ADHD: Historical Overview

1
ADHD Historical Overview

• FIDGITY PHIL 1845 by German Psychiatrist, Dr.
  Heinrich Hoffman
• James H. Johnson, Ph.D
• University of Florida

2
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)

3
Assumed Core Features

• Various characteristics have been highlighted as
  the core feature of the disorder.
• These have included
• Minimal Brain Damage
• Hyperactivity
• Attention Deficits
• Disinhibition of Behavior

4
The Evolution of ADHD

• Views of the condition we now refer to as ADHD
  have evolved over the years.
• Today I would like to briefly walk you through
  the evolution of this disorder.
• The next few slides list some of the events that
  have influenced how we view this disorder today.
• This discussion draws heavily on Barkley (1998,
  2005).

5
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
  (1930s)
• Beginnings of child psychopharmacology
  Amphetamines for treatment 1930-1940.
• Strauss work on Minimal Brain Dysfunction
  (1940's -1950's)
• MBD becomes Hyperkinetic Disorder (the 1960s)

6
ADHD Evolution of the Disorder (cont.)

• Hyperkinesis becomes ADD The decade of the 70s
• Focus on Dietary Factors Feingold and the
  1970s
• Studies of pschophysiological responsivity the
  1970s
• Development of objective diagnostic criteria DSM
  III and the recognition of Attention Deficit
  Disorder The early 80s

7
ADHD Evolution of the Disorder (cont.)

• The decade of the 80s DSM III DSM III-R
  stimulates ADHD research
• Development of new assessment methods
• New treatment methods
• Increased focus on biological factors.
• The 1990s and beyond Focus on Neuroimaging,
  genetics, reevaluation of the DSM system,
  Evidence Based Practice and Practice Guidelines,
  etc.

8
Still (1902) ADHD An Early Case study

• Perhaps the earliest scientific account of what
  we today refer to as ADHD was by Still (1902).
• Still was a British Physician who published a
  series of lectures that he had given to the Royal
  College of Physicians in London in 1902.
• Here he described 43 children seen in his medical
  practice who displayed features similar to those
  we now associate with ADHD.

9
Still (1902)

• Still described these children as displaying a
  range of chronic problems
• Aggressive, defiant, resistant to discipline.
• Excessively emotional and as showing "little
  inhibitory volition".
• The need for immediate gratification seemed to be
  one of their primary attributes.
• He suggested that these children showed a "major
  defect in moral control and that most displayed
  an insensitivity to punishment.

10
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.

11
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.

12
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".

13
Still (1902)

• Aspects of Still's description of these children
  is supported by what we know about ADHD today.
• Presence of minor physical anomalies.
• Association with heredity or possible
  neurological involvement.
• Association with Tic Disorders, sex ratio, fairly
  early age of onset, problems of attention,
  activity and impulsivity.
• Association with problems of conduct
• Still's group likely included a number of
  children with comorbid ODD/CD rather than pure
  cases of ADHD.
• Barkley (2006)

14
ENCEPHALITIS EPIDEMIC OF 1917 - 1918

• In 1917 and 1918 there was a serious outbreak of
  encephalitis in the United States and Europe.
• Many of the children who were affected by this
  disease died.
• Many who survived the acute stages of this
  illness experienced major cognitive and
  behavioral sequelae.

15
ENCEPHALITIS EPIDEMICOF 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.

16
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.

17
Ebaughs 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.

18
Ebaugh 1923

• Ebaugh believed that ADHD and related problems
  could arise acutely in normal children following
  brain injury (10 of his cases)
• They could also represent preexisting problems
  that were exacerbated by brain injury (7 of his
  cases)
• In contrast to Still, Ebaugh believed that
  premorbid unruliness and problem behavior of some
  of his children resulted from poor parenting.
• It should be noted that the problems in this
  sample were much more severe that those seen in
  outpatient ADHD cases, due to the illness
• Impairments in these children likely involved
  cortical, subcortical, and cerebellar, brain
  stem, and cranial nerve levels of brain
  organization (Barkley, 2007).

