New research led by experts at the University of Nottingham has found that teachers may be attributing signs of age-related immaturity in children to conditions such as Attention-Deficit/Hyperactivity Disorder (ADHD) or Autism.
The results of the study, which are published in the journal European Child and Adolescent Psychiatry, showed that the youngest students in a class, with birth dates just before the school entry cut-off date, were overrepresented among children receiving an ADHD diagnosis or medication for the condition.
Experts looked at how being one of the youngest children in a class can influence the likelihood of being diagnosed with ADHD or Autism. ADHD is a condition where individuals have significant challenges with attention and can be overly active.
Professor Kapil Sayal from the School of Medicine at the University, and senior author of the paper, said: “This review shows that adults involved in identifying or raising concerns over a child’s behaviour – such as parents and teachers – may be inadvertently misattributing relative immaturity as symptoms of ADHD. The child’s age in relation to their classmates (their ‘relative’ age) needs to be considered when making this kind of diagnosis.”
Detailed searches were used to identify all studies written on this topic worldwide. Researchers reviewed the 32 studies identified. Most of these studies focused on ADHD, and two focused on autism.
The findings confirmed that younger students in the school year are more likely to be diagnosed with ADHD and receive medication for this compared to their older classmates. The scale of this ‘relative age’ effect varied between the studies.
For autism, the youngest children in a class were also more likely to be diagnosed, but more research is needed because there are only a few studies available.
Interestingly, there was a more notable difference in how teachers rated these younger children compared to how parents did.
Dr Eleni Frisira, from the School of Medicine and lead author of the study, said: “Teachers play an important role in identifying ADHD symptoms in children. Our findings suggest that they can be more likely to rate younger students in a class as having ADHD symptoms than their older classmates. Teachers must be supported in considering the relative age of a child in a classroom when ADHD is being queried.”
The research emphasises how important it is to consider a child’s age in relation to their classmates when assessing for and diagnosing conditions like ADHD and autism. This is an important take-home message for healthcare professionals who assess young children, but also for teachers and parents when observing and reporting symptoms.
Dr. Shizuka Shimabukuro, lead author of the study, explains a game that is included in the program, which mothers can play with their children to improve their visual memory while having fun. CREDIT Okinawa Institute of Science and Technology
Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by elevated levels of inattention, impulsivity, and hyperactivity that can impair academic and social functioning. ADHD is also associated with increased levels of parenting stress and less effective parenting practices and can disrupt the parent-child relationship. The importance of support for parents of children with ADHD is widely acknowledged in Japan, but specialized parent training programs targeting ADHD have not been available.
However, a new program developed at the Okinawa Institute of Science and Technology (OIST) aims to reduce the strain on families of children with ADHD by helping mothers improve their ADHD-specific parenting skills, as well as developing confidence in their own parenting. Dr Shizuka Shimabukuro has worked to develop and evaluate Well Parent Japan (WPJ). WPJ is a 13-week group-based parent training program that enhances mothers’ psychological well-being and teaches culturally tailored parenting skills for ADHD. She is the lead author of a recently published paper in the Journal of Child Psychology and Psychiatry (DOI) that evaluates the efficacy and cost-effectiveness of WPJ compared with treatment as usual for Japanese mothers of children with ADHD.
“We implemented WPJ across three sites in Japan and found that the program was more effective than treatment as usual in these settings, as well as being moderate in cost to deliver,” explains Dr. Shimabukuro, and adds that, importantly, “the study was conducted in regular hospitals and a developmental support centre, not the research lab, as we wanted to test if it worked when delivered in the community.”
Finding solace in the community
The group-based approach was found to be very effective in providing social support and encouraging shared learning amongst the participating mothers, who might otherwise feel isolated or hesitate to seek help in dealing with their children’s difficulties. “The primary caregiver in Japan is usually the mother, and because they hesitate to put their own needs ahead of others, they often feel alone with their problems. We wanted to invite them to a comfortable, shared space where everyone is dealing with similar issues and can safely share their struggles and concerns and learn from and support one another,” explains Dr. Shimabukuro.
Just as the mothers came together to share and address their parenting difficulties, so is WPJ the product of ten years of co-production and collaboration between researchers, clinicians, parents, and children with ADHD, drawing on international literature and the voices of Japanese parents who participated in the studies. Professor Gail Tripp, head of the unit and another author on the paper, describes the present study as an exercise in crossing divides: “We worked closely with a local hospital here in Okinawa, two university hospitals in other parts of Japan, an economist in Tokyo, and a research colleague in the UK. OIST Innovation supported the study and our efforts to move toward broader implementation. It’s a highly collaborative effort, and I’m glad to see it coming to fruition.”
