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The History of ADHD

The term Attention Deficit Hyperactivity Disorder (ADHD) was first used in 1987 when the Diagnostic and Statistical Manual of Mental Disorders IIIR (DSMIIIR), the revised version of DSMIII was published.  Previously it had been termed 'Attention Deficit Disorder (ADD)' in the original DSMIII (1980) and 'Hyperactive Disorder of Childhood' in DSMII in 1968. Sometimes when the term ADD is used today it is used in its original generic sense i.e. interchangeably with ADHD. On other occasions it is a specific descriptor of passive ADHD (without hyperactivity).

 

The early history of ADHD-like conditions goes back at least as far as 1902, when Dr Fredric Still documented cases involving impulsiveness and labelled them a “defect of moral control”.  It was later renamed ‘minimal brain damage’.  In 1922 the symptoms were further defined and given the name "post encephalitic behaviour disorder". The term “minimal brain dysfunction” was used in the early 1960s. Except for Still’s defects of moral control, early emphasis (1902-1968) was on aetiology (cause) based descriptions.  This is despite the fact that the cause or causes had never been established. 

In 1937 American doctor Charles Bradley first recommend stimulants to treat hyperactive children.  Bradley had observed the effect of stimulants on children who became less active and more compliant when he gave amphetamine to children in order to treat headaches that resulted from spinal taps.  In 1950 he undertook a study of 275 hyperactive children given amphetamines and reported “between 60 per cent and 70 per cent to be much improved while on the drugs”.  In 1956 Ritalin was first used as a treatment for hyperactivity.  During the 1960s the use of stimulant medication to treat hyperactive children and adolescents became more common.  However it was not until the 1990s that prescribing rates began increasing rapidly.

With some minor exceptions the definition of ADHD and its predecessors has been progressively broadened with each new edition of the DSM.  DSMIII (1980) required six of nine inattentive behaviours and six of nine impulsive/hyperactive behaviours.  The diagnostic bar was lowered significantly in DSMIV (1994) when the requirement was reduced to six of nine inattentive or six of nine hyperactive/impulsive behaviours.[4] This resulted in the recognition of the three subtypes of ADHD, namely Primarily Inattentive (often called Passive ADD or just ADD), Primarily Hyperactive/Impulsive, and Combined Type (both inattentive and impulsive).  In addition when DSMIV was updated in 2000 (DSMIVTR[6]) another category was added, ADHD – Not Otherwise Specified, for individuals whose “symptom pattern does not meet the full criteria for the disorder”.

For a full description of the history of how the diagnostic criteria for ADHD have from evolved between up until 2010 (prior to DSM5's publication in 2013 see Whitely, Speed Up & Sit Still, p.16.

The latest edition, of the Diagnostic and Statistical Manual of Mental Disorders DSM5, was released in May 2013.  An earlier draft of DSM5 released for public comment attracted critical attention for further broadening the diagnostic criteria. The draft proposed the inclusion of four extra ways of exhibiting impulsivity:

  1. Tends to act without thinking.

  2. Is often impatient.

  3. Is uncomfortable doing things slowly and systematically.

  4. Finds it difficult to resist temptations or opportunities.

For anyone aged 17 or older the ADHD diagnostic threshold was proposed to be lowered further.  If the proposed changes were adopted it would be sufficient to meet as few as 4 (down from 6) of either the 9 inattentive or 4 of the proposed expanded 13 impulsive/hyperactive criteria.[1] 

In the final version of DSM5 for those aged 17 or over the number was reduced to 5 and the four extra criteria were not included.

Another significant change was the relaxation of the requirement that signs of the behaviour should be displayed before age seven to age twelve. Other significant changes included in the final version of DSM5 included:

  1. The relaxation of the expectation that teachers independently provide evidence.[2] 

  2. Replacing hyperactive actions in the wording of criteria to feelings or perceptions of ‘restlessness’.

  3. Pathologising the normal phenomena that ADHD behaviours are “typically more marked during times when the person is studying or working” than “during vacation”.

  4. The inclusion of adult relevant examples in most of the diagnostic criteria which had previously been primarily orientated to children in a school setting.[3]

 

The development of the DSM has reflected the shift within psychiatry from a psychoanalytic dominated approach, emphasising personal historical circumstances and later consequences, to a system of defining behavioural symptoms of an increasing number of discrete although often comorbid disorders.  The progressive loosening of the diagnostic criteria has also resulted in the sale of a lot more drugs and increasing pharmaceutical company profits.

References

[1]  American Psychiatric Association, ‘DSM-5 Development, Proposed Revision’, Attention Deficit/Hyperactivity Disorder.   Was available at http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 (accessed 25 July 2011 but is no longer available).

[2]  DSM-IV (p87) states ‘The clinician should therefore gather information from multiple sources (e.g. parents, teachers) and inquire about the individual’s behavior in a variety of situations within each setting. DSM5 states ‘In children and young adolescents, the diagnosis should be based on information obtained from parents and teachers.  When direct teacher reports cannot be obtained, weight should be given to information provided to parents by teachers that describe the child’s behavior and performance at school’.

  

[3]  For example one of the hyperactive/impulsive diagnostic criteria in DSM-IV states; "often leaves seat in classroom or in other situations in which remaining seated is expected".  This was replaced in DSM5 with is “often restless during activities when others are seated (may leave his or her place in the classroom, office or other workplace, or in other situations that require remaining seated)”.