January vs. December babies: Youngest kids in the class most likely to be diagnoses with ADHD

A systematic review and meta-analysis, published in European Child and Adolescent Psychiatry in April, shows children with birthdates just before the school entry cut-off date are overrepresented among those diagnosed with attention deficit hyperactivity disorder (ADHD). The findings are attributed to relative age effect (RAE), where the youngest children in a class, who may be less developmentally mature, are expected to meet the behavioural and educational levels of their older classmates, who could be up to 12 months older.Recent findings also suggest RAE can factor in the diagnosis of other neurodevelopmental disorders, such as autism spectrum disorder (ASD), according to the study. “Children who are relatively younger in the school year may show variation in language skills and be less likely to meet the social demands of their classroom, both of which could resemble common features of ASD.”The systematic review completed by University of Nottingham researchers looked at evidence of relative age effect as it pertained to ratings of ADHD symptoms by teachers or parents, diagnosing of ADHD, and the prescribing of medication for ADHD.The review included 32 study papers, of which 31 studies examined the role of relative age and ADHD. Only two studies, both from Taiwan, looked at RAE and ASD. The studies came from 18 countries, three from Canada, and participants included in the studies were up to age 18.Twenty-three studies were included in the meta-analysis for ADHD diagnosis and medication, the rest were not included due to case control design or insufficient data. The results of the meta-analysis showed children who are younger relative to their peers within the same school year are 38% more likely to receive an ADHD diagnosis and 28% more likely to be prescribed ADHD medication.Two studies showed that children held back a year were more likely to be prescribed ADHD medication. This may be due to children having more complex special developmental needs or because parents worry more about perceived relative immaturity and neurodevelopmental diagnoses, the study says. The study showed that teacher ratings of ADHD were influenced by relative age, while parent ratings showed no or weak association with relative age. However, parents may be subject to social desirability bias, potentially overlooking certain behaviours, the study says.Teachers also had the potential to miss ADHD symptoms in older children due to comparing them to their younger and slightly less mature classmates, the study says.Teachers and parents play a significant role in the diagnostic process by reporting ADHD-related symptoms to clinicians and providing insight into a child’s functional difficulties in different settings. Relative age bias can influence this process. Healthcare professionals can be influenced by RAE when diagnosing ADHD due to diagnostic uncertainty, time pressure and reliance on subjective evaluations or over-reliance on standardized questionnaires which might limit their ability to perform age-matched comparisons for children, the study says. “Clinicians would benefit from collaborative involvement of parents and teachers in their assessments, whilst taking into account the possible differences in the relative age effect bias of these two informants,” the authors wrote.The influence of relative age effect on ADHD has been reported in a number of studies over the past decade. However, there continues to be a lack of guidance on how to best account for relative age in the diagnostic process. International guidelines, such as the UK’s National Institute for Health and Care Excellence (NICE) and the American Academy of Pediatrics do not incorporate relative age considerations, says the study.“It will be useful to incorporate this phenomenon in the clinical guidelines and training of healthcare professionals specialising in neurodevelopmental disorders as well as teachers to help them think critically about children’s symptoms during their assessments.”

January vs. December babies: Youngest kids in the class most likely to be diagnoses with ADHD

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