Is It ADHD or Immaturity?

How to avoid a misdiagnosis when a child is young for his class

Caroline Miller

Several studies in recent years have found that children who are among the youngest in their class are diagnosed with ADHD at a much higher rate than their older classmates.

This suggests that a significant percentage of kids with ADHD are being misdiagnosed just because they are less mature. It raises important questions about how kids are being diagnosed, and how to avoid misinterpreting the behavior of children who might be having trouble meeting expectations just because they are younger.

The findings in these studies of large populations of kids — in Michigan,British Columbia and (most recently) Taiwan — are consistent. The youngest children are significantly more likely to be diagnosed than the oldest in the same class: boys as much as 60 percent and girls as much as 70 percent. The Taiwan study even showed the prevalence of kids diagnosed with ADHD decreased month by month from the youngest to the oldest in the class.

What can we do to address this problem while still making sure kids get the help they need?

How to avoid misdiagnosis

Most ADHD diagnoses are the result of children struggling to meet expectations for behavior and performance in school. All young children find it challenging to sit still, pay attention, wait their turn, finish tasks and keep from interrupting. By school age most have developed skills to manage these things as expected. Those who don’t are often flagged by teachers who have a lot of experience with typical behavior and child development.

But the age range of students in a given classroom can span a whole year, which means that the developmental differences between the youngest and the oldest can be substantial. That’s why it’s important that if children are being evaluated for ADHD, their behavior should be compared with that of other children their age, not all the other children in their class.

“If a child is behaving poorly, if he’s inattentive, if he can’t sit still, it may simply be because he’s 5 and the other kids are 6,” explained Todd Elder, lead author of the Michigan study. “There’s a big difference between a 5-year-old and a 6-year-old, and teachers and medical practitioners need to take that into account when evaluating whether children have ADHD.”

Here are other “best practices” that should be followed to avoid misdiagnosis:

A variety of sources:

A child shouldn’t get a diagnosis of ADHD based on a teacher’s observations alone. A clinician evaluating a child should collect information from several adults, including teachers, parents and others who spend time with him.

Not just at school:

For a child to be properly diagnosed with ADHD, the signs and symptoms that are associated with the disorder — inattention, impulsivity and hyperactivity — have to be present in more than one setting. Are they noticeable at home and in social situations, as well as school? Do his parents worry that he’s so impulsive he’s a danger to himself? Does she have trouble keeping friends because she can’t follow rules, can’t wait her turn or has tantrums when she doesn’t get her way?

Rating scales:

Scales that are filled out by teachers and parents should be used to collect specific information about the frequency of behaviors we associate with ADHD, and compare them with other children the same age, rather than relying on general impressions.

A thorough history:

To get a good, nuanced understanding of a child’s behavior, a clinician needs to know how it’s developed over time, notes Dr. Matthew Rouse, a clinical psychologist at the Child Mind Institute. “What was she like at two or three or four? Is kindergarten the first time these issues have come up, or was she kicked out of preschool because she couldn’t behave?”

Level of impairment:

The biggest difference between kids with ADHD and those who are just immature is likely to be how much their behavior impacts their lives. Are they in a negative spiral at home because they can’t seem to do what they’re asked to do, and parents are very frustrated? Are they unable to participate in sports because they can’t follow rules? Do they get excluded from play dates?

A wait and see approach

If a child is struggling because he’s immature, things could get better over time, as he adjusts to the expectations of a new classroom.

“Some children starting kindergarten might have a difficult time fitting into a new setting, adjusting to new rules,” notes Dr. Rouse. “It might be the first time the child has been in a setting with so many other kids around, and the first time taking direction from people not his parents.”

Giving kids time to adjust is one reason Dr. Rouse says that when a child presents symptoms that look like ADHD in kindergarten, when it’s his first year in school, he’ll make a provisional or “rule out” diagnosis, and reevaluate when the child is 6.

Treatment recommendations

While medication has been shown repeatedly to be the most effective at reducing symptoms of ADHD, it isn’t necessarily the go-to treatment for the youngest kids. The potential for misdiagnosis is one reason why Dr. Rouse recommends behavioral therapy for younger children with ADHD, rather than starting with stimulant medication.

Similarly, the American Association of Pediatricians recommends behavioral therapy administered by parents and teachers as the first line of treatment for children 4 to 5 years old. Stimulant medication is recommended only if the behavioral therapy doesn’t produce results, and the child continues to have moderate to severe symptoms.

Delay in brain development

One reason immaturity might be confused with ADHD is that ADHD itself has been linked to a delay in brain maturation. An older child with ADHD might present behaviors that are typical in a younger child — and the opposite could be true if your frame of reference is older children. Several important neuroimaging studies have shown delays in brain development in kids with ADHD.

