the conceptual history of attention deficit hyperactivity ... on adhd history.pdf · which denote...

Deviant Behavior An Interdisciplinary Journal 2293ndash115 2001Copyright Oacute 2001 Taylor amp Francis0163-962501 $1200 1 00

the conceptual history ofattention decit hyperactivitydisorder idiocy imbecilityencephalitis and the childdeviant 1877ndash1929

Adam RafalovichSouthern Oregon University Ashland OregonUSA

This article examines the medical discourse that formedthe foundations of what mental health professionalstoday call Attention Decit Hyperactivity Disorder(ADHD) The article examines literature from twomedical discussions 1) the discussion of lsquolsquoimbecilityrsquorsquoand lsquolsquoidiocyrsquorsquo in the late 19th and early 20th centuriesin Western Europe and in the United States and 2) thediagnosis of encephalitis lethargica in children duringthe 1920s The diagnosis of encephalitis lethargica washeavily inuenced by the previous discussion ofimbecility and occupied a seminal place in the historyof medicalizing child behavior It served as a specicdisease category for kids who demonstratedunconventional behavior in a variety of social contextsIt will be argued that the discussion of encephalitislethargica began a research modality in psychiatrywhich sought to nd neurological bases for childhooddeviance typied by the contemporary discussionof ADHD

Attention Decit Hyperactivity Disorder (ADHD) has known avariety of names during the 20th century Some of these include

Received 10 February 2000 accepted 14 June 2000Address correspondence to Adam Rafalovich Sociology Department Southern Oregon

University 1250 Siskiyou Blvd Ashland OR 97520 E-mail Rafalovasouedu

93

94 A Rafalovich

Encephalitis Lethargica (sequelae thereof) Minimal Brain DamageMinimal Cerebral Palsy Mild Retardation Minimal Brain Dysfunc-tion Hyperkinesis Atypical Ego Development Attention DecitDisorder (ADD) and Attention Decit Hyperactivity Disorder(ADHD) (For discussions of past and current ADHD nomenclaturesee Armstrong 1995 Barkley 1990 Dumont 1976 Kessler 1980Rank 1954 Wender 1971) These categories of disease all addresssimilar collections of symptoms that specically describe child-hood deviance These symptoms have included but are certainlynot limited to poor performance in school extreme extroversionoutbursts of violent behavior inability to lsquolsquostay on taskrsquorsquo thieverydisturbances in sleep patterns morality inconsistent with age andforgetfulness

The history of compiling these symptoms into formal diag-noses represents an increasing drive to medicalize unconventionalchildhood behavior The violation of certain institutional frame-worksmdashthe school the family the economy and so onmdashareinvariably implied in such diagnoses Though the moralistic symp-toms of thievery and violence no longer have utility for thecontemporary diagnosis of ADHD1 the current symptomatologyof the disorder retains many of the themes that were present whenADHD was being diagnosed in the early part of the 20th centuryAccording to the American Psychiatric Associationrsquos (APA) Diag-nostic and Statistical Manual fourth edition (APA 1994) someof todayrsquos ADHD symptoms include having difculty organizingtasks being easily distracted by outside stimuli dgeting withhands or squirming in onersquos seat excessive talking failing to nishschoolwork and feelings of restlessness (see DSM-IV [APA 1994]78ndash85 for a complete listing of the symptoms and requirementsfor diagnosing ADHD)

ADHD is an acronym embedded in popular culture yet itsconceptual history is little discussed both in the popular realmand in academia Brief histories of ADHD have been provided byADHD researchers (Barkley 1990 1991 1997 Kessler 1980) andalso by their opposition (Breggin 1998 Conrad 1976 Shrag andDivoky 1975 Walker 1998) Shrag and Divoky (1975) and PeterBreggin (1998) for example treat the history of ADHD as one of

1 The particular symptoms of violent behavior are not commonlyassociatedwith ADHDbut reserved for the diagnosis of disorders thought to be manifested in the adolescentand young adult populations These disorders are Conduct Disorder (APA 199485ndash90)and Oppositional Deant Disorder (APA 199491ndash94) For a study of these disordersrsquocomorbidity with ADHD see Mathys Cuperus and Van Engeland (1999)

The Conceptual History amp ADHD 95

lsquolsquochild controlrsquorsquo Conversely historical accounts by Kessler (1980)and Barkley (1990 1991 1997) discuss the history of ADHD asone characterizing the progress of modern clinical practice slowlyhoning its nomenclature to greater levels of scientic validity andpractical effectiveness There are two qualities that tend to unifyhistorical accounts of ADHD First they are disturbingly ideolog-ical each account appearing to serve the agenda of the authorsrsquoperspective on the legitimacy (or lack thereof) of ADHD as adisease category Second each of these accounts is markedlybrief These histories are written as introductions to the aforemen-tioned authorsrsquo books serving as a background for their readershiprather than as a signicant topic of inquiry

ADHD has had a limited discussion in sociology virtuallyignored both as a topic of discourse and as a diagnosis with veryreal consequences Previous discussions of ADHD have invokedsociological accounts of mental deviance especially those modelswhich denote processes of labeling and of medicalization Inu-enced by the work of Goffman Lemert Becker and the like weas sociologists and social critics need merely lsquolsquoinsertrsquorsquo the mentaldisorder of ADHD into an established niche of the sociologyof deviance lexicon A study of hyperactivity like the study ofother mental disorders becomes a forum for an empirical accountof previous sociological positions Peter Conradrsquos (1975 1976)studies of hyperkinesis stand as strong examples of this type ofresearch

In Identifying Hyperactive Children (1976) a book claimed tobe the lsquolsquorst empirical analysis of the process of medicalizationrsquorsquo(Conrad 19765) Conrad examines the process by which medicalprofessionals problematize childhood deviance Conradrsquos positionrests upon an interest in the growing sphere of medical practiceand its encroachment upon social life

What is signicant however is the expansion of the spherewhere medicine now functions as an agent of social controlIn the wake of a general humanitarian trend the success andprestige of modern medicine the increasing acceptance ofdeterministic social and medical concepts the technologicalgrowth of the twentieth century and the diminution of religionas a viable institution of control more and more deviantbehavior has come into the province of medicine (Conrad19764ndash5)

