I see the same question a lot on the social media circles I run in – “I was diagnosed with ADD as a kid, what’s the difference between that and ADHD?”.
After jumping through a few thought circles, it really got me thinking about the history of ADHD. There’s a lot out there so here I present The Brief History of ADD/ADHD. (If you’re interested in only the difference between them, I’ve explained that here.)
This is a long one, but I’ve done my best to break it up into digestible chunks.
This is the first part of a series called ADHD in History, where I’ll explore the history of ADHD as a condition, its treatments, its leading researchers and doctors, and more! You can view the rest of the ADHD in History posts here.
ADHD wasn’t “invented” in the 1980s. Since the evolution of homo sapiens (and maybe further back!), people have experienced chemical imbalances and various neurological and psychological conditions, including ADHD. But it took many eras for modern medicine to give people the window into what causes their conditions and why we act and think the way we do today.
China was one of the earliest civilizations to identify and treat mental health conditions, using herbs, acupuncture and “emotional therapy”. There are many records starting from around 1100 B.C. that describe symptoms and therapies, and they were one of the first civilizations to identify trauma as a possible cause for these conditions – they believe it opened the soul to allow for demonic possession.
ADHD may have first been mentioned in the context of Ancient Greece, when Hippocrates (460-375 BC) referenced patients that couldn’t keep their focus and seemed to react more quickly and overtly to external stimuli than others. He attributed the condition to being an “overbalance of fire over water” and prescribed a bland diet and regular physical activity.
Theophrastus, a student of Aristotle, may have provided the first contextual description of ADHD through his book “Characters”, which outlines his perspective of the 30 types of moral identities. He wrote of a character he called “The Stupid Man”, and many see a correlation between this character type and some manifestations of ADHD. “The Stupid Man” is forgetful, often physically active, emotionally overwhelmed, and easily frustrated.
I don’t love the archetype presented by Theophrastus, mostly because of the use of “stupid” and “slow”, but felt it worth mentioning in the context of ancient historical writings of possible neuropsychological conditions.
Establishing a More Formal View
ADHD wasn’t formally described in any surviving works for quite some time until the 17th century, when John Locke made reference in his essay “Some Thoughts Concerning Education” to groups of young students who couldn’t pay attention no matter how hard they tried.
In the late 18th century, the German physician and philosopher Melchior Adam Weikard and the Scottish physician Sir Alexander Crichton both individually published textbooks focused on psychiatric conditions.
Both works included descriptions that edged us closer to an ADHD diagnosis. They mentioned difficulties with attention, focus, and hyperactivity.
Weikard attributed these difficulties to a lack of personal discipline, a life containing persistent under-stimulation, and poor parenting, though he acknowledged a “dysregulation of cerebral fibers resulting from over- or under stimulation”, meaning he noted there could be a connection to brain function and structure.
Crichton’s book indicated that a person could actually be born with this condition, and that symptoms may arise very early in childhood.
Through the 19th century, several physicians published works that included depictions of ADHD in its various forms, all focused on children. They described difficulty with attention, mood, behavior, and self-control, but unfortunately there was no consensus yet that these manifestations continued into adulthood.
I hypothesize that it’s because much of the focus was on hyperactivity, which may be less obvious to observe in adults, especially those who have learned to mask.
The Goulstonian Lectures
In 1902, British physician Sir George Frederic Still gave a series of lectures to the Royal College of Physicians of London, called the Goulstonian Lectures, “On Some Abnormal Psychical Conditions in Children”.
He described the conditions he studied as a “defect of moral control as a morbid manifestation, without general impairment of intellect and without physical disease”.
This wasn’t the first, and certainly not the last observation that these types of “inappropriate” behaviors, like inattention, hyperactivity and impulsivity, could be attributed to moral or personal failings. Even today, many who have ADHD are told to “just try harder”, or are stigmatized by labels like lazy. The great difference at the time is that Still identified one could experience these manifestations and still be considered to have average or above-average intellect.
