TL, DR: ADHD History. Here we look at the medical history of ADHD and how the name and definition evolved, aka why ADD is 35 years out of date.
ADHD is an initialism that translates to Attention Deficit Hyperactivity Disorder. It’s a terrible name that only describes the behavioural characteristics of a few percent of the people who are or can be labelled with ADHD. That is, the initialism is based on a description that is very out of date and only really only literally describes a small percentage of ADHDers.
ADHD Medical History
Consider that ADHD was first noted in medical literature about 250 years ago. German physician Melchior Adam Weikard, wrote the first known medical textbook description of a disorder with the hallmarks of what we would now call ADHD in 1779, in a chapter titled “Mangel der Aufmerksamkeit”, (literally “Lost Attention”), in his fourth volume in his series “Der Philosophice Artz”, pages 114 to 120.
While a bit contested, some consider that Weikard wasn’t the first describe ADHD, he was just the first modern medical reference. Hippocrates (460-375 BC), considered the father of modern medicine, described patients who had “… quickened responses to sensory experience, but also less tenaciousness because the soul moves on quickly to the next impression” approximately in 493 BCE. It may be that what Hippocrates was describing was a very similar thing, however this is quite hard to have high confidence of due to a very difference context, culture and language perhaps leading to misinterpretation.
Every 50 or so years, various European medical texts have re-described the behaviour patterns, often with new names. None of these diagnostic descriptions persisted until 1902 when Sir George Frederic Still, considered the father of British Paediatrics, described some struggling children. He described mostly boys, and how they seemed to move too much. He called this category of people “hyperkinetic”. Hyper means “above the average” and kinetic means “movement”, that is, they move too much.He described it as “an abnormal defect of moral control in children” and that these children “couldn’t control their behaviour the way a normal child would” even though some of “these children were intelligent”. Thankfully we no longer try to use the idea of “moral control” as a medical description!
Medicine evolved and so did the name. Hyperactive/Hyperkinetic Syndrome, Maladjusted Children, Minimal Brain Dysfunction and ADD (Attention Deficit Disorder) are some of the names that ADHD has been historically called in the past.
Moral Failing, Neurological Condition or Mental Illness – Finding the First Successful Treatments
Up until relatively recently, ADHD had been recognised as a neurological disorder. It was thought to be “untreatable”.
This changed when Leandro Panizzon, an Italian Chemist in the employ of Swiss pharmaceutical company Ciba, now known as Novartis, synthesised a new chemical in 1944 called methylphenidate. He named the compound Ritalin after his wife Rita (short for Marguerite). Methylphenidate was found to help blood pressure and performance. It was also found to help calm down the hyperactive children such that their movements were muted, their concentration improved and there behaviour improved. This was the first medicine that reliably helped hyperactive people who fit Sir Still’s behavioural description. This first medication was followed by an amphetamine treatment in the early 1960’s, originally compounded to treat breathing difficulties.
We now know that both of these medications work in different ways to produce a similar effect – they increase the available chemical Dopamine in certains parts of the brain. This gives us some clues as to what we are really dealing with. More about that later in Part 2.
Even at the point of these medications being discovered to work, ADHD, currently called Hyperkinetic Syndrome, was categorised as a neurological condition.
When ADHD was included in the American Manual for Mental Disorders’ second release, the DSM II (1968), ADHD diagnosis and some viable medication treatment options entered mainstream medical awareness.
On the one hand, this inclusion meant that people struggling with ADHD could be recognised, diagnosed and given some kind of medical treatment. On the other hand, it recategorised a neurological problem into a mental illness in both the medical and social perception. Even with this greater awareness, ADHD was frequently not diagnosed, and due to Sir Still’s early perceptions of it being a boys disease, it was even less likely to be diagnosed in females.
The medical definition for ADHD is very loose. “Attention-deficit/hyperactivity disorder (ADHD) is marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development” [source: https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd]. That describes what to look for in some people, but not what ADHD is or why people have ADHD brains. Worse, it also fails to include a larger number of people who don’t show this trait/symptom.
Recall that the original reason for ADHD behaviour was considered to be a moral failing of the patient. This idea continues to persist in messages like “try harder”, “focus more”, “write lists”, “you are just lazy”, or “stop using ADHD as an excuse”. The more modern inclusion of ADHD in a list of mental illnesses has a new twist, – people think they are crazy and are often gaslit into thinking that they are just mentally ill. “Well, I can’t focus well, because I have a mental illness”. This completely ignored the many ADHDers who live fully functioning, high quality and fulfilling lives.
While ADHD can be disabling, it is not in and of itself a disability. Many people use the creativity and energy of their ADHD to accomplish many great things. Take a look at the entertainment industry – most of that is powered by ADHD. Take a look at the emergency services – again, mostly powered by ADHD. There are pros and cons to ADHD.
The modern take on ADHD is that this is still a neurological difference, as it was first classified after medicine started to let go of the moral aspect of disease. I’m using the literal definition of disease here – dis – ease. When things aren’t right, and you can’t be at ease. The ADHD community identified as Neurodivergent from the mainstream Neurotypical population. Much like left handed people, different but not broken.
The poor medical definition of what ADHD is, and how it works, has led to very badly designed studies. This often confused exactly what the scientist is actually testing, measuring and understanding; which then frequently leads to erroneous conclusions and people using scientific contradictions to handwave that “ADHD isn’t real”, “it is just a label for naughty people”, or other excuses to be negligent in helping or disenfranchising a decent percentage of the population.
Prevalence – How common is ADHD?
Speaking of a percentage of the population, because the definition of inclusion for ADHD is so vague, it is next to impossible to get a rational scale of prevalence for ADHD in the world population, or country populations and genetic populations. The common average proposed by various scholars is around 5% of the world population. I think that is underestimated and I propose that the real number is closer to 10% to 15%.
Currently, ADHD is diagnosed based on behaviours that persist for more than 6 months and look either inattentive, and or hyperactive.
Most countries will include that the behaviours must have been noted before the age of 12 years of age (which can make a late adult diagnosis tricky when the professionals didn’t notice or record relevant difficulties), but not all countries. Some countries refuse to consider that ADHD is even a thing at all!
This poor medical and scientific definition has led to the inclusion of anything that can lead to attention struggles, such as acquired or congenital brain damage, metal toxicity and other neurological conditions. This makes international prevalence, diagnosis and treatment comparisons like trying to compare apples and bananas. Yes, they are both fruit, but that’s about their only point of similarity. In my opinion, this is very wrong. We have tests and categories for those other conditions, and while ADHD medication may help those conditions too, methylphenidate also helps blood pressure, and that clearly isn’t ADHD. So including these conditions in the local “ADHD” population is not valid. I strongly recommend not following these poor definitions. That is, don’t include brain damage, metal toxicity etc in the population of ADHD.
In my professional opinion, ADHD is a very strongly heritable congenital neurological difference characterised primarily by low dopamine supply issues not otherwise described by other better conditions, and a secondarily related adrenaline imbalance in most ADHDers. The Dopamine issue can present as brain fog, struggles with focus, concentration, sticking to tasks, short term memory errors, confusion, dissociation and some binge eating disorders. The adrenaline issues can present as anxiety, aggression, extreme moodiness, self harming behaviours, suicidal ideation, sleep problems, kinesthetic hyperactivity and impulsivity.