Younger kindergarteners more likely to be diagnosed with ADHD

In a class of kindergarteners, a child born in August is about 30% more likely to be diagnosed with attention deficit hyperactivity disorder (ADHD), and 25% more likely to be treated for it, than a child born in September — if you have to be 5 years old by September 1st to start kindergarten.

These were the findings of a study published in the New England Journal of Medicine. They didn’t find such a difference between any two other months — and in schools that didn’t have a September 1 cutoff for entry, the difference between August and September disappeared.

It’s not a Leo versus Virgo thing: it’s age. In schools with a September 1 cutoff, children born in August are a full year younger than children born in September. For children who are only 5, a year is a lot, especially when it comes to maturity, and the ability to stay focused and engaged on academic subjects. While some children might be naturally more mature than others, a child who is turning 6 is likely going to be able to sit still and focus more than a child who just turned 5.

But that doesn’t mean that the 5-year-old has ADHD; it means that the 5-year-old is acting normally for his or her age. And that’s what is worrisome about the study: it suggests that at least in some cases, teachers and doctors are mistaking normal behavior for a problem. Even worse, some children are getting medications that they really don’t need — or they wouldn’t need, if they were just a little bit older or the classroom demands were a little bit different.

Some families may see this study as proof that they should “red-shirt” their child. (The term is borrowed from school sports when a high school or college student is kept out of varsity sports for a year to gain skills while still keeping their eligibility to play; apparently they wear red shirts to set them apart from other new players.) When parents red-shirt their child, they wait an extra year before starting kindergarten. Parents are more likely to do this when their child has a spring or summer birthday, especially if their child is a boy. It’s thought that the extra year gives them more time to mature and be ready for school.

There are certainly some children who benefit from a bit more time before starting kindergarten, which has become increasingly focused more on academics than on socialization and play. But I would argue that parents shouldn’t have to do it — and many families simply can’t afford to pay for another year of preschool or childcare.

As a pediatrician, I see two big take-homes from this study. First, teachers and doctors need to do a better job of factoring in a child’s age and maturity level when assessing their behavior; just because they are different from their classroom peers doesn’t always mean that they have a psychiatric diagnosis, let alone need medication. Some do, of course, but many just need time.

Second, we need to do a better job of accommodating the relative differences in ages and maturity levels that exist in a perfectly normal kindergarten classroom. We need to be able to meet children where they are, and help each child get where they need to be — with patience and support, not labels or medications. That definitely means more support for teachers, but it also may mean that we need to rethink kindergarten curricula. Maybe we had it more right when we focused more on socialization and play. If a child needs to be 6 to do what we are asking a 5-year-old to do, maybe the problem isn’t with the child. Maybe it’s with us.

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Can watching sports be bad for your health?

As the new year begins, sports fans rejoice! You’ve had the excitement of the college football bowl games and the national championship, the NFL playoff games are winnowing teams down to the Super Bowl contestants, and basketball and hockey seasons are in full swing. There’s even some early talk of spring training for the upcoming Major League Baseball season.

While I hate to rain on anyone’s parade, the truth is that there can be health risks associated with watching sports. I’ve seen it firsthand while working in a walk-in clinic near Fenway Park, where people would show up bleeding from cuts that needed stitches (from trips and falls at the stadium), broken bones (from trying to catch a foul ball or after an altercation with another fan), dehydration, or other minor problems.

The problems can be more serious. In fact, studies have shown that watching sports — whether live at the stadium or on television — can have dire health consequences.

The big game may come with a big cost

Doctors and nurses often describe how quiet things get in the emergency room during a World Series game or the Super Bowl. But once the game ends, things get busy. It seems that many people with chest pain, trouble breathing, or other symptoms of a potentially serious problem delay seeking care until after the game.

Of course, there’s another possibility: the game itself — especially if a game is close and particularly exciting — might cause enough stress on the body that heart attacks, strokes, or other dangerous conditions develop.

A number of studies support the idea that watching sports can lead to health problems. For example, a 2017 study found that spectators of Montreal Canadiens hockey games experienced a doubling of their heart rate during games. The effect was more pronounced for live games than televised games, but even the latter experience led to faster heart rates similar to that during moderate exercise.

A similar observation had been made in the 1990s by researchers studying spectators of live Scottish football matches: blood pressure and heart rate rose dramatically compared to baseline measures while at home. The maximal heart rates were recorded just after a goal had been scored by the favored team.

Perhaps these observations explain why other studies have linked hospital admission for heart failure and even cardiac arrest with watching sporting events. The former study (in New Zealand) only found higher rates of heart failure admissions among women, and the latter study (in Japan) only found higher rates of cardiac arrest among older men. The gender differences remain unexplained.

Keeping it in perspective

It’s worth emphasizing that most people who choose to watch sports enjoy it and do not experience any health problems during or afterwards. My sense is that people with no health problems are at little risk even if they get worked up while watching sports, but there may be some small risk (similar to what might accompany moderate or vigorous exercise) for people who have cardiovascular disease.

What’s a sports fan to do?

The obvious recommendation is to remember, it’s only a game. But, ask anyone who cares about sports, sporting events, or a particular team — it’s much more than that.

It’s also easy to suggest being careful about how much you drink, to avoid overeating (especially salty junk food), and to be aware of your surroundings. For example, if you’re at a baseball game, pay attention to the game so you’ll at least have a chance of getting out of the way of a line-drive foul ball. Notice where the railings are and avoid leaning over dangerous ledges. And, of course, avoid altercations with hostile fans. Stay well-hydrated if you’re out in the heat for hours — remember that although beer is a liquid, it can actually make you more dehydrated.

For people who have cardiovascular disease, don’t forget to take your medications, even when there’s a big game on. Ask your doctor about how much exercise your heart can take, and whether you have any conditions that restrict your ability to exercise. If you do, improving your cardiac fitness might help improve your ability to exercise — and it might also make it safer to enjoy watching the sports you love.

Follow me on Twitter @RobShmerling

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