"The whole people must take upon themselves the education of the whole people and be willing to bear the expenses of it. There should not be a district of one mile square, without a school in it, not founded by a charitable individual, but maintained at the public expense of the people themselves." -- John Adams

"No money shall be drawn from the treasury, for the benefit of any religious or theological institution." -- Indiana Constitution Article 1, Section 6.

"...no man shall be compelled to frequent or support any religious worship, place, or ministry whatsoever, nor shall be enforced, restrained, molested, or burthened in his body or goods, nor shall otherwise suffer on account of his religious opinions or belief; but that all men shall be free to profess, and by argument to maintain, their opinion in matters of religion, and that the same shall in no wise diminish enlarge, or affect their civil capacities." – Thomas Jefferson

Wednesday, December 19, 2018

What's Bugging Me Today: ADHD Denial, Misdiagnosis, and the Harvard Study

The parents of a young child with a summer birthday asked the pediatrician if their child was ready to start school. The pediatrician told them, "Go ahead and send him. It's never too early to start them in school."

Even if I hadn't been a teacher involved in early education when I heard this, I would have known that this was bad advice. Starting school too early can be damaging. I knew because...


In Chicago, in the early 1950s, the Kindergarten entrance date cutoff was October 1. My mid-September birthday made me eligible for entrance to Kindergarten which, back then, started the day after Labor Day, about two weeks before my 5th birthday.

I struggled all through school. I made progress...now and then good progress, but I had trouble paying attention; I didn't always know what was going on at a given moment during class; I couldn't focus on the task at hand; I couldn't remember what I had read.

Every year I would start the school year with high hopes. I promised myself that I would keep up with the work, pay attention, and stay organized. And every year, by about the second or third month, those promises would be lost.

While in Elementary School I was diagnosed with Minimal Brain Damage, the horrifying 50s term for Attention Deficit Hyperactivity Disorder (ADHD). My treatment consisted of therapy with a child psychologist of which I remember very little other than the fact that I assumed that there was something "wrong" with me. At some point, and without any memorable closure, the therapy stopped. Nothing more was done for my MBD/ADHD, and I continued to struggle with the social and academic aspects of Elementary School.


At various times my parents and teachers said things like this to me (note the mixed messages):
  • What were you thinking?
  • Why didn't you think before you [insert behavior]?
  • You could do so much better if only you would try harder.
  • Did you even try?
  • You're just lazy.
  • You'd lose your head if it wasn't screwed on.
and my parents heard things like this from my teachers,
  • He's just not bright enough to do the work.
  • He's smart enough and can do the work, he's just lazy.
  • He could do so much better if only he put forth some effort.
  • He needs to learn to pay attention.
In high school, I learned that words have power. One day during my senior year, my English teacher kept me after class. She was a good teacher who clearly cared about her students (think: Professor McGonagall). She said to me, "You could do so much better if only you would try harder." Once again, I knew something was "wrong" with me...because I did try, but each year I would "forget" to pay attention. I would procrastinate. I would lose things. At that time in my life, I wasn't really sure what "try harder" meant. I ended up with a "C" in her class, and I have dragged her words around with me ever since then.

Still, I somehow managed to get by and survive Elementary and High School. High school band and orchestra helped - I always got an A in each.

College was the same. I got into college because of my musical ability (though I only stayed in the music school for one semester) and barely made it through my freshman year. I was allowed to come back for a third semester as a freshman, on the condition that I improve. I did, slightly, but continued the same pattern from elementary school and high school. I managed to graduate with a bachelors degree using several rounds of summer school to make up for classes I missed or failed.

Sullivan High School (Chicago) Orchestra, c.1966


After college, I worked in retail and, much to my surprise, I did very well, becoming the head of a sub-department in less than a year. When my first child was born I became interested in child development so I decided to go back to school. With the help of adulthood, marriage, and the responsibility of a child, I was able to get a teaching certificate and was even inducted into an education honor society. I followed this with a masters degree and a Reading Recovery certificate.

I spent my teaching career engaged in what was, ironically, the source of my childhood shame, embarrassment, and failure: elementary school education. I had some success and some failures as a teacher, but I kept at it and kept trying to improve. I eventually learned about ADHD (and ways to compensate for my own ADHD symptoms). In the middle of my career, I started working with children who were struggling in school...children who were like I was.


