ADHD and immaturity: examining the UK context

Imagine you are a family grappling with the difficulties faced by having a child with Attention Deficit Hyperactivity Disorder (ADHD), a developmental disorder characterised by pervasive symptoms of inattention, hyperactivity, and impulsivity. But at least you have a diagnosis and people around you are sympathetic and assisting you with the range of help you need to deal with your child. Then you pick up a newspaper and read ‘ADHD is vastly overdiagnosed and many children are just immature, say scientists’. The ‘scientist’ reference makes this sound very credible, of course. Then you discover the story has hit every UK media outlet with other headlines, such as ‘ADHD children may just be immature, research suggests’ and ‘Is it really ADHD or just immaturity’. You are now battling not only with the challenges you meet with your child, but a society that questions the diagnosis and suggests your child is just immature……..what is behind these headlines?

The study involved an assessment of a large sample of children (378, 881) in Taiwan (yes, Taiwan, not the UK – I will get back to that point), who were enrolled in a National Health Insurance Research Database. The cut-off birth date for entry to school in Taiwan is August 31st. The researchers examined the likelihood  of receiving an ADHD diagnosis if you were born in August, versus if you had been born in September. 2.9% of children in their sample who were born in August (i.e. the children youngest in the school class) received a diagnosis of  ADHD, while 1.8% of those born in September (the oldest in the school class) received a diagnosis of ADHD.

There are two major points to be made about these findings. First, this study was conducted with children born and raised in Taiwan, who have a very different culture, including school education, from children in the U.K. The paper confirms that the children were diagnosed by psychiatrists in Taiwan, but there is absolutely no information in the paper about the diagnostic system used, whether symptoms were verified across settings, the severity of ADHD, or the rates of co-occurring conditions the children may have had. It is very difficult to get a clinical picture of these children.

The findings of this Taiwan study do not transfer automatically to children in the UK. You would never know this though from the media coverage in the UK over the last week. None of the coverage that I have encountered explained that the findings may be specific to the way children are diagnosed in Taiwan. They all implied children with ADHD in the UK may just be immature. There is as yet no such evidence to suggest that. Eric Taylor, Emeritus Professor at Kings College London and a retired child psychiatrist, a leading UK expert in the area of ADHD, has commented specifically on the differences in diagnosis across the world in an article on the topic. He said:  ‘I agree over-diagnosis and over-medication are a problem in the US and Australia, but I think we under-diagnose and under-treat here in the UK. We prescribe stimulants at only about a tenth of the rate that applies in the US.’

Other UK clinicians have commented similarly. Professor Peter Hill, Consultant Child and Adolescent Psychiatrist at Wimpole Street Clinic, commented in a report that “In the UK, the assessment and diagnosis of ADHD is carried out by specialists. There are protocols for these processes and for further management. Although some voices have expressed fears of overdiagnosis and overtreatment, there is no evidence that this is happening nationally. No specialist would want this to happen and the guidance on good practice that exists will in any case prevent it”. Another UK clinician has highlighted the danger of children NOT receiving a diagnosis that was warranted in the same report. Dr Joanne Barton, Consultant Child and Adolescent Psychiatrist, University of Keele, commented “It is possible that some of the children with ADHD excluded from school could still be in mainstream education had they been identified and treated earlier. It is impossible to emphasise enough the importance of identifying and treating ADHD as early as possible”.  Both of these statements can be found in an ADDISS report. ADDISS (Attention Deficit Disorder Information and Support Service)  is a national UK charity that provides information and resources to families, teachers and health professionals affected by ADHD.

The second point to be made from reading this study relates to the implications for understanding ADHD in Taiwanese children. Being born in September didn’t remove the potential to receive a diagnosis of ADHD – it reduced it. 1.8% of the oldest children still received a diagnosis of ADHD, which cannot be explained at all by immaturity.  Interestingly, this 1.8% is still higher than the estimated prevalence of ADHD in the U.K. A group of researchers from the University of Exeter Medical School looked at figures, including ADHD diagnoses from the UK Millennium Cohort Study, which is a sample of more than 19,000 children, representative of the UK population.  1.4% of parents reported a diagnosis of ADHD in this UK sample.

ADHD is very real for the families affected by it. In the UK, the public body of the Department of Health that provide advice and guidance on health – the National Institute for Clinical Excellence (NICE) – recognise the difficulties faced by families affected. They have stated: “The consequences of severe ADHD for children, their families and for society can be very serious. Children can develop poor self-esteem, emotional and social problems and their educational attainment is frequently severely impaired. The pressure on families can be extreme.” What families really don’t need is to read headlines that suggest their children are just immature, based on a study conducted in a very different country, where diagnosis cannot readily or easily be compared to the UK.

Russell, G. et al. (2014). Prevalence of Parent-Reported ASD and ADHD in the UK: Findings from the Millennium Cohort Study. Journal of Autism and Developmental Disorders. DOI: 10.1007/s10803-013-1849-0