What is ADHD? Paradigm Shifts in Psychopathology

Wow. Lots of psycho linguists around lately, huh? How about a change of pace? Think you guys can handle something not about Lord Chomsky?

Over the last one hundred years, paradigm shifts in the study of psychopathology have altered our conceptualization of attention deficit/hyperactivity disorder (ADHD), as a construct and as a diagnostic category. With few exceptions, it has generally been accepted that there is a brain-based neurological cause for the set of behaviors associated with ADHD. However, as technology has progressed and our understanding of the brain and central nervous system has improved, the nature of the neurological etiology for ADHD has changed dramatically. The diagnostic category itself has also undergone many changes as the field of psychopathology has changed.

In the 1920s, a disorder referred to as minimal brain dysfunction described the symptoms now associated with ADHD. Researchers thought that encephalitis caused some subtle neurological deficit that could not be medically detected. Encephalitis is an acute inflammation of the brain that can be caused by a bacterial infection, or as a complication of another disease such as rabies, syphilis, or lyme disease. Indeed, children presented in hospitals during an outbreak of encephalitis in the United States in 1917-1918 with a set of symptoms that would now be described within the construct of ADHD.

In the 1950s and 1960s, new descriptions of ADHD emerged due to the split between the neo-Kraepelinian biological psychiatrists and the Freudian psychodynamic theorists. The term hyperkinetic impulse disorder, used in the medical literature, referred to the impulsive behaviors associated with ADHD. At the same time, the Freudian psychodynamic researchers (who seem to have won the battle in the DSM-II) described a hyperkinetic reaction of childhood, in which unresolved childhood conflicts manifested in disruptive behavior. The term "hyperkinetic," which appears in both diagnoses, describes the set of behaviors that would later be known as hyperactive – despite the fact that medical and psychological professionals were aware that there were many children who presented without hyperactivity. In either case, it was the presenting behavior that was the focus – which was implicit, given the behavioral paradigm that guided the field.

When the cognitive paradigm became dominant, inattention became the focus of ADHD, and disorder was renamed attention deficit disorder (ADD). Two subtypes would later appear in the literature, which correspond to ADD with or without hyperactivity. The diagnostic nomenclature reflects the notion that the primary problem was an attentional (and thus, cognitive) one and not primarily behavioral. The attentional problems had to do with the ability to shift attention from one stimulus to another (something that Jonah Lehrer has called an attention-allocation disorder, since it isn't really a deficit of attention). The hyperactivity symptoms were also reformulated as cognitive: connected with an executive processing deficit termed “freedom from distractibility.”

In DSM-IV, published in 1994, the subtypes were made standard and there wasn’t much change in the diagnostic criteria per se, but there were changes in the name of the disorder, which reflected changes in the literature in terms of the understanding of the etiology of the disorder. The term ADD did not hold up, and the disorder became known as ADHD, with three subtypes: ADHD with hyperactivity/impulsiveness, ADHD with inattention, and a combined subtype in which patients have both hyperactive and attention-related symptoms. Due to improved neuroimaging technology, these subtypes seem to reflect structural and functional abnormalities found in the frontal lobe, and in its connections with the basal ganglia and cerebellum.

The set of the symptoms associated with ADHD seem not to have changed much in the last one hundred years. However, paradigm shifts within the field of psychopathology have changed the way in which researchers understand the underlying causal factors, as well as which of the symptoms are thought to be primary.

5 responses so far

  • melodye says:

    You know what's really fascinating to look at, actually, is how they attempt to distinguish between bipolar disorder and ADHD in the DSM. The "mania" present in bipolar II can look remarkably similar to hyperactivity / inattention / hyperfocus and so on. It's also the case that ADHD has unusually high rates of co-morbidity with depression. With both disorders, there seems to be a problem with prefrontal dysregulation. So are they really two separate disorders? Or disorders on a continuum?

    Thanks for linking to the Lehrer piece by the way. I'm glad he's giving that side press...

  • Chan Stroman says:

    Dang, just when I was waiting for y'all to get to Wittgenstein. (Kidding; it's all good.) This is very interesting and illuminating, especially re: inattentive subtype ADHD (which we'd never heard of until a diagnosis for a decidedly non-"hyperactive" family member a few years ago, & which is still hard to explain to those who aren't familiar with it).

  • Jennifer says:

    I'm interested in what Brain Balance – http://www.brainbalancecenters.com – has to say about the issue: that all neurobehavioral disorders have in common an underlying condition called functional disconnection syndrome. Their stance is that through diet, behavior modification, brain exercises and educational techniques that help make connections, you can reduce or eliminate symptoms. While their site doesn’t really talk cause (environment, genetics, etc.) it is worth a read, particularly the “truth” section. I think it gets to the heart of what you can DO once your loved one is affected. They are brain based, not drug based so it's a much more natural approach to improving brain function.

  • JD says:

    Great article, thanks for the info!

  • Åse says:

    Very interesting, thanks. I figure it was prompted by the recent genetic findings (no, that does not make me believe it is purely genetic). I was having a class in theory of science for a bunch of therapists to be the same day as that one hit the headlines, and of course that made for a few detours in discussions. It is particularly... well... interesting perhaps, here at Lunds University in Sweden. There's been a scientific dispute going on here since before I moved back (in 2004) between a doctor in Gothenburg who has a strong medical/biological thesis about ADHD, and some sociologists here in Lund, who have a more "the environments we create are too limited to fit all variants of humans" theory. All well and good, both could have some truth to it. But, in all this, the sociologists wanted to access the doctors data, in order to examine it, which he refused, citing the privacy of his clients. It may have gone so far as a court order (I do not recall, and am currently too lazy to look it up), but the upshot was that the doctors wife and a coworker, supposedly, shredded all of the records so that no records could be shared. Now, I appreciate privacy, but this is something that is handled all the time, and sharing data is important in science.

    My students tend to be on the sociologists side, and they were all grumbling about this genetic evidence.

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