Despite what certain critic’s claim Attention Deficit Hyperactivity Disorder (ADHD) is not a novel phenomenon constructed during the 1980’s in the USA, rather it appears to be the result of an accumulation of research findings and clinical observations over the course of more than two centuries. During that time the condition has been known by numerous pseudonyms, influenced by zeitgeists, and strengthened by diverse inter- and intra-field debates. It is important to remember that this discussion represents only a very brief overview of some of the pertinent dates and events in ADHD history. From the disorders humble beginnings as characters in literature through its numerous reinventions to modernity’s appreciation of ADHD as a condition characterised by differential manifestations of inattention, hyperactivity, and impulsivity.
Ancient ADHD History
It would be difficult, if not impossible, to note every literary reference to behaviours potentially attributable to ADHD, however, certain instances it would be remiss not to mention. The earliest character suffering from a malady of attention appears in a play (King Hennery VIII, circa 1613) by William Shakespeare, perhaps unsurprising given his uncanny ability to understand and portray human nature and mental illness. ADHD type symptoms appear in a number of other academic and medical literature before a German doctor, Heinrich Hoffman, coined the term Hyperkinetic Syndrome, and wrote a children’s story which clearly describes some of these behaviors,
“Fidgety Phil, he won’t sit still, he wriggles, and giggles … The naughty restless child growing still more rude and wild” (Stewart,1970, p. 94).
As Ilina Singh (2008) sensibly asserted, the mere presence of characters demonstrating ADHD like symptoms in antiquated literature does not support the validity of a medical diagnosis. However, the use of inductive reasoning as a precursor to scientific method is unarguably of merit in, if not central to, empirical pursuits. But such observations do refute arguments from the likes of Conrad (1976) who suggested that modern society created the problem or was medicalizing normal behaviours. If this were true then what were Shakespeare and Hoffman reacting to ... I wonder???
Timeline of ADHD
1613 William Shakespeare’s play King Hennery VIII
1798 ‘Mental Restlessness’ (Critchton)
1809 ‘Observations on Madness and Melancholy.’ (Haslam)
1845 ‘Hyperkinetic Syndrome’ and ‘Fidgety Phil’ (Hoffman)
1902 ‘Deficits in Moral Character’ (Still)
1908 ‘Minimal Brain Damage’ (Tredgold).
1913 ‘Partial Moral Dementia’ (Stein)
1917 Post-encephalitis behavioural disorders
1931 ‘Hyperkinetic child’ (Winnicott)
1934 ‘Hyperkinetic Disease’ (Kramer – Pollnow)
1937 Charles Bradley study of Benzedrine.
1940 ‘Minimal Brain Damage’.
1957 ‘Hyperkinetic’ Impulse Disorder / Behaviour Syndrome
1960 ‘Minimal Brain Dysfunction’
1968 ‘Hyperkinetic Reaction of Childhood’ in the DSM-II
1972 V. Douglas’s research on inattention
1977 ‘Hyperkinetic Syndrome of Childhood’ in the ICD -9
1980 ‘Attention Deficit Disorder’ (ADD) in the DSM-III
1987 ADHD in the DSM-III-Rremoved sub-typing
It is also important to stress that the condition was not absent from the medical arena, indeed, the earliest paper on what would today be classified as ADHD, entitle Mental Restlessness was published by Dr Crichton in 1798 (Palmer & Finger, 2001), and clearlydescribes individuals with the inattentive subtype (their difficulties with concentration, persistence, and distractibility) as having 'the fidgets'. His contention that the condition was attributable to nervous system damage was supported by Maudsley (1867), and what is perhaps the most remarkable about the earliest descriptions, is that a biological basis was assumed. Although, such sentiments were far from universally accepted, William James (1890) the founder of his field and an attention enthusiast, describes attributes and processes associated with an 'explosive will' in his infamous text the Principles of Psychology.
• ADHD has a long history, the earliest medical text describing ADHD symptoms is over 200 years old (Crichton, 1798).
• Clinical and scientific publications number in the thousands.
• Early consideration of moral and nervous system defects have been refined.
• Diagnostic criteria and the central features of the condition have become apparent across time based on research.
• The three core features of ADHD hyperactivity (1917), inattention (1972), and more recently impulsivity (1987) are based on cumulative research and clinical findings.