96 A Rafalovich

Conradrsquos work claims that the discovery of hyperactivity orhyperkinesis can be attributed to the interplay between threesocial factors lsquolsquo(1) the pharmaceutical revolution (2) trends in themedical profession and (3) government actionrsquorsquo (Conrad 197612)Conradrsquos pharmaceutical revolution analysis points the nger atthe company responsible for the synthesis and marketing of RitalinCibaGeneva which in the 1960s addressed a large-scale adver-tising campaign to the medical and educational sectors alike Hisexamination of medical trends2 though slightly unclear generallyrefers to the increased interpretation of behavioral problems asbiochemical or organic in origin The government action side ofConradrsquos analysis directs attention towards government agenciesin this case the US Public Health Service who were responsible forformally labeling hyperkinesis as lsquolsquominimal brain dysfunctionrsquorsquo Bydiscussing the role of this government agency Conrad is describingthe power of a public institution to contribute to medicalizationthrough decreeing a unied diagnosis

This three-fold description of the agents that contributed to thediscovery of the hyperkinesis phenomenon shows hyperkinesis asa specic project of a somewhat concerted effort on behalf ofthese agents From Conradrsquos perspective the three social factorsrepresent a great asymmetry in power between lay actors andformal organizations ADHD then can be seen as a product ofexpert control in which lay actors have been removed from thedebate This system of experts use language that is obscure andinaccessible to lay actors Conrad states lsquolsquoBy dening a problemas medical it is removed from the public realm where there canbe discussion by ordinary people and put on a plane where onlymedical people can discuss itrsquorsquo (Conrad 197518)

In dening a problem as medical rather than lsquolsquoordinaryrsquorsquo inConradrsquos terms there is a profound separation between those whoarticulate hyperkinesis as a problem and their lay audience Itis not surprising that Conrad (1976) gives credence to HowardS Beckerrsquos discussion of moral entrepreneursmdashagents that furtherthe medical cause by bringing attention to a problem

2 In Identifying Hyperactive Children Conrad asserts little about the specics of trends inmedical practice and even less about how they relate to the diagnosis of hyperactivity Forexample there is no empirical evidence presented by the author to establish that medicalpractices had in fact gone through some signicant changes that would make the diagnosisof hyperactivity more prevalent


There were however also agents outside the medical profes-sion itself that were signicant in lsquolsquopromotingrsquorsquo hyperkinesisas a disorder that was within the medical framework Theseagents might be conceptualized in Howard S Beckerrsquos termslsquolsquomoral entrepreneursrsquorsquo those who crusade for creation andenforcement of the rules whose violation constitutes devianceIn this case the moral entrepreneurs were the pharmaceuticalcompanies and the Association for Children with LearningDisabilities (Conrad 197615)

Through describing a combination of the formal nomenclature ofmodern medicine and the passionate voice of moral entrepreneursConrad sets the stage for an analysis of hyperactivity that invokesthe canons of deviance theory

With his perspective rmly rooted in the established sociologyof deviance lexicon Conrad then begins his specic empiricalstudy of hyperactivity This is done through qualitative anal-yses of interviews with parents of children being treated at aHyperactivity-Learning Disabilities Clinic (HA-LD) in a north-eastern city Throughout this interview process using a groundedtheory approach Conrad describes the interactions between vari-ous social agents and how they ultimately label a child as beinghyperactive These primary agents are schools parents and to alesser extent physicians

Conradrsquos account of hyperactivity is a seminal study of medical-ization However it neglects a historical treatment of the conceptsthat led to the lsquolsquodiscoveryrsquorsquo of hyperactivity In focusing upon theactions of a few agents (eg the US Public Health Service andthe advertising campaigns of pharmaceutical companies) Conradrsquosanalysis emphasizes the conscious role of the agents associatedwith the lsquolsquocreationrsquorsquo of hyperactivity The discourses that propelthese agencies that is the concepts and sets of statements thatserve as their rationale remain unexamined We are left to analyzehyperactivity as a construction of these agentsrsquo specic interests

METHOD

The present study wishes to add another dimension to Conradrsquoswork by introducing a historical element into the analysis ofADHD Of particular concern are the conceptual antecedents thathave given rise to the present discussion of the disorder Thisstudy operates under the assumption that medical discourse of the

98 A Rafalovich

past has been as integral in shaping the way childhood behavioris medicalized today as are the agents of medicalization Conradarticulates The data for this article are British and North Amer-ican medical literature in the form of journal articles and booksbetween 1877ndash1929 A signicant amount of this literature hasbeen excerpted and placed in the text of this article Much ofthese data were chosen based upon their citation in contempo-rary clinical literature about ADHD It is intriguing that so manyresearchers in the ADHD eld cite the studies in this article yeta qualitative sociological analysis of them has not been pursuedThis analysis draws attention to inuential medical concepts thatthis medical literature propelled during this time period The threemajor concepts which will be examined are 1) idiocy 2) imbe-cility and 3) encephalitis lethargica

The most common starting point of ADHD history is a series oflectures given by George Frederic Still in 1902 Both skeptics ofADHD (Armstrong 1995 Breggin 1998 Shrag and Divoky 1975)and advocates of ADHDrsquos validity (Barkley 1990 1991 1997Goldstein and Goldstein 1990) trace the lineage of the disorderto these lectures Though this article addresses the work of StillI choose not to begin a conceptual history of ADHD It is moregermane to study medical concepts that were en vogue at the timeof Stillrsquos research idiocy and more signicant for Still imbecilityImbecility was part of the medical nomenclature that enabledmedical science to begin inquiries into the mental health of personswho were not drastically maldeveloped or mentally handicappedPeople could become suspected of being imbeciles from a failureto meet the demands of conventional institutions Stillrsquos work wasan interesting permutation of the imbecility discourse becausehe wished to apply the term to the unconventional behavior ofchildren

This article will analyze the work of Still as a composite of themedical discourses surrounding imbecility and morality in the late19th and early 20th century After reviewing a sample of medicalliterature devoted to idiocy and imbecility I demonstrate howStillrsquos work was signicant with its particular medical focus uponchild deviance I argue that Still was the rst to link the notionof imbecility to the morality of children even though he failed toprovide an ofcial diagnosis for this childhood behavior

