Further serious clinical interest in ADHD did not occur again until the appearance of three lectures by the English physician George Still (1902) before the Royal Academy of Physicians. Described as aggressive, passionate, lawless, inattentive, impulsive, and overactive, many of these children today would be diagnosed not only as ADHD but also as having oppositional defiant disorder (ODD). Still reported on a group of 20 children in his clinical practice whom he defined as having a deficit in “volitional inhibition” (p. Still’s observations were quite astute, describing many of the associated features of ADHD that would come to be corroborated in research over the next century: (1) an overrepresentation of male subjects (ratio of 3:1 in Still’s sample); (2) high comorbidity with antisocial conduct and depression; (3) an aggregation of alcoholism, criminal conduct, and depression among the biological relatives; (4) a familial predisposition to the disorder, likely of hereditary origin; (5) yet with the possibility of the disorder also arising from acquired injury to the nervous system.
That research may have been fortuitous, as it may be leading to the conclusion that a subset of those having ADD without hyperactivity may actually be exhibiting a separate, distinct, and qualitatively unique disorder rather than a subtype of ADHD; one tentatively named sluggish cognitive tempo (Barkley, 2012a, 2012b; Milich, Ballantine & Lynam, 2001).
These cases and others known to have arisen from birth trauma, head injury, toxin exposure, and infections (see Barkley, 2006) gave rise to the concept of a brain-injured child syndrome (Strauss & Lehtinen, 1947), often associated with mental retardation, that would eventually become applied to children manifesting these same behavior features but without evidence of brain damage or retardation (Dolphin & Cruickshank, 1951; Strauss & Kephardt, 1955). Prevalence of mental disorder in military children and adolescents: Findings from a two-stage community survey.
This concept evolved into that of minimal brain damage, and eventually minimal brain dysfunction (MBD), as challenges were raised to the original label in view of the dearth of evidence of obvious brain injury in most cases (see Kessler, 1980, for a more detailed history of MBD). Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1514-1524.
Nevertheless, the manner in which clinicians and educators view the disorder remains quite disparate; in North America, Canada, and Australia, such children have ADHD, a developmental disorder, whereas in Europe they are viewed as having conduct problem or disorder, a behavioral disturbance believed to arise largely out of family dysfunction and social disadvantage. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 798-801.
By the 1970s, research emphasized the problems with sustained attention and impulse control in addition to hyperactivity (Douglas, 1972).