By Mary Fetzer
ADHD is a common neurodevelopmental disorder, but it has taken decades to define what it is, who it affects and what can be done about it.
We wanted to explore the 121-year evolution of the ADHD diagnosis. Here’s what we found:
‘An Abnormal Defect of Moral Control’
“The understanding, treatment and public perception of ADHD have evolved significantly over time, reflecting advances in research, changes in diagnostic criteria and shifting societal attitudes toward mental health,” says Michelle Giordano, community outreach advocate at Live Another Day, a nationwide recovery resource organization for individuals dealing with mental illness or substance abuse.
In 1902, Sir George Frederic Still, a British pediatrician, made the first known mention of the condition that came to be known as ADHD, which he described as “an abnormal defect of moral control in children.” He found that some children, “regardless of their intelligence,” were unable to control their behavior.
“In the early 20th century, ADHD was not yet recognized as a distinct disorder,” Giordano says. “Children who exhibited symptoms of hyperactivity, impulsivity and inattention were often labeled as problem children or troublemakers and were subjected to harsh disciplinary measures.”
It would be decades before progress would be made to help children with their so-called behavioral defect.
Discovery of How Stimulants Could Help
That progress came in 1937 when physician Charles Bradley made an unexpected but important discovery while serving as the medical director of a Rhode Island hospital for children with nervous disorders. When his young patients suffered headaches as a side-effect of neurological evaluations, Bradley treated them with benzedrine, a stimulant. He noted that the drug did little for the headaches but appeared to have a positive impact on the children’s behavior, citing “spectacular changes in behavior” and “remarkably improved school performance.”
Despite this important finding and subsequent research, however, psychological interventions — not medications — continued to be regarded as the best treatment for behavior disorders. Decades passed before stimulants would become widely used for ADHD.
“ADHD was long misunderstood and treated as a stigma,” says Joni Ogle, CEO of The Heights Treatment, a treatment center for substance use disorders, trauma and mental health conditions, in Houston and Los Angeles. “People thought that individuals with ADHD just had to ‘do better and try harder’ because they lacked willpower and discipline or because they had behavioral problems and were ‘being difficult.'”
Even the American Psychological Association failed to recognize ADHD. In 1952, the organization issued the first Diagnostic and Statistical Manual of Mental Disorders — a list of all known mental disorders along with their causes, risk factors and treatments — but did not include anything that looked like what is today known as ADHD.
An important positive step occurred in 1955 when Ritalin was approved by the U.S. Food and Drug Administration. The psychostimulant, scientifically known as methylphenidate, became a common treatment for “hyperactive” children and is still in use today for ADHD. The use of Ritalin reinforced the notion that the disorder was more than just behavioral.
ADHD Finally Listed in DSM
In 1968, a second DSM was released by the APA. This edition did include the disorder we now call ADHD, but it was called the hyperkinectic reaction of childhood and focused on the excessive motor activity of the disorder.
A third edition of the DSM, the DSM-III, was published in 1980. Hyperkinectic reaction of childhood was renamed attention deficit disorder, or ADD, and broken into two sub-types: ADD with hyperactivity and ADD without hyperactivity.
A 1987 revision to the DSM-III, however, removed that distinction. The new scientific thinking was that all occurrences of ADD included hyperactivity — along with impulsivity and inattentiveness — and the name was revised to what we use today: attention deficit hyperactivity disorder, or ADHD.
“In the 1980s and 1990s, the diagnosis of ADHD became more common, reflecting a greater understanding of the disorder and improved diagnostic criteria,” Giordano says. “At the same time, public awareness of ADHD increased, and more resources became available for individuals with the disorder and their families.”
The increased diagnoses and awareness led to new treatment options for children and adults with ADHD, including stimulant and non-stimulant medications, psychotherapy and specialized educational programs.
In 2000, the APA released the DSM-IV, which listed the three subtypes of ADHD that are still in use today: predominantly inattentive type ADHD, predominantly hyperactive-impulsive type ADHD, and combined type ADHD.
“In recent years, there has been a growing recognition of the importance of multimodal treatment for ADHD, including medication, therapy and behavioral interventions,” says Giordano. “There has also been a greater emphasis on understanding the unique challenges faced by individuals with ADHD and providing support and accommodations to help them succeed.”
Much More to Learn
Now, in 2023, there is still much to learn about ADHD, its causes and treatments. Researchers continue to explore the genetic and environmental risk factors that may lead to the disorder. The more we learn about the underlying causes of ADHD, the more effective we will become at treating it.
“The understanding, treatment and public perception of ADHD have come a long way in the past decades, but there is still more work to be done,” says Megan Tangradi, clinical director at Achieve Wellness & Recovery, an addiction and mental health treatment center in Northfield, N.J. “Mental health experts play an important role in educating people about ADHD, as well as helping parents and caregivers learn how to best support their loved ones with the disorder. Through continued research and education, we can continue to provide those with ADHD the care and support they need.”