Evolution of Attention Deficit Hyperactivity Disorder (ADHD) - Historical Perspective, Slides of Public Health

Download Evolution of Attention Deficit Hyperactivity Disorder (ADHD) - Historical Perspective and more Slides Public Health in PDF only on Docsity! ADHD: Historical Overview Docsity.com ADHD: Not a New Problem • Characteristics of this disorder have been recognized for over a century. See the Story of Fidgity Phillip • The disorder has been referred to by a variety of labels over the years; – Minimal Brain Dysfunction (MBD) – Hyperkinetic Reaction of Childhood – Attention Deficit Disorder (ADD) – Attention Deficit Hyperactivity Disorder (ADHD) Docsity.com ADHD: Milestones in the Evolution of the Disorder • The Still (1902) Lectures to the Royal College of Physicians • Encephalitis epidemic of 1917 (Ebaugh 1923) • Frontal lobe ablation studies with primates (1930’s) • Beginnings of child psychopharmacology; Amphetamines for treatment – 1930- 1940. • Strauss’ work on Minimal Brain Dysfunction (1940's -1950's) • MBD becomes Hyperkinetic Disorder (the 1960’s) Docsity.com ADHD: Evolution of the Disorder (cont.) • Hyperkinesis becomes ADD – The decade of the 70’s • Focus on Dietary Factors – Feingold and the 1970’s • Studies of pschophysiological responsivity – the 1970’s • Development of objective diagnostic criteria: DSM III and the recognition of Attention Deficit Disorder – The early 80’s Docsity.com ADHD: Evolution of the Disorder (cont.) • The decade of the 80’s: DSM III & DSM III-R stimulates ADHD research • Development of new assessment methods • New treatment methods • Increased focus on biological factors. • The 1990’s and beyond: Focus on Neuroimaging, genetics, reevaluation of the DSM system, Evidence Based Practice and Practice Guidelines, etc. Docsity.com Still (1902) • Children in this sample were also said to display major problems with sustained attention. • The majority were overly active, they tended to be accident prone. • Most of the children in Still's group developed these problems before age 8. • There was a 3 to 1 mail to female sex ratio. Docsity.com Still (1902) • Many of these children displayed minor physical anomalies which he referred to as "stigmata of degeneration". • Examples included large head size, malformed palate, and epicanthal folds. • Alcoholism, criminality and affective disorders were found to be common in biological relatives. • Some. but not all, had a history of convulsions or other evidence of brain damage. • Some had tic disorders. Docsity.com Still (1902) • Still thought that the major problems in sustained attention and the deficits in inhibitory control and moral control were related and were manifestations of an underlying neurological deficiency. • He speculated that these children either had an altered threshold for inhibition of responding to stimuli or a "cortical disconnection syndrome", "where intellect is disassociated from will" and this might be due to some sort of "Neuronal cell modification". Docsity.com ENCEPHALITIS EPIDEMIC OF 1917 - 1918 • These sequelae were described in a large number of articles that noted the behavioral effects on such children. • Many of these children displayed behavioral characteristics which are now commonly associated with ADHD. • They were often seen as hyperactive, impulsive and socially disruptive, with significant attention deficits. • They also had memory difficulties and other types of cognitive impairment. Docsity.com ENCEPHALITIS EPIDEMIC • Many such children were also described as showing features that we would now think of as reflecting ODD or CD • As these characteristics were observed in children who had experienced actual disease-related neurological impairment, it provided early evidence that behavioral problems like those we now associate with ADHD can result from biological causes. Docsity.com Ebaugh’s 1923 Article • An especially influential paper was a publication by Ebaugh (1923 – See Barkley 2007) • This paper provided additional support for the view that ADHD could arise from acquired brain injury. • Described 17 child survivors of the encephalitis epidemic. • He noted that characteristics of such children included impulsiveness, hyperkinesis, inability to concentrate, unruly behavior, school problems, aggressiveness, and failure to respond to discipline. Docsity.com Brain Insults & Behavior Difficulties: Other Links • By the 1930's and 1940's many investigators had begun to develop an interest in the link between "behavioral pathology" and "brain disease." • For example, a range of cognitive and behavioral impairments such as mental retardation, learning problems, and problems with hyperactive/impulsive behavior were found to be related to a history of birth trauma, head injury, viral infections & exposure to toxins. Docsity.com Brain Insults & Behavior Difficulties: Other Links • It is noteworthy that many of these children had clear signs of neurological impairments and a much wider range of problems than are now typically associated with ADHD. • These sort of findings did, however, suggest to many that the problems exhibited by children with hyperactivity may be associated with some sort of brain damage. Docsity.com FRONTAL LOBE ABLATION STUDIES • Early interest in the possible link between hyperactivity and brain impairment was also sparked by the results of animal studies. • Of specific interest was the observed similarity between the behavior of hyperactive children and the behavior of primates that had brain lesions. Docsity.com THE CONCEPT OF MBD • At that time it would have been quite reasonable to assume that childhood problems, like the ones we are talking about here, might have resulted from brain damage