During the first few decades of the twentieth century there was a preoccupation with descriptions of supposed aetiology. Dr George Still (1902) is often (incorrectly) cited as the first to apply a medical label to the disorder, which he referred to as a ‘Defect of Moral Control’ resulting from a neurobiological ‘affliction’. In a series of lectures at the Royal College of Physicians in London, Still described 43 children who experienced chronic difficulties, with attention and self-regulation, many of them displayed challenging and oppositional behaviours, and others were said to be emotionally volatile. However, these difficulties were not associated with environmental factors, nor were these children in any way intellectually impaired. Similarly, Stein (1913) described the condition as a ‘moral dementia’ caused by the mind being ‘saturated’ with insanity while still in the womb. By modern standards the emphasis on moral failings appears ludicrous, however, at the time there was a reliance on religious and supernatural explanations for disabilities. Thus, the fact that in such times it was viewed as a medical, not spiritual, problem is significant.
The Evolution of Classification and Diagnostic Criteria
In 1917 a pandemic of encephalitis lethargica swept across Europe and North America, and some of the children, who recovered from the brain inflammation, were reported to have developed cognitive deficits, and tended to be overactive, distractible, and prone to impulsive acts (Fitzgerald, Belgrave, & Gill, 2007).In the wake of this epidemic was an insurgence of academic and clinical interest in both aetiology and symptomology.
Creswell (1974) credits the events of 1917 with the subsequent decade’s emphasis on hyperactivity, and in all likelihood this is partial true, however, another plausible explanation is that it is the most notable (i.e., overt) symptom. Thus, it is unsurprising that it was originally believed to be the most problematic (Fitzgerald, Belgrove, & Gill, 2007), and why educators continue to view it as such (DuPaul& Stoner, 2004), causing it to be the most commonly cited reason for the referral of young people to clinics in the USA (Brown, 2006; Cantwell, 1996). In addition, when, quite by accident, Charles Bradley (1937) stumbled upon the calming effects Benzedrine had on overactive children the centrality of hyperactivity seems to have been firmly cemented.
The second edition of the DSM-II (APA, 1968) introduced the label Hyperkinetic Reaction of Childhood, replacing Minimal Brain Dysfunction (previously Minimal Brain Damage) due to the lack of observable brain abnormalities (Fitgerald, Belgrove, & Gill, 2007). The emphasis on motor activity and the use of ‘reaction’, supplanted the fields preoccupation with a supposed biological basis. The psychoanalytic leaning has since been discarded, but the preference for behaviourally based descriptions (i.e., symptom centred) continues today. It was not until the 1970’s that the centrality of hyperkinesias was questioned by Virginia Douglas and her colleagues at McGill University in Canada.Following a battery of behaviour and cognitive measures on‘hyperkinetic’ and ‘normal’ children, the research team observed,
"... a core group of symptoms involving inability to sustain attention and to control impulsivity can account for most of the deficits found [in hyperactivity]..."(Douglas, 1972, p.1).
These findings along with the observed effects of stimulants on inattention were groundbreaking and have contributed to current appreciation of executive functioning deficits. Thus, the third edition of the Diagnostic and Statistical Manual (DSM-III) published by the American Psychiatric Association (APA) in 1980, radically altered the definition of the condition to Attention Deficit Disorder (ADD), which presented with or without hyperactivity (Barkley, 2006). As such, the diagnostic criteria also changed to reflect the emphasis on inattention as the defining features of the disorder. Despite a peaked interest and research into the possibility of a unique and qualitatively different disorder, the term ADD fell out of favour quickly. The validity of Douglas’ model, emphasising inattention as the core characteristic of ADHD, was questioned for its inability to account for all of the behavioural symptoms. Moreover, it was felt that de-emphasising hyperactivity, and to a lesser degree impulsivity, posed significant problems for differential diagnosis and treatment outcomes (Weiss &Hetchman, 1993). Thus, the condition became known by its current nomenclature attention deficit hyperactivity disorder in the 1987 revision of the DSM-III. Indeed, the current version (DSM-IV; APA, 1994) does not require inattentive symptoms for a diagnosis of ADHD (the predominantly hyperactive-impulsive subtype).
