History of ADHD

russell A. Barkley

Attention-deficit/hyperactivity disorder (ADHD) continues to be the current diagnostic label for children and adults presenting with significant problems with attention, and typically with impulsiveness and excessive activity as well. Children and adults with ADHD represent a rather heterogeneous population that displays considerable variation in the degree of members' symptoms, age of onset, cross-situational pervasiveness of those symptoms, and the extent to which other disorders occur in association with ADHD. The disorder represents one of the most common reasons children with behavioral problems are referred to medical and mental health practitioners in the United States and is one of the most prevalent childhood psychiatric disorders. Currently, referrals of adults for ADHD are also increasing at a rapid pace; until the 1990s and even to date, this age group has been a markedly underrecognized and underserved segment of the ADHD population.

This chapter presents an overview of ADHD's history — a history that spans more than two centuries in the medical and scientific literature. Whereas the previous edition noted that the medical history of ADHD began with Still's description of childhood cases in 1902, we now know that a number of earlier physicians described such cases dating back to the textbook by Melchior Adam Weikard published in German in 1775 (Barkley & Peters, 2012). This extends the history of ADHD in the medical literature back another 127 years. These new additions to the history of ADHD are described below. But given that the history of ADHD as understood from 1902 through 2006 has changed little since the preceding edition of this text (Barkley, 2006), little has been needed to update those sections of this chapter. In contrast, developments since that previous edition are described at the end of this chapter.

In the history of ADHD reside the nascent concepts that serve as the foundation for the current conceptualization of the disorder as largely involving self-regulation and executive functioning, as discussed here by Eric Willcutt (Chapter 15) and myself (Chapter 16). In this history also can be seen the emergence of current notions about its treatment. Such a history remains important for any serious student of ADHD, for it shows that many contemporary themes concerning its nature arose long ago. They have recurred throughout the subsequent history of ADHD to the present as clinicians and scientists strove for a clearer, more accurate understanding of the condition, its comorbid disorders, life course, impairments, and etiologies. Readers are directed to other and earlier sources for additional discussions of the history of this disorder (Accardo & Blondis, 2000; Goldstein & Goldstein, 1998; Kessler, 1980; Ross & Ross, 1976, 1982; Schachar, 1986; Taylor, 2011; Warnke & Riederer, 2013; Werry, 1992).

The Historical Origins of ADHD

The Late 1700s

One can find literary references to individuals having serious problems with inattention, hyperactivity, and poor impulse control in Shakespeare, who made mention of a malady of attention in King Henry VIII. But as of this writing, the medical history of ADHD-like descriptions traces back nearly 240 years to 1775. This early history has been expertly detailed in several sources (Taylor, 2011; Warnke & Riederer, 2013) but should be amended by more recent discoveries in that history, as discussed below.

It now appears that the first description of disorders of attention, at least as of this writing, occurred in the medical textbook by Melchior Adam Weikard in German in 1775 (or perhaps even 1770; see Barkley & Peters, 2012). Initially published anonymously, hence the difficulty with ascertaining the year of its initial publication, the medical textbook by Weikard described adults and children who were inattentive, distractible, lacking in persistence, overactive, and impulsive, which is quite similar to today's description of ADHD. Weikard implied that the disorder could result from poor childrearing but also suggests some biological predispositions as well. For treatment, he recommended sour milk, plant extracts, horseback riding, and even seclusion for severe cases.

This textbook would be followed in short order in 1798 with much more detailed descriptions of ADHD-like symptoms in the medical textbook by the Scottish physician Alexander Crichton (see Palmer & Finger, 2001), who may well have studied with Weikard in his medical training. Crichton described two types of attention disorders. The first was a disorder of distractibility, frequent shifting of attention or inconstancy, and lack of persistence or concentration, and aligns more closely with the attention disturbance evident in ADHD. The second was a disorder of diminished power or energy of attention that seems more like the attention problem evident in current descriptions of children and adults with sluggish cognitive tempo (SCT), which is briefly discussed in Chapter 2 on ADHD symptoms and subtypes and far more detailed coverage in Chapter 17, this volume. Crichton had little to say about this second disorder of attention other than it may be associated with debility or torpor of the body that weakens attention and results in individuals who are often characterized as retiring, unsocial, and having few friendships or attachments of any kind; even those few friendships seldom were of a durable nature. He argued that the faculty of attention can become sufficiently weakened that it may leave an individual insensible to external objects or to impressions that ordinarily would awaken social feelings.

