- Email: [email protected]
The role of schools in the diagnosis of ADHD
Comment
The role of schools in the diagnosis of ADHD There is a perception in the community that too many children are diagnosed with attention-deficit hyperactivity disorder (ADHD) and treated with medication. Conversely, some experts believe the disorder could be underdiagnosed and that efforts should be made to improve diagnostic reliability.1,2 Findings of studies in different countries have shown that many children who meet diagnostic criteria for ADHD—including impairment criteria—never receive a clinical diagnosis.3,4 Rates of diagnosis vary considerably both between and within countries, with many variables affecting the likelihood of diagnosis. One key variable is whether somebody in the child’s world—usually a parent or a teacher—notices problematic symptoms and raises concerns. For a diagnosis of ADHD to be made, as with many developmental disorders, evidence is needed of a persistent pattern of cross-situational impairment, meaning functional difficulties attributable to ADHD symptoms at both home and school.5,6 Therefore, those who diagnose and treat ADHD—paediatricians, psychologists, and child psychiatrists—depend on reports from teachers about the child’s behaviour, developmental competencies, and performance in school. Standardised questionnaires are designed to evaluate the child’s behaviour by comparison with his or her peers. For example, the commonly used Vanderbilt teacher rating scale says: “Each rating should be considered in the context of what is appropriate for the age of the child you are rating”. Despite this wording, children’s behaviour is likely to be often calibrated by teachers against gradelevel, rather than age-level, expectations. In The Lancet Psychiatry, Kapil Sayal and colleagues report findings of a study of relative age within the school year (by month of birth) and ADHD diagnosis.7 The authors used data from two national population patient registers to study children from age 7 years who were born in Finland between 1991 and 2004. Compared with children born in January (reference age), those born in the later months of the year had higher incidence ratios for ADHD diagnosis. The effect was seen in both boys and girls and was more pronounced in recent years. The relative age effect was noted for children diagnosed at age 7–9 years, but not for those diagnosed age 10 years or older. A sensitivity analysis showed no difference in findings whether comorbid www.thelancet.com/psychiatry Vol 4 November 2017
conduct disorder, oppositional defiant disorder, or comorbid learning disorder were present. Researchers in North America, Europe, and Asia have undertaken epidemiological studies with various methods to investigate a relative age effect on ADHD diagnosis, including using prescription data for ADHD medication as a proxy for diagnosis. Although some effect was noted in most studies, results have been mixed. The study by Sayal and colleagues adds weight to the cumulative evidence in favour of a relative age effect for ADHD diagnosis. What are the implications of these findings, and should we be concerned? Because most children who are diagnosed with ADHD by paediatricians or child psychiatrists are treated with medication—often for several years—the stakes are high. If behaviour congruent with relatively young age within the school year is being systematically misclassified as developmental immaturity, many incorrect diagnoses of ADHD could be made, and children might be treated unnecessarily with medication. The response to ADHD treatment is non-specific and not dependent on a correct diagnosis—ie, most children treated with stimulant medications show improvement in attentional control. Therefore, treating clinicians are likely to conclude that medication is effective and continue prescribing it for some time. As well as potential exposure to side-effects, other risks of wrong diagnosis and treatment include stigmatisation and missing alternate explanations for academic, social, and behavioural difficulties—eg, learning disorders, emotional disturbance, or trauma. To put the finding of Sayal and colleagues in context, it is useful to consider what factors might lead to a child with ADHD symptoms being referred for assessment. With respect to intrinsic child factors, children with combined presentation ADHD—ie, a combination of inattentive and hyperactive-impulsive symptoms—are referred more consistently than are those with only inattentive symptoms, and boys with ADHD are more likely to be identified than are girls.3 Family variables are also important: the effect of a child’s behaviour on the family is one of the main drivers of help-seeking for children with ADHD in the community.8 Other variables that might affect access to assessment services for
Published Online October 9, 2017 http://dx.doi.org/10.1016/ S2215-0366(17)30406-6 See Articles page 868
825
Comment
children include parental education, a parent’s mental health, and (in some health systems) family income. How do school-level variables affect rates of referral for assessment? So-called schooling practice has been suggested as a mediating mechanism to ADHD diagnosis.9 Singh describes school as “a culture in which children’s development intersects with prevailing expectations and values in relation to their behaviour, performance and achievement”9 and synthesises arguments that teachers might be more likely to recommend a misbehaving child is prescribed medication than to attempt to improve the child’s behaviour using pedagogical techniques. Younger children are, on average, less mature in relation to selfregulation, and, therefore, teachers are more likely to raise concerns about these children to their parents, which could lead them to seek an assessment. To enrich our understanding of the issue of relative age, future research should assess both teachers’ and parents’ perceptions of problematic behaviour and thresholds for concern in children who are young for year level. These issues would be best explored using qualitative methodology. In practice, clinicians need to ensure they assess attentional capacity and impulse control relative to the child’s chronological age and overall developmental status, rather than age for year level.
