By Dr Helen Bannister

Attention deficit hyperactivity disorder (ADHD) – a psychiatric disorder displaying a spectrum of behaviour traits indicating inattentiveness, hyperactivity and impulsiveness – began in the US as a childhood disorder predominately diagnosed in boys. Since the 1970s, this disorder has increasingly been identified as a growing epidemic that, in the 21st century, has spread globally to countries where the Diagnostic and statistical manual of mental disorders (DSM), which came from US psychiatry, and the pharmaceutical industry have penetrated.

Currently, ADHD in Australia could be viewed as reaching epidemic proportions. In 2022, an estimated one million Australians were affected by the condition. Of these, approximately 6 to 10% were children and adolescents and 2 to 6% were adults – which may be an underestimate as 1.5 million ADHD medication prescriptions were issued in the 2020–21 financial year (Vukasin, 2022, p. 1). Women are rapidly becoming a significant cohort of adults with ADHD, including in Australia (ABC News, 2023, April 24).

The origins of ADHD

In the US during the 1960s and 1970s, school children’s deviant, overactive, restless and disruptive behaviours came to be diagnosed and treated as symptoms of the new medical condition of hyperkinesis, variously known as minimal brain disorder or dysfunction (MBD), hyperactivity (HA) and learning disability (LD).

The ‘discovery’ of hyperkinesis can be traced back to a report in 1937 on the effects of stimulant medication (Benzedrine) on a group of school children with behavioural disorders or learning disabilities. This treatment produced a number of side effects but was reported to have resulted in ‘a striking improvement in behaviour and school performance in some of the children’ (Lange et al., 2010, p. 248). Strauss and Lehtinen (1947) hypothesised that children with behavioural disorders had minimal brain dysfunction, while Laufer et al. (1957) proposed the label ‘hyperkinetic impulse disorder’ to describe this behavioural disorder. Use of the term MBD began to decline in the 1960s, while hyperkinetic impulse disorder became popularly known as hyperactivity syndrome (Lange et al., 2010, p. 251).

Mathew Smith, in his history of ADHD (2012), observes that it was not until the 1950s that paediatricians and psychiatrists began to see hyperactivity as a childhood problem. Cold war politics meant that the Soviet Union’s launching of Sputnik led to America beginning a space and education race with the Soviet Union, placing pressure on schools such that “it became less acceptable for some children to perform poorly in school” Hirschbein (2013 :702).

Sociologist Peter Conrad’s (1975) analysis of this new psychiatric disorder of hyperactivity as the medicalisation of deviant behaviour (recklessness and overactivity) began his lifetime exploration of the increasing medicalisation of society (Fawcett et al., 2020, p. 99); medicalisation that has since been variously defined as ‘a process by which personal, behavioural and social issues are increasingly viewed through a biomedical lens and diagnosed and treated as individual pathologies and problems by medical authorities’ (Lantz et al., 2023, p. 61). Hyperactivity did not evolve through scientific discovery (Hirschbein, 2013, p. 702) as stimulant medication had been used as a treatment for behavioural disorders for some 20 years before the DSM began defining the disorder of hyperactivity in 1968 (Conrad, 1975, p. 16; Schechter, 1982, p. 411). That first definition, appearing in the DSM-II, characterised hyperactivity as a disorder ‘characterised by overactivity, restlessness, distractibility and short attention span’ (APA, 1968, p. 50); and the DSM-III, issued in 1980, renamed hyperactivity as ‘attention deficit disorder’ (ADD). Conrad explained the popularity of a medical model of children’s hyperactive behaviour as due, in part, to the pharmaceutical industry’s aggressive marketing of psychostimulant medications (beginning with Ritalin) and the role of parents and professionals in the Association for Children with Learning Disabilities, who raised teachers’ and schools’ awareness of the conception of hyperactivity as a medical problem (Conrad, 1975, p. 17).

‘ADHD [today] has … become arguably the most controversial neurological condition in modern life’ (Hooton, 2024, p. 11). There is uncertainty about the diagnosis and treatment, with medical professionals divided on the extent to which the condition is under or overdiagnosed. Mills argues, ‘ADHD has long been associated with controversy and division’ (Mills, 2022, p. 2); and in the present day, some 50 years after they were first made, the criticisms of MBD, HA and LD and their treatment with stimulant medications ‘apply equally to ADHD’ (Mills, 2022, p. 1).

