Commentary: When does the history of ADHD not begin?

This commentary discusses the history of ADHD and how it can inform contemporary debates about the disorder. It critiques retrospective histories of ADHD, which propose earlier origins for the disorder than match the historical evidence. It concludes by indicating when ADHD did emerge as a distinctive disorder and why it did so.

Often when you hear people talking about why they disliked history at school, dates-and the need to memorise them-are cited.Despite being a professional historian, I can sympathise.Dates can be boring.And tedious to memorise.And, on their own, they do not always tell you much about history, about why things happen and what things really matter.When history boils down to dates, it can be dismissed as irrelevant and not particularly useful.
But in this essay, I want to convince you that, from time to time, dates can extremely useful if you want to understand the history of something properly.This certainly applies to the history of attention deficit hyperactivity disorder or ADHD.In the case of ADHD, coming to grips with dates can transform how we understand this controversial disorder.
In particular, it can challenge the prevailing view amongst most physicians that ADHD is a universal, timeless and essential condition (Timimi & Maitra, 2009).That is, a disorder that has always existed-and existed in the same way-in human populations across the globe.Packaging ADHD in this way-as universal, timeless and essential-provides evidence for the idea that it is fundamentally a neurological condition, passed down genetically and best treated with medication.The corollary to this view is that historical figures (including both people lost to history and famous people, such as Leonardo da Vinci and Mozart) have had ADHD, whether they knew it or not.Such thinking also reinforces the notion that ADHD is a condition that has little to do with the environment in which it is found.I will use dates to contest this view.To do so, however, we wi'll need to go a little beyond mere memorisation.

False starts
When does the history of ADHD begin?For me, a historian having researched the history of ADHD since 2001, this is an easy question.And one that I am not going to answer just yet.Philip screams with all his might. . .Philip, the meal, glasses, crockery, cutlery and tablecloth all end up on the floor much to his parents' annoyance and his 'disgrace'.His resemblance to a hyperactive child has convinced many that he must have had ADHD.The fact that Hoffman was a psychiatrist has also indicated to some that Philip and the other naughty children in Der Struwwelpeter were based on cases he saw and that all can be retrospectively diagnosed with twentyfirst-century diagnoses.In other words, they read Der Struwwelpeter as an indication that the children found in the poems represented actual German children who were clearly afflicted with mental disorders.
But this is to take Fidgety Philip and Der Struwwelpeter out of context.As children's literature expert Jack Zipes (2002) has explained, Hoffman was inspired to write these poems for his son simply because he was dissatisfied with the quality of children's literature.He was not inspired by clinical experiences.Although Zipes suspects that the poems amounted to tongue-in-cheek cautionary tales for children, Margaret Higonnet believes that the poems, which include tales about other naughty children, including 'Little Suck a Thumb', 'Cruel Frederick' and 'Johnny Head in the Air' (another ADHD candidate) are actually a parody of contemporary moralising nursery rhymes (Higonnet, 1992).In other words, they may celebrate misbehaviour.Regardless, there is no indication that Hoffman intended to pathologise the behaviour-or the children-in his poems.But subsequent readers keen to retrospectively diagnose ADHD have done just that.
The next year that is often cited in this 'pre-history' of ADHD is usually 1902.In that year, English paediatrician George Still (1868Still ( -1941) ) gave a series of lectures on abnormal behaviour in children, which were subsequently published in the Lancet.In textbook histories of ADHD, the 20 children Still described are almost always cited as having ADHD.A closer look, however, reveals another story (Still, 1902).
Specifically, Still's children appear to be significantly disturbed.They are violent to their parents, other children, animals and themselves, they engage in pica, exhibit pathological dishonesty, engage in sexually inappropriate behaviour and commit theft and other crimes.So, why are these children so commonly cited as being the first hyperactive children described by physicians?It is likely Still's observation that such children, despite their behavioural problems, are thought to be of average or higher intelligence.This has also been a characteristic of children diagnosed with ADHD: intelligent children who nonetheless struggle to achieve academically.But Still's focus was not on the academic abilities of such children; it was on their violent, disturbing behaviour.His children may be many things, but they are not the typical child diagnosed with ADHD today.
Others have noticed that, a few years earlier, Scottish psychiatrist Thomas Clouston (1840-1915) described three behavioural problems that resemble ADHD, namely 'simply hyperexcitability', 'hypersensitiveness' and 'mental explosiveness' (Clouston, 1899) Given that the symptoms of Clouston's children seem more similar to those diagnosed with ADHD today than those of Still, it is odd that he is mentioned far less often than Still.Clouston's hyperexcitable child who 'becomes ceaselessly active, but ever-changing in its activity' does have the ring of ADHD.But there are also key differences.
First, Clouston emphasised that hyperexcitability was temporary, only lasting a few months or so.This differs from today's assumption that ADHD is a lifelong disorder.Second, Clouston observed that mentally explosive children, who were impulsive, irritable, violent and defiant, tended to be girls.In contrast, girls diagnosed with ADHD have tended to be of the inattentive, rather than the hyperactive, type.One of the reasons it is believed that girls are underdiagnosed is that they tend not to be disruptive and, therefore, fly under the radar.Even more important, however, was that both Clouston and Still argued that such children were exceedingly rare.They could never make up the 5% of children that are believed by some physicians to have ADHD.What does link Clouston to today's approach to ADHD is his willingness to use drugs to treat children, in his case, 'large dosages' of bromides.
An even more intriguing description of what sounds like ADHD comes from an earlier Scottish physician, Alexander Crichton (1763Crichton ( -1856)).In his Inquiry into the Nature and Origin of Mental Derangement (1798), Crichton included a chapter called 'Attention and its Diseases', where he described a condition called 'mental restlessness'.Although Crichton was up until recently far less frequently cited in textbook histories of ADHD, his description of mental restlessness does sound like ADHD, not least because he emphasises the role of inattention.He also explicitly discussed its impact on educational pursuits, which differentiates him from Clouston and Still.
What is fascinating, however, is how Crichton proposed to deal with such problems.Chiefly, his focus was not on the individual and their presumed deficiencies, but rather the types of environments and external factors that undermine an individual's attention.Adjust these, according to Crichton, and it is much easier for anyone to concentrate.This often boiled down to changing the learning environment, by centring it squarely on the interests of individual learners and ensuring that it wasn't boring.So, instead of 'fixing' the learner, Crichton proposed improving education.Such a philosophy seems far removed from today's obsession on league tables and exam results, which compels the learner to change.
Finally, there is the case of Charles Bradley's (1902Bradley's ( -1979) ) research on amphetamines, conducted at Emma Pendleton Bradley Home in Rhode Island during the 1930s.Bradley subjected his child psychiatric patients to pneumoencephalography in order to get better images of the brain.The children experienced severe headaches as a result and Bradley prescribed them amphetamines to help ease the symptoms.Although the headaches persisted, he observed that the children performed better academically while on the drugs.Here was the first observation that stimulant drugs could improve academic performance and behaviour.But even though Bradley kept researching the connection, it took another 25 years for anyone to really notice and before Ritalin was approved for us in children for behavioural problems in 1961.Why?Because children with ADHD-like symptoms were not seen to be particularly problematic until the late 1950s.Instead, it was the opposite type of child who attracted the attention of physicians, namely, the shy, withdrawn, inactive, neurotic and studious children depicted in the journal The Nervous Child, which ran from 1941-1956.Here we finally arrive at the beginning of ADHD's history: 1957.

