Evolution of ADHD

One of the first people to talk about what today is called ADHD was Alexander Crichton in 1798. He was also one of the first people to focus on mental illness from a medical perspective. He was working with children who had attention difficulties. He defined attention as “When any object of external sense, or of thought, occupies the mind in such a degree that a person does not receive a clear perception from any other one, he is said to attend to it.” After his observations, he came up with two types of abnormal inattention. The first one was “The incapacity of attending with a necessary degree of constancy to any one object” and the second one was “A total suspension of its effects on the brain.” He then classified the attention problems he observed as either innate or caused by nervous disorders. In his book where he published his findings, he never once mentions hyperactivity. So although he definitely observed the inattentive portion of ADHD, his definition doesn’t match the current DSM-V classification.

            Another early pioneer of ADHD was Heinrich Hoffman. He was also in favor of viewing mental illnesses as medical issues, similar to Alexander Crichton. He was the author of children’s books that chronicled problems that arise throughout childhood. Two of his stories were possibly displaying symptoms of ADHD. The first was called Fidgety Phil, the story of a little boy who couldn’t sit still during dinner. He ends up falling out of his chair and knocking over table. The other story was about Johnny Head-in-air. It followed a little boy who wandered around outside without paying attention to his surroundings. These stories show hyperactivity and inattentiveness, textbook symptoms of ADHD.

            Next was George Frederic Still. His area of focus was on children who had defects in their moral control, with and without mental retardation. In his study, there were 20 children- 5 girls and 15 boys, which is not a coincidence. It is a reflection of the present-day ADHD statistics, with many more boys than girls being diagnosed with the disorder. His definition of the symptoms of the children he was studying was “A defect of moral control as a morbid manifestation, without general impairment of intellect and without physical disease.” Again this isn’t a perfect match with the DSM-V because his children were exhibiting frustration, anger, hostility, and aggression, which would fit much better with things like conduct disorder, antisocial personality disorder, and oppositional defiance disorder.

            In 1932, Franz Kramer and Hans Pollnow came up with the diagnosis of hyperkinetic disease of infancy, which was characterized by children’s inability to sit still, urgent acting out of impulses, distinct distractibility by extraneous stimuli, and lack of a clear goal in activities. To date, this was the most similar to DSM-V ADHD.

Between 1917 and 1928, there was a massive epidemic of encephalitis among children. Upon returning to school, teachers of these children began noticing their hyperactivity, distractibility, irritability, anti-sociality, destructivity, unruly, and unmanageability, symptoms they never exhibited before encephalitis. This came to be known as post-encephalitic behavior disorder.

Charles Bradley, in 1937, was treating children with encephalitis. They were undergoing brain scans to check the progression of the illness, and suffering from severe headaches as a result of the spinal fluid lost during that procedure. He gave them stimulant medication as a treatment for the head aches. But what he noticed was that some of the symptoms of post-encephalitic behavior disorder were disappearing.

Then there was Leandro Panizzon. In 1954, he got methylphenidate approved for treatment of children with signs of hyperactivity and attention problems. He named it Ritalin as a tribute to his wife, whose name was Rita. It soon became the drug of choice for those types of problems, and remains to the day the most prescribed drug in the treatment of ADHD.

Last came the disorders that made it into the DSM. We had hyperkinetic reaction of children in the DSM-II, “characterized by overactivity, restlessness, distractibility, and short attention span, especially in young children; the behavior usually diminishes by adolescence.” Then Attention Deficit Disorder, with and without hyperactivity in the DSM-III, which had three separate symptom lists for inattention, impulsivity, and hyperactivity. Next was Attention Deficit Hyperactivity Disorder in the DSM-III-R, which stated that there was no evidence to support that ADD without hyperactivity was significant different than ADD with hyperactivity. So they merged into ADHD in 1987. When the DSM-IV came out, it was still in there as ADHD but this was when they discovered that there were structural brain differences in children with ADHD. Also, they expanded the diagnostic criteria to include adults as well.