ADHD through the retrospectoscope

Isolation in response to COVID-19 pandemic has driven many people to reestablish long forgotten connections between old friends and geographically distant relatives. Fed by the ease in which Zoom and other electronic miracles can bring once familiar voices and faces into our homes, we no longer need to wait until our high school or college reunions to reconnect.

The Class of 1962 at Pleasantville (N.Y.) High School has always attracted an unusually large number of attendees at its reunions, and its exuberant response to pandemic-fueled mini Zoom reunions is not surprising. With each virtual gathering we learn and relearn more about each other. I had always felt that because my birthday was in December that I was among the very youngest in my class. (New York’s school enrollment calendar cutoff is in December.) However, I recently learned that some of my classmates were even younger, having been born in the following spring.

This revelation prompted a discussion among the younger septuagenarians about whether we felt that our relative immaturity, at least as measured by the calendar, affected us. It was generally agreed that for the women, being younger seemed to present little problem. For, the men there were a few for whom immaturity put them at an athletic disadvantage. But, there was uniform agreement that social immaturity made dating an uncomfortable adventure. No one felt that his or her immaturity placed them at an academic disadvantage. Of course, all of these observations are heavily colored by the bias of those who have chosen to maintain contact with classmates.

A recent flurry of papers and commentaries about relative age at school entry and the diagnosis of attention deficit/hyperactivity disorder prompted me to ask my Zoom mates if they could recall anyone whom they would label as having exhibited the behavior we have all come to associate with ADHD (Vuori M et al. Children’s relative age and ADHD medication use: A Finnish population-based study. Pediatrics 2020 Oct. doi: 10.1542/peds.2019-4046, and Butter EM. Keeping relative age effects and ADHD care in context. Pediatrics. 2020;146[4]:e2020022798).

We could all recall classmates who struggled academically and seemed to not be paying attention. However, when one includes the hyperactivity descriptor we couldn’t recall anyone whose in-classroom physical activity drew our attention. Of course, there were many shared anecdotes about note passing, spitball throwing, and out-of-class shenanigans. But, from the perspective of behavior that disrupted the classroom there were very few. And, not surprisingly, given the intervening 6 decades, none of us could make an association between immaturity and the behavior.

While I have very few memories of what happened when I was in grade school, many of my classmates have vivid recollections of events both mundane and dramatic even as far back as first and second grade. Why do none of them recall classmates whose behavior would in current terminology be labeled as ADHD?

Were most of us that age bouncing off the walls and so there were no outliers? Were the teachers more tolerant because they expected that many children, particularly the younger ones, would be more physically active? Or, maybe we arrived at school, even those who were chronologically less mature, having already been settled down by home environments that neither fostered nor tolerated hyperactivity?

If you ask a pediatrician over the age of 70 if he or she recalls being taught anything about ADHD in medical school or seeing any children in his or her first years of practice who would fit the current diagnostic criteria, you will see them simply shrug. ADHD was simply not on our radar in the 1970s and 1980s. And it’s not because radar hadn’t been invented. We pediatricians were paying attention, and I trust in my high school classmates’ observations. I am sure there were isolated cases that could easily have been labeled as ADHD if the term had existed. But, the volume of hyperactive children a pediatrician sees today in the course of a normal office day just didn’t exist.

I have trouble believing that this dramatic increase in frequency is the result of accumulating genetic damage from Teflon cookware or climate change or air pollution. Although I am open to any serious attempt to explain the phenomenon I think we should look first into the home environment in which children are being raised. Sleep schedules, activity, and amusement opportunities as well as discipline styles – just to name a few – are far different now than before the ADHD diagnosis overtook the landscape.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Isolation in response to COVID-19 pandemic has driven many people to reestablish long forgotten connections between old friends and geographically distant relatives. Fed by the ease in which Zoom and other electronic miracles can bring once familiar voices and faces into our homes, we no longer need to wait until our high school or college reunions to reconnect.

The Class of 1962 at Pleasantville (N.Y.) High School has always attracted an unusually large number of attendees at its reunions, and its exuberant response to pandemic-fueled mini Zoom reunions is not surprising. With each virtual gathering we learn and relearn more about each other. I had always felt that because my birthday was in December that I was among the very youngest in my class. (New York’s school enrollment calendar cutoff is in December.) However, I recently learned that some of my classmates were even younger, having been born in the following spring.

This revelation prompted a discussion among the younger septuagenarians about whether we felt that our relative immaturity, at least as measured by the calendar, affected us. It was generally agreed that for the women, being younger seemed to present little problem. For, the men there were a few for whom immaturity put them at an athletic disadvantage. But, there was uniform agreement that social immaturity made dating an uncomfortable adventure. No one felt that his or her immaturity placed them at an academic disadvantage. Of course, all of these observations are heavily colored by the bias of those who have chosen to maintain contact with classmates.

A recent flurry of papers and commentaries about relative age at school entry and the diagnosis of attention deficit/hyperactivity disorder prompted me to ask my Zoom mates if they could recall anyone whom they would label as having exhibited the behavior we have all come to associate with ADHD (Vuori M et al. Children’s relative age and ADHD medication use: A Finnish population-based study. Pediatrics 2020 Oct. doi: 10.1542/peds.2019-4046, and Butter EM. Keeping relative age effects and ADHD care in context. Pediatrics. 2020;146[4]:e2020022798).

