Pre-DSM Attention/Hyperactivity Problems

Beginning in the early twentieth century, members of the medical community began to really explore the possibility of biological and physiological causes of inattention and hyperactivity in individuals, before shifting focus to a more solidly psychological viewpoint (Lange et al., 2010; Palmer & Finger, 2001). A number of diseases and disorders featuring ADHD-like symptoms were described and discussed, each with its own proposed causes and treatments (Bond & Appel, 1935; Conrad & Potter, 2000; Lange et al., 2010; Menkes, Rowe, & Menkes, 1967; Palmer & Finger, 2001; Werner & Strauss, 1941). In this subsection we will see that before the DSM (Diagnostic and Statistical Manual) began to recognize conditions similar to ADHD, there were already several discussions concerning  conditions that featured aspects of inattention and hyperactivity.

Postencephalitic behavior disorder (Early to mid 20th Century)

From 1917 to 1928 an encephalitis epidemic affected millions of people around the globe, but the “post-encephalitis” effects that lingered afterwards in surviving patients also caused concern among doctors and the parents of affected children (Lange et al., 2010). Some of the apparent postencephalitic symptoms were psychological in nature, thought to be caused by brain damage (Bond and Appel, 1935; Lange et al., 2010). Children displaying these symptoms were said to have “postencephalitic behavior disorder” (Lange et al., 2010; Palmer & Finger, 2001), which  was characterized by aggression, destructiveness, and anti-social behavior (Bond & Appel, 1935; Lange et al., 2010).

However, this disorder also featured symptoms similar to those observed in individuals with ADHD, including attention problems, hyperactivity, and impulsiveness (Bond & Appel, 1935; Lange et al., 2010; Palmer & Finger, 2001). For example, in their description of postencephalitic children, Bond and Appel (1935) characterize them as “disobedient, untrainable at home or school,” “inordinately restless,” and exhibiting “motor restlessness” and “distractibility” (p. 44). Difficulty following instructions, motor restlessness or hyperactivity, and impaired concentration can be observed in individuals with ADHD.

A comparison of a normal brain and one affected by encephalitis. Damage to the brain from the disease was believed to sometimes result in postencephalitic behavior disorder, which shared some traits with ADHD. / Image from WebMD

According to Lange et al. (2010), “the assumption of a causal connection between brain damage and symptoms of hyperactivity and distractibility [made by medical experts studying postencephalitic behavior disorder] was important to the further conceptualization of ADHD” (p. 247). Postencephalitic behavior disorder also brought hyperactive and inattentive behavior to greater attention in the medical community, making it possible for people to start perceiving these behaviors as more than merely the result of disciplinary problems in children (Lange et al., 2010).

Hyperkinetic Disease of Infancy (1932)

In some cases, the restlessness of postencephalitic behavior disorder was also observed in children who had not had the encephalitis virus (Lange et al., 2010). Franz Kramer and Hans Pollnow dubbed this disorder “hyperkinetic disease of infancy,” and its most notable feature was hyperactivity, an impulse to be constantly moving, climbing, fidgeting, etc. (Lange et al., 2010). In addition to hyperactivity, Kramer and Pollnow also noted several other symptoms related to ADHD in these children, including impaired concentration, distractibility, learning and academic difficulties, impulsive behavior and emotional outbursts, impairments to social functioning, and trouble with completing tasks (Lange et al., 2010). Kramer and Pollnow’s hyperkinetic disease of infancy separated itself from similar disorders with physical causes, setting up the idea that hyperactivity and attentional impairments could be symptoms of a psychological condition rather than a physiological one. However, the latter view remained popular into the 1950s and 1960s (Palmer & Finger, 2001).