The latter half of this article is devoted to an examination ofthe literature describing encephalitis lethargica or lsquolsquosleepy sick-nessrsquorsquo in children during the 1920s According to leading ADHD


researchers (Barkley 1990 1997 Goldstein and Goldstein 1990Kessler 1980 Stewart 1970) the medical discussion of this diseaseis crucial in understanding how ADHD would later crystallize inneuropsychological nomenclature The psychological sequelae ofencephalitis lethargica were supposed to be the root of a litany ofchildhood behavioral problems including many of those associatedwith ADHD today inability to function in school hyperactivityimpulsivity and so forth Hence the nomenclature that addressedthe residual effects of encephalitis lethargica realized much ofStillrsquos suspicions in 1902 What Still had suspected as an organicmanifestation or lesion in the immoral child those who studiedencephalitis lethargica medicalized into what was perceived to bea clinical reality of that time period The discussion of encephalitislethargica provided a specic diagnosis of the symptoms for whichimbecility had limited utility Imbecility became quickly antiquatedin medical discourse partially because organic causes of the condi-tion could not be found Encephalitis lethargica it will be shownspecically implicated organic processes in child deviance it wasin the eyes of the medical community a disease which couldexplain antisocial children

Idiocy and Imbecility

Today both idiocy and imbecility are so popularized that theirclinical meanings have all but been forgotten Interestingly thosewho wrote about idiocy and imbecility in the medical literature ofthe 1870s also struggled to keep its meaning within the connesof medical nomenclature (see Ireland 1877) The idiot was a typeof person who needed to be claried and understood as a medicalphenomenon not jeered and mocked as a social mist Nor wasidiot to be a catch-all typology for someone deemed socially ineptImbecility was articulated in a partial effort to provide clarity to thediagnosis of idiocy and eventually owned its own place in mentalhealth nosology William Ireland (1877) provided a distinctionbetween the two terms

Idiocy is mental deciency or extreme stupidity dependingupon malnutrition or disease of the nervous centres occurringbefore birth or before the evolution of the mental faculties inchildhood

The word imbecility is generally used to denote a lessdecided degree of mental incapacity Thus when a mandistinguishes between an idiot and an imbecile he means

100 A Rafalovich

that the mental capacity of the former is inferior to that of thelatter (Ireland 18771)

Imbecility denotes a condition much less severe than that of idiocybut the extent of the difference between the two terms is unclearThe idiot is presented as someone who has an organic disorderof some kind the onset of which occurs at the earliest phases oflife The imbecile is presented as someone with a lesser degreeof the same symptoms as the idiot The imbecile can certainlydemonstrate mental deciency or stupidity yet not as much asthe idiot What is missing in Irelandrsquos rudimentary analysis is aconceptual standard by which a more calculated distinction canbe made between the idiot and the imbecile

British physician Charles Mercier (1890) expanded on thedistinction between these two mental affectations Lumping bothidiocy and imbecility into the category of lsquolsquocongenital mentaldeciencyrsquorsquo or dementia naturalis (Mercier 1890286) Mercierprovided a more sophisticated discussion of the distinction betweenthe two diagnoses His analysis rested upon the presuppositions ofmental development

The rst thing the child learns is to avoid physical dangermdashtokeep from falling into the water running against obstaclesburning and cutting itself and all forms of physical injury when the activities answering to this class of circumstanceshas been thoroughly acquired then and not till then beginsthe acquisition of those activities by which the livelihood isto be earned Then begins the formal process of educationwhich is the rst step in tting the individual to get his livingWhen this has been done when sufcient time has beenspent daily in the acquisition of these activities then whatremains over can be devoted to recreation and other purposes(Mercier 1890289ndash290)

Mercier claimed that the development of certain faculties through-out the early part of life will enable the individual to functionat increasingly higher levels The lowest level of functioningis denoted by the individualrsquos ability to display minimal self-preservation thereby avoiding physical injury The higher levels offunctioning included receiving an education and nding adequateemployment


Mercier claimed that the idiot is a type of individual whodemonstrated poor development at the most basic level of humanexistence Idiots were a danger to themselves because of a total lackof awareness of their surroundings whereas imbeciles representeda slightly higher though still inadequate level of development

In idiocy the deciency is still greater The imbecile fails toadapt himself to his vital environment he fails to complete thesecond step in his intellectual development but he surmountscompletely the rst step that which enables him to adapthimself to his physical environment (Mercier 1890290)

Imbeciles could avoid dangerous moving objects but could not beadequately educated to make a living They personied a failureto meet the demands of social and institutional expectations

As its own category of mental defect imbecility became widelyknown in the medical community as a specic phenomenon notto be confused with the more obvious and impairing condition ofidiocy The denition of imbecility became decreed by the RoyalCollege of Physicians in England (arguably the most esteemedcollection of physicians in Europe during that time) in 1912 Fromthe Royal Collegersquos ofcial denition an imbecile lsquolsquois incapablefrom mental defect existing from birth or from an early age(a) of competing on equal terms with his normal fellows or (b) ofmanaging himself or his affairs with ordinary prudencersquorsquo (Goddard191512)

The maladroit behaviors described in the discussion of imbecilitywere eventually linked to an individualrsquos inability to display moralrestraint and lawful behavior In what became known as lsquolsquomoralimbecilityrsquorsquo3 medical practitioners conceptualized the acquisitionof morality as a problem of human biological development

We now and then read of a lsquolsquomoral imbecilityrsquorsquo a varietyof the unhappy invention styled lsquolsquomoral insanityrsquorsquo originallyintended to signify a total want of moral feelings as provedby reckless and shameless conduct without any intellectualimpairment The title lsquolsquomoral imbecilesrsquorsquo however is so

3 Charles Mercier (1917) has stated that is was he who coined the term lsquolsquomoralimbecilityrsquorsquo The date of the inception of the term could not be found in my research Due tono ndings of another person to stake claim to the origin of the term perhaps the placementof lsquolsquomoral imbecilityrsquorsquo into the vicissitudes of medical discourse should be awarded to thelate doctor

102 A Rafalovich

far correct that there are certain children who show fromthe beginning a proneness to evil a callous selshness anda want of sympathy with other people which is the moststriking part of this disorder (Ireland 1900287)

This passage represents much of the literature that addressed moralimbecility around the turn of the century Such writing presenteda new direction of study for medical science The inability todemonstrate moral behavior in that it was placed under the rubricof imbecility became a medical problem Ireland (1900) describeda case of moral imbecilitymdasha boy housed in a hospital dormitory