The first (truly) children with ADHD
Prior to 1957, it is very difficult to find any instances of children in the medical literature present the symptoms of ADHD.Then, in 1957, an article describing 'hyperkinetic impulse disorder' changes everything (Denhoff et al., 1957).In it, we finally get children who resemble those diagnosed with ADHD today.The children have the symptoms that we would recognise (hyperactivity, inattention and impulsivity) and-crucially-the authors stress that such children are 'very common', to be found in every classroom.Moreover, they state that these symptoms are 'to some extent normally found in the course of development of children ' (p. 45).
The other key development in 1957 was the Soviet Union's launch of the Sputnik satellites (Smith, 2012).Sputnik threw the US political, scientific and educational establishment into a panic, prompting calls for abrupt changes in US education.In order to out-compete the Soviets in the 'brain race', students had to stay in school for longer and achieve higher standards.It was no longer acceptable for teenagers to leave high school for unskilled jobs (which were disappearing anyway).As a result, the progressive education approach that had dominated since the 1930s (which took a childcentred, 'learning by doing', approach) was replaced by a return to subject-centred learning focussed on core subjects.Such changes were reinforced by the $1billion National Defense Education Act (1958), which provided thousands of guidance counsellors to look out for children of average or above-average intelligence who struggle academically.These children, who also tended to be hyperactive, inattentive and impulsive, would actually be the first to be diagnosed with what we now call ADHD, and to be prescribed stimulant medication.
At the same time as educational expectations of American children were increasing, many other environmental factors were increasing the likelihood that they were hyperactive, inattentive and impulsive.These include increasing consumption of food chemicals, exposure to atmospheric lead, less time in nature and engaging in physical activity, and even lower rates of corporal punishment.
All of this means that, if we really want to understand the history of ADHD, we need to do two things: (1) we need to analyse when ADHD's history really begins and (2) we need to think more about the environmental factors that give rise to the disorder.so is the first step to resolving the debates that surround this controversial disorder.

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2024 The Author(s).Child and Adolescent Mental Health published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.
But if you dip into any textbook on ADHD, you get all sorts of contenders.Unfortunately, none of them are correct.