The 1800s

In 1809, John Haslam described what may have been a case of ADHD in a 10-year-old boy who was uncontrollable, impulsive, and "a creature of volition and the terror of the family" (p. 199). Three years later, the famous American physician Benjamin Rush (1812) discussed three cases involving "the total perversion of moral faculties" (p. 359), which included the inability to focus attention. In the mid-1800s, the German pediatrician Heinrich Hoffman (1865) published a book of poems about psychological conditions of children based on observations from his clinical practice. He described both a very impulsive fidgety child he called "Fidgety Phil" and a very inattentive, daydreamy child he called "Johnny Head-in-Air" (see Stewart, 1970). Two years thereafter in England, Henry Maudsley (1867) published a report about a child who was driven by impulsiveness and was also quite destructive. In 1899, the Scottish psychiatrist, Thomas Clouston discussed cases of impulsive children who had learning problems. Much later in the United States, William James (1890/1950) noted in his Principles of Psychology a normal variant of character that he called the "explosive will," which may resemble the difficulties experienced by those who today are described as having ADHD.

In France the concept of ADHD may have originated in 1845 in the description of children and adults with attention problems by Jean-Etienne Dominique Esquirol, who believed that the insane no longer "enjoy the faculty of fixing, and directing their attention" (p. 28). Or perhaps the French history of ADHD began in the notion of "mental instability" that appears in the French medical literature in the 1885–1895 period under the leadership of Désiré-Magloire Bourneville (1885, 1895; see Bader & Hidjikhani, in press) at the Hospital Bicêtre in Paris. He observed children and adolescents who had been labeled "abnormal" and placed in medical and educational institutions, many of whom were characterized by attention and other behavioral problems. Charles Baker, a student of Bourneville, wrote a clinical description of hyperactive and impulsive symptoms in 4 children in his 1892 thesis, according to Bourneville (1895). Attention problems were also mentioned in one case in this work.

The Period 1900 to 1959

Still's Description in 1902

In the earlier editions of this text, credit for authoring the first medical description of cases resembling ADHD was awarded to George Still in 1902, owing to the lack of information on the earlier works of Weikard and Crichton. While this no longer remains the case, having been ousted from this credit by the discovery of Weikard's description noted earlier, Still did provide probably the most detailed account of the symptoms of these cases and the largest sample of such cases to that time. For these reasons, his observations deserve some recognition here. In a series of three published lectures to the Royal College of Physicians in 1902, Still described 43 children in his clinical practice who had serious problems with sustained attention; he agreed with William James (1890/1950) that such attention may be an important element in the "moral control of behavior." Most were also quite overactive. Many were often aggressive, defiant, resistant to discipline, and excessively emotional or "passionate." These children showed little "inhibitory volition" over their behavior, and they also manifested "lawlessness," spitefulness, cruelty, and dishonesty. Still proposed that the immediate gratification of the self was the "keynote" quality of these children, among other attributes. Passion (or heightened emotionality) was the most commonly observed attribute and the most noteworthy. Still noted further that such children had an insensitivity to punishment, for they would be punished (even physically) yet engage in the same infraction within a matter of hours.

Still believed that these children displayed a major "defect in moral control" over their behavior; a defect that was relatively chronic in most cases. He believed that in some cases, these children had acquired the defect secondary to an acute brain disease, and it might remit on recovery from the disease. He noted a higher risk for criminal acts in later development in some, though not all, of the chronic cases. Although this defect could be associated with intellectual retardation, as it was in 23 of the cases, it could also arise in children of near-normal intelligence, as it seemed to do in the remaining 20.

