This study examined whether the age of beginning primary school affects symptoms of Attention Deficit Hyperactivity Disorder (ADHD) using data from a large sample of students in Turkey where the compulsory school entry age was lowered. Teachers reported that students who began school before age 72 months displayed more ADHD symptoms and lower academic/social functioning compared to older students. Additionally, the percentage of students identified as "at risk for ADHD" was highest among the youngest students in 1st grade. However, limitations included a lack of diagnostic assessments. The findings suggest educational policymakers should consider potential impacts on students' development and functioning when changing school entry ages.

1. DOES THE AGE OF BEGINNING
PRIMARY SCHOOL AFFECT
ATTENTION DEFICIT HYPERACTIVITY
DISORDER SYMPTOMS?
Sule Yazgan*, MD, FAAP (presenter)
S Gokce** (principal investigator)
Y Yazgan* (corresponding author),
G Bulut, E Kayan, B Ayaz, C Dedeoglu
C Yusufoglu, S Demirhan, A Sancak, Ö Konuk,
*Guzel Gunler Pediatric Clinic, ***Erenkoy Psychiatric Hospital
Istanbul
Presented at #AAP2015, Washington, D.C. 1

2. disclosure
• I have no financial disclosures that can be
associated with a treatment or a commercial
product.
2

3. Background: prevalence may
vary
Attention deficit hyperactivity disorder (ADHD) is the most
common mental and behavioral disorder for school-age children.
US : 11%, CDC (2013),
Global : 5.3 % (Polanczyk et al 2007) and 7.2 % (6.7-7.8) Thomas,
R et al, 2015
Turkey: 2.7- 9.6 % for parent-based estimates, 2-10.1 % for
teacher-based estimates (Guler et al 2013) 12.7 %, K-SADS based (Ercan
et al 2015)
ADHD prevalence rates may vary due to methodological
differences as well as age, gender and SES differences.
3

4. Background: Age affects diagnosis
and treatment
In particular, the youngest children in the classroom may be:
• diagnosed inappropriately if teachers and parents mistake
their immaturity for ADHD leading to more diagnoses,
• treated for (ADHD) more often than their older classmates,
And
• may show academic underperformance during childhood.
(Zoëga et al 2012; Elder TE. 2010)
4

5. When age for school entry was
redefined as 60 months
• In April 2012, Turkish national education system was modified
and compulsory age for school entry (1st Grade) was redefined
as minimum 60 months (replacing the minimum 72 months
criterion).
• Following public and expert objections, the compulsory age was
moved upto 66 months, however, 60 months rule was also kept
with parental consent. This led to 100,000’s of children to be in
the 1st grade without a K experience, and almost no
preschooling before that.
• This regulation provided an “opportunity” to study the
relationship between ADHD Sx/dX since the school entry age
was spread to a 18-month period in a single grade for that
particular year.
5

6. Hypothesis
• In this study, we hypothesized that students
starting school before 72 months (the
previous age standard for the 1st Grade)
may experience:
• (i) greater number of symptoms of
attention deficit and hyperactivity disorder
(ADHD),
• (ii) lower functioning in social, behavioral
and academic domains. 6

7. Method: sample
• We performed this cross-sectional
community based study in the 1st and 2nd
grades from all of the 38 primary schools
(4,352 students) located in the Kadıköy
county of Istanbul (531,997 inhabitants).
• IRB approvals were obtained from both
medical and educational review boards.
7

8. Instruments:
Teachers filled out behavioral scales
1. for identifying symptoms and measuring severity of
ADHD:
– SNAP-IV (Swanson, 1997; Guler et al, 2013). An 18 item,
DSM based Likert scale (0-3) measure used in the MTA study.
2. for evaluating level of functioning in academic, social and
behavioral domains:
Perceived Competence Scale (PCS) (Guler et al,
2013; Wolmer et al, 2011).
3. A sociodemographic information form about the child and
family
8

9. Results: subjects
• We recruited a total of 4352 children, all first
and second grade students.
– 439 students (10.1%) were excluded due to missing
information and unreliable information, and
– 217 students (4.9 %) entry age older than 83
months due to intellectual disability were not
included in the analysis.
– 3696 (85.0 %) children were included for statistical
analyses.
9