The rst symptom of insanity was his smashing of panes ofglass in the passage and other places where he would not bereadily noticed When asked why he did so he said that heliked to see the glass y This went on for about six monthsOne day he took out of his pocket a knife which he had gothold of and deliberately made an incision in a boyrsquos hand(Ireland 1900288)

The imbecile represents one more piece in the historical tapestryof discourse which has objectied the nature of the criminal theuneducated or the undisciplined In Discipline and Punish (1977)Foucault discusses such processes of objectication as constructingthe lsquolsquomodern soulrsquorsquo This modern soul represents the perceivedessence of those who engaged in deviant behaviormdashan essencebelieved to be understandable and manipulable only throughthe administration of scientic techniques Foucaultrsquos work inDiscipline is mainly credited with analyzing modern sciencersquosexamination and objectication of the criminal (homo criminalisin Foucaultrsquos words) but this process of seeking the essence ofthe deviant through scientic study encompasses virtually anyonewho has persistent troubles with conventional institutions Withinthe discourse of imbecility during the later 19th and early 20thcenturies there was particular attention given to children Anexamination of medicinersquos focus upon the moral savoir faire ofchildren is crucial in drawing a bridge between this early discourseand the gradual unfolding of the discourse that has surroundedADHD The ADHD child much like homo criminalis represents anobject of study who could not t into the institutional frameworksof everyday life and needed in one way or another to be moldedto meet the demands of these institutions


Moral imbecility evolved as a concept both medically andlegally It was formally inducted into the British Mental De-ciency Act of 1913 constituting a class of lsquolsquoPersons who froman early age display some permanent mental defect coupledwith strong vicious or criminal propensities on which punish-ment has had little or no deterrent effectrsquorsquo (Tredgold 191743) Thecontinued failure of reformative intentions of punishment or thethreat thereof led many medical practitioners to believe that themoral imbecile represented a case of incorrigibility in the face ofthe disciplinary mechanisms of that time period There was anincreasing pressure on the medical establishment to conceptualizeand reconceptualize moral imbecility in an effort to apply moreeffective techniques of reform

Part of the later conceptualization of the moral imbecile involvedthe discussion of this type of imbecile having in many casesnormal or even superior intelligence The moral imbecile physi-cians argued was a more complex creature than physicians hadinitially postulated Physician Alfred Tredgold (1917) in an articleon moral imbecility stated lsquolsquoMany undoubted moral imbecilesare so cunning so plausible and so seemingly intelligent thatmental defect as normally understood would appear to be andin truth is quite out of the questionrsquorsquo (43) Charles Mercier (1917)in an article covering the same topic two months later statedlsquolsquoI would go farther than Dr Tredgold and say that some moralimbeciles are not only seemingly intelligent but really intelligentI have met more than one who have engaged me in a battle ofwits in which I did not win every roundrsquorsquo (303) This discussionon behalf of medical practitioners is ironic given the concep-tual history of imbecility The imbecile was generally dened assomeone who functioned at a lower level than his or her peersperhaps just a step or two above the idiot The concept of the moralimbecile was able to abandon these human development presup-positions because it represented a awed condition in which otherhuman facultiesmdashthose of intelligence and physical skillmdashcouldbe regarded as normal

Examining the Work of George F Still

The work of George F Still (1902) argued by both the pro andcon contingents of the ADHD debate to be the rst medicalaccount of ADHD needs to be understood within the contextof the aforementioned discourse of imbecility and idiocy Stillrsquosdiscussion of moral control in children as a medical problem rides

104 A Rafalovich

the crest of the discussion of moral imbecility by his peers and nodoubt reects their inuence Because of this Stillrsquos work shouldnot be regarded as a point of origin in the discourse on ADHDchildren It might be better understood as a product of the dominantmedical literature of its time In addition ADHD researcher RussellBarkley (1990) presents Stillrsquos research into immoral children asmore meticulous than it was Stillrsquos work I believe representsa plea to the medical community rather than a critical medicaldiscovery4

Stillrsquos plea began in a series of lectures given before the RoyalCollege of Physicians of London in March 1902 in which heproposed a new topic of medical examination

Mr President and gentlemen the particular psychical condi-tions with which I propose to deal in these lectures arethose which are concerned with an abnormal defect ofmoral control in children For some years past I havebeen collecting observations with a view to investigating theoccurrence of defective moral control as a morbid conditionin children a subject I cannot but think calls urgently forscientic investigation (Still 19021008)

In this address Still tentatively hypothesized the relationshipbetween self-control and the biological propensity for under-standing the moral demands of onersquos environment He stateslsquolsquoMoral control can only exist where there is a cognitive relation toenvironmentrsquorsquo (Still 19021008) Individual morality was a devel-opmental phenomenon Still argued that stemmed from organicfunctions of the brain He contended that at a certain age therewere biological standards for moral conduct and to have lessmoral control than others in a particular age category constitutedthe basis for suspecting a pathological condition5

4 Barkleyrsquos misrepresentation of Stillrsquos work distorts the experimental and conceptualhistory that has given us the legacy of ADHD During the time period of Stillrsquos writingthere was no hypothesizing about neurological structures and moral acquisition and nolarge-scale studies performed to ascertain the nature of this lsquolsquoailmentrsquorsquo (most of Stillrsquos limitednumber of subjects were part of an institutionalized population subjected to countlesssocially-inuenced variables all of which were unaddressed)

5 A standard of self-control as set by a particular age category is still a consistentdiagnostic tool in the assessment of ADHD as well as other childhood mental disordersSee the APArsquos DSM IV criteria for diagnosing ADHD as an example


Still eliminated mental retardation as a variable affecting thisimmoral condition His discussion separates lsquolsquothe idiotrsquorsquo from thosewith more particular moral difculties

The driveling idiot who recognizes no one does not distin-guish his food and is little more than a mere automat onstands in little or no cognitive relation to his surroundingsand a fortiori lacks that higher form of reasoning compar-ison which we call moral consciousness Here thereforethe absence of moral control is complete Such cases are ofinterest chiey as exemplifying one cause of failure of devel-opment of moral control they have otherwise little bearingon the question before us and need not detain us further (Still19021009)

