ADHD through the Ages
Perhaps due to my own experience growing up in the 90s, it seemed to me that ADHD sprang up out of nowhere, and suddenly, every fourth kid in my classroom had been diagnosed. Knowing what I know now about the Neurodiversity Movement, that makes a lot of sense. Raised awareness helped a lot of kids get the support they needed in the late 90s and early 2000s. Interestingly, Attention-Deficit/Hyperactivity Disorder (ADHD) has a complex history impacted by the changes in understanding of behavior, cognition, and mental health. The origins of ADHD can be traced back over a century through various diagnostic labels and criteria, as research has expanded our understanding of this condition.
Early Understandings
ADHD’s history began in the early 20th century. The term itself had not yet been coined, and the understanding of the condition was limited. However, symptoms that would later be associated with ADHD were documented under various terms, such as "moral deficiency" or "nervous disorder." In 1902, British pediatrician Sir George Frederic Still published lectures describing children who displayed impulsivity and hyperactivity, suggesting a possible biological cause for their behaviors. He described children with "defect of moral control," as the reason for their impulsivity, overactivity, and difficulty in sustaining attention. While it still wasn’t identified as a formal diagnosis, this was one of the first times a condition was discussed that shared similarities with what we now call ADHD (Still, 1902).
In the 1920s, ADHD behaviors were often seen in the context of discipline and moral training. The popular belief being that with proper upbringing the symptoms could be effectively managed. The societal belief of this time placed the importance on parenting and moral instruction, and focused less on biological or neurological factors (Barkley, 2006).
In the 1930s, the term "minimal brain dysfunction" (MBD) was introduced, suggesting that these children exhibited deficits caused by subtle neurological impairments. During this period, the focus was more on the physical conditions of the brain rather than behavioral observations (Barkley, 2015).
The 1960s and 1970s: A Shift to Hyperactivity
As the understanding of children’s behavior grew and changed, so did the terminology. The 1960s brought us the term "hyperkinetic impulse disorder" (APA, 1968). This shift emphasized hyperactivity as the primary symptom, leading to increased recognition and diagnosis of children exhibiting these behaviors.
It was the 1970s that brought a more comprehensive view of the disorder. The American Psychiatric Association (APA) included "Attention Deficit Disorder" (ADD) in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, 1980). This was a key transition because it was the first time that the diagnosis acknowledged that children could have attention issues without necessarily being hyperactive. The diagnostic criteria focused on a range of symptoms around attention deficits, impulsivity, and hyperactivity, which was helpful but confusing, leading to under-diagnosis and over-diagnosis.
The 1990s: Refinement of Criteria
In 1994, the DSM-IV made further refinements, solidifying the modern conception of ADHD. It classified the disorder into three types:
Predominantly Inattentive Presentation
Predominantly Hyperactive-Impulsive Presentation
Combined Presentation
This change in structure helped us better understand ADHD in a more detailed way, so we could help kids who may not show hyperactivity but still struggle with paying attention. The new criteria included signs like having trouble staying focused, not finishing tasks, fidgeting, and talking too much (APA, 1994).
Contemporary Understanding
The DSM-5, published in 2013, maintained and updated the ADHD criteria established in DSM-IV. Importantly, additional qualifiers were introduced for adulthood, recognizing that ADHD symptoms could persist into later life. The DSM-5 focused on age-related symptom expression and acknowledged the importance of impairment across different contexts (APA, 2013).
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the DSM-5-Text Revision (DSM-5-TR) outline criteria for Attention-Deficit/Hyperactivity Disorder (ADHD) with some key differences.
In the DSM-5, ADHD symptoms are categorized into two main types: inattention and hyperactivity-impulsivity, with specific criteria that must be met for diagnosis. The DSM-5 also includes a note on the presentation of symptoms, specifying that symptoms may present differently in various contexts (e.g., home, school).
The DSM-5-TR retains the core diagnostic criteria but adds contextual information about how cultural and developmental factors may affect symptom presentation. It emphasizes that ADHD symptoms can manifest differently across the lifespan, highlighting the importance of understanding an individual's developmental stage when making a diagnosis.
These updates aim to provide a more comprehensive framework for clinicians, enhancing the clarity and applicability of the ADHD diagnostic criteria.
Signs and Symptoms: Inclusion and Exclusion over Time
Throughout the history of ADHD, various signs and symptoms have been included and excluded based on emerging research:
Included Symptoms:
Inattention: Difficulty sustaining focus, frequent careless mistakes, disorganization.
Hyperactivity: Fidgeting, excessive talking, difficulty remaining seated.
Impulsivity: Interrupting others, difficulty waiting for one’s turn, acting without considering consequences.
Excluded Symptoms:
Over the years, the understanding of Attention-Deficit/Hyperactivity Disorder (ADHD) has evolved, leading to the exclusion of certain symptoms from its official diagnosis. Historically, impulsivity, mood swings, and excessive emotional responses—symptoms commonly associated with various behavioral conditions—were sometimes considered indicative of ADHD. However, the current diagnostic criteria prioritize symptoms like inattention, hyperactivity, and impulsivity that specifically impair functioning in multiple settings. Changes in the DSM (Diagnostic and Statistical Manual of Mental Disorders) editions reflect this shift; for example, the DSM-5 emphasizes the need for symptoms to present in more than one context to warrant a diagnosis (American Psychiatric Association, 2013). Additionally, research has pointed out that symptoms such as emotional dysregulation, while important, are more indicative of comorbid conditions rather than core aspects of ADHD itself (Rydell et al., 2020). Therefore, understanding ADHD has led to a more refined and specific diagnosis that focuses on particular behaviors and their impacts.
Conclusion
The diagnosis of ADHD has evolved from early descriptions of behavior to a complex understanding that incorporates multifaceted symptom profiles. Each iteration of the DSM has aimed to refine the diagnostic process, accommodating new findings and societal understandings of mental health.
The evolution of ADHD diagnosis reflects broader shifts in mental health awareness, recognizing the importance of understanding neurodiversity. I think we can all agree it has improved significantly since the time of being identified as “morally defective”, and as research continues and societal perceptions evolve, there is hope for even more refined diagnostic tools and supportive interventions for those affected by ADHD.
References
American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.). Washington, DC: Author.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Arlington, VA: Author.
Barkley, R. A. (2006). Attention-deficit/hyperactivity disorder: A handbook for diagnosis and treatment. Guilford Press.
Barkley, R. A. (2015). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). Guilford Press.
Conners, C. K. (2008). Conners 3rd Edition (Conners 3). Multi-Health Systems Inc.
Rydell, A. M., Lundh, L.-G., & Borja, S. (2020). The relationship between emotional dysregulation and childhood ADHD symptoms: A meta-analysis. Clinical Psychology Review, 78, 101837.
Still, G. (1902). Some abnormal psychical conditions in children. Proceedings of the Royal Society of Medicine, 6(1), 1-15.