In the 1970s, Roger Freeman, professor of psychiatry at the University of British Columbia, argued that the boundaries of the conditions of MBD, HA and LD (conditions that came to be labelled hyperactivity) were ill-defined and ‘did not distinguish between children failing to match society’s expectations, at school, home, or elsewhere, from a small number of children whose difficulties were biologically based’ (Freeman, 1976, p. 22). Freeman observed an epidemic ‘of alarming proportions’ in the diagnosis and treatment of hyperactivity because of the ‘massive support from frustrated parents, professionals, government and the drug and remedial-education industries’ (Freeman, 1976, p. 22). Neil Schechter, a director of paediatrics at a major hospital, similarly ‘expressed his concern at the “creation of an epidemic of hyperactivity” in which the criteria for diagnosis were vague and subjective and children were overtreated with medication’ (Schechter, 1982, p. 411).

Psychoanalysts argued that the causes of hyperactivity could be found in intra-family dynamics, while social psychiatrists examined socio-economic factors. However, the biological psychiatrists’ hypothesis of hyperactivity prevailed, not on the grounds that it was more scientific but because their ‘methods were less expensive, time-consuming and complicated than those of [their] rivals’ (Smith, 2008, p. 248). In other words, ‘treating a neurological disorder with stimulant medication such as Ritalin was quick, simple and inexpensive’ (Fawcett et al., 2020, p. 101). A biological model of psychiatry was already in its ascendancy in this period, which Freeman described as ‘an unfortunate episode in the history of the progressive medicalisation of deviant or troublesome behaviour’ (Freeman, 1976, p. 22). The publication of DSM-III in 1980 proved to be the ‘seminal’ moment for psychiatry in the move from a psychosocial model to a biological model – a move owing more to ‘careful political manoeuvring’ (Mills, 2022, p. 2) than the scientific discovery of biomarkers for mental disorders.

In the revised DSM-III issued in 1987, ADD became attention deficit hyperactivity disorder (ADHD), and adults were included for the first time when the workplace was referred to as somewhere ADHD symptoms might be observed (APA, 1987, p. 50). (The consumer advocacy group Children and Adults with Attention Deficit Hyperactivity Disorder (CHADD) sponsored by pharmaceutical companies had been lobbying to have adult ADHD included in the DSM.)

In 1994, the diagnostic boundaries were expanded with new criteria in DSM-IV. Up until the 1990s, boys had predominately been diagnosed with ADHD, but in the 1994 DSM-IV a subcategory of ADHD without hyperactivity appeared, which led to an increase in girls being diagnosed with ADHD – though girls were characterised as more likely to be inattentive and less likely to be hyperactive. ‘Field trials … found that the new criteria compared to the DSM-III criteria could be expected to lead to a 23% increase in the number of children with ADHD’ (Whitaker & Cosgrove, 2015, p. 92). Allen Frances, a member of the DSM-IV taskforce, observed that the expansion of criteria had resulted in ‘false epidemics’ not only in ADHD but also in autism and adult bipolar disorder (Frances, 2013a, p. 75). By 2012, ‘3.5 million American youth were prescribed an ADHD medication, nearly 6 times the number in 1990’ (Whitaker & Cosgrove, 2015, p. 92). In 2013, DSM-5 was published, adding 3 different categories of ADHD: predominately inattentive, predominately hyperactive and a combination of both. This further expansion of the diagnostic boundaries of ADHD resulted in an unclear boundary with ‘normality’ (Frances, 2013b); and not only were more children diagnosed with ADHD but there was also the possibility of more teenagers and adults being similarly diagnosed (Whitaker & Cosgrove, 2015, p. 113).

