Comment
The role of schools in the diagnosis of ADHD
There is a perception in the community that too
many children are diagnosed with attention-deficit
hyperactivity disorder (ADHD) and treated with
medication. Conversely, some experts believe the disorder
could be underdiagnosed and that efforts should be made
to improve diagnostic reliability.1,2 Findings of studies in
different countries have shown that many children who
meet diagnostic criteria for ADHD—including impairment
criteria—never receive a clinical diagnosis.3,4 Rates of
diagnosis vary considerably both between and within
countries, with many variables affecting the likelihood
of diagnosis. One key variable is whether somebody in
the child’s world—usually a parent or a teacher—notices
problematic symptoms and raises concerns.
For a diagnosis of ADHD to be made, as with many
developmental disorders, evidence is needed of a
persistent pattern of cross-situational impairment,
meaning functional difficulties attributable to ADHD
symptoms at both home and school.5,6 Therefore,
those who diagnose and treat ADHD—paediatricians,
psychologists, and child psychiatrists—depend on reports
from teachers about the child’s behaviour, developmental
competencies, and performance in school. Standardised
questionnaires are designed to evaluate the child’s
behaviour by comparison with his or her peers. For
example, the commonly used Vanderbilt teacher rating
scale says: “Each rating should be considered in the
context of what is appropriate for the age of the child you
are rating”. Despite this wording, children’s behaviour
is likely to be often calibrated by teachers against grade-
level, rather than age-level, expectations.
In The Lancet Psychiatry, Kapil Sayal and colleagues
report findings of a study of relative age within the
school year (by month of birth) and ADHD diagnosis.7
The authors used data from two national population
patient registers to study children from age 7 years
who were born in Finland between 1991 and 2004.
Compared with children born in January (reference age),
those born in the later months of the year had higher
incidence ratios for ADHD diagnosis. The effect was
seen in both boys and girls and was more pronounced
in recent years. The relative age effect was noted for
children diagnosed at age 7–9 years, but not for those
diagnosed age 10 years or older. A sensitivity analysis
showed no difference in findings whether comorbid
www.thelancet.com/psychiatry Vol 4 November 2017 825
conduct disorder, oppositional defiant disorder, or Published Online
October 9, 2017
comorbid learning disorder were present. http://dx.doi.org/10.1016/
Researchers in North America, Europe, and Asia S2215-0366(17)30406-6
have undertaken epidemiological studies with various See Articles page 868
methods to investigate a relative age effect on ADHD
diagnosis, including using prescription data for
ADHD medication as a proxy for diagnosis. Although
some effect was noted in most studies, results have
been mixed. The study by Sayal and colleagues adds
weight to the cumulative evidence in favour of a relative
age effect for ADHD diagnosis.
What are the implications of these findings, and
should we be concerned? Because most children who
are diagnosed with ADHD by paediatricians or child
psychiatrists are treated with medication—often
for several years—the stakes are high. If behaviour
congruent with relatively young age within the
school year is being systematically misclassified as
developmental immaturity, many incorrect diagnoses
of ADHD could be made, and children might be
treated unnecessarily with medication. The response
to ADHD treatment is non-specific and not dependent
on a correct diagnosis—ie, most children treated
with stimulant medications show improvement in
attentional control. Therefore, treating clinicians
are likely to conclude that medication is effective
and continue prescribing it for some time. As well as
potential exposure to side-effects, other risks of wrong
diagnosis and treatment include stigmatisation and
missing alternate explanations for academic, social,
and behavioural difficulties—eg, learning disorders,
emotional disturbance, or trauma.
To put the finding of Sayal and colleagues in context,
it is useful to consider what factors might lead to a child
with ADHD symptoms being referred for assessment.
With respect to intrinsic child factors, children with
combined presentation ADHD—ie, a combination of
inattentive and hyperactive-impulsive symptoms—are
referred more consistently than are those with only
inattentive symptoms, and boys with ADHD are more
likely to be identified than are girls.3 Family variables
are also important: the effect of a child’s behaviour on
the family is one of the main drivers of help-seeking for
children with ADHD in the community.8 Other variables
that might affect access to assessment services for
 Comment
children include parental education, a parent’s mental
health, and (in some health systems) family income.
How do school-level variables affect rates of
referral for assessment? So-called schooling practice
has been suggested as a mediating mechanism
to ADHD diagnosis.9 Singh describes school as “a
culture in which children’s development intersects
with prevailing expectations and values in relation to
their behaviour, performance and achievement”9 and
synthesises arguments that teachers might be more
likely to recommend a misbehaving child is prescribed
medication than to attempt to improve the child’s
behaviour using pedagogical techniques. Younger
children are, on average, less mature in relation to self-
regulation, and, therefore, teachers are more likely to
raise concerns about these children to their parents,
which could lead them to seek an assessment.