ADHD has a long a distinguished past, and the validity of the diagnosis is supported by a storehouse of research findings in both the biological and behavioural sciences (Barkley, 2006). The constant reconceptualising of the disorder, particularly the research beginning in the latter half of the twentieth century, has created a wealth of knowledge about the disorder, and contributed to a vast array of discourses surrounding ADHD. In addition, the diagnostic criteria have been refined. In the beginning individuals were observed to have ‘the fidgets’ or suffer from moral defect, however, the realization that hyperactivity was central was further refined, to include our current appreciation of the role of inattention and impulsivity. There is little doubt that the future holds many more reconfigurations as investigation attempts to explicate the ADHD enigma, in terms of what it is and does.
European History Post-1980’s
Barkley (2010) suggested that ADHD is perceived very differently in Europe in comparison to the US view of a developmental disorder, primarily impacting cognition and learning. Conversely, he suggests, Europe is preoccupied with antiquated theories emphasising hyperactivity, disorderly behaviour, brain damage and social or family causal factors (the latter two in combination seems somewhat counterintuitive though). When the World Health Organization (WHO) did not follow in the footsteps of the DSM-III (APA, 1980) down the proverbial inattention rabbit hole; this does appear to have represented a major departure between the two geographical locations. This divergence does continue, albeit increasing less, to the present day.
It is certainly true to say, that at the time, the creation of the ADD entity was based more on enthusiasm than on hard scientific evidence. Never the less, it did spark a great deal of ground breaking research, and one could cautiously suggest that it was a precursor to our current appreciation of executive functions, it certainly has played a role. At the time, it was more prudent to view inattention with a little healthy scepticism; the problem is with its continued blanket rejection of the significance of inattention (beyond a cursory nod to its existence) to this day.
The ICD-10 argues for its exclusion based on a lack of understanding of the aetiology and specific psychological processes underpinning it stating,
It is widely thought that constitutional abnormalities play a crucial role in the genesis of these disorders, but knowledge on specific aetiology is lacking at present. In recent years the use of the diagnostic term "attention deficit disorder" for these syndromes has been promoted. It has not been used here because it implies a knowledge of psychological processes that is not yet available, and it suggests the inclusion of anxious, preoccupied, or "dreamy" apathetic children whose problems are probably different. However, it is clear that, from the point of view of behaviour, problems of inattention constitute a central feature of these hyperkinetic syndromes.” (WHO, 1994; p. 206).
This is somewhat foolhardy and ill-advised (possibly even blindingly ignorant), since the aetiology of most, if not all psychiatric disorders is problematic (at best), and such an argument also extends to the entire HKD construct. Moreover, psychological processes underlying any disorder are determined in large part by your personal theoretical orientation, for example, psychoanalytic differ greatly from cognitive theories. Indeed, it was due to the insurmountable debates surrounding these issues that any reference was left out of the DSM-IV and there has be no move to reinstate these in the revision either (Hyman, 2011).
Furthermore, Barkley (2011) argues that this antiquated view conceives a rarer more sever condition, which fundamentally results in behavioural and conduct problems. In contrast, he suggests ADHD is viewed more developmentally in the US. It would be imprudent to accept such assertions outright, however, there is veracity to his claims. Let us consider, for example, how ADHD is classified in these different jurisdictions.
It was necessary to use the education arena, because European countries have failed to include a definition for ADHD under disability legislation, but there is usually literature (e.g., OECD, 2007) surrounding how it is treated in schools.Globally the condition is considered a ‘difficulty’ along with learning problems (e.g., Dyslexia), social, emotional, and behaviour problems (S/EBD), and economic disadvantage (OECD, 2007). Of note is its absence from the ‘disorder’ category containing medical conditions and syndromes. By contrast, in the USA it is classified as Other Health Impairment and its medicalized description highlights neuronal dysfunction of attention and its adverse effects on educational attainment (Osborne & Russo, 2007). Their neighbours to the north, Canada, include ADHD in the specific learning difficulty category, alongside dyslexia and other cognitive impairments, and this system separates ADHD from the behavioural / emotional problems category (OECD, 2007).
In contrast, the various jurisdictions in the UK and Ireland tend to use variations of these three constructs (social, emotional, and behavioural) in their categorization of ADHD (Cooper & Jacobson, 2011).