Still observed the conditions he studied in 15 boys and 5 girls, though he noted that this ratio may have been disproportionate (a phenomenon that continues today).
Still identified many manifestations of ADHD still used for classification, including difficulties with:
- Sustained attention
- Delayed gratification
- Understanding consequences
- Emotional regulation
- Frustration tolerance
However, some manifestations that Still observed in the children he studied are not typically associated with ADHD. They may have been associated with other (sometimes comorbid) conditions. This included extreme aggression and anger, lack of affection toward animals and other people, and general “deviant” and “amoral” behavior.
Still’s studies may not have actually included many children with ADHD (or with only ADHD), but his work paved the ways for others to study how some behaviors and thought patterns may be a result of differences in the brain.
Minimal Brain Dysfunction
Based on Still’s lectures, as well as the work and reports of other physicians in the early 20th century, the popular notion arose that brain damage, whether at birth or during childhood, was the main cause for hyperactivity, attention and behavior conditions in children.
Physicians didn’t necessarily need evidence of brain damage to make the assumption that it was the cause for what they called “hyperkinetic impulse disorder” (a precursor of ADD/ADHD). They assumed there was damage that simply couldn’t be observed.
This concept was labelled “minimal brain damage”, or MBD.
In the 1960s, critics of MBD emerged, arguing that many children showing manifestations of hyperkinetic impulse disorder also had no observable physical brain damage at any point in their lives.
During this time, Dr. Maurice W. Laufer and colleagues posited that hyperkinetic impulse disorder may be caused by brain dysfunction rather than damage, and the term was relabeled “minimal brain dysfunction”, though still MBD.
In 1966, a task force assigned by the National Institute of Neurological Diseases and Blindness formally defined minimal brain dysfunction:
“The term minimal brain dysfunction refers to children of near average, average or above average general intelligence with certain learning or behavioural disabilities ranging from mild to severe, which are associated with deviations of function of the central nervous system. These deviations may manifest themselves by various combinations of impairment in perception, conceptualisation, language, memory and control of attention, impulse or motor function.”
In 1968, hyperactivity was officially incorporated into the DSM-II. It was called “Hyperkinetic Reaction of Childhood” and defined as such:
“The disorder is characterized by overactivity, restlessness, distractibility, and short attention span, especially in young children; the behavior usually diminishes by adolescence”
A Shift in Perspective
In the 1970s, a shift occurred from a focus on mostly hyperactive behavior to a focus on attention deficits.
Virginia Douglas, a Canadian Psychologist, presented a paper to the Canadian Psychological Association in 1972 called “Stop, look and listen: The problem of sustained attention and impulse control in hyperactive and normal children”. In this paper, she argued that difficulties with sustained attention and impulse control were more common manifestations of hyperkinetic impulse disorder than hyperactivity.
Her paper gained much prominence. It prompted additional inquiry among researchers, and was a pivotal turning point in re-conceptualization of the condition called Hyperkinetic Reaction of Childhood.
Interlude to say – this really got me pumped up that a woman is considered one of the most influential researchers in the modern history of ADHD!
In 1980, the DSM-III was published with new diagnostic criteria and a name change. The American Psychiatric Association officially adopted the label “Attention Deficit Disorder (ADD) (with or without hyperactivity)”.
This new edition listed the three main manifestations of the condition to be inattention, impulsive behavior, and/or hyperactivity. The DSM-III also provided guidelines for the age of onset, as well as a requirement for exclusion of other possible psychiatric conditions.
A Backward Slide?
Almost immediately after publication of the DSM-III, a discussion began amongst researchers that questioned whether or not ADD without hyperactivity could be qualitatively compared to ADD with hyperactivity.
A revised version of the DSM-III was printed in 1987 that relabeled ADD with its two subtypes into one condition. It was called “Attention Deficit-Hyperactivity Disorder (ADHD)”, which included the diagnostic criteria of difficulties with: attention, curbing impulsive behavior and hyperactivity.