To enrich our understanding of the issue of relative age,
future research should assess both teachers’ and parents’
perceptions of problematic behaviour and thresholds
for concern in children who are young for year level.
These issues would be best explored using qualitative
methodology. In practice, clinicians need to ensure they
assess attentional capacity and impulse control relative to
the child’s chronological age and overall developmental
status, rather than age for year level.
WHO QualityRights: transforming mental health services
A movement to profoundly transform the way mental
health care is delivered and to change attitudes towards
people with psychosocial, intellectual, and cognitive
disabilities is gaining momentum globally.
The Convention on the Rights of Persons with
Disabilities (CRPD), which came into effect in 2008,
clearly shows that changing attitudes towards—and
Published Online practices—in mental health care is not only a necessity,
July 12, 2017
http://dx.doi.org/10.1016/
but also an obligation under international human rights
S2215-0366(17)30271-7 law. The vision and principles expressed in the CRPD
This online publication has been have spread across the UN system. For instance, key
corrected. The corrected version
first appeared at principles of the CRPD were integrated into the WHO
thelancet.com/psychiatry comprehensive mental health action plan of 2013–20.1
on July 24, 2017
In July, 2016, a resolution2 led by Portugal and Brazil was
adopted by the human rights council, calling on states
and other UN agencies to take steps towards ending
the “widespread discrimination, stigma, prejudice,
826 www.thelancet.com/psychiatry Vol 4 November 2017
Daryl Efron
Murdoch Children’s Research Institute, Melbourne, VIC, Australia;
Department of Paediatrics, University of Melbourne, Melbourne,
VIC, Australia; and *The Royal Children’s Hospital; Melbourne,
VIC 3052, Australia
daryl.efron@rch.org.au
I declare no competing interests. I am funded by a Clinician Scientist Fellowship
from the Murdoch Children’s Research Institute.
1 Taylor E. Attention deficit hyperactivity disorder: overdiagnosed or
diagnoses missed? Arch Dis Child 2017; 102: 376–79.
2 Thomas R, Sanders S, Doust J, et al. Prevalence of attention-deficit/
hyperactivity disorder: a systematic review and meta-analysis.
Pediatrics 2015; 135: e994–1001.
3 Froehlich TE, Lanphear BP, Epstein JN, et al. Prevalence, recognition, and
treatment of attention-deficit/hyperactivity disorder in a national sample
of US children. Arch Pediatr Adolesc Med 2007; 161: 857–64.
4 Efron D, Sciberras E, Anderson V, et al. Functional status in children with
ADHD at age 6–8: a controlled community study. Pediatrics 2014;
134: e992–1000.
5 American Psychiatric Association. Diagnostic and statistical manual of
mental disorders (5th edn). Arlington: American Psychiatric Publishing,
2013.
6 National Institute for Health and Care Excellence. NICE clinical guideline 72:
attention deficit hyperactivity disorder—diagnosis and management.
February, 2016. https://www.nice.org.uk/guidance/cg72 (accessed
Sept 29, 2017).
7 Sayal K, Chudal R, Hinkka-Yli-Salomäki S, Joelsson P, Sourander A.
Relative age within the school year and diagnosis of attention-deficit
hyperactivity disorder: a nationwide population-based study.
Lancet Psychiatry 2017; published online Oct 9. http://dx.doi.org/10.1016/
S2215-0366(17)30394-2.
8 Efron D, Moisuc O, McKenzie V, et al. Service use in children aged 6–8 years
with attention deficit hyperactivity disorder. Arch Dis Child 2015;
101: 161–65.
9 Singh I. ADHD, culture and education. Early Child Dev Care 2008; 178: 347–61.
violence, social exclusion and segregation, unlawful
or arbitrary institutionalization, overmedication and
treatment practices [seen in the field of mental health]
that fail to respect…autonomy, will and preferences”. As
mandated by this resolution, the High Commissioner
for human rights subsequently issued a report3 on
mental health and human rights in January, 2017. This
report3 recommended ending violations against people
with psychosocial disabilities and people using mental
health services, and included recommendations related
to capacity building and technical support. Separate to
this, the UN Special Rapporteur on the right to health
also issued a landmark report4 in May, 2017, on the right
to mental health, which denounced abuses and harmful
practices in psychiatry and pressed for a “paradigm
shift” in the field. In his report, the special rapporteur
also noted that we are at a “juncture in history” in which