History of attention-deficit hyperactivity disorder  

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Hyperactivity has long been part of the human condition. Sir Alexander Crichton describes "mental restlessness" in his 1798 book. The terminology used to describe the symptoms of ADHD has gone through many changes over history including: "minimal brain damage", "minimal brain dysfunction", "learning/behavioral disabilities" and "hyperactivity". In the DSM-II (1968) it was the "Hyperkinetic Reaction of Childhood". In the DSM-III "ADD (Attention-Deficit Disorder) with or without hyperactivity" was introduced. In 1987 this was changed to ADHD in the DSM-III-R and subsequent editions.

Contents

Terminology

"ADD" and "ADHD" are not the same thing, and do not constitute a single syndrome, with several important and distinctive variations. The clinical definition of "ADHD" dates to the mid-20th century, but was known by other names. Physicians developed a diagnosis for a set of conditions variously referred to as "minimal brain damage", "minimal brain dysfunction", "minimal brain disorder", "learning/behavioral disabilities" and "hyperactivity". Some of these labels became problematic as knowledge expanded. For example, as awareness grew that many children with no indication of brain damage also displayed the syndrome, the label which included the words "brain damage" did not seem appropriate.

The DSM-II (1968) began to call it "Hyperkinetic Reaction of Childhood" even though the professionals were aware that many of the children so diagnosed exhibited attention deficits without any signs of hyperactivity. In 1980, the DSM-III introduced "ADD (Attention-Deficit Disorder) with or without hyperactivity." That terminology (ADD) technically expired with the revision in 1987 to ADHD in the DSM-III-R. In the DSM-IV, published in 1994, ADHD with sub-types was presented. The current version (as of 2008), the DSM-IV-TR was released in 2000, primarily to correct factual errors and make changes to reflect recent research; ADHD was largely unchanged.

Under the DSM-IV, within the ADHD syndrome, there are three sub-types, including one which lacks the hyperactivity component. Approximately one-third of people with ADHD have the predominantly inattentive type (ADHD-I), meaning that they do not have the hyperactive or overactive behavior components of the other ADHD subtypes.

Even today, the ADHD terminology is objectionable to many. There is some preference for using the ADHD-I, ADD, and AADD terminology when describing individuals lacking the hyperactivity component, especially among older adolescents and adults who find the term "hyperactive" inaccurate, inappropriate and even derogatory.

18th century

In 1798, a Scottish-born physician and author, Sir Alexander Crichton (1763–1856), described what seems to be a mental state much like the inattentive subtype of ADHD, in his book An inquiry into the nature and origin of mental derangement: comprehending a concise system of the physiology and pathology of the human mind and a history of the passions and their effects. In the chapter "Attention", Crichton described a "mental restlessness".

"The incapacity of attending with a necessary degree of constancy to any one object, almost always arises from an unnatural or morbid sensibility of the nerves, by which means this faculty is incessantly withdrawn from one impression to another. It may be either born with a person, or it may be the effect of accidental diseases.

"When born with a person it becomes evident at a very early period of life, and has a very bad effect, inasmuch as it renders him incapable of attending with constancy to any one object of education. But it seldom is in so great a degree as totally to impede all instruction; and what is very fortunate, it is generally diminished with age."

Dr. Crichton further observed: "In this disease of attention, if it can with propriety be called so, every impression seems to agitate the person, and gives him or her an unnatural degree of mental restlessness. People walking up and down the room, a slight noise in the same, the moving of a table, the shutting a door suddenly, a slight excess of heat or of cold, too much light, or too little light, all destroy constant attention in such patients, inasmuch as it is easily excited by every impression."

Crichton has noted that "they have a particular name for the state of their nerves, which is expressive enough of their feelings. They say they have the fidgets". Dr. Crichton suggested that these children needed special educational intervention and noted that it was obvious that they had a problem attending even how hard they did try. "Every public teacher must have observed that there are many to whom the dryness and difficulties of the Latin and Greek grammars are so disgusting that neither the terrors of the rod, nor the indulgence of kind intreaty can cause them to give their attention to them."

Alexander Crichton was just over a hundred years ahead of his time in his observations of what is now known as the Inattention subtype of ADHD. He wrote about the salient features of this disorder, including attentional problems, restlessness, early onset, and how it can affect schooling, without any of the moralism introduced by George Still and later authors.

20th century

In March of 1902, the father of British paediatrics Sir George Frederick Still (1868–1941) gave a series of lectures to the Royal College of Physicians in London under the name “Goulstonian lectures” on ‘some abnormal psychical conditions in children’, which were published later the same year in the Lancet.

He described 43 children who had serious problems with sustained attention and self-regulation, who were often aggressive, defiant, resistant to discipline, excessively emotional or passionate, which showed little inhibitory volition, had serious problems with sustained attention and could not learn from the consequences of their actions; though their intellect was normal. He wrote “I would point out that a notable feature in many of these cases of moral defect without general impairment of intellect is a quite abnormal incapacity for sustained attention.

Dr. Still wrote: “there is a defect of moral consciousness which cannot be accounted for by any fault of environment” When Still was talking about Moral Control, he was referring to it as William James had done before him, but to Still, the moral control of behavior meant "the control of action in conformity with the idea of the good of all."

"Another boy, aged 6 years, with marked moral defect was unable to keep his attention even to a game for more than a very short time, and as might be expected, the failure of attention was very noticeable at school, with the result that in some cases the child was backward in school attainments, although in manner and ordinary conversation he appeared as bright and intelligent as any child could be." He proposed a biological predisposition to this behavioral condition that was probably hereditary in some children and the result of pre- or postnatal injury in others.

George Still certainly did not use the current terminology for this disorder, but many historians of ADHD have inferred that the children he described in his series of three published lectures to the Royal College of Physicians would likely have qualified for the current disorder of ADHD combined type, among other disorders.

Encephalitis epidemic 1917–1918

The treatment of children with similar behavioral problems who had survived the epidemic of encephalitis lethargica from 1917 to 1918 and the pandemic of influenza from 1919 to 1920 led to terminology which referred to "brain damage."

See also




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