To Still (1902), the moral control of behavior meant "the control of action in conformity with the idea of the good of all" (p. 1008). Moral control was thought to arise out of a cognitive or conscious comparison of the individual's volitional activity with that of the good of all — a comparison he termed "moral consciousness." For purposes that will become evident later, it is important to realize here that to make such a comparison inherently involves the capacity to understand the consequences of one's actions over time and to hold in mind forms of information about oneself and one's actions, along with information on their context. Those forms of information involve the action being proposed by the individual, the context, and the moral principle or rule against which it must be compared. This notion may link Still's views with the contemporary concepts of self-awareness, working memory, and rule-governed behavior discussed later in this text. Still did not specifically identify these inherent aspects of the comparative process, but they are clearly implied in the manner in which he used the term "conscious" in describing this process. He stipulated that this process of comparison of proposed action to a rule concerning the greater good involved the critical element of the conscious or cognitive relation of individuals to their environment, or "self-awareness." Intellect was recognized as playing a part in moral consciousness, but equally or more important was the notion of volition or will. The latter is where Still believed the impairment arose in many of those with defective moral control who suffered no intellectual delay. Volition was viewed as being primarily inhibitory in nature, that a stimulus to act must be overpowered by the stimulus of the idea of the greater good of all.

Still concluded that a defect in moral control could arise as a function of three distinct impairments: "(1) defect of cognitive relation to the environment; (2) defect of moral consciousness; and (3) defect in inhibitory volition" (p. 1011). He placed these impairments in a hierarchical relation to each other in the order shown, arguing that impairments at a lower level would affect those levels above it and ultimately the moral control of behavior. Much as researchers do today, Still noted a greater proportion of males than females (3:1) in his sample, and he observed that the disorder appeared to arise in most cases before 8 years of age (typically in early childhood). Many of Still's cases displayed a proneness to accidental injuries — an observation corroborated by numerous subsequent studies reviewed in a later chapter. And Still saw these youngsters as posing an increased threat to the safety of other children because of their aggressive or violent behavior.

Alcoholism, criminality, and affective disorders such as depression and suicide were noted to be more common among their biological relatives — an observation once again buttressed by numerous studies published in recent years. Some of the children displayed a history of significant brain damage or convulsions, whereas others did not. A few had associated tic disorders, or "microkinesia"; this was perhaps the first time tic disorders and ADHD were noted to be comorbid conditions. We now recognize that while 10–15% of children with ADHD may manifest some form of tic disorder, as many as 50–70% of children with tic disorders and Tourette syndrome may have ADHD (Simpson, Jung, & Murphy, 2011).

Although many of Still's subjects were reported to have a chaotic family life, others came from households that provided a seemingly adequate upbringing. In fact, Still believed that when poor childrearing was clearly involved, the children should be exempt from the category of lack of moral control; he reserved it instead only for children who displayed a morbid (organic) failure of moral control despite adequate training. He proposed a biological predisposition to this behavioral condition that was probably hereditary in some children but the result of pre-or postnatal injury in others. In keeping with the theorizing of James (1890/1950), Still hypothesized that the deficits in inhibitory volition, moral control, and sustained attention were causally related to each other and to the same underlying neurological deficiency. He cautiously speculated on the possibility of either a decreased threshold for inhibition of responding to stimuli or a cortical disconnection syndrome, in which intellect was dissociated from "will" in a manner that might be due to neuronal cell modification. Any biologically compromising event that could cause significant brain damage ("cell modification") and retardation could, he conjectured, in its milder forms lead only to this defective moral control.

Also in England, Alfred Tredgold (1908) described children of low intelligence having abnormal behavior and limited powers of attention, impulse control, and willpower. He extended Still's theories and observations that early brain damage might present as behavioral and learning problems in later childhood. Foreshadowing current views of treatment, both Still (1902) and Tredgold found that temporary improvements in conduct might be achieved by alterations in the environment or by medications, but they stressed the relative permanence of the defect even in these cases. They emphasized the need for special educational environments for these children. We see here the origins of many later and even current notions about children with ADHD and oppositional defiant disorder (ODD), although it would take almost 70 years to return to many of them — owing in part to the ascendance in the interim of psychoanalytic, psychodynamic, and behavioral views that overemphasized childrearing as largely causing such behavioral disorders in children. The children described by Still and Tredgold would probably now be diagnosed as having not only ADHD but also ODD or conduct disorder (CD), and most likely a learning disability as well (see Chapters 5 and 6).

Around this same time, in Spain, the physician Rodriguez-Lafora (1917) wrote about his interests in childhood mental illness and described a group of children having psychopathic constitutions, a subset of which he called the "unstables." His description of them matches closely the modern view of ADHD (Bauermeister & Barkley, 2010), including inconstancy of attention, excessive activity, and impulsive behavior, as does his observation that such children get carried away by their adventurous temperament.