Are children today being over diagnosed with attention deficit hyperactivity disorder? The rate of the diagnosis has almost doubled in the last 20 years with considerable variation in the diagnosis across states. More than 5 percent of children in the U.S take ADHD medication. Does the reported increase reflect a real change in the behavior of children these days as compared to previous generations or do other factors enter into the changing statistics? This diagnosis is made primarily based on the perceptions and reports of parents and teachers, although psychiatric and psychological examinations are also part of the process. Recently, in a conversation with my 20-something grandson he referred to himself as an ADHD. Asked why he said that, he answered he had been given that diagnosis. Did he agree with the diagnosis? He thinks he has outgrown the hyperactivity part but agrees that he has an attention deficit based on his difficulty focusing and distractibility. His final evidence is that coffee helps him concentrate instead of making him jittery, this paradoxical reaction confirming in his mind that he has an AD disorder It was interesting to hear this given that there is a large subjective element in this diagnosis. Of course, at his age and developmental stage he is able to reflect upon his own behavior and apparently has also done some research on the diagnosis. Young children given the diagnosis are not participants in the perceptions and expectations of parents and teachers - or their tolerance level for behavior. When does active become hyperactive? When does restlessness, become an attention deficit? What is the tolerance level of a particular parent or teacher? What are their expectations for behavior? Numerous factors in the world of education have had an impact on the answers to these questions. Large classes make individual attention difficult, leading to a greater demand for compliance and conformity on the part of teachers. Teacher evaluations based on student success can mean less tolerance for a student who has difficulty keeping up with the class. Children attend groups at younger ages and judgments are often made of their behavior in relation to expectations that exist for appropriate school behavior. Functioning in a group requires skills that young children have not yet developed or are still developing. Development of these skills is a process that takes place over time and proceeds at a different pace for different children. Not all children of the same chronological age are at the same place in their development. When it comes to activity level there is great variation in young children. Sitting at attention in a circle or at a table or desk can be very challenging for some children. As they go forward in school, this may become a significant factor in their readiness to attend in the manner a teacher may require or wish for. These factors are significant in light of recent studies showing a correlation between an ADHD diagnosis and birthdate. School entry has a cutoff date in September. Those children born in August become the youngest in the class while the September children who just miss the cutoff become the oldest. The significance of being the youngest in the class is striking to an observer. Often, when concern is expressed about the behavior of a particular child, it emerges that the child is the youngest in the class. Behavior that may seem deviant in an older child can be developmentally appropriate in a younger child. Those extra months of development make a big difference. One more factor to consider before applying the ADHD label. Elaine Heffner, LCSW, Ed.D., has written for Parents Magazine, Fox.com, Redbook, Disney online and PBS Parents, as well as other publications. She has appeared on PBS, ABC, Fox TV and other networks. Dr. Heffner is the author of “Goodenoughmothering: The Best of the Blog,” as well as “Mothering: The Emotional Experience of Motherhood after Freud and Feminism.” She is a psychotherapist and parent educator in private practice, as well as a senior lecturer of education in psychiatry at Weill Cornell Medical College. Dr. Heffner was a co-founder and served as director of the Nursery School Treatment Center at Payne Whitney Clinic, New York Hospital. And she blogs at goodenoughmothering.com.