19
Ebaugh 1923

• Children displayed sleep problems, depression,
  tic disorders, suicidality, and a range of
  psychosomatic symptoms
• While this article tells us more about the
  sequelae of encephalitis in children than those
  with just ADHD, the similarities are striking.
• As Barkley (2007) has suggested, this is probably
  due to the involvement of the frontal lobes,
  basal ganglia and cerebellum in both encephalitis
  and ADHD.
• This article was a significant early contribution
  to understanding how ADHD may arise due to the
  consequence of obvious brain damage.

20
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.

21
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.

22
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.

23
FRONTAL LOBE ABLATION STUDIES

• For example, in the 1930's there were a number
  of Frontal Lobe Ablation Studies of Monkeys which
  suggested that frontal lobe lesions often result
  in excessive restlessness, inability to sustain
  interest in activities, behavioral
  disorganization
• This caused investigators to speculate that
  childhood hyperactivity might result from defects
  in the area of the frontal lobes.
• Given what we have learned since, this
  speculation seems not too far off base.

24
THE CONCEPT OF MBD

• During the late 1930's and the 1940's it became
  fashionable to assume that the problems displayed
  by children like those described here resulted
  from some sort of neurological impairment or
  brain injury.
• As has been seen, there was evidence, even at
  this time, that the development of problems of
  activity level, attention, impulsivity, and
  conduct (along with others), CAN result from
  neurological insult.

25
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.

26
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.

27
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.

28
THE CONCEPT OF MBD

• Finding relationships between a history of brain
  damage and these sorts of behavioral
  characteristics, Strauss argued that these
  markers could be used to infer the presence of
  brain damage in ambiguous cases, even if there
  was no clear-cut evidence of neurological
  impairment.
• Here, hyperactivity was given special status as
  the most valid indicator of brain damage.

29
MBD Or, if you cant find it is it really there?

• Characteristics thought to be the result of brain
  damage were taken to be indicators of brain
  damage, even in children without evidence of
  neurological impairment.
• Thus, children were thought to display
  hyperactivity and other problems as a result of
  brain damage -- and -- children who were
  hyperactive were assumed to display brain damage
  simply as a result of their behavior.
• The circularity of this argument can be readily
  seen.

30
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.

31
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.

32
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.

33
The Beginnings of Child Psychopharmacology

• Interest in child psychopharmacology appeared in
  the late 1930's and early 1940's when studies
  began to suggest that amphetamines were useful in
  reducing disruptive behavior and in improving
  academic performance.
• Early observations suggested that such medication
  helped at least half of the treated children.
• Obviously interest in the role of medication in
  the treatment of children has continued to this
  day.

34
Questioning the Notion of MBD

• By the early 1960's investigators began to
  seriously question the circular reasoning
  associated with the concept of minimal brain
  dysfunction.
• And they began to questioned the notion of a
  unitary concept of brain damage which suggested a
  specific constellation of symptoms, resulting
  from brain damage.

35
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.

36
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 childs excessive activity level.

37
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.

38
The Hyperactive Child Syndrome

• Chess noted that children with this disorder did
  often have an array of difficulties such as
  educational problems, oppositional behavior, peer
  problems, attentional difficulties, which could
  contribute to their difficulties.
• The core symptom, however, was thought to be
  hyperactivity

39
The Hyperactive Child Syndrome

• By the mid to late 1960's the focus of attention
  was clearly on HYPERACTIVE CHILDREN rather than
  on those presumed to be BRAIN DAMAGED.
• Here it can be noted that in 1969 DSM II,
  published by the American Psychiatric
  Association, included the category HYPERKINETIC
  REACTION OF CHILDHOOD, which provided for a
  diagnosis of those children now referred to as
  ADHD

40
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.

41
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.

42
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.

43
The Focus on Attention

• In 1972, Virgina Douglas gave her Presidential
  address to the Canadian Psychological Association
  in which she argued that deficits in sustained
  attention and impulse control were most likely
  the core symptoms of this disorder, rather than
  hyperactivity.
• Here she cited a her own work which suggested
  that hyperactive children have some of their
  greatest difficulties on tasks like the
  Continuous Performance Test which assess
  vigilance, sustained attention and impulsivity.

44
The Focus on Attention

• She noted that a primary characteristic of this
  disorder was the extreme degree of variability in
  the task performance of such children,
  specifically as it related to issues of
  attention.
• She presented research to suggest that the degree
  of attentional control demonstrated by such
  children varied with reinforcement schedules
  (with attention being better under conditions of
  continuous reinforcement) and exceptionally poor
  under very thin schedules of partial
  reinforcement.