10. Comparison of Attention and Hyperactivity/Impulsivity scores
according to SNAP ADHD Teacher scale between groups
( ANCOVA, multivariate analysis controlled for gender)
1st grades 2nd grades
<72
months
72-77
months
78-84
months
p <72
months
72-77
mont
hs
78-84
months
P
mean±SD
(min-max)
mean±SD
(min-max)
SNAP
IV total
score
11.8±13.5
4
(0-54)
10.05±12.
64
(0-54)
8.3±11.3
7
(0-54)
p<0.001
˟
F=11.34
11.71±11.
75
(0-54)
11.80±
12.60
(0-54)
9.98±11.3
9
(0-54)
P=0.012
˟
F=4.433
SNAP
IV
İnattent
ion
score
6.8±7.9
(0-27)
5.4±7.0
(0-27)
4.3±6.0
(0-27)
p<0.001
˟
F=19.4
6
6.42±6.7
(0-27)
6.28±
6.4
(0-27)
5.16±6.0
(0-27)
P=0.002
˟
F=6.03
SNAP
IV
H/I
4.9±6.7
(0-27)
4.5±6.4
(0-27)
4.0±6.1
(0-27)
P=0.03
4˟
F=3.19
5.29±6.3
(0-27)
5.52±
6.6
(0-27)
4.81±6.1
(0-27)
P=0.106
F=2.24
10

11. Comparison of academic, social, behavioral and total
functioning between groups according to the PCS
(ANCOVA, multivariate analysis controlled for gender)
1st grades 2nd grades
<72
months
72-77
months
78-84
months
Sign. <72
months
72-77
months
78-84
months
Sign.
mean±SD
(min-max)
mean±SD
(min-max)
Academi
c
3.9±1.1
(1-5)
4.2±0.9
(1-5)
4.4±0.9
(1-5)
p<0.001˟
F=24.7
4.21±0.
8
(2-5)
4.12±0.
9
(1-5)
4.30±0.
8
(1-5)
P<0.001˟
F=7.576
Social 4.16±0.9
(1-5)
4.34±0.8
(1-5)
4.43±0.7
(1-5)
p<0.001˟
F=15.5
4.21±0.8
(2-5)
4.27±0.7
(1-5)
4.38±0.7
(1-5)
P=0.012˟
F=4.411
Behavioral 4.21±0.9
(1-5)
4.39±0.8
(1-5)
4.47±0.7
(1-5)
p<0.001˟
F=13.1
4.26±0.7
(2-5)
4.26±0.8
(1-5)
4.35±0.8
(1-5)
P=0.124
F=2.093
Total 12.3
±2.6
(3-15)
13.7
±2.2
(3-15)
13.3
±2.1
(3-15)
p<0.001
F=22.4
12.6
±2.1
(6-15)
12.6
±2.2
(3-15)
13.0
±2.1
(3-15)
P=0.004
F=5.5
11

12. Children who scored +1 standart deviation (SD)
above the mean on SNAP IV AND Teacher PCS (that
is, both symptomatic and impaired as reported by the
teacher) were classified as “at risk for ADHD” or
“case”
At risk
cases
<72
months
n (%)
72-77
mo
n (%)
78-83
mo
n (%)
Total
n (%)
1st
grades
72 (15.9) 82 (9.4) 53 (6.4) 207 (9.6)
2nd
grades
5 (6.9) 67 (9.2) 53 (7.1) 125 (8.6)
12

13. Summary
• Our results from a whole city community
sample of first and second graders that were
subject to a government regulation
redefining the compulsory enrollment age to
the 1st grade allowed us to compare the
“pre-term” (72 mo< ) and
“conventional” (>=72 mo) beginners in
terms of symptoms of ADHD and
functioning levels on teacher reports.
13

14. Summary
• The number of ADHD symptoms was
greater and the level of academic, social and
behavioral functioning was lower in the
“pre-term” group.
14

15. summary
• The number of children who would be
defined as “at risk” cases were highest
among the “pre-term” (under 72 months) 1st
grader children.
• The opposite was true for the second grader
“under 72 months”, whose earlier entry was
expedited due to their well developed
cognitive and behavioral readiness.
15

16. Limitations
• Our findings are limited to an urban sample
with favorable living and school conditions.
However, children from less favorable
conditions would have increased symptoms
and caseness.
whe16

17. Limitations
• Using standardized diagnostic instruments
such as K-SADS would better confirm the
diagnosis, and possibly yield a lower
prevalence. However, the bias may not be
specific to a subgroup of our sample.
17

18. Implications
• The higher prevalence of symptoms of
ADHD and lower functioning in the
youngest group and the higher prevalence of
being “at risk for ADHD” should be taken
into account by educational policy makers
and school systems for preventing
unnecessary diagnosis and treatment for
ADHD and academic underachievement.
18

19. Implications
• Changes in the school age entry may be
associated with behavioral problems and
academic underachievement in the absence
of universal preschooling, and without
appropriate curriculum, classroom
modifications and staff qualifications.
19

20. Post script
• The 2012 modification of the compulsory
age of entry from 72 months to 60 months
has been revised as 69 months.
• We do not fully know yet the impact of the
earlier decision.
20

21. 21
Thank you.
Questions and comments?