ADD with no presenting signs of hyperactivity was relabeled, as a separate condition, as “undifferentiated ADD”.
I’m only speculating here, but this shift in perspective seems to have created a reality in which anyone exhibiting other manifestations without hyperactivity may run the risk of being misdiagnosed. To state that ADHD innately comes with hyperactivity, especially to include the word in its clinical label, would ensure that many young non-hyperactive girls couldn’t get properly diagnosed. We now understand that it includes a primarily inattentive type, which some believe is more common in girls than boys. But for many decades, thousands of women may have slipped through the cracks because they didn’t fit the formal diagnostic criteria.
New Research in The 90s
Despite the shift in diagnostic criteria in the DSM-III, some researchers continued to study ADD/ADHD throughout the late 1980s and early 1990s based on the two earlier established subtypes, with and without hyperactivity.
New research aimed to look past the idea that a deficit of attention was the most common cause, and that there could be other issues with motivation and reward systems. New imaging techniques also allowed the study of brain structure to look for genetic abnormalities, not ones necessarily caused by early childhood brain damage, as previously assumed for much of the 20th century.
Finally, a historical breakthrough occurred when researchers declared ADHD to be not exclusively a childhood condition, but one that could persistently continue into adulthood.
The DSM-IV was published in 1994, and again recategorized ADHD into its currently agreed upon three subtypes – inattentive type, hyperactive-impulsive type and combined inattentive-hyperactive type.
Today and Beyond
The DSM-V was published in 2012, and the core definition of ADHD remained unchanged from the DSM-IV edition, though some diagnostic criteria were modified.
Researchers today continue to study the causes and manifestations of ADHD. It’s now widely accepted that ADHD may be hereditary, though no specific gene has been identified as a cause yet. Most researchers also agree that manifestations of ADHD are mostly due to underdevelopment of executive functions, which I’ve briefly described here.
We know it’s not caused by too much sugar, video games, cell phone use, or bad parenting. The science behind it points to neurotransmitter deficiencies in multiple areas of the brain, including the frontal cortex, which is responsible for our ability to organize, pay attention, and control impulses.
And yet despite decades of valuable research and conclusive evidence, today some doctors and scientists doubt the existence of ADHD as its own specific condition, and instead view it as an amalgamation of multiple conditions.
It’s important that ADHD research be continued so we may better understand what causes it, and how those who experience it can receive the best treatment and support possible.
If you’re interested, ADDitude Magazine has compiled a very comprehensive list of research studies conducted on ADHD in 2020.
Have an ADHD fun history fact that I didn’t share here? Comment below or drop me a line on your preferred social media channel, I’d love to hear it!
References, in no particular order or citation style:
- “History of mental disorders”, Wikipedia, https://en.wikipedia.org/wiki/History_of_mental_disorders
- “More Fire Than Water: A Short History of ADHD”, CHADD, https://chadd.org/adhd-weekly/more-fire-than-water-a-short-history-of-adhd/
- “Who says this is a modern disorder? The early history of attention deficit hyperactivity disorder”, World Journal of Psychology, Jose Martinez-Badía and Jose Martinez-Raga, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694551/
- “The history of attention deficit hyperactivity disorder”, Klaus W. Lange, Susanne Reichl, Katharina M. Lange, Lara Tucha, and Oliver Tucha, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3000907/
- “Virginia Douglas”, Wikipedia, https://en.wikipedia.org/wiki/Virginia_Douglas
- “The Science of ADHD”, CHADD, https://chadd.org/about-adhd/the-science-of-adhd/
- “Is ADHD Genetic? Yes and No”, ADHD Editorial Board, Larry Silver, M.D., Additude Magazine, https://www.additudemag.com/is-adhd-hereditary-yes-and-no/
- “The Characters of Theophrastus”, Translated by R.C. Jebb, 1870, https://www.eudaemonist.com/biblion/characters/