Daryl Efron Murdoch Children’s Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; and *The Royal Children’s Hospital; Melbourne, VIC 3052, Australia [email protected] I declare no competing interests. I am funded by a Clinician Scientist Fellowship from the Murdoch Children’s Research Institute. 1 2 3 4 5 6
7
8 9
Taylor E. Attention deficit hyperactivity disorder: overdiagnosed or diagnoses missed? Arch Dis Child 2017; 102: 376–79. Thomas R, Sanders S, Doust J, et al. Prevalence of attention-deficit/ hyperactivity disorder: a systematic review and meta-analysis. Pediatrics 2015; 135: e994–1001. Froehlich TE, Lanphear BP, Epstein JN, et al. Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. Arch Pediatr Adolesc Med 2007; 161: 857–64. Efron D, Sciberras E, Anderson V, et al. Functional status in children with ADHD at age 6–8: a controlled community study. Pediatrics 2014; 134: e992–1000. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th edn). Arlington: American Psychiatric Publishing, 2013. National Institute for Health and Care Excellence. NICE clinical guideline 72: attention deficit hyperactivity disorder—diagnosis and management. February, 2016. https://www.nice.org.uk/guidance/cg72 (accessed Sept 29, 2017). Sayal K, Chudal R, Hinkka-Yli-Salomäki S, Joelsson P, Sourander A. Relative age within the school year and diagnosis of attention-deficit hyperactivity disorder: a nationwide population-based study. Lancet Psychiatry 2017; published online Oct 9. http://dx.doi.org/10.1016/ S2215-0366(17)30394-2. Efron D, Moisuc O, McKenzie V, et al. Service use in children aged 6–8 years with attention deficit hyperactivity disorder. Arch Dis Child 2015; 101: 161–65. Singh I. ADHD, culture and education. Early Child Dev Care 2008; 178: 347–61.
WHO QualityRights: transforming mental health services
Published Online July 12, 2017 http://dx.doi.org/10.1016/ S2215-0366(17)30271-7 This online publication has been corrected. The corrected version first appeared at thelancet.com/psychiatry on July 24, 2017
826
A movement to profoundly transform the way mental health care is delivered and to change attitudes towards people with psychosocial, intellectual, and cognitive disabilities is gaining momentum globally. The Convention on the Rights of Persons with Disabilities (CRPD), which came into effect in 2008, clearly shows that changing attitudes towards—and practices—in mental health care is not only a necessity, but also an obligation under international human rights law. The vision and principles expressed in the CRPD have spread across the UN system. For instance, key principles of the CRPD were integrated into the WHO comprehensive mental health action plan of 2013–20.1 In July, 2016, a resolution2 led by Portugal and Brazil was adopted by the human rights council, calling on states and other UN agencies to take steps towards ending the “widespread discrimination, stigma, prejudice,
violence, social exclusion and segregation, unlawful or arbitrary institutionalization, overmedication and treatment practices [seen in the field of mental health] that fail to respect…autonomy, will and preferences”. As mandated by this resolution, the High Commissioner for human rights subsequently issued a report3 on mental health and human rights in January, 2017. This report3 recommended ending violations against people with psychosocial disabilities and people using mental health services, and included recommendations related to capacity building and technical support. Separate to this, the UN Special Rapporteur on the right to health also issued a landmark report4 in May, 2017, on the right to mental health, which denounced abuses and harmful practices in psychiatry and pressed for a “paradigm shift” in the field. In his report, the special rapporteur also noted that we are at a “juncture in history” in which www.thelancet.com/psychiatry Vol 4 November 2017
The role of schools in the diagnosis of ADHD There is a perception in the community that too many children are diagnosed with attention-deficit hyperactivity disorder (ADHD) and treated with medication. Conversely, some experts believe the disorder could be underdiagnosed and that efforts should be made to improve diagnostic reliability.1,2 Findings of studies in different countries have shown that many children who meet diagnostic criteria for ADHD—including impairment criteria—never receive a clinical diagnosis.3,4 Rates of diagnosis vary considerably both between and within countries, with many variables affecting the likelihood of diagnosis. One key variable is whether somebody in the child’s world—usually a parent or a teacher—notices problematic symptoms and raises concerns. For a diagnosis of ADHD to be made, as with many developmental disorders, evidence is needed of a persistent pattern of cross-situational impairment, meaning functional difficulties attributable to ADHD symptoms at both home and school.5,6 Therefore, those who diagnose and treat ADHD—paediatricians, psychologists, and child psychiatrists—depend on reports from teachers