The child with inadequate control of his or her moral facultiesit was argued should not be confused with the intellectuallyinferior This line of reasoning resonates with the literature thatseparated the morally inferior from the intellectually inferior LikeMercier (1917) and Tredgold (1917) would later do Still pled withthe medical community to not misunderstand immoral childrenas being less intelligent than children who demonstrated moralprowess The immorality Still wished to address was presentedas signicantly too advanced for visibly deranged or mentallyincapacitated children Immorality in the normal child at leastthe child who deed categories like lsquolsquoretardedrsquorsquo was argued tobe symptomatic of some larger medical issue Some of thesesymptoms included lsquolsquo(1) passionateness (2) spitefulness-cruelty(3) jealousy (4) lawlessness (5) dishonesty [and] (6) wantonmischieviousness-destructivenessrsquorsquo (Still 19021009)6

For Still these behaviors represented some degree of personalagency on behalf of those children who displayed them Thesewere not children who due to being too stupid to understandthe moral codes of society acted out against those codes Thesechildren perhaps had a clear understanding of the contents ofthe law and willfully chose to disregard it Nameless to modernmedicine these children were too intelligent to be categorizedunder the established nomenclature of idiocy and too young to be

6 In his discussion of Stillrsquos work Russell Barkley (1990) makes the comment that lsquolsquoMostof these children were impaired in attention and were quite overactiversquorsquo (Barkley 19904)This is not documented in Stillrsquos address

106 A Rafalovich

understood as lsquolsquocriminal mindsrsquorsquo For Still as with those researcherswho would follow in his footsteps these were the lsquolsquoother childrenrsquorsquowho needed to be more specically understood through medicalexamination Still raises the question of whether or not thesechildren represented an entirely new form of idiocy or imbecility

Lastly the question must be raised whether we can associatedefect of moral control with any particular type or types ofidiocy or imbecilitymdasha question of considerable importancefor if it were possible to do so we might hope by a study ofthese types to nd some anatomical basis for this abnormalityof function (Still 19021012)

Stillrsquos lecture was given during a time when there were otherdiscussions about the biological characteristics of immorality andmore specically criminal behavior Lombroso and his infamousLrsquoUomo Delinquente (18761907) was an unquestionable inu-ence in the medical discussions of morality in Europe during thistime period7 Through examining the morphology of the criminalrsquosskull as well as other parts of the anatomy Lombroso provided thescholarly community with a tangible form of the criminal Stillrsquosdiscussion though a product of Lombrosorsquos inuence differedsignicantly from Lombroso Even though Still commented aboutthe physicality of these children in an effort to make a distinc-tion between them and those in the lsquolsquonormalrsquorsquo population Stillrsquosanalysis proposed a different focus of scientic studymdasha neuro-logical one There was an implicit assumption in his idea of thecognitive component of morality that the cause of these immoralbehaviors lay hidden inside the mind of the child The cause ofthis immorality was not as blatant as the slobbering idiot or theadult with criminal indentations on his head rather the causewas unknown and hidden To understand the cognitive originsof moral pathology would imply a more methodical examinationThough he suspected a specic type of imbecility Still offered noconclusions about the cause of these moral failings his tone is onethat seemed to recognize the long hard road ahead for modernmedicine As theoretically simplistic as it was Stillrsquos work reected

7 Barkley (1990) in his commentary on Stillrsquos address also discusses the inuence ofthe work of people like Lombroso lsquolsquoWe must not forget however that in this Victorian eramedical scientists were frankly obsessed with head size and physical stigmata as reectingdefective intellect or morals rsquorsquo (Barkley 19904)


a passion within medicine beginning a process of inquiry anddebate which today has yet to be resolved

Stillrsquos work is signicant for the examination of the earlydiscourse surrounding ADHD and represents a break from themore general medical discussions of morality because he proposedchildren as objects of study Though ADHD is being increasinglydiagnosed in adults it remains a disorder perceived primarily toafict the young at times in their lives when commitments toinstitutions of socialization are so crucial Up to the point of Stillrsquosaddress the elaboration of diagnostic categoriesmdashespecially thoselike moral imbecilitymdashwere not understood in a direct relationshipto children Stemming from the discourse of idiocy and imbecilityStill provided the groundwork for a category of mental illness thatis in practicality specic to child deviance

Encephalitis Lethargica as Explanation of Childhood Deviance

Leading ADHD researchers contend that the discussion of encepha-litis lethargica in the 1920s was crucial in describing specicchildhood symptoms that would later be attributable to ADHDAlso known as lsquolsquosleepy sicknessrsquorsquo this disease reached epidemicproportions towards the close of World War I It was unknownto medicine at its outbreak but quickly became a centerpiece ofmedical attention8 Encephalitis lethargica was an often fatal illnesscharacterized by tremendous sluggishness hallucinations andfever sometimes bringing with it periods of remissionmdashsomethingdoctors viewed as a hopeful sign These remissions were oftenshort-lived and a full relapse of the illness was a common occur-rence Abrahamson (1920b) described his experience lsquolsquoThe earlyoptimism I enjoyed quickly perished and I learned to dreadthis disease so often fatal not infrequently inicting perma-nent damage on those who survived it and sometimes bringingin its train progressive functional deteriorationrsquorsquo (Abrahamson1920b428)

What became as signicant as the symptoms of the diseaseitself were its residual effects This is what Stryker (1925) calledthe lsquolsquobehavior residualsrsquorsquo of encephalitis (see also Paterson andSpence [1921] and Hohman [1922]) It was a disease thought toirreversibly damage many who suffered it leaving people withextensive physical and mental impairments These physical andpsychological sequelae came in so many forms that it was common

8 For a brief history of this disease see Abrahamson (1920a17)

108 A Rafalovich

for neurologists to refer to them as a syndrome In a brief historyof minimal brain dysfunction (the diagnosis most in use beforethose of ADD and ADHD) Jane Kessler (1980) commented thatencephalitis lethargica had as many as 27 different symptomsincluding lsquolsquosleep reversals emotional instability irritability obsti-nacy lying thieving impaired memory and attention personaluntidiness tics depression poor motor control and general hyper-activityrsquorsquo (Kessler 198018) Encephalitis lethargica was hardly anelegant category of disease

