's ability to prioritize actions and tasks and exercise self-control to regulate behavior and meet long-term goals.
Children were considered impaired in an area of functioning if their assessment scores in that area were more than one standard deviation worse than the mean score for their age. They were considered unready for school if they were impaired in two or more of the five areas of functioning measured in the study.
Struggling in 4 of 5 areas
Children with ADHD were no more likely than their peers to show impairment in the area of cognition and general knowledge, the study found. This area includes IQ and, importantly, knowledge people traditionally associate with kindergarten readiness, such as being able to identify letters, numbers, shapes and colors.
But children with ADHD were much more likely than their peers to struggle in all four other areas measured. They were 73 times more likely than children without ADHD to be impaired in approaches to learning; more than seven times as likely to have impaired social and emotional development; six times as likely to have impaired language development; and three times as likely to have impaired physical well-being and motor development.
The assessment was broader than other school-readiness measures researchers have used in the past, Loe said. "We looked at many aspects of the child more comprehensively," she said, adding that approaches to learning or executive function as a component of school readiness has been especially under-studied.
The findings suggest that identifying and helping preschoolers with significant levels of ADHD symptoms could reduce their struggles in elementary school.
"We need to help general pediatricians figure out how they can flag kids who might be at risk for school failure," Loe said. Families also need better access to behavioral therapy for preschoolers with ADHD, which is not always available or covered by insurance, even though it is recommended as the first-line ADHD treatment for this age group, she added.
"Thinking about how we can provide services for young children with ADHD or who are at high risk for the diagnosis is really important," she said.
https://www.sciencedaily.com/releases/2019/07/190722085826.htm
School year 'relative age' causing bias in ADHD diagnosis
October 9, 2017
Science Daily/University of Nottingham
Younger primary school children are more likely to be diagnosed with attention deficit hyperactivity disorder (ADHD) than their older peers within the same school year, new research has shown.
The study, led by a child psychiatrist at The University of Nottingham with researchers at the University of Turku in Finland, suggests that adults involved in raising concerns over a child's behaviour -- such as parents and teachers -- may be misattributing signs of relative immaturity as symptoms of the disorder.
In their research, published in The Lancet Psychiatry, the experts suggest that greater flexibility in school starting dates should be offered for those children who may be less mature than their same school-year peers.
Kapil Sayal, Professor of Child & Adolescent Psychiatry at the University's School of Medicine and the Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan at the Institute of Mental Health in Nottingham, was the lead author on the study.
He said: "The findings of this research have a range of implications for teachers, parents and clinicians. With an age variation of up to 12 months in the same class, teachers and parents may misattribute a child's immaturity. This might lead to younger children in the class being more likely to be referred for an assessment for ADHD.
"Parents and teachers as well as clinicians who are undertaking ADHD assessments should keep in mind the child's relative age. From an education perspective, there should be flexibility with an individualised approach to best meets the child's needs."
Evidence suggests that worldwide, the incidence of ADHD among school age children is, at around five per cent, fairly uniform. However, there are large differences internationally in the rates of clinical diagnosis and treatment.
Although this may partially reflect the availability of and access to services, the perceptions of parents and teachers also play an important role in recognising children who may be affected by ADHD, as information they provide is used as part of the clinical assessment.
The study centred on whether the so-called 'relative age effect' -- the perceived differences in abilities and development between the youngest and oldest children in the same year group -- could affect the incidence of diagnosis of ADHD.
Adults may be benchmarking the development and abilities of younger children against their older peers in the same year group and inadvertently misinterpreting immaturity for more serious problems.
Previous studies have suggested that this effect plays an important role in diagnosis in countries where higher numbers of children are diagnosed and treated for ADHD, leading to concerns that clinicians may be over-diagnosing the disorder.
The latest study aimed to look at whether the effect also plays a significant role in the diagnosis of children in countries where the prescribing rates for ADHD are relatively low.
It used nationwide population data from all children in Finland born between 1991 and 2004 who were diagnosed with ADHD from the age of seven years -- school starting age -- onwards. In Finland, children start school during the calendar year they turn 7 years of age, with the school year starting in mid-August. Therefore, the eldest in a school year are born in January (aged 7 years and 7 months) and the youngest in December (6 years and 7 months).
The results showed that younger children were more likely to be diagnosed with ADHD than their older same-year peers -- boys by 26 per cent and girls by 31 per cent.
For children under the age of 10 years, this association got stronger over time -- in the more recent years 2004-2011, children born in May to August were 37 per cent more likely to be diagnosed and those born in September to December 64 per cent, compared to the oldest children born in January to April
The study found that this 'relative age affect' could not be explained by other behavioural or developmental disorders which may also have been affecting the children with an ADHD diagnosis.
However, the experts warn, the study did have some important limitations -- the data did not reveal whether any of the young children were held back a year for educational reasons and potentially misclassified as the oldest in their year group when in fact they were the youngest of their original peers.
The flexibility in school starting date could explain why the rate of ADHD in December-born children (the relatively youngest) were slightly lower than those for children born in October and November.
And while the records of publicly-funded specialised services which are free at the point of access will capture most children who have received a diagnosis of ADHD, it will miss those who were diagnosed in private practice.
https://www.sciencedaily.com/releases/2017/10/171009191508.htm