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.” Rhode Island physician Dr. Charles Bradley pioneered the use of medications to treat ADHD in 1937. Since that time, the prescription of stimulants has become a first-line treatment for ADHD.

Historical Perspective

ADHA was first described by Sir Alexander Crichton in 1798. In 1937, Dr. Charles Bradley discovered that stimulants were effective in the treatment of ADHD.

Discovery

One of the earliest recorded mentions of a disorder resembling our modern conception of ADHD comes from “On Attention and its Diseases,” a book published in 1798 by Scottish physician Sir Alexander Crichton. 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 created some illustrated children’s stories including “Fidgety Phil” (“Zappelphilipp”), who is nowadays a popular allegory for children with ADHD. Hoffmann was known for his efforts to improve the living conditions of psychiatric patients.

The Goulstonian Lectures of Sir George Frederic Still, a British pediatrician, in 1902 are by many authors considered to be the scientific starting point of the history of ADHD. He became involved in research into childhood disease and wrote several medical textbooks about his findings. In his Goulstonian Lectures, a series of three lectures to the Royal College of Physicians of London “On Some Abnormal Psychical Conditions in Children,” Still discusses “the particular psychical conditions (…) which are concerned with an abnormal defect of moral control in children.” He defines moral control as “the control of action in conformity with the idea of the good of all.” Still states that “moral control (…) is dependent upon three psychical factors, a cognitive relation to environment, moral consciousness, and volition.” Since both “cognitive relation to environment,” which implies a “capacity for reasoning comparison,” and moral consciousness are intellectual capacities, Still states that defective moral control as a morbidity can often be observed in cases children suffering from mental retardation.

However, “there are other cases which cannot be included in this category” and which, as he points out, “in particular (…) call for careful observation.” They comprise the cases considered as historical descriptions of ADHD—i.e., children with a defect of moral control but without a “general impairment of intellect.” Still divided these cases in two further 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 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 reported that a group of children with behavioral problems improved after being treated with stimulants. In 1957, the stimulant methylphenidate (Ritalin), which was first produced in 1950) became available under various names (including Focalin, Concerta, Metadate, and Methylin); it remains one of the most widely prescribed medications for ADHD. Initially the drug was used to treat narcolepsy, chronic fatigue, depression, and to counter the sedating effects of other medications. The drug began to be used for ADHD in the 1960s and steadily rose in use.

In 1975, Pemoline (Cylert) was approved by the FDA for use in the treatment of ADHD. While an effective agent for managing the symptoms, the development of liver failure in 14 cases over the next 27 years would result in the manufacturer withdrawing this medication from the market. New delivery systems for medications were invented in 1999 that eliminated the need for multiple doses across the day or taking medication at school. 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 a liquid methylphenidate sludge 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 ADHD. In 2007 Lisdexamfetamine becomes the first prodrug to receive FDA approval for ADHD. The landmark study of 1999 – The largest study of treatment for ADHD in history – is published in the American Journal of Psychiatry. Known as the Multimodal Treatment Study of ADHD (MTA Study), it involved more than 570 children with ADHD at 6 sites in the United States and Canada randomly assigned to 4 treatment groups. Results generally 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. More than 40 studies have subsequently been published from this massive dataset.

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, affecting their neurological functions. Some of these exhibited immediate behavioral problems which may correspond to 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 the USA by 1966, following observations that the condition existed without any objectively observed pathological disorder or injury, researchers 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.