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How has the understanding of and knowledge about ADHD changed over the years? (Hint: a lot!!) Read on for a historical account of ADHD, as well as research from 2020 about emotional dysregulation in honour of ADHD awareness month.
ADHD is now accepted as a difference in brain structure and chemistry that is primarily genetic. But the understanding of the condition has changed immensely over the past hundred and twenty years, since it was first studied as a unique condition in western medical history. Read on to understand more about the history of ADHD - from its name, to its presumed causes, to the evolution of research on the emotional regulation aspects of ADHD.
ADHD has only been considered a unique condition in written western medical history consistently (with some sporadic earlier mentions) since around the turn of the 20th century with the work of Sir George Frederick Still and Sir Thomas Smith Clouston. That being said, the traits of inattention, hyperactivity, and impulsiveness have been studied together for much longer - with some references to something that could potentially have been ADHD as early as 493BC in the writing of the Greek physician Hyppocrites. ADHD isn’t something that is new and it’s not cultural, despite pervasive myths and misconceptions. It’s conceptualization in western medicine, however, does have a relatively short and tumultuous history.
Through the first half of the 20th century, ADHD was identified as a unique set of traits by a few physicians, but did not have a unified name. The cause of the traits was hypothesized by Sir George Frederick Still to be the result of a brain difference, unrelated to home environment and intelligence, while other physicians of the early 1900s argued that the traits were likely the result of brain damage (Rodden 2019).
It wasn’t until the 1960s that this changed definitively and ADHD was added to the DSM. In 1968, ‘the second edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the DSM-II lists the disorder, but under the name “hyperkinetic reaction of childhood.”(CHADD 2020).
At that time, ‘it was thought to cause restlessness and distractibility in children, but believed to go away or lessen by adolescence’ (CHADD 2020).
A key moment in ADHD research came in 1972 when Dr. Paul Wender was able to link ADHD to a person's genetics by showing that ADHD runs in families (Charach et al. 2011). As Rodden (2019) points out, this is what ultimately spurred future genetic research into ADHD.
The name ADD was finally written into the DSM-III in 1980. The specific diagnosis of ADHD has only been around since 1987, when it first appeared in the revised third edition of the DSM (Rodden 2019). The DSM IV, in 1994, refined the diagnosis to include the three subtypes - inattentive type, hyperactive/impulsive type, and combined type.The current DSM updated these to be called ‘presentations’ and not types - affirming that someone’s presentation can change over time.
Public controversy around the use of stimulant medication as treatment for people with ADHD has been rampant throughout the century, despite improvements in wellbeing for many people with ADHD who take stimulant medication.
The first stimulant medications given to children with ‘emotional problems’ were tested in 1937 by the psychiatrist Dr. Charles Bradley, at which point they had the unexpected side effect of improving interest in school (Rodden 2019).
Through the 1950s there was broad experimentation with using stimulants to treat various mental illnesses, which ended up being a part of developing improved medications for ADHD over time (but recall: ADHD was still called hyperkinetic reaction of childhood until 1980! So at the time this would not have been a known outcome or goal of the research into stimulants). Ritalin was approved by the FDA in 1955.
Through the 1970s there was significant backlash to treating children with stimulants (Mayes et al 2008). The Amphetamine epidemic (and subsequent classification of Amphetamines as schedule III then schedule II substances) meant growing public scepticism for treating mental health conditions with stimulants, as well as difficulty accessing stimulant medication (Rodden 2019).
There are currently two stimulant medications that are approved in the US to treat ADHD: methylphenidate and amphetamine, along with three non-stimulant medications. ADHD medications are available in different forms and dosage, which significantly impact that effectiveness of medication. There needs to be more research on optimizing ADHD medication dosages for individual patients, as well as de-stigmatizing the use of stimulants, which can be extremely effective for supporting attentional and emotional regulation for some people with ADHD.
In the early 20th Century (and onwards), there was debate over whether ADHD was primarily behavioural and/or the result of certain environments, or it was genetic. This question has been more definitively answered since studies using neuroimaging have revealed differences in brain structure between people with ADHD and people without ADHD.
In the words of Dr. Oren Mason and Dr. Tamara Rosier ‘Neuroimaging studies have revealed the structural differences in the ADHD brain. Several studies have pointed to a smaller prefrontal cortex and basal ganglia, and decreased volume of the posterior inferior vermis of the cerebellum — all of which play important roles in focus and attention.’ (2020)
What neuroimaging clearly showed is what many ADHD researchers and people with ADHD have been saying all along: that ADHD is not a set of behavioural problems and it is not primarily environmental. Instead, ADHD is the result of a difference in brain structure and chemistry that affects a person’s perceptions and experiences throughout environments over time.
Dr. Daniel Amen writes that ‘In my opinion, imaging completely changes the discussion around mental health. After looking at their scans, patients often see that their problems are medical, not moral.’ This change in perspective about ADHD that is aligned with the neurodiversity paradigm - that brain differences are a natural and valuable part of human diversity - is also the most scientifically accurate conceptualization.
One of the emerging areas of our understanding about ADHD concerns an area of traits that are not even considered in the DSM-5 and thus in many diagnostic environments: emotional regulation differences shared by many ADHD minds. In replication analysis of a study conducted in 2015, Dr. Frederick Reimherr found emotional dysregulation to be a key feature for many people with ADHD, going on to suggest that two presentations of ADHD, an emotional dysregulation type and an inattentive type, and that classifying ADHD based on levels of emotional dysregulation offers a "more clinically relevant approach for diagnosing ADHD in adults than the current DSM-5 criteria", which only examines attentional dysregulation (2020).
Dr. William Dodson (2020) has pointed out that there are three very common emotional dysregulation traits related to emotional regulation in people with ADHD, and that these are actually characteristic across all three presentations of ADHD. These traits are: an interest-based nervous system; emotional hyperarousal; and rejection sensitivity (Dodson 2020). What this means is that people with ADHD are motivated differently and react in ways that are different to people without ADHD. A better understanding of and acknowledgment of emotional dysregulation traits in ADHD could likely lead to better diagnosis and better treatment going forward.
The way ADHD is understood, diagnosed and treated has changed significantly over the past two decades and will likely change going forward, although myths and misunderstandings - like the notion children grow out of ADHD - unfortunately persist (CDC 2020).
Some researchers and doctors working with ADHD patients, Dr. William Dodson and Dr. Frederick Reimherr among them, are advocating strongly for the emotional dysregulation features of ADHD to be more actively included in diagnostics, particularly for adults. It’s well documented that diagnosis can have a positive impact on quality of life on people with ADHD (Pawaskar et al. 2019), so it’s key that this first step towards self-understanding and treatment options is accessible to people with ADHD brains.
We hope for (and will work towards) a future where there is more understanding of, acceptance of, and support for people with ADHD. We also hope that validation, early diagnosis, and effective, multifaceted treatments will continue to improve over the next twenty years.
Infographic of how the understanding of and knowledge about ADHD has changed over the years.