The marketing of ADHD

In the US, the adoption of neoliberal economic policies during the 1980s consolidated pharmaceutical industry–academic partnerships in which the pharmaceutical industry controlled much of the research and development of new drugs. In this period, medicine became increasingly market based. From the 1970s, psychiatric journals began to have free ‘throwaway’ magazines in which the content was written by ghostwriters contracted by pharmaceutical firms sponsoring the journal (Nik-Khah, 2014, p. 497). The psychiatric journals and throwaway magazines contained coloured ads for psychostimulants, which in 1971 contributed to a $13 million profit for the company producing Ritalin (Conrad, 1975, p. 17). In addition to Ritalin, new stimulant medications for ADHD were developed such as Adderall, Concerta, Strattera and Metadate. Doctors were bombarded with advertising promoting these psychostimulants. Concerta would ‘improve interactions between adolescent patients and their parents’ and ‘allow your patients to experience life’s successes every day’. Adderall XR ‘enhances social functioning’ and a Stratterra ad asks, ‘[W]hat can a child with ADHD gain? Control and confidence’ (cited in Schwarz, 2016, pp. 118–119).

In the mid-1990s, stories about ADHD and the success of stimulant medications regularly appeared in mainstream media. Newsweek’s cover story ‘Mother’s Little Helper’ declared ADHD the nation’s ‘No 1 Psychiatric Disorder’, and featured psychologist James Swanson declaring the life-changing nature of ADHD medication. ‘If you can have an impact with these kids, you can change whether they go to jail or Harvard Law school’ (Newsweek, 1996, March 17). A New Yorker cover showed a teacher scratching ‘Readin, Ritin, Ritalin’ on a chalkboard (The New Yorker 1996, September 9). ADHD also made an appearance in the popular television show, The Simpsons when Bart Simpson, ‘the ill-behaved and exasperating fourth grader is diagnosed by school officials with ADHD’ (Schwarz, 2016, p. 74). Adults too began to be featured in stories about ADHD. In 1994, TIME magazine drew attention to adult ADHD, with cover art depicting a business man and the headline reading ‘Disorganised? Distracted? Discombobulated? Doctors say you may have attention deficit disorder’. The article even speculated that Benjamin Franklin, Winston Churchill and Albert Einstein might have had ADHD (TIME, 1994, July 18). A few years later, The New York Times had a feature about a woman who believed that a diagnosis of ADD had given her life back (The New York Times, 1997, September 2).

In 1985, the first direct-to-consumer advertising of prescription drugs was allowed in the US. Stimulant medication for ADHD appears on the internet, in television ads and in magazines such as Ladies’ Home Journal, People, Family Circle, Good Housekeeping, Parenting and Redbook. The first ad for ADHD medication in a consumer magazine was in the Ladies’ Home Journal – a smiling mother holds her son and is assured that one dose of Metadate will cover her son’s ADHD for the whole school day (Ladies’ Home Journal, 2001, August). Adderall XR’s message for the mother and son was, ‘He’s as smart as you think’ (People, 2005, September). ‘For years, Adderall advertisements … used the slogan “Schoolwork that matches his intelligence”’ (Lacasse & Leo, 2009, p. 26).

Adderall’s website also raised parents’ fears about the consequences of their children having ADHD. ADHD children were at ‘high risk for repeating a grade or dropping out’ or, worse, ‘many children with ADHD have conduct disorder … that can put them in trouble with the law’ and ‘adolescents with ADHD who didn’t take medication regularly had four times as many serious injuries and three times as many car accidents’. However, Adderall would provide ‘better symptom control’ (Schwarz, 2016, p. 131). Strattera went even further, claiming it was a medication that ‘would deter adolescent substance abuse and sexually transmitted diseases’ (Schwarz, 2016, p. 131).

From the 2000s, adults were especially targeted by celebrities who were paid by drug companies to promote ADHD medications on television, radio and the internet. The Adderall website drew on a celebrity testimonial from Ty Pennington, a television personality diagnosed with ADHD, who claimed that Adderall had transformed his life and did not affect his appetite or sleep (Lacasse & Leo, 2009, p. 2). Adam Levine, lead singer in a band, spoke of successfully meeting the challenges of ADHD and became the face of ADHD for 18 to 35 year olds. He appeared on television shows and video streams where his testimonial was viewed 40 million times (Schwarz, 2016, p. 191). Quizzes on phone surveys and websites helped adults assess whether they had ADHD. Half the people who took these quizzes were told they might have ADHD and to visit their doctor to seek further advice.