Franklin G Ebaugh (1923) described the sequelae of encephalitisas they were demonstrated through behavior patterns contrastingwith those prior to the encephalitis afiction The sequelae rangedanywhere from alterations in sleeping and eating patterns tomarked oppositional behavior To Ebaugh these and other sequelaedescribed a lsquolsquototal change in the patientrsquos character and disposi-tionrsquorsquo (Ebaugh 192390) of what were at one time completelynormal childrenmdashchildren who were well-adjusted happily in-volved with conventions like school family life friendships and soforth After the onslaught of the formidable illness of encephalitisthese children exhibited behaviors which not only fell outside theparameters of appropriate behavior within these contexts but alsoat times went directly against them Ebaugh described some of hispatientsrsquo reactions to school

In three of our patients marked hysterical phenomena wereobserved One child developed spells of the functionalvariety usually to escape from a difcult situation The spellsconsisted of prolonged periods of rapid respirations the childthus feigning illness in order to stay out of school (Ebaugh192391)

In a later discussion of the sequelae of encephalitis RogerKennedy (1924) formulated similar descriptions citing numerouscase studies each organized according to a particular category ofsequelae Within the sequelae described as lsquolsquoChange in Personalityand Behaviorrsquorsquo (Kennedy 1924169) he commented on the state ofa 10-year-old

A boy aged 10 years was brought to the clinic May 9 1922because of nervousness In March 1920 he had inuenzafollowed by an acute attack of encephalitis which lasted eightdays He improved gradually and returned to school but


had to be taken out because he asked so many questionsand removed books from other desks to his own (Kennedy1924170)

Kennedyrsquos is one of the rst accounts that attempted to create acase for these sequelae especially the ones associated with de-ance and oppositional behavior to be understood as a syndromeHe argued that the deant behaviors and other symptoms inthe postencephalitic child are representative of a physiologicalmechanism This position remains the dominant perspective oftodayrsquos neurochemically-oriented ADHD researchers Kennedystates lsquolsquoThis case illustrates the main features to be considered indealing with children who are suffering from this syndrome In therst place the absolutely different personality which they displayis well exemplied They are apparently acting in response to amost urgent stimulus which they are powerless to resistrsquorsquo (Kennedy1924170) The postencephalitic child was not responsible for hisor her actions These children the medical literature argued weremerely acting according to a neurological principle the specicsof which remained a mystery

Similar to Stillrsquos initial discussion of child immorality as amedical problem Kennedy also wished to exclude those whowere retarded or had some kind of obvious mental defect

Second and perhaps of most importance is the considerationof mental status As has been indicated there is no evidenceto show that a considerable proportion of such patients arementally retarded or decient they are moral rather thanmental imbeciles Some of them appear dull and drowsybut in their antics and behavior they display a cunning thatis not commensurate with greatly impaired mental faculties(Kennedy 1924171)

The idea that a child could be lsquolsquodull and drowsyrsquorsquo speaks notto an issue of intelligence but to the dominant understandingof encephalitis lethargica Again this disorder was thought tobe characterized by an untimely sluggishness in the child Thissluggishness apparently disappeared when the child responded tothe neurological stimulus in his or her brain and acted improperlyThis was a different kind of mental impairment distinct fromretardation where the aficted child was described as cunningand calculating This account differs little from the description of

110 A Rafalovich

the moral imbecile whom Mercier and others in the late 19th andearly 20th centuries considered to be both a defective imbecileand at the same time owning a reasonable (sometimes high)intelligence

Kennedyrsquos perspective depicting the immoral behavior of thepostencephalitic child as the result of neurological processes wasexpanded by Edward Strecker (1929) Strecker made distinctionsbetween two types of behavior exhibited by the postencephaliticchild 1) lsquolsquomotorrsquorsquo behaviors and 2) lsquolsquostudiedrsquorsquo types of conduct(Strecker 1929137ndash138) Motor types of behavior referred toactions that were unintentional outside the control of the childStudied behaviors were those that resulted from a conscious effort

An example of some misconduct of the motor type is asfollows A boy aged 10 who had acute encephalitis at theage of 7 is described as being overactive constantly inmotion roaming about the streets at night wandering aboutthe house at night whistling and singing once he dashedup to an infant sisterrsquos crib and swung the baby about bythe heels In the severe studied type one witnesses suchdeviations as stealing forgery deliberate lying to gain an endmoral lapses and running away carefully planned and with adenite objective (Strecker 1929137ndash138)

Strecker painted two very distinct pictures of this type of child Onone hand such children were apparently driven by impulses thatfell outside of conscious thought or reason On the other handthese children demonstrated a certain malice in the things they dida neurological defect or lesion provided a source of graticationfor defying conventional behavior

The Coincidence of Encephalitis and ADHD

The moral imbecile child portrayed by the medical discourse ofthe late 19th century was eclipsed by the much more elaborateanalysis describing the postencephalitic child The diagnosis ofencephalitis lethargica provided a physiological explanation forunconventional antiinstitutional child behavior The discourse onencephalitis lethargica has been documented by Barkley KesslerStewart and others as a place in the history of the gradual sophis-tication of medical practice ultimately leading to the teasing outof the more correct diagnosis of ADHD Barkley for exampleclaims that children with ADHD in the 1920s were mixed in


with the population of those suffering from encephalitic traumaDue to the rudimentary knowledge of neurology during that timeperiod encephalitis lethargica Barkley argues served as a catch-all diagnosis Researchers such as Barkley tell us we had to startsomewhere and look how far we have come

The progressive interpretation of past medical practice byBarkley and others ignores some valuable points of analysis Suchperspectives assume that ADHD though unnamed and strange atthe time was a real condition that had existed a long while Onlyrecently researchers argue has it become adequately understoodThrough the meeting of the neurological interest in childhoodmorality with the object of the postencephalitic child it is arguedthat we began a journey that is both humane and just But the nexusof neurology and the postencephalitic child is presented much toocoincidentally as if it were good fortune that the encephalitic andADHD populations were mixed