We could all recall classmates who struggled academically and seemed to not be paying attention. However, when one includes the hyperactivity descriptor we couldn’t recall anyone whose in-classroom physical activity drew our attention. Of course, there were many shared anecdotes about note passing, spitball throwing, and out-of-class shenanigans. But, from the perspective of behavior that disrupted the classroom there were very few. And, not surprisingly, given the intervening 6 decades, none of us could make an association between immaturity and the behavior.

While I have very few memories of what happened when I was in grade school, many of my classmates have vivid recollections of events both mundane and dramatic even as far back as first and second grade. Why do none of them recall classmates whose behavior would in current terminology be labeled as ADHD?

Were most of us that age bouncing off the walls and so there were no outliers? Were the teachers more tolerant because they expected that many children, particularly the younger ones, would be more physically active? Or, maybe we arrived at school, even those who were chronologically less mature, having already been settled down by home environments that neither fostered nor tolerated hyperactivity?

If you ask a pediatrician over the age of 70 if he or she recalls being taught anything about ADHD in medical school or seeing any children in his or her first years of practice who would fit the current diagnostic criteria, you will see them simply shrug. ADHD was simply not on our radar in the 1970s and 1980s. And it’s not because radar hadn’t been invented. We pediatricians were paying attention, and I trust in my high school classmates’ observations. I am sure there were isolated cases that could easily have been labeled as ADHD if the term had existed. But, the volume of hyperactive children a pediatrician sees today in the course of a normal office day just didn’t exist.

I have trouble believing that this dramatic increase in frequency is the result of accumulating genetic damage from Teflon cookware or climate change or air pollution. Although I am open to any serious attempt to explain the phenomenon I think we should look first into the home environment in which children are being raised. Sleep schedules, activity, and amusement opportunities as well as discipline styles – just to name a few – are far different now than before the ADHD diagnosis overtook the landscape.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Isolation in response to COVID-19 pandemic has driven many people to reestablish long forgotten connections between old friends and geographically distant relatives. Fed by the ease in which Zoom and other electronic miracles can bring once familiar voices and faces into our homes, we no longer need to wait until our high school or college reunions to reconnect.

The Class of 1962 at Pleasantville (N.Y.) High School has always attracted an unusually large number of attendees at its reunions, and its exuberant response to pandemic-fueled mini Zoom reunions is not surprising. With each virtual gathering we learn and relearn more about each other. I had always felt that because my birthday was in December that I was among the very youngest in my class. (New York’s school enrollment calendar cutoff is in December.) However, I recently learned that some of my classmates were even younger, having been born in the following spring.

This revelation prompted a discussion among the younger septuagenarians about whether we felt that our relative immaturity, at least as measured by the calendar, affected us. It was generally agreed that for the women, being younger seemed to present little problem. For, the men there were a few for whom immaturity put them at an athletic disadvantage. But, there was uniform agreement that social immaturity made dating an uncomfortable adventure. No one felt that his or her immaturity placed them at an academic disadvantage. Of course, all of these observations are heavily colored by the bias of those who have chosen to maintain contact with classmates.

A recent flurry of papers and commentaries about relative age at school entry and the diagnosis of attention deficit/hyperactivity disorder prompted me to ask my Zoom mates if they could recall anyone whom they would label as having exhibited the behavior we have all come to associate with ADHD (Vuori M et al. Children’s relative age and ADHD medication use: A Finnish population-based study. Pediatrics 2020 Oct. doi: 10.1542/peds.2019-4046, and Butter EM. Keeping relative age effects and ADHD care in context. Pediatrics. 2020;146[4]:e2020022798).

We could all recall classmates who struggled academically and seemed to not be paying attention. However, when one includes the hyperactivity descriptor we couldn’t recall anyone whose in-classroom physical activity drew our attention. Of course, there were many shared anecdotes about note passing, spitball throwing, and out-of-class shenanigans. But, from the perspective of behavior that disrupted the classroom there were very few. And, not surprisingly, given the intervening 6 decades, none of us could make an association between immaturity and the behavior.

While I have very few memories of what happened when I was in grade school, many of my classmates have vivid recollections of events both mundane and dramatic even as far back as first and second grade. Why do none of them recall classmates whose behavior would in current terminology be labeled as ADHD?

Were most of us that age bouncing off the walls and so there were no outliers? Were the teachers more tolerant because they expected that many children, particularly the younger ones, would be more physically active? Or, maybe we arrived at school, even those who were chronologically less mature, having already been settled down by home environments that neither fostered nor tolerated hyperactivity?

If you ask a pediatrician over the age of 70 if he or she recalls being taught anything about ADHD in medical school or seeing any children in his or her first years of practice who would fit the current diagnostic criteria, you will see them simply shrug. ADHD was simply not on our radar in the 1970s and 1980s. And it’s not because radar hadn’t been invented. We pediatricians were paying attention, and I trust in my high school classmates’ observations. I am sure there were isolated cases that could easily have been labeled as ADHD if the term had existed. But, the volume of hyperactive children a pediatrician sees today in the course of a normal office day just didn’t exist.

I have trouble believing that this dramatic increase in frequency is the result of accumulating genetic damage from Teflon cookware or climate change or air pollution. Although I am open to any serious attempt to explain the phenomenon I think we should look first into the home environment in which children are being raised. Sleep schedules, activity, and amusement opportunities as well as discipline styles – just to name a few – are far different now than before the ADHD diagnosis overtook the landscape.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.