In a 2006 study at the National Institutes of Mental Health, the brains of several hundred children were scanned over a 10-year period. As the brain matures, the cortex thickens and then thins again following puberty, when connections are pruned to increase the efficiency of the brain. Researchers found that what they call “cortical maturation” — the point in which the cortex reaches peak thickness — was three years later in kids with ADHD than kids in a control group: 10.5 years old, compared to 7.5. The kids with ADHD also lag behind other kids in the subsequent cortical thinning.

The researchers noted that the most delayed areas of the brain are those that “support the ability to suppress inappropriate actions and thoughts, focus attention, remember things from moment to moment, work for reward and control movement – functions often disturbed in people with ADHD.”

They also added, tantalizingly, that the only area that matured faster than usual in kids with ADHD was the motor cortex. Combine that with the late-maturing frontal cortex areas that direct it, and the mismatch, they suggested, could account for the restlessness associated with the disorder.

Then in 2013, a study using scans of brain functioning, rather than structure, also found a lag in maturity in kids with ADHD. That study, at the University of Michigan, found that children and teens with ADHD are behind others of the same age in how quickly their brains form connections within, and between, key brain networks.

Specifically, they found less-mature connections between what’s called the “default mode network,” which controls internally directed thought, and networks that focus on externally directed tasks. Researchers propose that this lag in connectivity could help explain why children with ADHD find their thoughts wandering and struggle to complete tasks and stay focused.

Maturing out of ADHD symptoms

Finally, we know that some children grow out of ADHD symptoms as they become teenagers and young adults. Hyperactive and impulsive symptoms often wane through adolescence, while inattentive symptoms may continue to be a problem into adulthood.

Regardless of whether or not a child has ADHD, if his behaviors interfere with learning, making friends and being a part of the family, then he needs help. But the behavioral therapies and medications that can work wonders for kids with ADHD aren’t appropriate for children who are struggling to meet expectations just because they are less mature than those they are being compared to.

There are also other problems that can be misread as ADHD. Anxiety and trauma, for instance, can also cause inattention and what looks like impulsivity. That’s why it’s important that kids with behavior issues be evaluated thoroughly; careful and effective diagnosis benefits everyone.

ADHD and Behavior Problems

Why are tantrums, outbursts and defiance so common in kids with the disorder? And how can we help them behave better?

We think of kids with ADHD as having trouble paying attention. But for many of them — and their parents — behavior is a big problem, too. Sometimes a bigger problem. They may be quick to lash out, throw a tantrum or be defiant when they are asked to do things they don’t want to do.

Tantrums and defiance are not symptoms of ADHD itself, but they are often a result of ADHD symptoms. Inattention and impulsivity can make it very difficult for kids to tolerate tasks that are repetitive, or take a lot of work, or kids find boring. Children with ADHD can be overwhelmed with frustration, and throwing a shoe or pushing someone or yelling “shut up!” can be the result of impulsivity. They are less able than other kids their age to manage powerful feelings without an outburst.

But behavior problems can also go beyond impulsive outbursts. Some kids with ADHD develop negative behavior patterns, and those, argues David Anderson, director of the ADHD and Behavior Disorders Center at the Child Mind Institute, are a response to years of finding themselves in conflict with adults

In cases where kids with ADHD are chronically defiant, they are also diagnosed with a behavior disorder called oppositional defiant disorder (ODD). As many as 40 percent of kids with ADHD are also diagnosed with ODD. But many more of them are in conflict with parents or teachers over their behavior — as many as 80 percent, observes Dr. Anderson, a clinical psychologist.

Why do kids with ADHD act out?

To understand why kids with ADHD are often angry, aggressive or defiant, Dr. Anderson says, you have to think about their history growing up with ADHD.

Kids with ADHD are wired to be attracted by things that are outside the bounds of what we want them  to be doing, he explains, which leads to conflict with parents from a very young age. “There’s no malicious intent on the part of these young kids,” he adds. “Because of the hyperactive and impulsive symptoms of ADHD, they don’t want to stay in their seat. They want to explore the entire restaurant. They want to run away from you at the park to check something out that looks cool. That can result in pretty stressed out parents pretty quickly.”

This leads to a lot of negative interaction. “If you’re being told from an early age that your behavior is wrong, or isn’t what a kid is supposed to be doing, either you internalize it and you start thinking, ‘There really is something wrong with me,’ or you react aggressively towards the people who are telling you that you’re wrong.”

Why do kids with ADHD throw tantrums?

For kids with ADHD, tasks that are repetitive or boring or require a lot of effort can be acutely challenging, and elicit a lot of resistance, especially if it means stopping something that’s pleasurable — like playing a video game. So things like homework, going to bed, getting dressed and coming to dinner can become battlegrounds. Unfortunately for parents, the avoidance strategies that these kids typically use are tantrums, arguing, defiance and power struggles.