From lockdown to the future
The process of testing the efficacy of WPJ was not without its challenges. The clinical trials began just before the onset of the unexpected coronavirus pandemic, which meant they had to adapt the original research design to the changing social conditions. “We were trying to coordinate the trials across three sites, with the regulations constantly changing with the nature of the pandemic,” as Dr. Shimabukuro recounts it. “I’m very grateful and proud of the work that the research group leaders put into first and foremost ensuring the health and safety of our research participants, while also ensuring robust data.”
Despite the difficulties faced, the researchers were pleased to see that WPJ was effective in ‘the real world’, with the program outperforming treatment as usual in reducing parenting-specific stress, improving parenting efficacy and reducing family strain. “Considering the disruptions brought by COVID, we had an extraordinarily high participant retention,” explains Prof. Tripp, adding that “comparable studies from abroad in non-pandemic conditions usually report a participant attrition rate – the rate of participants of dropping off during the study – of about 15%, but ours was just around 7%.” Dr. Shimabukuro suggests that “our results show how much parents engaged with the program and valued the time and space to talk about their children, even during the height of the COVID crisis.”
The high participant retention and the positive results confirms the value of programs like the WPJ in Japan. As Dr. Shimabukuro puts it, “as parents are agents of change for their children, it is very important to take care of them before they can take care of others.”
Dr. Shimabukuro is now turning her focus to another environment where children with ADHD spend much of their time – schools. “Teachers are also important agents of change for the children, and the children spend so much of their time with them – but like parents, they often face the challenges that ADHD can bring alone. It would be much easier for children with ADHD to establish good behavioral habits if parents and teachers dealt with any problems that arise consistently,” explains Dr. Shimabukuro.
The team is now running a feasibility study for implementing an educational video series, a modified version of WPJ, for teachers in schools. Both to educate the teachers about what it means for a child to have ADHD and how to adjust their teaching techniques to accommodate this, but also to – like with the mothers – provide a space for the teachers to share their professional insights and experiences of accommodating children with ADHD, with one another. As licensed clinical psychologists, Dr. Shimabukuro and Prof. Tripp are working to combine their clinical experience with their research in the lab for the good of the children, their families, and their communities. In Dr. Shimabukuro’s words, “we are ultimately hoping to help enhance people’s understanding of ADHD, improve the quality of support and increase the number of places to receive help in the community – we want to help these families under strain.”
A new study explored the importance of household structure and stability for healthy sleep in teens.
Results of structural equation modelling show that household chaos and sleep hygiene were significant mediators of the relationship between ADHD symptoms and poor sleep quality. The results suggest that improving the daily routine and stability of the household is an important strategy to consider when seeking to improve sleep quality in adolescents with symptoms of attention-deficit/hyperactivity disorder.
“These results begin to explicate some contextual factors that may help explain the increase in sleep difficulties observed in youth with higher symptoms of ADHD,” said lead author and co-principal investigator Jamie Flannery, who is a doctoral candidate in developmental psychology at the University of Notre Dame in South Bend, Indiana. “It suggests that when ADHD symptoms are high, aspects of the individual — poor sleep hygiene — and the familial environment — household chaos — are associated with poor sleep quality in adolescents.”
The American Academy of Sleep Medicine recommends that teenagers 13 to 18 sleep 8 to 10 hours. Healthy sleep is associated with better health outcomes, including improved attention, behavior, learning, memory, emotional regulation, quality of life, and mental and physical health.
The researchers collected data from 259 pairs of mothers and adolescents from across the U.S. Mothers used a scale to rate the severity of their adolescent’s ADHD symptoms, while adolescents completed three separate surveys about sleep quality, home environment and sleep hygiene.
Flannery noted that it’s important for adolescents and their families to know that more than individual characteristics can impact their sleep.
“While improving sleep hygiene in youths with ADHD may be beneficial, a household characterized by a lack of structure, routine and stability may undermine the adolescent’s sleep quality,” Flannery said.
One million more children in the U.S. are diagnosed with ADHD in 2022 than in 2016
An exploration into the national U.S. dataset on children ever diagnosed with ADHD has revealed an “ongoing and ever-expanding” public health issue.