in cases where there was a history of trauma or illness that was capable of resulting in some type of neurological impairment. • However, some working in this area took things a step further, leading to the evolution of the concept of Minimal Brain Damage or Minimal Brain Dysfunction. Docsity.com THE CONCEPT OF MBD • On of the individuals most closely associated with the concept of Minimal Brain Dysfunction was Alfred Strauss . • In a series of studies, conducted in the 1940's and 1950's, Strauss and his colleagues attempted to isolate characteristics that would discriminate between groups of mentally retarded children with and without documented brain damage. Docsity.com THE CONCEPT OF MBD • These studies suggested a number of psychological and behavioral markers thought to be reliably associated with a history of brain damage. • Among these were; – hyperactivity, – aggressiveness, – impulsiveness, and distractibility – along with emotional lability, – perceptual motor deficits, and – poor coordination as well as others. Docsity.com The Notion of “Minimal” Brain Dysfunction • The descriptor "Minimal" in Minimal Brain Dysfunction, related to the assumption that brain damage can be seen as existing on a continuum. • That is one that can have mild or minimal brain damage or dysfunction which is reflected primarily in its impact on the organization behavior, rather than in any sort of hard neurological signs. • This concept of Mimimal Brain Dysfunction flourished in the 1950's. Docsity.com Correlates of MBD • Along with Strauss's impact on the developing concept of MBD, he also provided recommendations regarding the education of children with this disorder. • One had to do with the view that children with this disorder were over stimulated. • This was thought to be due to their neurological difficulties which made it impossible to filter out extraneous stimuli. • This increased stimulation was seen as contributing to the child's attention and activity-level problems. Docsity.com MBD & Over Stimulation • Strauss suggested the importance of an educational environment where the child would be placed in small classes and where stimulation which could be distracting to the child was removed. • Teachers would wear no jewelry or brightly colored clothing, there would be few pictures on the walls, etc. • This represented the beginnings of a stimulus reduction model of ADDH. • In the 1960's these sorts of educational suggestions were applied in the classroom by Cruikshank. Docsity.com The Demise of MBD • This resulted in less of a focus on the issues of "minimal brain damaged" and an increased focus on more homogeneous groupings of child problems. • Here, there was increased interest in more specific problems such as learning disabilities, language disorders, mental retardation, and problems such as hyperactivity. Docsity.com Focus on Hyperactivity • As a result, many investigators became interested in what came to be referred to as the Hyperkinetic Child Syndrome or the Hyperactive Child Syndrome. • The emphasis on hyperkinesis was highlighted in a seminal article by Stella Chess (1960) where the core symptom of this disorder was described in terms of the child’s excessive activity level. Docsity.com The Hyperactive Child Syndrome • Here, the hyperactive child was described as one who “carries out activities at a higher than normal rate of speed than the average child or who is constantly in motion or both." • In this paper Chess stressed the need to consider objective evidence of the symptoms, apart from parent and teacher report, and to separate the Hyperactive Child Syndrome from the notion of the Brain Damaged Child. Docsity.com The Hyperactive Child Syndrome • For those working with children with this disorder, it was often assumed that hyperactivity represented a brain-dysfunction syndrome. • Assumptions regarding causality were, however, usually presented in terms of the involvement of brain mechanisms rather than in terms of frank brain damage. Docsity.com Hyperkinetic Reaction of Childhood • The disorder was seen has having a relatively homogeneous set of symptoms, most notably excessive activity level. • It was thought to have a relatively benign course and to often be outgrown by puberty (which we now know to be inaccurate in most cases). • Treatment was through stimulation medication and psychotherapy along with stimulus reduced educational environments. Docsity.com THE 70'S - ATTENTION TO ATTENTION DEFICITS • By the early to mid 1970's the concept of the hyperkinetic child syndrome was broadened to include associated characteristics such as impulsivity, low frustration tolerance, and attentional difficulties. • While the focus of research interest had moved from a focus on brain damage to a focus on hyperactivity this was to change, in large part due to the work of McGill psychologist Virginia Douglas. Docsity.com The Focus on Attention • An additional argument for attentional problems being the core deficit was that problems with attention and concentration seem to continue even into later life, while problems with activity level often diminish significantly as the child gets older. • Douglas's work, and the results of other research stimulated by her work on attention, appear to have been the primary reason for the renaming this disorder as Attention Deficit Disorder when DSM III was published in 1980. Docsity.com Focus on Dietary Factors • The 1970's also witnessed much attention being given to the role of dietary factors in hyperkinetic behavior. • The assumption was that allergic or toxic reactions to food additives such as dyes, preservatives, and salicylates caused hyperactive behavior. • This view, developed and popularized