“Minimal Brain Damage,” “Minimal Brain Disorder,” and “Minimal Brain Dysfunction” (Early to mid 20th Century)

In 1908, Tredgold made the argument that abnormalities in children’s learning and behavior could be caused by early brain damage that went undetected during infancy and earlier childhood (Lange et al., 2010; Palmer & Finger, 2001). Later, in the mid-20th century, this idea of “minimal brain damage” or a “minimal brain disorder/dysfunction” and its effect on learning and behavior–particularly in regards to hyperactivity and distractibility–would be explored more fully in the medical and psychiatric community (Lange et al., 2010; Menkes et al., 1967; Palmer & Finger, 2001; Werner & Strauss, 1941).

In 1941, Werner and Strauss studied children they labelled as “brain-injured,” noting that they had abnormal responses to figure-background relationships compared to healthy children and mentally handicapped children without brain damage. They hypothesized that one potential explanation for this behavior was that the “brain-injured” children had difficulties with attention, exhibiting a tendency to become distracted and fixate on “wrong,” less significant stimuli in their perceptual field.

A sample question from one of Werner and Strauss’ figure-background tests. The child had to select which of the bottom three pictures most closely matched the top one. “Brain-injured” children tended to choose the image showing only the background pattern from the top picture. / Image from Werner & Strauss, 1941

Werner and Strauss describe this attention problem as “the inability of the brain-injured organism to withstand the attraction of stimuli which may be extraneous to the task at hand” (1941, p. 247). The individual in question might become so distracted that they find themselves having great difficulty finishing the aforementioned task (Strauss & Werner, 1941), much in the way that children diagnosed with ADHD might have trouble focusing on schoolwork. In their article, Strauss and Werner (1941) relate the example of a boy preparing to brush his teeth and getting distracted by water in a sink and a box of soap while attempting to fill a cup with water.

In 1948, Rosenfeld and Bradley followed up on the ideas of Tredgold and Werner and Strauss, finding that brain damage in infancy resulted in the following symptoms: “1. Unpredictable variability in mood; 2. Hypermotility; 3. Impulsiveness; 4. Short attention span; 5. Fluctuant ability to recall material previously learned; and 6. Conspicuous difficulty with arithmetic in school” (p. 74, cited by Lange et al., 2010, p.249). Many of these characteristics have been mentioned before as falling under the umbrella of behaviors produced by ADHD–hyperactivity, impulsive behaviors and emotional outbursts, distractibility and inattention, and some learning difficulties.

Hyperactivity came to be used as a criterion for diagnosing minimal brain damage, regardless of whether or not there was actually any physical evidence of brain damage (Lange et al., 2010). Laufer et al. suggested use of the term “hyperkinetic impulse disorder” in 1957, intending to apply it to children who displayed the symptoms of “minimal brain damage” but whose behavior did not appear to have a physical cause such as effects from encephalitis or head trauma (Lange et al., 2010). Others began to use terms such as “hyperkinetic syndrome” and “hyperactivity syndrome” to refer to the same disorder (Conrad & Potter, 2000; Palmer & Finger, 2001).

Over time, neurologists came to realize that in many instances hyperactive children did not actually have any brain damage at all, and that their behavior could not be credited simply to an injured or diseased brain (Lange et al., 2010; Palmer & Finger, 2001). Thus, in many cases the phrase “minimal brain damage” came to be replaced with “minimal brain dysfunction.” (Lange et al., 2010).

A later study conducted by Menkes et al. (1967) examined “hyperkinetic” children with “minimal brain dysfunction,” whom they compared to Werner and Strauss’ brain-injured children. Individuals with minimal brain dysfunction were “hyperactive,” “easily distractible,” “emotionally labile,” “easily frustrated,” “impulsive,” and possessed “a short attention span” (Menkes et al., 1967). Note that the symptoms here are essentially the same as the ones found in minimal brain damage, but the label has changed to reflect a shift in terminology. However, prior to the 1970s, many of the terms described in this section were used interchangeably (Conrad & Potter, 2000) until hyperactivity/attention disorders came to be described in more specific ways (Lange et al., 2010).

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