Findings uncover that approximately one million more children aged 3-17 had received an ADHD diagnosis in 2022 than in 2016.
The paper reveals around one in nine children have ever received an ADHD diagnosis – 11.4%, or 7.1 million children. Some 6.5 million children (10.5%) currently live with ADHD.
Among children currently living with ADHD, 58.1% have moderate or severe ADHD.
77.9% have at least one co-occurring disorder, approximately half of the children with current ADHD (53.6%) received ADHD medication, and 44.4% had received behavioural treatment for ADHD in the past year.
Nearly one-third (30.1%) did not receive any ADHD-specific treatment.
The results follow an analysis of the 2022 National Survey of Children’s Health (NSCH) dataset. They demonstrate that the estimated prevalence of ADHD (based on a parent report) is higher in the United States than comparable estimates from other countries.
The expert team of authors includes representatives from institutions such as the Centers for Disease Control and Prevention, the Oak Ridge Institute for Science and Education, and the Health Resources and Services Administration.
In the paper, the team explains the increase in ADHD prevalence can partially be explained by “sociodemographic and child characteristics”, whilst they state societal context can also “contribute to the overall trends in the diagnosis of ADHD”. These include the context around children’s mental health before and during the COVID-19 pandemic.
“Public awareness of ADHD has changed over time. ADHD was historically described as an externalizing disorder with a focus on easily observable hyperactive-impulsive symptoms and was thought to primarily affect boys,” the authors say.
“With increased awareness of symptoms related to attention regulation, ADHD has been increasingly recognized in girls, adolescents, and adults.
“Moreover, ADHD has previously been diagnosed at lower rates among children in some racial
and ethnic minority groups. With increased awareness, such gaps in diagnoses have been narrowing or closing.
“Circumstances related to the pandemic may also have increased the likelihood that a child’s ADHD symptoms could cause impairment. For example, in families where children needed to engage
in virtual classroom learning while parents were also working from home, previously manageable ADHD symptoms may have become more impairing or symptoms that were previously unobserved by parents may have become recognizable.”
The aim of this new paper was to provide updated U.S. prevalence estimates of diagnosed ADHD; ADHD severity; co-occurring disorders; and receipt of ADHD medication and behavioral treatment.
The team assessed 45,483 completed interviews, monitoring, as well, differences in demographic and clinical subgroups. Questions asked parents for details such as the severity of the condition.
Findings highlight how socioeconomic and geographic factors play a part in diagnosis/prevalence of ADHD.
For example:
Asian and Hispanic/Latino children had a lower prevalence of diagnosed ADHD than White children.
Children living in households with high school as the highest level of education and lower-income households had a higher prevalence than children living in households with more education and with income ≥200% of the federal poverty level, respectively.
Children with public insurance (with or without private insurance) had a higher prevalence than children with private insurance alone.
Prevalence was also higher for children living in the Northeast, Midwest, or South compared to those living in the West and for children living in rural or suburban areas compared to children living in urban areas.
The results also demonstrated how such factors impacted upon medicated treatment:
Hispanic children and children living in non-English-speaking households had a lower prevalence of taking ADHD medication than non-Hispanic children and children living in primarily English-speaking homes, respectively.
A higher prevalence of children with both public and private insurance were taking ADHD medication than children with private insurance only.
A higher prevalence of children living in the Midwest and South were taking ADHD medication compared to children in the West.
Other behavioral treatments, such as mental health counseling, also followed similar patterns.
Explaining the findings further, the authors state: “Shifts in patterns of treatments may also be affected by changes in the demographic distribution of who receives ADHD diagnoses.
“There is evidence that the sex difference for diagnosis of ADHD may be narrowing; in prior years, the ratio of boys to girls diagnosed with ADHD was more than 2:1.”
Concluding, the team state that they hope their findings can be used by clinicians to understand diagnosis and treatment patterns to better inform clinical practice. As well, they hope it could be used by policymakers, government agencies, health care systems, public health practitioners, and other partners to plan for the needs of children with ADHD, such as by ensuring access to care and services for ADHD.
Cambridge scientists have shown that problems regulating emotions – which can manifest as depression, anxiety and explosive outbursts – may be a core symptom of attention deficit hyperactivity disorder (ADHD).
