A recent study on prescriptions of attention deficit hyperactivity disorder (ADHD) medications for children in Western Australia found a similar trend to that already shown by data from the US and other countries.
Children at the younger end of their school-year cohort had a higher rate of being prescribed stimulant medication for ADHD than older children in their year.
Specifically, in children between six and 15, 4.5% of those with June birthdays were being prescribed treatment for ADHD compared to 2.9% with July birthdays. Researchers found this odds ratio of 1.6 diminished with age.
Some interpreted these findings as ADHD being arbitrarily, and inappropriately, diagnosed in children who are less mature than their classmates. But this is a simplistic analysis. The reality is children with ADHD are more likely to struggle, and therefore be treated with stimulant medication at a younger age, when they are placed in a class with children who are older and relatively more mature.
Medication is only one aspect
It’s important first to note the prescription rates in the latest study are far less than the 11% estimated prevalence of ADHD in Australian children. This is because medication is only one aspect of ADHD management. At any one time, only a minority of children with ADHD are receiving medical treatment.
To be diagnosed with ADHD, children must meet a sufficient number of the recognised diagnostic criteria. They not only have to show the characteristic symptoms – which include poor concentration, impulsive behaviour and hyperactivity – but also have to have significant difficulties in their ability to function.
An example of this would be a child who is underachieving academically compared to their ability, showing behaviour that generates significant stress or disruption in the classroom, or having difficulty relating appropriately to peers.
These difficulties may in turn affect the child’s confidence and self-perception. They would first be managed by appropriate non-medical strategies. Examples include seating the child close to the teacher, additional support with learning, and encouraging the child to learn from their peers about how to play and interact appropriately.
If the child has a birthday in the months of April to June, the option of repeating the year may also be considered.
Stimulant medication for ADHD treatment is only for those children who meet diagnostic criteria and continue to show significant difficulties, despite appropriate support and management in the classroom and playground. The peak age of starting stimulant medication for ADHD, such as Ritalin (methylphenidate), in NSW is seven to 11 years.
Claims ADHD doesn’t exist are unhelpful
As children progress through school, their increasing maturity helps them cope with increasing behavioural expectations. But, at the same time, their work requires higher levels of concentration. And their peers become more discerning and choosy.
A child with ADHD who has difficulty stopping, listening and considering the views of others may be tolerated in the early years. But a bossy child may become increasingly ostracised in the later years of primary school. Other children may become tired of the attention-seeking classroom behaviour of someone who is bored because they cannot concentrate on their work.
For any child with ADHD, the age when they can no longer manage will depend on the balance of their personal characteristics and pressures and expectations of their environmental circumstances.
An intellectually able child who can finish their work quickly and easily in the early years of school can find the effect of their ADHD only becomes a problem later. Conversely, a child with ADHD who is in a class with predominantly older children is likely to struggle academically and socially at a younger age.
Contrary to popular opinion, parents are often reluctant to start their child on stimulant medication. They may be afraid others will criticise them, particularly people who deny the validity of ADHD.
Denying a child’s difficulties are due to diagnosable ADHD means another explanation is necessary. The child may be blamed for being lazy or the parents, particularly the mother, blamed for being “too soft” on discipline.
ADHD does exist and a warranted diagnosis offers help to children who are struggling due to this common, biological condition. Although many worry ADHD may be stigmatising for their child, a diagnosis raises the prospect of starting effective, evidence-based treatment. This often improves a child’s ability to function.
Experiencing success in treatment is likely to boost the child’s confidence and reassure parents. Therefore, appropriate diagnosis and treatment of ADHD are often highly beneficial to the child.
Alison Poulton has consulted and received non-financial support from Shire and has shares in GSK. She has received research funding from the Nepean Medical Research Foundation and from The Australian Women and Children's Research Foundation. She is a member of the Australian Medical Association (AMA).
Authors: Alison Poulton, Senior Lecturer in Paediatrics, Sydney Medical School Nepean, University of Sydney