A ttention deficit hyperactivity disorder (ADHD) has been hypothesized to be related to a delay rather than a deviance of normal brain development before it was first defined by the DSM-III (1). The hypothesis was initially based on the behavioral observation that children with ADHD behave like younger children who are naturally more active, more impulsive, and have a shorter attention span than older children. This is well expressed in the definition of the disorder in the DSM-IV, where ADHD is characterized by an age-inappropriate display of inattention, hyperactivity, and impulsiveness. The behavioral observation is further supported by the cognitive profile of ADHD children: They show deficits in late developing higher cognitive functions of inhibitory selfcontrol, attention, and temporal foresight (2, 3). The fact that ADHD symptoms tend to improve with age and up to 80% of children (depending on the follow-up length and definition of persistence) grow out of ADHD in adulthood (4) further supports the theory of a maturational lag that eventually normalizes in a considerable proportion of children. Indirect neurobiological support comes from cross-sectional structural imaging studies finding reduced size in cortico-striatal brain regions that are known to develop late in adolescence (5) and functional imaging studies showing reduced brain activation in ADHD compared with their age-matched peers in precisely those brain areas whose functions develop progressively with age between childhood and adulthood (6-10). Crosssectional studies, however, are confounded by cohort effects; direct testing of the maturational delay hypothesis requires longitudinal imaging studies that map the developmental trajectories of brain maturation in healthy and ADHD children. In a recent issue of PNAS, Shaw et al. (11) study largely longitudinal data to provide direct neurobiological evidence for the maturational delay hypothesis of ADHD.
ADHD Is a Delay of Normal Brain MaturationPrevious mixed longitudinal and crosssectional structural MRI studies of the same research group in ÏŸ150 ADHD children scanned repeatedly between 5 and 20 years showed that ADHD children are characterized by a nonprogressive reduction in gray and white matter (2) and cortical thickness in cortical and cerebellar brain regions (11). Developmental growth curves in almost all cortical regions in ADHD children were lower but still parallel to those of controls. These findings can be interpreted as a maturational delay, because they suggest that ADHD children are ''limping behind'' normal development in a nonprogressive fashion. However, the relatively gross volumetric analyses of the cortical lobes in the first study (2) and the relative lack of power to investigate nonlinear changes in the second study (12) prevented the authors from detecting differences in developmental peaks within cortical brain areas. Shaw et al. (11) measured cortical thickness that can demonstrate considerable variability in timing of cortical maturation within each lobe in sufficientl...