Doctor's Review: Medicine on the Move

December 19, 2014
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Attention grabber

ADHD may be a relatively new diagnosis, but the problem is as old as parenthood itself

Most physicians -- and all parents -- know how challenging children can be. Until fairly recently, however, virtually all childhood misbehaviours and hyperactive tendencies were chalked up to kids' personalities, lax discipline, a lack of sleep or too much sugar. Indeed, while the vast majority of general naughtiness and typical childhood impulsiveness can be attributed to a combination of these variables, this is not always the case. Now that attention deficit/hyperactivity disorder (ADHD) is accepted as a legitimate medical condition with a likely biological basis, the medical community recognizes that some kids are afflicted with more than their fair share of trouble.

 

This realization was a long time in coming. Though the practice of medicine was largely guesswork in ancient days, patients with mental disorders fared particularly poorly; since the intricate workings of the human mind were virtually unknown until recently, psychiatric conditions were woefully misunderstood in the past. Add old-fashioned superstitions and religious prejudices into the mix and anyone suffering from a psychiatric situation was at a serious disadvantage. ADHD was no exception, especially in that it affected children most of all.

Although the disorder has probably been around for as long as kids have been acting up, it was not officially recognized until the 20th century. Before then, brief mentions of conditions that would now most likely be considered ADHD did appear in literature from time to time. Of course, Hippocrates may have been the first to spot it when he referred to a cluster of symptoms suggestive of ADHD in his Aphorisms. Identifying the problem was far easier than treating it, however, and all he could do was suggest a change in diet.


FICTIONAL CHARACTERS, REAL CONDITION
Interestingly, the most likely evidence of knowledge of kids with ADHD appears not in medical literature, but in poetry. In Henry VIII, Shakespeare was the first to identify what he called a "malady of attention." But Shakespeare was referring to an adult; the first child to be described in similar terms was one Fidgety Philip, a character in a collection of children's poems, known as Der Struwwelpeter, written by the German doctor Heinrich Hoffmann (1809-1894) and published more than two centuries later in 1845. Hoffmann's character is a naughty little boy who won't sit still at dinner and learns his lesson the hard way when his chair falls over and takes the tablecloth -- and everything on it -- down with him.

In an aptly derived pseudonym, the boy first described in medical literature as having ADHD was referred to as Fidgety Phil. The case appeared in the British medical journal The Lancet in 1902 in which the syndrome "morbid defect of moral control" was discussed by George Still, an English pediatrician. He gave a series of three lectures that year to the Royal Academy of Physicians and shared his belief that a common disorder of "volitional inhibition" connected the 20 patients he had studied. The symptoms Still identified in these boys clearly allow for a retroactive diagnosis of what we now know as ADHD.

Still was likely influenced by the work of William James (1842-1910), the preeminent American psychologist. In his Principles of Psychology (1890), he noted:

"Everyone knows what attention is. It is the taking possession by the mind in clear and vivid form, of one out of what seem several simultaneously possible objects or trains of thought… It implies withdrawal from some things in order to deal effectively with others, and is a condition which has a real opposite in the confused, dazed, scatterbrained state."

James described this personality characteristic as "the explosive will" and he was perhaps the first to imply that in some cases, this trait and other "mercurial temperaments" were beyond the patient's control. Still later expanded on the notion of this lack of control as a disease when he described the morbid defect of moral control as being perhaps genetic or organic in nature and not solely the result of environment.


ENCEPHALITIS OUTBREAK
Attention to this mysterious disease was pushed to the fore a few years later when a terrible encephalitis epidemic spread across North America in 1917-1918, prompting more research into the matter. Parents and physicians were aware that many kids who survived the illness were left with lasting behavioural problems, presumably the result of the infection in their brains. Brain trauma, injury, disease and congenital defects were now known to have severe effects on behaviour. Still's morbid defect disease grew into "minimal brain damage," then "minimal brain dysfunction." By the 1960s, the term "hyperactive" had entered the descriptions of this disease, which was being diagnosed with increasing frequency.

Interest into the organic and/or genetic causes of these children resulted in the first effective drug therapy in 1937, when Charles Bradley (1902-1979), a Rhode-Island pediatrician with an interest in neurology, published a landmark paper in the treatment of ADHD called "The Behavior of Children Receiving Benzedrine." In it, he proved, somewhat ironically, that amphetamines actually relieved the aggressive, impulsive and hyperactive behaviour these children displayed. In 1955, this was followed by methylphenidate, shown to be even more effective in curbing symptoms. During the 1970s, a great deal of the studies into what was by then known in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as the "hyperkinetic reaction of childhood" (1968) went into proving that the disease was not caused by diet, bad parenting, poor social conditions or brain damage, but rather by brain chemistry and sensory problems.

This newfound focus inspired a change of terminology as well. In 1980, the term "attention deficit disorder" (ADD) appeared for the first time in the DSM III, with various subtypes. In 1987, in the DSM-III-R, the description of the disease was revised as simply "attention deficit/hyperactivity disorder," and finally, in the 1994 edition, DSM-IV, the definition of ADHD was expanded to include two categories and three subtypes as well. Oddly, almost as much debate has gone into the definition of this condition as into the nature of the disorder itself.


CONTROVERSIAL CONDITION
Despite all the promising research, ADHD remains a very controversial diagnosis, with many people even doubting its very existence. Beginning in the 1990s, wars have been waged in the press, exam room, boardroom and classroom over the exact nature of this disease. Parents and physicians alike often face prejudice and suspicion when an ADHD diagnosis is made, since old assumptions die hard and an abundance of pseudo-science and quackery regarding this disease continue to plague the Internet. Years of hard research prove otherwise; in fact, according to the American Medical Association, ADHD is "one of the best-researched disorders in medicine, and the overall data on its validity is far more compelling than for many medical conditions."

Modern science has virtually eliminated the myth that ADHD is caused by poor diet, poor parenting or some combination of the two. The medical and scientific communities agree that environmental factors do not on their own cause ADHD; although its etiology remains unknown, numerous studies show that ADHD is a disorder with a strong biological and/or genetic basis. Recent research also shows that although the disorder is prevalent in childhood, the need for early intervention and treatment is more important than ever, since up to two thirds of kids diagnosed with ADHD will grow up to be adults with ADHD.

It doesn't take a specialty in pediatric psychiatry to know that stuffing any kid with ice-cream and soda and plopping him down in front of the Late, Late Show is unlikely to yield exemplary behavioural results, but for those children and parents powerless to control the effects of this devastating condition on their own, a combination of behavioural, therapeutic and medical techniques has proven quite effective in managing symptoms. The hope is that the current studies focusing on the genetic components of ADHD may even provide the first steps toward a cure or, at least, better help in treating this common childhood psychiatric disorder. No matter what the future holds in terms of revealing the etiology of this condition, the rich history of research into ADHD has already allowed doctors to provide hope for patients and parents alike.

 

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