A Brief History of ADD
The first doctor to do research about Attention Deficit never actually knew the disorder by that name. George Fredrick Still described the syndrome in a series of lectures to the Royal College of Physicians in 1902. In these 20 lecture, Still spoke of children who were aggressive, defiant, resistant to discipline, excessively emotional or “passionate”. Showing little “inhibitory volition”, lawless, spiteful, cruel, dishonest, impaired in attention, overactive, prone to accidents, and a greater threat to other children due to aggressiveness. According to Still, these children displayed a major, chronic “defect in moral control”.
Also, in what appears to be an almost prophetic foreshadowing of the work of Dr. Russell Barkley, Still speculated that the children had a decreased threshold for inhibition of response to stimuli. In keeping with the prevailing mindset of the time, Still labeled his patients as having a “Defect of Moral Control“, although he did recognize a hereditary link in the disorder. This idea that behavior could have an organic cause rather than simply being a result of “bad parenting” was a radical concept in the early 20th century. The fact that these findings were published in the British medical journal Lancet did give some credibility to this new theory.
One ocean away and a little more than a decade later, American doctors were discussing children who had problems similar to those described by Still. The one thing that many of these children had in common, other than their ADD type symptoms, was that they were survivors of the encephalitis epidemic in 1917- 1918.
Interestingly enough, this is the same encephalitis epidemic which was the setting for the movie Awakenings with Robin Williams and Robert DeNiro.
Numerous papers describe children with “post encephalitic behavior disorder” as impaired in attention, regulation of activity, and impulse control. Like Still’s patients, these children were also socially disruptive and many had memory problems.
This connection between encephalitis and a “Defect of Moral Control” further verified that not all behavior was an act of the will. However, it also brought about a rationale for ADD that went something like this: “The Encephalitis outbreak left these children with brain damage; because other children who had not been exposed to the outbreak also exhibited some of the same symptoms, they too must have been brain damaged in some way as well.” The term Brain Damaged was used to describe some of these children.
In a move towards a “kinder, gentler diagnosis”, and the recognition that many of these children, although quite different from their peers, were still too bright to have been brain damaged to any great extent, the term “Minimal Brain Damage” became popular. This diagnosis became so popular that it was assumed that even if there was no obvious brain damage, or at least none that could be measured by objective medical testing, it was thought that the child must STILL be brain damaged anyway.
Another problem was that this label was too broad to be effective. For example, children who today would be described as learning disabled, developmentally delayed, ODD or ADD were all grouped under one heading, MBD.
Another important event in the era of MBD was the discovery in 1937 that amphetamines (stimulant medication- also keep in mind that Ritalin is a stimulant medication) reduced disruptive behavior in many of these children- specifically in those who were hyperactive and/or impulsive.
Hyperactivity was first described by Laufer and Denhoff (1957) and Stella Chess (1960). This description came to be generally accepted by the psychological community as the correct name for the disorder. The category of Hyperkinetic Reaction of Childhood was used in the Diagnostic and Statistical Manual of Mental Disorders (2nd ed.) (DSMII; American Psychiatric Association [APA], 1968).
While this new term certainly had validity for those who had symptoms of what would later be called ADHD, it still seemed to ignore the fact that many children exhibited attention deficits without any signs of hyperactivity. It was still apparent that more research was needed even on something as seemingly simple as what to call these behaviors.
By the 70’s, over 2,000 studies were published on hyperactivity. The defining features were over activity, inpulsivity, short attention span, low frustration tolerance, distractability, and aggressiveness. Overactivity was thought to be the primary feature. It was commonly believed that these symptoms would disappear by puberty.
Although Chess and other researchers kept pointing to biology rather than environment as the cause of these symptoms, others were not so sure. The Feingold~ Association was the most prominent of several groups who began to look at environmental toxins as a cause of Hyperactivity and other learning and behavior disorders.
In 1965 Dr. Ben F. Feingold began his observations of the link between certain foods and additives and their effect on some individuals’ behavior and ability to learn. It was not until June, 1973, that he presented his findings to the American Medical Association. Although these theories developed a significant popular following, they have not yet been openly embraced by the Mainstream Medical community.