Although the majority of EU countries do not have a specific classification it appears clear that they would follow suit. In France the condition is most likely associated with behavioural problems, and defined as a psychological disorder which impairs social interaction (OECD, 2007). And while Greece is likely to classify ADHD as a learning disability, this broad term refers to all conditions beyond significant mental or physical impairments (OECD, 2007).
The significance of this distinction could be very significant. In a recent international controlled research project ADHD VOICES lead by Ilina Singh (e.g., 2011) which interviewed children with ADHD in the UK and the USA about their experiences of ADHD and stimulant medication. The research team observed that,
"... the intense focus on negative behaviours in UK state school classrooms may mean that behaviour, not learning or academic performance, becomes children’s primary concern ..." (p. 892).
Conversely, participants in the states were more academic performance focused, describing problems with learning and concentrating, rather than being preoccupied with emotional and behavioural difficulties. Singh (2011) attributed the difference to what was culturally valued, in the UK there may be more of an expectation to regulate one’s behaviours, and individuality and idiosyncrasies may be less accepted, whereas, the highly individualize culture of the US is more accepting of shows of emotion.
How behaviour manifests and is attributed by observers has significant, even detrimental consequences for people struggling to cope, it determine what (if any) types of support they receive (Furnham&Sarwar, 2011). It is of little doubt that cultural values and prevailing attitudes in nations are reflected through their legislative initiatives.
Authors of the article:
Kate Carr-Fanning and Conor Mc Guckin, the School of Education, Trinity College Dublin, 2012.
References and Suggested Reading
1. Barkley, R.A. (2005). Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (3rd ed.). New York: The Guillford Press.
2. Barkley, R. (2010). Attention-Deficit/Hyperactivity Disorder, in E.J. Mash and R.A. Barkley's ed. of Child Psychopathology (2nd ed). New York: Guilford Press.
3. Bradley, W. (1937). The behaviour of children receiving Benzedrine. American Journal of Psychiatry,96, 577-585.
4. Cantwell, D.P. (1975). The hyperactive child. New York: Spectrum.
5. Douglas, V.I. (1972). Stop, look, and listen: The problem of sustained attention and impulse control in hyperactive and normal children. Canadian Journal of Behavioural Science,4, 259-282.
6. Palmer, E. D., and Finger, S. (2001). An early description of ADHD(Inattention Subtype): Dr. Alexander Crichton and the “Mental Restlessness” (1798). Child Psychology and Psychiatry Reviews, 6, 66-73.
7. Sharkey, L. & Fitzgerald, M. (2007). The History of Attention Deficit Hyperactivity Disorder in M. Fitzgerald, M. Belgrove, and M. Gill, M. eds. of the Handbook of Attention Deficit Hyperactivity Disorder. John Wiley & Son: England.
8. Tredgold, A.F. (1908). Mental Deficiency (amentia). New York: Wood.
9. Chess, S. (1960). Diagnosis and treatment of the hyperactive child. New York State Journal of Medicine, 60, 2379- 2385.
10. James, W. (1890). The Principles of Psychology. London: Dover.
11. Kessler, J. W. (1980). History of minimal brain dysfunction. In H. Rie and E. Rie (Eds.), Handbook of minimal brain dysfunctions: A critical view (pp. 18-52). New York: Wiley.
12. Stewart, M.A. (1970). Hyperactive Children. Scientific America, 222, 94-98
13. Still, G.F. (1902). Some abnormal psychical conditions in children. Lancet, 1, 1008-1012, 1077-1082, 1163-1168.
14. Singh, I. (2008). Beyond polemics: science and ethics of ADHD. Nature Reviews Neuroscience, 9, 957-964
15. Vohs, K. D., andBaumeister, R. F. (Eds.) (2011). Handbook of Self-Regulation: Research, Theory, and Applications (2nd ed). New York: Guilford Press.
16. Wakefield, J. C. (1999). Evolutionary versus prototype analyses of the concept of disorder. Journal of Abnormal Psychology, 108, 374-399.
17. Weiss, G., andHechtman, L. (1993). Hyperactive Children Grown Up (2nd ed.). New York: Guilford Press.
18. Whalen, C. K., &Henker, B. (1992). The social profile of attention-deficit hyperactivity disorder: Five fundamental facets. In G. Weiss (Ed.), Child and Adolescent Psychiatric Clinics of North America: Attention-deficit hyperactivity disorder (pp. 395-410). Philadelphia: Saunders.