The problems of that coincidence are ignored by a vestedinterest in the legitimacy of child psychology Factors other thanthe progressive mind of science need to be addressed in inter-preting the discourse on encephalitis lethargica Variables thatinuenced the environment of the children under study and thatcertainly affected behavior need to be addressed In my thoroughexamination of this literature a great majority of the children understudy were institutionalized before the time of being studied Thereasons for this institutionalization no doubt were varied andpose major hurdles to adequate interpretation of the conditionsof this population Goffmanrsquos (1961) idea of the looping effectdescribed how psychiatrists interpreted an individualrsquos resistanceto the environment of the institution as symptomatic of mentaldisorder Obviously this process negatively affects the degreeof validity in institutionally-oriented diagnoses Diagnosing thepostencephalitic child has not been shown to be exempted fromthis process Researchers who were formulating the nomenclatureon encephalitis lethargica never asked about the social variableswhich might have strongly affected childhood behavior Todayrsquosdominant ADHD research strays little from this mentality Suchresearch repeatedly argues that the roots of childhood deviancecan best be understood through an analysis of the childrsquos brain(see Baving et al 1999 Fisher 1996 Fuster 1997 Mataro 1997)rather than his or her social environment

The discussion of encephalitis lethargica was signicant notsimply because it drew suspicion to the causal connection between

112 A Rafalovich

behavior and neurological impulse but because it medicalizedunconventional behavior specic to children Many of these symp-toms would later be claimed by neurologists and placed under therubric of ADHD From the point in mental health history whereencephalitis took center stage as a cause of childhood immoralityup to the current era of ADHD child neuropsychology has restedupon a belief that persistently deviant childhood behaviors repre-sented psychological pathology

CONCLUSION THE POSSIBILITY OF ADHD

To understand the current discourse surrounding the diagnosis ofADHD it is crucial to examine some of the concepts which have ledto its inception thereby lsquolsquohistoricizingrsquorsquo the phenomenon Theseconcepts should be examined in a more critical light than as amere background to an unrelated argument concerning the validityof ADHD The ideas themselves and their clinical and social impli-cations beg a greater scrutiny The amorphous diagnoses of idiocyand imbecility and the more crystallized encephalitis lethargicaare units of analysis that reveal the possibility for todayrsquos renditionof ADHD Such a level of analysis which historicizes conceptsprovides a critical dimension into contemporary understandings ofmental illness (see Hacking [1995] and Young [1995] as examplesof historical critiques of mental illnesses)

An analysis of ADHD at the conceptual-historical level realizessome of the aims of the sociology of mental illness Alan Blum(1970) summarizes this aim

In this respect we do not intend to raise the question ofwhat factors cause mental illness in the sense of independentvariables or antecedent conditions such as urbanism indus-trialization and so forth We are not interested in explainingmental illness in this way but rather in merely describinghow it is possible

In stating that we have to answer the question lsquolsquoWhatis mental illnessrsquorsquo by describing how such a conception ispossible we are saying that a sociological phenomenon isdened in terms of its production That is it is dened in termsof the methods and procedures which members employ tomake the phenomenon describable (Blum 197032)


Todayrsquos predominantly neurochemical understanding of ADHD ispossible for a variety of reasons Some of these reasons are commonto the sociology of mental illness cultural scripts institutionalcontexts political inuences of psychiatry processes of popularlegitimation and so on (see Goffman [1961] and Scheff [1984]for well-known texts employing such analyses) Conradrsquos (1976)study of hyperactivity exemplies an analysis of these variables sopervasively articulated in sociological discussions of mental healthA thorough examination of past discourses that have contributedto the contemporary discussion of ADHD would provide a usefuladdition to such pertinent studies

It is inadequate to say that the increasing diagnoses of ADHDand consequent increase in the prescriptions for Ritalin Cylertand Adderall in school-age children are a result of pharmaceuticalcorporations an out-of-control mental health apparatus or a pillpopping sensibility ADHD comprised by the plethora of medicaldiscourses that have objectied it are a product not only of thecurrent era but also of the discourses that continue to strategize forits ownership The medical discussion of encephalitis lethargicafor example demonstrated neurologyrsquos interest in medicalizing themorality of the young The current position of psychiatry towardsADHD exemplies this century-old medicalizing modality

REFERENCES

Abrahamson I 1920a lsquolsquoThe Epidemic of Lethargic Encephalitisrsquorsquo NewYork Medical Record Dec 11th

Abrahamson I 1920b lsquolsquoThe Chronicity of Lethargic EncephalitisrsquorsquoArchives of Neurology and Psychiatry 4428ndash432

American Psychiatric Association 1994 Diagnostic and Statistical Man-ual fourth edition Washington DC Author

Armstrong T 1995 The Myth of the ADD Child New York PlumeBarkley R A 1990 Attention Decit Hyperactivity Disorder A Hand-

book for Diagnosis and Treatment New York Guilford PressBarkley R A 1991 Attention Decit Hyperactivity Disorder A Clinical

Workbook New York Guilford PressBarkley R A 1997 ADHD and the Nature of Self-Control London

Guilford PressBaving L M Laucht and M H Schmidt 1999 lsquolsquoAtypical Frontal Brain

Activation in ADHD Preschool and Elementary School Boys andGirlsrsquorsquo Journal of the American Academy of Child and AdolescentPsychiatry 381363ndash1377

114 A Rafalovich

Blum A F 1970 lsquolsquoThe Sociology of Mental Illnessrsquorsquo Pp 31ndash60 inDeviance and Respectability The Social Construction of Moral Mean-ings edited by J Douglas New York Basic Books

Breggin P 1998 Talking Back to Ritalin Monroe ME Common CouragePress

Conrad P 1975 lsquolsquoThe Discovery of Hyperkinesis Notes on the Medical-ization of Deviant Behaviorrsquorsquo Social Problems 2312ndash21

Conrad P 1976 Identifying Hyperactive Children The Medicalizationof Deviant Behavior Lexington MA Lexington Books

Dumont M 1976 lsquolsquoFocusing on Televisionrsquorsquo letter to the editor Amer-ican Journal of Psychiatry 133457

Ebaugh F G 1923 lsquolsquoNeuropsychiatric Sequelae of Acute EpidemicEncephalitis in Childrenrsquorsquo American Journal of Diseases of Children2589ndash97

Fisher B C 1996 Attention Decit Disorder Misdiagnosis ApproachingADD from a Brain-BehaviorNeuropsychological Perspective forAssessment and Treatment New York CRC Press

Foucault M 1977 Discipline and Punish the Birth of the Prison NewYork Pantheon

Fuster J M 1997 The Prefrontal Cortex Anatomy Physiology andNeuropsychology of the Frontal Lobe New York Raven

Goddard H H 1915 The Criminal Imbecile New York MacMillanGoffman E 1961 Asylums Notes on the Social Situation Mental Patients

and Other Inmates New York AnchorGoldstein S and M Goldstein 1990 Managing Attention Disorders in