45
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.

46
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.

47
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.

48
Focus on Dietary Factors

• Indeed, substances associated with the Feingold
  diet have been found to have little or no effect
  on child behavior.
• The more recent view, that refined sugar is the
  culprit in hyperactivity, has also failed to
  receive empirical support.
• While there may be a very small number of
  children who's hyperactive behavior is affected
  by some elements of their diet (and this is not
  even well documented), dietary factors are
  unlikely to be contributors to the behavior of
  most hyperactive children.

49
PSYCHOPHYSIOLOGICAL RESPONSIVITY

• An additional fruitful area of investigation in
  the 1970's involved studies of the
  psychophysiological responsivity of hyperactive
  children.
• Here a large number of studies were conducted
  which sought to measure variables such as GSR's,
  heart rate, EEG responses, evoked potentials, and
  other aspects of the psychophysiological
  responsivity of hyperactive children.

50
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.

51
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.

52
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.

53
The Concept of Optional Stimulation

• By the mid-1970's such findings were cited as
  arguments for an "optimal stimulation view of
  hyperactivity.
• This view holds that such children display less
  that optimal levels of stimulation and that their
  increased activity level and apparent
  distractibility can be seen as attempts to
  increase stimulation to some more optimal level.

54
The Early 80'S and The Advent of ADD

• In 1980 the American Psychiatric Association
  published its Third Edition of the Diagnostic and
  Statistical Manual of Mental Disorders.
• Compared with the diagnostic criteria for
  Hyperkinetic Reaction of Chldhood included in DSM
  II, the treatment of this disorder in DSM III
  was radically changed

55
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.

56
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

57
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.

58
DSM III and ADD

• Children displaying ADD without hyperactivity met
  diagnostic criteria for symptoms of inattention
  and impulsivity but not hyperactivity.
• Children diagnosed as ADD with hyperactivity met
  criteria for inattention, impulsivity and
  hyperactivity.
• While there was little research support for these
  subtypes when DSM III first appeared, later
  research did suggest that children displaying
  ADD with and without hyperactivity did differ in
  terms of major domains of adjustment.

59
DSM III and ADD

• This research seemed to suggest that children
  diagnosed with ADD (Without Hyperactivity) were
  characterized as more hypoactive and lethargic,
  with tendencies toward daydreaming, and as more
  likely to have learning disabilities or other
  academic problems and less likely to be
  aggressive than those displaying ADD (With
  Hyperactivity).
• In general, DSM III represented a major advance
  in classification and serve as a major impetus to
  research on ADD and other forms of child
  psychopathology.

60
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.

61
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.

62
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.

63
The Nature of DSM III-R

• 3. The need to establish that symptoms are
  developmentally inappropriate for the child's
  mental age was stressed more emphatically.
• 4. The coexistence of affective disorders with
  ADHD no longer excluded the diagnosis of ADHD.
• 5. The subtype of ADHD without hyperactivity was
  removed as a subtype and relegated to a vaguely
  defined category, Undifferentiated ADD, which was
  seen as a category in need of more extensive
  research

64
The Nature of DSM III-R

• 6. ADHD was now classified along with two other
  behavioral disorders (Oppositional Defiant
  Disorder and Conduct Disorder) in a supraordinate
  category known as Disruptive Behavior Disorders,
  because of their substantial overlap or
  comorbidity in clinic-referred populations of
  children.
• 7. Criteria for severity were also included which
  were ranked from mild to moderate to severe.
• It is noteworthy that a number of these changes
  were reversed with the publication of DSM IV.

65
Etiological Research of the 1980s

• In the 1980s 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

66
Decade of Neuroimaging and Genetics The 1990s

• 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 1990s 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.

67
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.

68
The New Millennium

• Here we will wait another year to see what will
  be all of the advances of the 2000s.
• A couple that are noteworthy are the the
  development of Straterra.
• This is the first effective medication for ADHD
  that is not a controlled substance and that
  targets a neurotransmitter other than dopamine.

69
The New Millennium

• Another is the Daytrana Patch, a drug delivery
  system for children not good with pills.
• . . . ?