Parents went to doctors to talk about ADHD in their children (and increasingly in themselves) and, 10 years on from the first magazine ad, nearly 2 million children were prescribed ADHD medication (Schwarz, 2016, p. 130). The ads that contributed to the soaring rates of ADHD medications for children were misleading, if not outrageous, and did not draw on scientific evidence. The regulatory body, the FDA (the Food and Drug Administration) was very slow in sending letters to the drug companies warning that they should cease the misleading promotions of the psychostimulants. Lacasse and Leo (2009) observe that mainstream child psychiatrists and paediatricians, and leading academic psychiatrists, failed to make public objections to the misleading information. The academic psychiatrists could have influenced the FDA to act much sooner on the misinformation peddled by the drug companies, but Lacasse and Leo argue that the money these psychiatrists have received from the pharmaceutical industry possibly explains their silence.

By the 1980s, pharmaceutical companies had begun hiring ghostwriters to write articles in peer-reviewed journals – articles published under the name of an academic paid by a pharmaceutical company. (For an extensive discussion of ghostwriters and the harms of ghost writing to ‘dispassionate intellectual research’ and patients, see Jureidini and McHenry, 2020.) Academics are paid by the industry to be honorary authors and consultants and, as such, have become key opinion leaders (KOLs). As KOLs, their role is to influence national and international medical practice and the prescribing habits of ‘local networks of doctors’ (Jureidini, 2012, p. 495). A UK House of Commons report on the influence of the pharmaceutical industry observed how KOLs’ promotion of new treatments and raising ‘awareness of the dangers of undiagnosed disease’ is a marketing strategy. The report identified this strategy as an example of ‘the medicalisation of society’, defined as the ‘trend towards categorizing more and more individuals as “abnormal” or in need of drug treatment’ (House of Commons Health Committee, 2005, p. 4). This is despite ‘the so-called diseases requiring treatment [being] merely ordinary conditions of life or conditions far too trivial to risk drug treatment’ (Jureidini, 2020, p. 12). Thus, just as shyness came to be marketed as ‘social anxiety disorder’ or ‘social phobia’ (Fawcett et al., 2020, p. 85), an ‘inability to concentrate’ became a category of ADHD, which exponentially increased the number of adults diagnosed with ADHD. This form of marketing by the pharmaceutical industry has been described as ‘disease mongering’ in Selling Sickness (Moynihan & Cassels, 2005), a study that Jureidini and McHenry praise as groundbreaking and explore at some length (2020, pp. 158–172).

Today, pharmaceutical companies’ marketing of ADHD as a neurological/biological disorder and the preferred treatment of psychostimulants continue apace on social media. Individuals share narratives about their diagnoses of ADHD, reinforced by celebrities identifying as having ADHD and extolling the life-changing nature of their treatment (which continues to predominately be psychostimulants). Social media is now replacing mainstream media as a major source of information about ADHD for adults. Followers of ‘influencers’ on TikTok and Instagram select from a general checklist of symptoms in order to self-diagnose ADHD, ‘symptoms which overlap with many other conditions, “such as anxiety, mania [or] personality disorder”’(Rakov cited in Vukasin, 2022, p. 3).

Conclusion

Whitaker and Cosgrove suggest it was psychiatry that created the ADHD market. ‘DSM-III and DSM-IV provided the diagnostic framework, and academic psychiatrists published research that told of its validity and of the efficacy of ADHD medications. Pharmaceutical companies then popularised that scientific story, and it all led to a steady rise in ADHD diagnoses’ (Whitaker & Cosgrove, 2015, p. 92). However, as we have seen, pharmaceutical companies have played a major role in creating this ‘scientific story’, as academic psychiatrists have increasingly been subject to conflicts of interest in the production of corporate-driven research. Despite psychiatry’s claims to the contrary, there is still no objective evidence that ADHD is a biological disorder. The prevailing biomedical model of psychiatry characterises the DSM’s descriptions of ADHD behaviours as the symptoms of a disease. Alternative understandings of ADHD necessitate more research into the economic, environmental, social and cultural conditions of late capitalism that may be powerful causal factors in ADHD, factors that mean it is likely that children will continue to be treated for ADHD and that adults will increasingly self-diagnose and seek treatment for it.

About the Author

Dr Helen Bannister

References

APA (American Psychiatric Association). (1968). Diagnostic and statistical manual of mental disorders, DSM-II, second edition. Washington, DC: APA.

APA (1980). DSM-III, third edition, Washington, DC: APA.

APA (1987). DSM-III-R, third edition revised. Washington DC: APA.