about the child’s behaviour, developmental competencies, and performance in school. Standardised questionnaires are designed to evaluate the child’s behaviour by comparison with his or her peers. For example, the commonly used Vanderbilt teacher rating scale says: “Each rating should be considered in the context of what is appropriate for the age of the child you are rating”. Despite this wording, children’s behaviour is likely to be often calibrated by teachers against gradelevel, rather than age-level, expectations. In The Lancet Psychiatry, Kapil Sayal and colleagues report findings of a study of relative age within the school year (by month of birth) and ADHD diagnosis.7 The authors used data from two national population patient registers to study children from age 7 years who were born in Finland between 1991 and 2004. Compared with children born in January (reference age), those born in the later months of the year had higher incidence ratios for ADHD diagnosis. The effect was seen in both boys and girls and was more pronounced in recent years. The relative age effect was noted for children diagnosed at age 7–9 years, but not for those diagnosed age 10 years or older. A sensitivity analysis showed no difference in findings whether comorbid www.thelancet.com/psychiatry Vol 4 November 2017
conduct disorder, oppositional defiant disorder, or comorbid learning disorder were present. Researchers in North America, Europe, and Asia have undertaken epidemiological studies with various methods to investigate a relative age effect on ADHD diagnosis, including using prescription data for ADHD medication as a proxy for diagnosis. Although some effect was noted in most studies, results have been mixed. The study by Sayal and colleagues adds weight to the cumulative evidence in favour of a relative age effect for ADHD diagnosis. What are the implications of these findings, and should we be concerned? Because most children who are diagnosed with ADHD by paediatricians or child psychiatrists are treated with medication—often for several years—the stakes are high. If behaviour congruent with relatively young age within the school year is being systematically misclassified as developmental immaturity, many incorrect diagnoses of ADHD could be made, and children might be treated unnecessarily with medication. The response to ADHD treatment is non-specific and not dependent on a correct diagnosis—ie, most children treated with stimulant medications show improvement in attentional control. Therefore, treating clinicians are likely to conclude that medication is effective and continue prescribing it for some time. As well as potential exposure to side-effects, other risks of wrong diagnosis and treatment include stigmatisation and missing alternate explanations for academic, social, and behavioural difficulties—eg, learning disorders, emotional disturbance, or trauma. To put the finding of Sayal and colleagues in context, it is useful to consider what factors might lead to a child with ADHD symptoms being referred for assessment. With respect to intrinsic child factors, children with combined presentation ADHD—ie, a combination of inattentive and hyperactive-impulsive symptoms—are referred more consistently than are those with only inattentive symptoms, and boys with ADHD are more likely to be identified than are girls.3 Family variables are also important: the effect of a child’s behaviour on the family is one of the main drivers of help-seeking for children with ADHD in the community.8 Other variables that might affect access to assessment services for
Published Online October 9, 2017 http://dx.doi.org/10.1016/ S2215-0366(17)30406-6 See Articles page 868
825
Comment
children include parental education, a parent’s mental health, and (in some health systems) family income. How do school-level variables affect rates of referral for assessment? So-called schooling practice has been suggested as a mediating mechanism to ADHD diagnosis.9 Singh describes school as “a culture in which children’s development intersects with prevailing expectations and values in relation to their behaviour, performance and achievement”9 and synthesises arguments that teachers might be more likely to recommend a misbehaving child is prescribed medication than to attempt to improve the child’s behaviour using pedagogical techniques. Younger children are, on average, less mature in relation to selfregulation, and, therefore, teachers are more likely to raise concerns about these children to their parents, which could lead them to seek an assessment. To enrich our understanding of the issue of relative age, future research should assess both teachers’ and parents’ perceptions of problematic behaviour and thresholds for concern in children who are young for year level. These issues would be best explored using qualitative methodology. In practice, clinicians need to ensure they assess attentional capacity and impulse control relative to the child’s chronological age and overall developmental status, rather than age for year level.
