Misdiagnosis of Inattentive ADHD

Recently the Journal of Health Economics published several studies pointing to the possibilities that million of children are diagnosed with ADHD because teachers perceive their behavior as immature when compared to the rest of their classmates and that these misdiagnosed children tend to be the youngest kids in the classroom. 

Researchers at the University of Michigan, Notre Dame, North Carolina State University and the University of Minnesota all looked at the cut off date for entry into school and the rate of ADHD for children born shortly before the cutoff date.  Todd Elder at the University of Michigan found that the youngest kids in a class were 60 percent more likely to be diagnosed with ADHD than the oldest children and that the youngest fifth and eighth graders in a class were the most likely to be on stimulant medication. The study concluded possibly 20% of children diagnosed with ADHD are misdiagnosed.

Teacher's perception of ADHD symptoms often does not jive with parent's perceptions of symptoms. Both parents and teachers must take maturity and development into account when assessing appropriate attention and hyperactivity levels in children.

Anyone who has spent 10 minutes with a two year old will know that attention span and hyperactivity are tied to developmental stages. Not all children develop at the same rate and though there is a standard continuum, which pediatricians consider when rating developmental delays, teachers often use classmates as the comparison standard, which according to the researchers of these studies can lead to a misdiagnosis of ADHD.

Many parents of children with 'late' birthdays, especially boys with late birthdays, have found that school and academic problems disappear when the start of Kindergarten or first grade is delayed by a year.   Where as parents of 'late birthday' boys may find it obvious that their hyperactive son is not prepared for first grade, 'late birthday' girls with inattention will likely go into their designated grade, no better prepared, and more likely to be perceived by their teachers as having Inattentive ADHD.

Inattentive and hyperactivity symptoms that are likely the cause of a child being young compared to their classmates should probably be treated with the 'delayed school start' treatment for ADHD rather that with stimulants regardless of whether the primary school problem is hyperactivity of inattention.

Considering that the study findings indicate that misdiagnosis and mistreatment of ADHD symptoms continues into Middle School, it is important that early treatment action not be taken for behaviors that are developmentally within normal range when a child is very young. 

It is imperative that parents take a proactive role, hopefully with the help of their pediatricians, in preventing and avoiding medical intervention for symptoms that are, developmentally, age appropriate. 

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Journal of Health Economics,2010 September
The importance of relative standards in ADHD diagnoses: evidence based on exact birth dates.
Elder TE
This paper presents evidence that diagnoses of attention-deficit/hyperactivity disorder (ADHD) are driven largely by subjective comparisons across children in the same grade in school. Roughly 8.4 percent of children born in the month prior to their state's cutoff date for kindergarten eligibility - who typically become the youngest and most developmentally immature children within a grade - are diagnosed with ADHD, compared to 5.1 percent of children born in the month immediately afterward. A child's birth date relative to the eligibility cutoff also strongly influences teachers' assessments of whether the child exhibits ADHD symptoms but is only weakly associated with similarly measured parental assessments, suggesting that many diagnoses may be driven by teachers' perceptions of poor behavior among the youngest children in a classroom. These perceptions have long-lasting consequences: the youngest children in fifth and eighth grades are nearly twice as likely as their older classmates to regularly use stimulants prescribed to treat ADHD.J Health Econ. 2010 Sep;29(5):657-73. Epub 2010 Aug 4.

Measuring inappropriate medical diagnosis and treatment in survey data: The case of ADHD among school-age children.
Evans WN, Morrill MS, Parente ST.
Department of Economics and Econometrics, University of Notre Dame

We exploit the discontinuity in age when children start kindergarten generated by state eligibility laws to examine whether relative age is a significant determinant of ADHD diagnosis and treatment. Using a regression discontinuity model and exact dates of birth, we find that children born just after the cutoff, who are relatively old-for-grade, have a significantly lower incidence of ADHD diagnosis and treatment compared with similar children born just before the cutoff date, who are relatively young-for-grade. Since ADHD is an underlying neurological problem where incidence rates should not change dramatically from one birth date to the next, these results suggest that age relative to peers in class, and the resulting differences in behavior, directly affects a child's probability of being diagnosed with and treated for ADHD.


  1. This certainly may be true for a percentage of children, but you would think this would correct itself by the time the youngest of the children is 7 or so. If a child really is having attention problems, there are non-drug options for intervention and education. This is why I like the Brain Balance approach to neuro-behavioral disorders like ADHD – http://www.brainbalancecenters.com . They actually teach and do targeted exercises that strengthen brain communication between the two sides of the brain so that medication, in most cases, can be lessened or discontinued. I particularly like the “truth” section of their website. They also make dietary changes and offer behavioral. It’s a whole person approach and is brain based, not drug based.

  2. Yes, it is mind blowing that this persists and it is not surprising that many kids 'grow out' of their ADHD diagnosis.


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