Last week I read a comment on a popular education blog that suggested that mental health diagnoses were quackery. The commenter accepted that there are mental health problems, but the diagnoses, at least to the commenter, were fake. The comment even referred to "alleged ADHD kids." I can only assume that there is some painful mental health problem to which the writer was exposed which was misdiagnosed, undiagnosed, left untreated, or incorrectly treated.

Are all mental health diagnoses quackery? Absolutely not.

We can't just deny that something exists because people screw up in their diagnosis. Medicine, like education, is not an exact science (there is no such thing as an exact science!), and the medicine of the brain is no different. We do the best we can with the knowledge we currently have, but we have to use that knowledge correctly.


Harvard study: Children who start school early more likely to get ADHD diagnosis — even if they don’t have it
Harvard University researchers have found that children who start school up to a year sooner than many of their peers are more likely to be diagnosed with ADHD — even if they don’t really have the condition. As a result, large numbers of children may be improperly labeled with the disorder when, instead, they are just immature.
In other words, those younger children were misdiagnosed with ADHD. That doesn't mean ADHD doesn't exist...or is "alleged."


What would my experiences in school have been if I hadn't started kindergarten at the age of four

Would I still have been diagnosed with ADHD (Minimal Brain Damage) as a child and then rediagnosed with the same as an adult?

Would I still have felt inclined to work with children who were struggling in class?

Would I have had a completely different career?
In a study published in the New England Journal of Medicine, the researchers looked at the records of more than 407,000 children from every state and found that younger children in the same grouping of students had a 30 percent higher risk for an ADHD diagnosis than older students.

Was I part of that 30%?

A 30% higher risk does not mean that everyone diagnosed with ADHD who has a summer birthday has been misdiagnosed.

ADHD does exist...and some people live with it even if they didn't start school at four years old. My lifelong experiences with the side effects and comorbid conditions related to ADHD suggest that I would have had the diagnosis anyway.

But the claim that ADHD is overdiagnosed is not new. Neither is the claim that ADHD is underdiagnosed. The truth is somewhere in between; ADHD is often misdiagnosed.


Schools and teachers shouldn't diagnose ADHD, a medical condition. However, a classroom teacher is often the first to notice a problem with the behaviors associated with ADHD. Primary Care Physicians are also not necessarily qualified to diagnose ADHD and many of those who do, often do not follow the diagnostic guidelines in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Misdiagnoses and overdiagnoses are caused by poor medical practices -- either by non-medical lay people (educators), slipshod work by untrained or overworked physicians, or mistakes by fallible, though well-meaning human beings.

That's why I wrote, above, and would like to emphasize...
Medicine, like education, is not an exact science, and the medicine of the brain is no different. We do the best we can with the knowledge we currently have, but we have to use that knowledge correctly.

The DSM has specific criteria which must be followed if ADHD is to be diagnosed. In order for a condition to be considered ADHD, the symptoms must occur...
...to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities...
and are present
...in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).
Misplacing your keys does not mean you have ADHD.

Occasional daydreaming does not mean your child has ADHD.

Excitability and clumsiness are normal human traits and do not mean that you or your child has ADHD.

ADHD in children is only ADHD if the suspected behaviors are "inconsistent with developmental level," have a serious negative impact on the child's life, and are present in more than one setting...otherwise, it's just "childhood."


Don't automatically enroll a child with a late-summer birthday in kindergarten the moment they become eligible. The later in the year a child is born, the more parents ought to consider preschool instead of Kindergarten.

A teacher should not be relied on to diagnose ADHD. If you're a teacher, remember that the youngest children in your classroom might have different behaviors than the older ones. It's also important to note that other conditions might "look like ADHD" such as childhood depression, some learning disabilities, oppositional defiant disorder, and bipolar disorder. Leave the medical diagnoses to medical professionals.

Perhaps it's time to let go of age-based grade grouping. No matter where we place the cutoff date for entrance into Kindergarten, there will be some children who are almost a year younger than the others. How about multi-age classrooms? Do the positive benefits of multi-age classrooms outweigh the negative?

Finally, it's essential that we end the trend towards curriculum push down. Developmentally appropriate practice is needed for our preschools and elementary schools. Children, even gifted children, are not just small adults. Physical and emotional development have an important part to play in learning. Children will not learn before they are ready and we can't depend on all students in a class learning the same thing at the same time.

In the meantime, we need to be responsible and use the best knowledge that we have to identify the problems and conditions of children in order to prevent misdiagnoses.


Links to articles dealing with the science of ADHD:


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