Daryl Efron Murdoch Children’s Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; and *The Royal Children’s Hospital; Melbourne, VIC 3052, Australia [email protected] I declare no competing interests. I am funded by a Clinician Scientist Fellowship from the Murdoch Children’s Research Institute. 1 2 3 4 5 6
7
8 9
Taylor E. Attention deficit hyperactivity disorder: overdiagnosed or diagnoses missed? Arch Dis Child 2017; 102: 376–79. Thomas R, Sanders S, Doust J, et al. Prevalence of attention-deficit/ hyperactivity disorder: a systematic review and meta-analysis. Pediatrics 2015; 135: e994–1001. Froehlich TE, Lanphear BP, Epstein JN, et al. Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. Arch Pediatr Adolesc Med 2007; 161: 857–64. Efron D, Sciberras E, Anderson V, et al. Functional status in children with ADHD at age 6–8: a controlled community study. Pediatrics 2014; 134: e992–1000. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th edn). Arlington: American Psychiatric Publishing, 2013. National Institute for Health and Care Excellence. NICE clinical guideline 72: attention deficit hyperactivity disorder—diagnosis and management. February, 2016. https://www.nice.org.uk/guidance/cg72 (accessed Sept 29, 2017). Sayal K, Chudal R, Hinkka-Yli-Salomäki S, Joelsson P, Sourander A. Relative age within the school year and diagnosis of attention-deficit hyperactivity disorder: a nationwide population-based study. Lancet Psychiatry 2017; published online Oct 9. http://dx.doi.org/10.1016/ S2215-0366(17)30394-2. Efron D, Moisuc O, McKenzie V, et al. Service use in children aged 6–8 years with attention deficit hyperactivity disorder. Arch Dis Child 2015; 101: 161–65. Singh I. ADHD, culture and education. Early Child Dev Care 2008; 178: 347–61.
WHO QualityRights: transforming mental health services
Published Online July 12, 2017 http://dx.doi.org/10.1016/ S2215-0366(17)30271-7 This online publication has been corrected. The corrected version first appeared at thelancet.com/psychiatry on July 24, 2017
826
A movement to profoundly transform the way mental health care is delivered and to change attitudes towards people with psychosocial, intellectual, and cognitive disabilities is gaining momentum globally. The Convention on the Rights of Persons with Disabilities (CRPD), which came into effect in 2008, clearly shows that changing attitudes towards—and practices—in mental health care is not only a necessity, but also an obligation under international human rights law. The vision and principles expressed in the CRPD have spread across the UN system. For instance, key principles of the CRPD were integrated into the WHO comprehensive mental health action plan of 2013–20.1 In July, 2016, a resolution2 led by Portugal and Brazil was adopted by the human rights council, calling on states and other UN agencies to take steps towards ending the “widespread discrimination, stigma, prejudice,
violence, social exclusion and segregation, unlawful or arbitrary institutionalization, overmedication and treatment practices [seen in the field of mental health] that fail to respect…autonomy, will and preferences”. As mandated by this resolution, the High Commissioner for human rights subsequently issued a report3 on mental health and human rights in January, 2017. This report3 recommended ending violations against people with psychosocial disabilities and people using mental health services, and included recommendations related to capacity building and technical support. Separate to this, the UN Special Rapporteur on the right to health also issued a landmark report4 in May, 2017, on the right to mental health, which denounced abuses and harmful practices in psychiatry and pressed for a “paradigm shift” in the field. In his report, the special rapporteur also noted that we are at a “juncture in history” in which www.thelancet.com/psychiatry Vol 4 November 2017