Hyperactive patience

New findings that attention-deficit hyperactivity disorder may stem from a developmental delay that children could outgrow, rather than a cognitive deficit, have raised questions for parents of the 4.4 million children diagnosed with the disorder.

The findings from a National Institute of Mental Health study, published online by the Proceedings of the National Academy of Sciences, compared brain scans of 446 children with and without the disorder. The brains of children with ADHD appeared to develop normally but more slowly, lagging on average about three years behind other children.

The Washington Post spoke with several experts about what the findings might mean for parents.

Q. Why the sudden change in thinking?

A. It’s not really sudden. Scientists have long suspected that ADHD may be tied to delays in brain development, but until now there has been little biological evidence. In the new study, biological differences were most evident in the cortex, the part of the brain that governs attention, planning and judgment. On average, in children with ADHD, thickening of the cortex appeared to peak at age 10.5, compared with age 7.5 in children without the disorder.

“It helps present a better, non-stigmatized, biological explanation for why … some kids have ADHD symptoms,” said William Coleman, professor of developmental and behavioral pediatrics at the University of North Carolina and chairman of the Committee of Psychosocial Aspects of Child and Family Health at the American Academy of Pediatrics. “They’re not bad, not lazy, not unmotivated. They don’t have bad parents. They just have a developmental lag.”

Q. Does this mean that my child will outgrow his ADHD symptoms by the time he’s a teen?

A. Perhaps.

“(The study) doesn’t show that the brains of kids with ADHD completely ‘normalize’ by age 12 or so,” the study’s lead author, Philip Shaw, wrote in an e-mail last week. “We only looked at one aspect of brain development. Many other structural and functional brain differences persist in the brains of teens with ADHD.”

“While a lot of people with ADHD do improve with age, as many as two-thirds still have symptoms of the disorder which persist into adulthood,” Shaw said. Among possible explanations: There may be more than one genetic variant of the disorder, or perhaps some kids with ADHD have other conditions that are responsible for their symptoms.

“The primary problem may be a learning disability,” Coleman said. “(Researchers) say that once the cortex thickens, kids get better, but if they have ongoing, undiagnosed problems, their symptoms may persist.”

Q. So, should I stop giving my child stimulant medications, such as Ritalin, to help with attention problems?

A. That’s beyond the reach of this latest study. “The study gives no implication of what treatments should be used,” said Judith Rapoport, chief of the child psychiatry branch at the National Institute of Mental Health and one of the authors of the study.

An estimated 2.5 million children in the United States took medications for ADHD in 2003, according to the Centers for Disease Control and Prevention.

Thomas Kobylski, past president of the Child and Adolescent Psychiatry Society of Greater Washington, says intervention with behavioral therapy or medication is important so that children don’t fall behind academically or develop secondary problems, such as anxiety or low self-esteem.

“The field has clearly stated that delays are worrisome,” he said. “You don’t want kids to become more delayed. You don’t want them to fall behind.”

Whether medication is appropriate depends on a careful evaluation of a child’s symptoms, environment, relationships and demands placed on him, Coleman said. “Always ask your physician: ‘What is normal for my child developmentally?’ ”

Q. Would it help to hold a child back in school so he can catch up to his peers?

A. That depends, said Coleman, who generally advises against holding a child back in school for academic reasons alone. But if a child is feeling left out and is socially or emotionally behind his peers, it may benefit him to stay back a grade, he said.

Q. Isn’t there a way to help nudge the development process along?

A. Sadly, no. Adolescent brains are structurally different from children’s brains, and there is no known way to speed up the growth process, Coleman said. What does help many children is a combination of medication and therapy – working closely with parents, teachers and physicians to help a child work through academic and social weaknesses.