In research published in Nature Mental Health, the team found that as many as one in two children with ADHD show signs of emotional dysregulation and that Ritalin – the commonly prescribed drug to help the condition – appears to be less effective at treating this symptom.
ADHD affects around one in 14 young people under the age of 18, and in around half of these cases, it persists into adulthood. The condition causes problems including hyperactivity, impulsivity and difficulty in focusing attention.
It has become increasingly clear that some people with ADHD also have self-control problems, affecting their ability to regulate emotions. For example, one in 50 (2.1%) children with a diagnosis of ADHD also have a mood disorder, such as depression, while more than one in four (27.4%) have an anxiety disorder. Many also have verbal or physical outbursts due to an inability to regulate their emotions.
These problems were thought to be a result of other symptoms associated with ADHD, such as problems with cognition and motivation. But today’s study shows that emotional dysregulation occurs independently of these.
The researchers examined data from the ABCD Study, a large longitudinal cohort that tracks children’s brain development and mental health across the United States. Data on ADHD symptoms was available for just over 6,000 of these children, allowing the researchers to attribute a score to each individual indicating their likelihood of having ADHD.
A team of scientists from Fudan University in Shanghai, China, and the University of Cambridge identified 350 individuals within the cohort who had high symptom scores that met the clinical cut-off for ADHD. Two-thirds (65.7%) of these were male.
Parents or guardians of the children and adolescents in the cohort had previously completed a series of questionnaires, which included questions that related to emotional behaviour, for example:
When my child is upset, he/she has difficulty controlling his/her behaviours.
When my child is upset, he/she knows that he/she can find a way to eventually feel better.
When my child is upset, he/she starts to feel very bad about him/herself.
The researchers found that half (51.4%) of the individuals in the high-symptom group showed signs of emotion dysregulation, which was independent of cognitive and motivational problems.
Among children with only low-ADHD symptoms at both ages 12 and 13 years, those with high scores of emotion dysregulation at age 13 years were 2.85 times more likely to have developed high-ADHD symptoms by age 14 years compared with those with a low score of emotion dysregulation.
When the researchers examined brain imaging data available for some of the participants, they discovered a particular region of the brain known as the pars orbitalis that was smaller among children who scored highly for ADHD and emotional problems. The pars orbitalis is at the front of the brain and plays an important role in understanding and processing emotion, communication, and inhibitory control over behaviour, which may explain some of the behaviours seen in ADHD.
Professor Barbara Sahakian from the Department of Psychiatry at the University of Cambridge and a Fellow of Clare Hall said: “The pars orbitalis is a well-connected part of the brain, and if it hasn’t developed properly, it might make it difficult for individuals to control their emotions and communicate with others appropriately, especially in social situations.
“Parents and teachers often say they have problems controlling children with ADHD, and it could be that when the children can’t express themselves well – when they hit emotional difficulties – they may not be able to control their emotions and have an outburst rather than communicating with the parent, teacher or the other child.”
Professor Sahakian hopes that acknowledging emotion dysregulation as a key part of ADHD will help people better understand the problems the child is experiencing. This could lead to using effective treatments for the regulation of emotion, such as cognitive behavioural therapy.
The findings may also point to potential ways to help the child manage their emotions, for example by using cognitive behavioural techniques to learn to stop and think before they react and to express their feelings verbally, or use techniques such as exercise or relaxation to calm themselves or alleviate symptoms of depression and anxiety.
This may be particularly important as the researchers found that Ritalin, the drug used to help manage ADHD symptoms, does not appear to fully treat symptoms of emotion dysregulation. Identifying the problem earlier would allow for alternative, more effective interventions to help the child better manage their emotions, potentially helping the individual in adulthood.
Professor Qiang Luo from Fudan University and a Life Member at Clare Hall, Cambridge, said: “If you’re having trouble controlling your emotions, this can lead to problems with social interactions, which further exacerbates any depression or anxiety that you might have. It also might mean that you’re saying things or doing things that exacerbate a situation rather than calming it down. Teaching vulnerable individuals from an early age how to manage your emotions and express yourself could help them overcome such problems further down the line.”
While it is not clear exactly what causes these problems in the first place, the researchers found signs of a link to possible dysfunction of the immune system, with individuals who exhibited signs of emotion dysregulation showing higher percentages of certain types of immune cell.
Professor Sahakian added: “We already know that problems with the immune system can be linked to depression, and we’ve seen similar patterns in individuals with ADHD who experience emotion dysregulation.”
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