Letters from Maine

Beware of the Ides of August


I suspect, like me, you have never put much stock in astrology. It just doesn’t feel like a good fit with our science-based training. But recent evidence suggests that maybe we should be paying more attention to the whether our patient is a Taurus or a Leo when we are hunting for a diagnosis.

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Three researchers from Harvard’s Schools of Medicine and Public Health have followed several hundred thousand children born between 2007 and 2009 until 2016 (“Attention deficit–hyperactivity disorder and month of school enrollment,” N Engl J Med. 2018;379:2122-30). Their data revealed that, in states with a Sept. 1 school entry cutoff, children born in August had rates of diagnosis and treatment of ADHD that were 34% higher than those born in other months.

Their findings could mean that astrology deserves a lot more credibility than we have been giving it. More likely it suggests that those of us committed to the health and education of children deserve a booby prize for objectivity. In a New York Times Op-Ed piece, the study’s investigators point out that their data show that the relative immaturity of the youngest children in a class too often is interpreted as a symptom of ADHD (“The Link Between August Birthdays and ADHD,” 2018 Nov 28. Jena AB et al.).

For many of us who practiced pediatrics before the ADHD phenomenon erupted, this new study substantiates our suspicion that the condition is currently being both overdiagnosed and overtreated. The data leave unanswered the question of whom or what is to blame for starting the epidemic. However, the study does suggest that physicians and educators deserve some culpability by failing to maintain their objectivity when interpreting childhood behavior.

I clearly can recall the first time I spoke to a group of teachers about the articles I had been reading that suggested a beneficial effect of treating “hyperactive” children with stimulant medication. The teachers uniformly were incredulous and repulsed by the counterintuitive notion of medicating children whom they saw as difficult, but not out of the broad range of age and developmental maturity they could expect to see in their classrooms.

Dr. William G. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years.

Dr. William G. Wilkoff

A mere 5 years later I began to see children in the office whose teachers were urging me to consider prescribing stimulant medication. Exactly what had happened over that interval is unclear. But I suspect that, through the educational grapevine, teachers were hearing about children with major problems with hyperactivity and inattention who had responded dramatically to a stimulant. My guess is that those dramatic responders were in that group of unfortunate children who enter into the world with an as yet poorly defined structural and/or biochemical constitution that I would call “true” ADHD.

The next part of the narrative is where the story gets sad. Deceived by those success stories we – doctors, parents, and educators – began to narrow our view of normal behavior because we now had a medication to “correct” a certain constellation of problem behaviors. Pharmaceutical companies joined us with their best efforts to meet the demand we were creating.

Forgotten was the fact that children mature at different rates and that normal but less mature children can exhibit many of the behaviors we now place under the ADHD umbrella and be considered as candidates for medication. Until recently, other causes of hyperactivity such as sleep deprivation were ignored. Hopefully, this new study will rekindle an interest in how parents, pediatricians, and educators evaluate and manage those children who arrive in school several months behind their peers in emotional and behavioral development.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

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