“If they throw a fit, it’s very likely that someone will change the task demands, make it easier on them, or settle for the bare minimum compliance,” adds Dr. Anderson. That works for the kid, so the behavior tends to be repeated.

Discipline strategies may not work

When kids have developed a pattern of negative interaction, discipline that works with other kids may be ineffective. “People do certain things naturally in parenting,” says Dr. Anderson. “For most kids, it works just fine. For kids with a behavioral issue, these things fail miserably.”

One thing that doesn’t work is losing your temper. For a child who rarely misbehaves, a parent who raises her voice may have an impact. “But kids who misbehave often habituate to this quickly. If you yell a lot, they eventually decide that’s the way of the world. People are just going to yell at them so why pay that much attention?”

Similarly, Dr. Anderson explains, punishment loses its effectiveness. “If kids get punished a lot, punishments stop mattering because, after all, they’re living in a perpetual state of punishment.  How much is it really going to matter if they get punished a little bit more?“

Discipline strategies that do work

Kids with ADHD often need more structure than other kids, and clearer instruction as to what kinds of behavior an adult is looking for. “As parents we need to help kids figure out what acceptable behaviors are, teach those acceptable behaviors and catch kids being good as often as we possibly can,” says Dr. Anderson. Praise and opportunities for a positive relationship with parents are powerful tools for managing disruptive behavior, which tends to escalate when a relationship is mostly negative interactions.

Clinicians call this kind of proactive structure “scaffolding.” Kids who are having trouble regulating their own behavior within acceptable limits need a family environment that provides external regulation of behavior. The structure that parents provide is a model for what we want kids to learn, and keeps them in good standing as they develop better self-regulation.

 

Trouble regulating emotions

Self-regulation is the ability to manage your emotions and behavior in accordance with the demands of the situation. It includes being able to resist highly emotional reactions to upsetting stimuli, to calm yourself down when you get upset, to adjust to a change in expectations and to handle frustration without an outburst.

Poor self-regulation is so common in kids with ADHD that some experts, including veteran ADHD researcher Russell Barkley, think it should be one of the core symptoms of the disorder.

But Dr. Anderson notes that it makes sense as an outgrowth of the impulsivity that’s part of ADHD; these kids have difficulty with inhibition, with planning and with delay of gratification.

“You take all of that together, you’ve got a kid who’s more likely to look for the short-term payoff than long-term payoffs,” he says. “You’ve got a kid who doesn’t want to wait, who finds it excruciating to wait, who’s quickly distractable, and for one reason or another is impaired on repetitive tasks, tasks that take a lot of work or tasks that kids find boring.

Trouble with friends

Unfortunately, the behavior problems kids with ADHD exhibit often affect their relationships not just with adults but with other kids.

“There are a host of reasons why we see friendships being impaired by ADHD symptoms,” notes Dr. Anderson. “For a kid who’s highly distractable, it could be they can’t keep up with a pace of conversation and their friends just notice they’re zoned out. For the kid who’s really impulsive, it might be they interrupt other kids and don’t let anybody else get a word in edgewise. For kids who have real difficulty delaying gratification, it may be that they always have to choose the activity, and anybody who doesn’t want to go along with it gets some impulsive speech directed at them.”

In one study of kids at summer camp, after only a few hours of interaction, the boys with ADHD were far more likely to be disliked and rejected by their peers than the boys without a diagnosis.

The main reasons given for the quick negative perceptions was their explosive, retaliatory and impulsive behavior patterns, researchers found. Stephen Hinshaw, one of the authors of the study and now the professor of psychology at the University of California, Berkeley.

And Dr. Hinshaw notes that girls with ADHD are subject to even more peer rejection than boys, “probably because their behavior patterns are more gender atypical.”

 

Help for behavior problems

When children with ADHD develop serious behavior problems, whether they had a diagnosis of ODD or not, the most effective treatment is parent training. There are many parent training programs, but what they have in common is that they teach parents how to reset the relationship with the child.

Parents learn how to use praise effectively, to encourage the behaviors they want to encourage, and how to deploy consistent consequences when kids don’t comply. The result is that kids learn to modulate their behavior to meet expectations and enjoy much more positive interactions with their parents. Social skills training and individual cognitive behavioral therapy can also help kids interact in a healthier way with both adults and their peers.

For kids with ADHD, stimulant medication that reduces symptoms of inattention, impulsivity and hyperactivity may also help improve behavior. Anti-psychotic medications like Abilify (aripiprazole) and Risperdal (risperdone), which have been shown to reduce aggression and irritability, are frequently used in cases where a child is at risk of being removed from the school or home.

But even when medication is used, experts recommend that it be paired with parent training for the best results.