In 1972, Virginia Douglas, in a Presidential address to the Canadian Psychological Association, presented her theory that deficits in sustained attention and impulse control were more likely to account for the difficulties of these children than hyperactivity. She argued that hyperactive children were not necessarily more distractable than other children and that sustained attention problems could emerge under conditions where no distractions existed. Thus the focus and research began to shift from hyperactivity to attention issues.
Douglas’s colleague, Gabriel Weiss, engaged in long-term follow-up studies and showed that as children reach adolescence, the hyperactivity may diminish, but the attention and impulse problems persist. This also was a new idea. Previously the general consensus had been that ADD was a childhood disorder that somehow “disappeared” in adolescence, and certainly by adulthood.
The DSM-III, published in 1980 recognized these new developments. Perhaps the most controversial change from the DSM-II was the subdivision of the previous category of Hyperkinetic Reaction of Childhood. This resulted in the following two categories: Attention-deficit with hyperactivity (i.e., ADHD) and Attention-deficit Disorder Without Hyperactivity (ADD/WO). Thus, it became possible to diagnose a patient as experiencing an impairment of attention without his or her actually being hyperactive.
In subsequent revisions, DSM-III went on to further subdivide the category. DSM-III-R used the term “Undifferentiated Attention-deficit Disorder” (UADD) and restricted its use to disturbances in which the prominent feature is the persistence of developmentally inappropriate and marked inattention that is not a symptom of another disorder, such as Mental Retardation or Attention-Deficit Hyper-activity Disorder (ADILD), or of a disorganized and chaotic home environment. The DSM-III-R also substituted two disorders, Attention-Deficit Hyperactivity Disorder (ADHD) and Undifferentiated Attention deficit Disorder (UADD), for the previous ADD terms (Goodyear & Hynd, 1992).
In the decade from 1980 to 1989, thousands of new research studies were published, making ADHD the most studied childhood psychiatric disorder of the decade, and most likely in the entire history of pediatric psychology.
Not only was ADHD the most studied of childhood disorders, it is perhaps the most labeled. DSM-IV (American Psychiatric Association, 1994) defines the disorder into subtypes based on the predominant symptom pattern. The syndrome that was once covered under the blanket term “Minimal Brain Damage” now has an entire menu of divisions and subtypes:
| Attention Deficit/ Hyperactivity Disorder | Predominantly Inattentive Type; |
| Attention- Deficit/ Hyper-activity Disorder. | Predominantly Hyperactive-Impulsive Type |
| Attention-Deficit/ Hyperactivity Disorder | Combined Type. |
Another important development in the mid 1980’s was the outlining of Attention Deficit Disorder, Residual Type in an article by David Woods, MD, which appeared in the January 1986 edition of Psychiatric Annals. The idea that ADD continued on into adulthood, rather than somehow disappearing as the child got older, was accepted relatively quickly by the psychiatric and medical communities. Even more interesting is the manner in which this concept was so quickly accepted by the general public, especially among people in the United States. Public interest mushroomed in the 1990’s and seemed to become hyperfocused.
Dr. Russell Barkley’s book, simply titled Attention Deficit Hyperactivity Disorder, is perhaps the best history of ADD up to this time. In a more popular vein, the book Driven to Distraction by Dr. Edward Hallowell and John Ratey was published in 1994. This book became standard reading for many parents of children with ADD.
As these parents read about the disorder their children lived with, they began to recognize more and more of these symptoms in their own lives. Thus, the popularity of research and books dealing with Adult ADD increased dramatically.
With this increased interest of ADD in general and Adult ADD in particular, attention Deficit Disorder expanded from being only an educational issue to one of employment and eventually law. Perhaps the culmination of this was the inclusion of ADD as part of the Americans With Disabilities Act and other legislation on local, state and federal levels.
Increased public awareness led to increased controversy about the diagnosis during the 1990’s. Charges that Ritalin and other medications were being over-prescribed were followed by the law suits. At the same time, validity of AD/HD as a serious disorder was confirmed by Mental Health: A Report of the Surgeon General and continued research.