APA (1994). DSM-IV, fourth edition. Washington DC: APA.

APA (2000). DSM-IV-TR, fourth edition (text revision). Washington. DC: APA.

APA (2013). DSM-5, fifth edition. Arlington, VA: APA.

Conrad, P. (1975). The discovery of Hyperkinesis: Notes on the medicalisation of deviant behaviour. Social Problems, 23(1), 12–22.

Cooper, R. (2004). What is wrong with the DSM? History of Psychiatry, 15, 5–25.

Fawcett, B., Weber, Z., & Bannister, H. (2020). The medicalisation of everyday life. A critical perspective. Macmillan International Higher Education, UK.

Frances, A. (2013a). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York: HarperCollins.

Frances, A. (2013b). The new crisis of confidence in psychiatric diagnosis. Annals of Internal Medicine, 159(3), 221–222.

Freeman, R. D. (1976). Minimal brain dysfunction, hyperactivity, and learning disorders. Epidemic or episode? School Rev., 85, 5–30.

Hirschbein, L. D. (2013). Hyperactive: The controversial history of ADHD by Mathew Smith [book review]. Journal of the History of Medicine and Allied Sciences, 68(4), 702–704.

Hooton, A. (2024). ADHD rising. Good Weekend. Saturday Age, March 9.

House of Commons Health Committee. (2005). The influence of the pharmaceutical industry, Vol. 1. London: The Stationery Office.

Jureidini, J. (2012). Key opinion leaders in psychiatry: A conflicted pathway to career advancement. Australian & New Zealand Journal of Psychiatry, 46(6), 495–497.

Jureidini, J., & McHenry, L. B. (2020). The illusion of evidence-based medicine. Exposing the crisis of credibility in clinical research. South Australia: Wakefield Press.

Ladies’ Home Journal (2001, August).

Lacasse J. R., & Leo, J. (2009). Consumer advertisements for psychostimulants in the United States: A long history of misleading promotion. Psychiatric Times, 26(2).

Lange, K. W., Reichl, S., Lange, K. M., Tucha, L., & Tucha, O. (2010). The history of attention deficit hyperactivity disorder. Attention Deficit and Hyperactivity Disorders, 2(4), 241–255.

Lantz, P. M., Goldberg, D. S., & Gollust, S. (2023). The perils of medicalization for population health and health equity. The Millbank Quarterly, 101(S1), 61–82.

Laufer, M. W., Denhoff, E., & Solomons, G. (1957). Hyperkinetic impulse disorder in children’s behaviour problems. Psychosomatic Medicine, 19, 38–49.

Leo, J., & Lacasse, J. R. (2015). The New York Times and the ADHD epidemic. Society, 52(1), 3–8.

Mills, S. (2022). The scientific integrity of ADHD. A critical examination of the underpinning theoretical constructs. Frontiers in Psychiatry, 2021 December, 13.

Moynihan, R., & Cassells, A. (2005). Selling sickness: How the world’s biggest pharmaceutical companies are turning us all into patients. New York: Nation Books.

New York Times (1997, September 2).

Newsweek (1996, March 17).

Nik-Khah, E. (2014). Neoliberal pharmaceutical science and the Chicago School of Economics. Social Studies of Science, 44(4), 489–517.

People (2005, September).

Schechter, N. L. (1982). The baby and the bathwater: Hyperactivity and the medicalisation of childrearing. Perspectives in Biology and Medicine, 25(3), 406–416.

Schwarz, A. (2016). ADHD nation. Children, doctors, big pharma, and the making of an American epidemic. New York: Scribner.

Smith, M. (2012). Hyperactive: The controversial history of ADHD. London: Reaktion.

Smith, M. (2017). Hyperactive around the world? The history of ADHD in global perspective. Social History of Medicine, 30(4), 767–787.

Strauss, A. A., & Lehtinen, L. E. (1947). Psychopathology and the education of the brain injured child. New York: Grune and Stratton.

The New Yorker (1996, September 9).

TIME (1994, July 18).

Vukasin, F. (2022). Is the soaring rise of ADHD stimulants a cause for concern? News GP.

Whitaker, R., & Cosgrove, L. (2015). Psychiatry under the influence. Institutional corruption, social injury, and prescriptions for reform. US: Palgrave Macmillan.