Attention-deficit hyperactivity disorder historical perspective

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Charmaine Patel, M.D. [2], Haleigh Williams, B.S.

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Overview

ADHD symptoms have been recognized in children and described in medical texts since the nineteenth century, though the formal diagnosis had not yet been devised. ADHD was first included in some form in the DSM in its second edition, when it was referred to as “hyperkinetic reaction of childhood.” It was not until the third edition of the DSM was released in 1980 that the disorder was formally identified as “ADD (Attention-Deficit Disorder) with or without hyperactivity.” In 1937, Rhode Island physician Dr. Charles Bradley pioneered the use of medications to treat ADHD. Since that time, the prescription of stimulants has become a first-line treatment for ADHD.

Historical Perspective

Discovery

• In 1798, Scottish physician Sir Alexander Crichton published “On Attention and its Diseases,” which contains one of the earliest recorded mentions of a disorder resembling our modern conception of ADHD. In his book, Crichton spoke of a disorder characterized by an “incapacity of attending with a necessary degree of constancy to any one object.”

• In 1844, the German physician Heinrich Hoffmann published a series of illustrated children’s stories including a character called “Fidgety Phil” (“Zappelphilipp”), who has become a popular representation of children with ADHD. Hoffmann was known for his efforts to improve the living conditions of psychiatric patients.

• In 1902, British pediatrician Sir George Frederic Still delivered a series of Goulstonian Lectures to the Royal College of Physicians of London “On Some Abnormal Psychical Conditions in Children,” in which he discussed ADHD extensively. In his Goulstonian Lectures, Still discussed “the particular psychical conditions (…) which are concerned with an abnormal defect of moral control in children.” He defined moral control as “the control of action in conformity with the idea of the good of all.”

• Still divided these cases in two groups, children with a “morbid defect of moral control associated with physical disease,” such as a brain tumor, meningitis, epilepsy, head injury or typhoid fever, and children with a “defect of moral control as a morbid manifestation, without general impairment of intellect and without physical disease.” Some patients of the latter group, however, showed a “history of severe cerebral disturbance in early infancy.” This differentiation was the origin of later concepts of brain damage, minimal cerebral dysfunction, and hyperactivity as historical precursors to ADHD.

• Further, Still observed the higher incidence of ADHD in boys as compared to girls that remains a hallmark of the disorder today.

Landmark Events in the Development of Treatment Strategies

• In 1937, Dr. Charles Bradley of Providence, RI was the first to discover that children with behavioral problems improved after being treated with stimulants. In 1954, the stimulant methylphenidate was marketed as (Ritalin); it remains one of the most widely prescribed medications for ADHD. Initially, the drug was used to treat narcolepsy, fatigue, depression, and to counter the sedative effect of certain other medications. Use of the drug to treat ADHD steadily rose over time.

• In 1975, Pemoline (Cylert) was approved by the FDA for use in the treatment of ADHD. While Pemoline proved effective for managing the symptoms associated with ADHD, the development of liver failure in 14 cases over the next 27 years caused the manufacturer to withdraw this medication from the market. In 1999, new delivery systems for medications were invented that eliminated the need for multiple doses across the day. These new systems include pellets of medication coated with various time-release substances to permit medications to dissolve hourly across an 8–12 hour period (Medadate CD, Adderall XR, Focalin XR) and an osmotic pump that extrudes liquid methylphenidate across an 8–12 hour period after ingestion (Concerta).

• In 2003, Atomoxetine (Strattera) received the first FDA approval for a nonstimulant drug to be used specifically for treating ADHD. In 2007, Lisdexamfetamine became the first prodrug to receive FDA approval for ADHD. The Multimodal Treatment Study of ADHD (MTA Study) showed that medication alone was more effective than psychosocial treatments alone, but that their combination was beneficial for some subsets of ADHD children beyond the improvement achieved only by medication.

• The use of stimulants to treat ADHD rose slowly but steadily between 1996 and 2008, going from a prevalence rate among youth of 0.6 percent in 1987 to 2.7 percent in 1997, with the rate stabilizing around 2.9 percent in 2002. Overall, prescription use among 6-12-year-olds was found to be the highest, going from 4.2 percent in 1996 to 5.1 percent in 2008. But the fastest growth of prescribed use occurred among 13-18-year-olds, going from 2.3 percent in 1996 to 4.9 percent in 2008.

Impact on Cultural History

• In 1918–19, the world-wide influenza pandemic left many survivors with encephalitis, which affected their neurological functions. Some survivors exhibited immediate behavioral problems which may correspond to our modern conception of ADHD, although no diagnosis for such a disorder existed at the time. This caused many later commentators to believe that the condition was the result of injury rather than heredity. (The concept of hyperactivity not being caused by brain damage was first described by Stella Chess as "hyperactive child syndrome" in 1960.) This caused a significant rift in the understanding of the disorder. Europeans saw hyperkinesis as unusual and often associated it with mental retardation, brain damage, and conduct disorder, and changes to the ICD were not made until 1994. In 1966,, following observations that the condition existed without any objectively observed pathological disorder or injury, researchers in the United States changed the terminology from Minimal Brain Damage to Minimal Brain Dysfunction. A study by two anthropologists looked at the way laypersons talk about ADHD, and found five thematic patterns: "(1) appropriating the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) descriptors; (2) schools as identity-construction sites; (3) resistance: biology versus moral culpability; (4) alternative solutions to a real problem; and (5) relief and hope in naming experience."

Famous Cases

Many famous people have shared their experiences after being diagnosed with ADHD. Such celebrities include Terry Bradshaw, Richard Branson, Jim Carrey, James Carville, Ryan Gosling, Woody Harrelson, Michael Phelps, and Solange Knowles.

References

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