by Benjamin Feingold, claimed that over half of children with hyperactivity had problems because of diet related issues. Docsity.com Focus on Dietary Factors • It was suggested that treatment should involve buying or making foods without dyes, preservative or salicylates. • This view became so widespread that organized parent groups which promoted this Feingold diet were organized in most states. • Despite the popularity of the Feingold approach, research designed to investigate the role of these sorts of dietary factors in the development of hyperactive behavior were not supportive of this hypothesis. Docsity.com PSYCHOPHYSIOLOGICAL RESPONSIVITY • These study often were designed to test the notions of cortical overstimulation that were first advanced in the 1950's. • Here it was suggested that because of brain damage, children were not able to filter out stimuli and that because of this they became overly stimulated and thus inattentive and hyperactive. • The basic assumption was they hyperactive children were over. rather than under stimulated. Docsity.com PSYCHOPHYSIOLOGICAL RESPONSIVITY • Taken together, results of these studies tended to provide support for the notion that hyperactive children showed underreactive as opposed to overreactive responses to simulation. • They tended to show lower amplitude responses to new stimulation and tended to habituate more rapidly than did normal children. • This underreactivity/underarousability, to stimuli appeared to be normalized by stimulant drugs in some cases. Docsity.com PSYCHOPHYSIOLOGICAL RESPONSIVITY • Thus, this line of research seemed to argue strongly against the notion of an overstimulated cerebral cortext as a cause of hyperactivity in children. • In fact, it seems that perhaps the opposite of this is more likely the case. • That is hyperactive children may benefit from stimulation less than normal children and may be if anything under aroused or underarousable in response to environmental stimulation. Docsity.com DSM III: Focus on ADD • In DSM III the disorder was renamed: Attention Deficit Disorder or ADD, so as to highlight the presumed central role of attentional difficulties and impulsivity in this condition. • Again, this change probably had much to do with research conducted by Virginia Douglas which highlighted deficits in attention and impulse control displayed by children with this disorder. Docsity.com DSM III: Focus on ADD • The treatment of this disorder in DSM III was noteworthy for several reasons: – The renaming of the disorder – The focus on inattention and impulsivity as defining features – The development of more objective diagnostic criteria – The presentation of numerical cutoff scores for symptoms – Age of onset criteria – Criteria for duration of condition – Exclusionary criteria Docsity.com DSM III and ADD • Most notable in these DSM III criteria, however, was the creation of ADD Subtypes. • Here, basic symptoms of the disorder were grouped into three classes. • 1. Symptoms of Inattention • 2. Symptoms of Impulsivity • 3. Symptoms of Hyperactivity • Based on the constellation of symptoms displayed children were to be diagnosed as having ADD either with or without hyperactivity. Docsity.com DSM III-R: AN Example of Inattention and Impulsivity • Despite the fact that DSM III served to stimulate research in the area of ADD and that basic distinctions between ADD subtypes were receiving support by research findings, major changes were made in DSM III-R which was published in 1987. • These changes appear to reflect a lack of attention to the developing research literature and an impulsive approach to publishing activity. Docsity.com The Nature of DSM III-R • The changes seen in DSM III-R provided for only the diagnosis of ADD with Hyperactivity and the name was changed to Attention Deficit Hyperactivity Disorder. • ADD - without hyperactivity was no longer recognized as a distinct subtype of ADD and was relegated to the category of UNDIFFERENTIATED ADD. • The revision contained in DSM III-R were significant on several counts. Docsity.com The Nature of DSM III-R • 1. A single item list of symptoms and a single cutoff score replaced the three separate lists (inattention, impulsivity and hyperactivity) and cutoff scores of DSM III. • 2. The item list was now based more on empirically derived dimension of child behavior from behavior rating scales and the items and cutoff scores underwent a large field trial to determine their discriminating power to distinguish ADHD from other disorders and normal children. Docsity.com Etiological Research of the 1980’s • In the 1980’s there were increasingly attempts to use sophisticated medical approaches to obtain information regarding the etiology of this disorder - in particular the role of brain functioning. These included - – studies on cerebral blood flow – studies designed to documented possible neurotransmitter deficiencies involvingdopamine and norepinephrine Docsity.com Decade of Neuroimaging and Genetics: The 1990’s • Newer imaging techniques employed in the 1990's added to this body of literature linking ADHD with abnormalities in brain functioning. • These involved PET scans, MRI and fMRI methodologies. • In the 1990’s there was also increased attention paid to the genetics of ADHD and expanded work in the area of molecular genetics which focused on findings specific genetic markers for ADHD. Docsity.com Other Developments of the 1990 • Development of new drugs to treat ADHD (Adderall, other sustained release stimulant medications) • First long term multimodal treatment study related to effectiveness of stimulant drugs and psychosocial treatments. • Developing of DSM IV • Consensus conference on ADHD. Docsity.com