Children A Guide for Practitioners New York Wiley-InterscienceHacking I 1995 Rewriting the Soul Princeton Princeton University

PressHohman L B 1922 lsquolsquoPostencephalitic Behavior Disorders in Childrenrsquorsquo

Johns Hopkins Hospital Bulletin 33372ndash375Ireland W W 1877 On Idiocy and Imbecility London J amp A ChurchillIreland W W 1900 The Mental Affectations of Idiocy Imbecility and

Insanity Philadelphia P BlakistonrsquosKennedy R L J 1924 lsquolsquoThe Prognosis of Sequelae of Epidemic

Encephalitis in Childrenrsquorsquo American Journal of Diseases of Children28158ndash172

Kessler J W 1980 lsquolsquoHistory of Minimal Brain Dysfunctionsrsquorsquo Pp 18ndash42in Handbook of Minimal Brain Dysfunction A Critical View editedby H Rie and E Rie New York Wiley-Interscience

Lombroso C [1876] 1907 LrsquoUomo Delinquente Bocca TurinMataro M 1997 lsquolsquoMagnetic Resonance Imaging Measurement of the

Caudate Nucleus in Adolescents with Attention-Decit HyperactivityDisorder and its Relationship with Neuropsychological and BehavioralMeasuresrsquorsquo Archives of Neurology 54963ndash968

Mathys W J M Cuperus and H van Engeland 1999 lsquolsquoDecient SocialProblem-Solving in Boys with ODDCD with ADHD and with Both


Disordersrsquorsquo Journal of the American Academy of Child and AdolescentPsychiatry 38311ndash325

Mercier C A 1890 Sanity and Insanity London ScottMercier C A 1917 lsquolsquoMoral Imbecilityrsquorsquo Practitioner October301ndash308Paterson D and J C Spence 1921 lsquolsquoThe After-Effects of Epidemic

Encephalitis in Childrenrsquorsquo The Lancet September 3rd491ndash493Rank B 1954 lsquolsquoIntensive Study and Treatment of Preschool Children

who Show Marked Personality Deviations or lsquolsquoAtypical Developmentrsquorsquoand their Parents Paper presented to the International Institute of ChildPsychiatry August 1954 Toronto

Scheff T 1984 Being Mentally Ill a Sociological Theory (3rd edition)New York Aldine De Gruyter

Schrag P and D Divoky 1975 The Myth of the Hyperactive Child andOther Means of Child Control New York Pantheon

Stewart M A 1970 lsquolsquoHyperactive Childrenrsquorsquo Scientic American22294ndash98

Still G F 1902 lsquolsquoSome Abnormal Psychical Conditions in Childrenrsquorsquo TheLancet April 12 (1008ndash1012) 19 (1079ndash1082) and 26 (1163ndash1167)

Strecker E A 1929 lsquolsquoBehavior Problems in Encephalitisrsquorsquo Archives ofNeurology and Psychiatry 21137ndash144

Stryker S B 1925 lsquolsquoEncephalitis Lethargica The Behavior ResidualsrsquorsquoThe Training School Bulletin 22152ndash157

Tredgold A F 1917 lsquolsquoMoral Imbecilityrsquorsquo Practitioner July43ndash56Walker S 1998 The Hyperactivity Hoax New York St Martinrsquos PressWender P 1971 Minimal Brain Dysfunction in Children New York

Wiley-InterscienceYoung A 1995 The Harmony of Illusions Inventing Post-Traumatic

Stress Disorder Princeton NJ Princeton University Press

94 A Rafalovich

Encephalitis Lethargica (sequelae thereof) Minimal Brain DamageMinimal Cerebral Palsy Mild Retardation Minimal Brain Dysfunc-tion Hyperkinesis Atypical Ego Development Attention DecitDisorder (ADD) and Attention Decit Hyperactivity Disorder(ADHD) (For discussions of past and current ADHD nomenclaturesee Armstrong 1995 Barkley 1990 Dumont 1976 Kessler 1980Rank 1954 Wender 1971) These categories of disease all addresssimilar collections of symptoms that specically describe child-hood deviance These symptoms have included but are certainlynot limited to poor performance in school extreme extroversionoutbursts of violent behavior inability to lsquolsquostay on taskrsquorsquo thieverydisturbances in sleep patterns morality inconsistent with age andforgetfulness

The history of compiling these symptoms into formal diag-noses represents an increasing drive to medicalize unconventionalchildhood behavior The violation of certain institutional frame-worksmdashthe school the family the economy and so onmdashareinvariably implied in such diagnoses Though the moralistic symp-toms of thievery and violence no longer have utility for thecontemporary diagnosis of ADHD1 the current symptomatologyof the disorder retains many of the themes that were present whenADHD was being diagnosed in the early part of the 20th centuryAccording to the American Psychiatric Associationrsquos (APA) Diag-nostic and Statistical Manual fourth edition (APA 1994) someof todayrsquos ADHD symptoms include having difculty organizingtasks being easily distracted by outside stimuli dgeting withhands or squirming in onersquos seat excessive talking failing to nishschoolwork and feelings of restlessness (see DSM-IV [APA 1994]78ndash85 for a complete listing of the symptoms and requirementsfor diagnosing ADHD)

ADHD is an acronym embedded in popular culture yet itsconceptual history is little discussed both in the popular realmand in academia Brief histories of ADHD have been provided byADHD researchers (Barkley 1990 1991 1997 Kessler 1980) andalso by their opposition (Breggin 1998 Conrad 1976 Shrag andDivoky 1975 Walker 1998) Shrag and Divoky (1975) and PeterBreggin (1998) for example treat the history of ADHD as one of

1 The particular symptoms of violent behavior are not commonlyassociatedwith ADHDbut reserved for the diagnosis of disorders thought to be manifested in the adolescentand young adult populations These disorders are Conduct Disorder (APA 199485ndash90)and Oppositional Deant Disorder (APA 199491ndash94) For a study of these disordersrsquocomorbidity with ADHD see Mathys Cuperus and Van Engeland (1999)






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the conceptual history of attention deficit hyperactivity ... on adhd history.pdf · which denote...

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Transcript of the conceptual history of attention deficit hyperactivity ... on adhd history.pdf · which denote...