ADHD Atten Def Hyp Disord
DOI 10.1007/s12402-014-0137-y
REVIEW ARTICLE
Sons and daughters beyond your control: episodes
in the prehistory of the attention deficit/hyperactivity syndrome
Paul Bernard Foley
Received: 5 February 2014 / Accepted: 24 March 2014
 Springer-Verlag Wien 2014
Abstract Hyperactive and inattentive children have been
discussed in both the pedagogic and medical literature
since the nineteenth century, and many controversies
associated with attention deficit and hyperactivity disorder
(ADHD) have been repeatedly analyzed in different con-
texts. The ‘prehistory’ of the ADHD concept—that is, up to
the definition of ADHD in DSM-III and of the corre-
sponding ‘hyperkinetic disorder’ in ICD-9—is outlined,
with an emphasis on the literature not previously discussed
in English language reviews of the subject.
Keywords Attention deficit/hyperactivity disorder

History of psychiatry
Classification of behavioral
disorders
Introduction
Reports of unruly and intransigent children have been
transmitted from as long ago as the eighth century BC,
when the author of Deuteronomy advised parents troubled
by a stubborn and unruly son to denounce him to the city
fathers, so that he might be stoned (21: 18–21). But iden-
tifying accounts of children presenting what might now be
interpreted as attention deficit and hyperactivity disorder
(ADHD) is more complicated, primarily because retro-
spective diagnosis is no more uncertain than when based on
P. B. Foley
Unit for History and Philosophy of Science,
University of Sydney NSW 2006, Australia
P. B. Foley (&)
Neuroscience Research Australia,
Randwick (Sydney) NSW 2031, Australia
e-mail: p.foley@neura.edu.au
the interpretation of behavior. Further, the controversial
nature of the concept of ‘ADHD’ itself means that any
history will be viewed by both its proponents and oppo-
nents as providing evidence for their respective viewpoints.
This brief overview will initially explore how problems
of attention and hyperactivity were described prior to the
twentieth century. Historical accounts of difficult are
plentiful, but we are not interested here in simply rebellious
or naughty children, for instance, nor in those with profound
intellectual problems or whose excessive motility is deter-
mined by psychosis; our review will be limited to children
of fairly normal intelligence who attracted adult attention
because of problems of attention and excessive voluntary
motor activity. Further, the evolution of the ADHD concept
since 1902 has been explored many times (Helmerichs
2002; Sandberg and Barton 2002; Barkley 2006; Lange
et al. 2010; Taylor 2011; Baumeister et al. 2012; Warnke
and Riederer 2013). While the milestones installed by these
previous reviews will not be ignored, a broader context for
this history will be provided by focusing upon sources lesser
known, in particular, to Anglophone readers. With regard to
the German literature, this means, for example, considering
not only the psychiatric literature, but also the pedagogic
journals in which the problem of inattentive, restless chil-
dren were discussed; the behavioral problems in post-
encephalitis lethargica children during the 1920s will be
discussed, as will the hyperactivity disorder described by
Kramer and Pollnow at about the same time. The most
prominent proponents of the French ‘unstable child’ con-
cept will also be discussed, as this model of behavior,
developed since the beginning of the twentieth century in
parallel with that of the ‘hyperactive child’ model, is even
less familiar to English-speaking readers.
A number of early descriptions of ‘ADHD’ have been
discussed recently (Kast and Altschuler 2008; Bonazza
123

et al. 2011; Barkley and Peters 2012), but these generally
require significant willful interpretation in order to fit the
ADHD mold. The most prominent example in this respect is
undoubtedly the depiction by Frankfurt psychiatrist Hein-
rich Hoffmann (1809–1894) of the Zappelphilipp (‘Fidgety
Philip’) in his illustrated children’s book Struwwelpeter,
often regarded as an early depiction of ADHD (Thome and
Jacobs 2004; Lange et al. 2010). Freiburg medical historian
and pediatrician Eduard Seidler (2004) has discussed in
detail why this is inappropriate, and it suffices here to note
that rocking back and forth on a chair, sometimes with
catastrophic consequences, is normal for young boys, as I
know from personal experience as a father (another of
Hoffmann’s characters, the distracted ‘Johnny-Stare-in-the-
Air,’ is similarly familiar). Hoffmann’s book, cautionary
tales composed for the amusement and mild admonition of
children, is no more a depiction of pathologic behavior than
Max und Moritz (1865) or the often gruesome tales col-
lected by the brothers Grimm from earlier in the nineteenth
century. Philipp may even contain an autobiographical
element: Hoffmann described himself as a child as dis-
tracted, forgetful, flighty, as I was, nothing stuck with me,
everything was dispersed (Hoffmann 1926, p. 26).
The nineteenth century: Restlessness as an obstacle
to education
It was not until the mid-nineteenth century that attention
deficits and hyperactivity in children attracted a significant
degree of published comment. This is no coincidence: It
was at this time that evolution of the modern concept of
childhood gathered pace, as did recognition of the social
and political importance of compulsory schooling (not
introduced in France and the United Kingdom until the
final quarter of the century), both major evidence of social
progress. At the same time, socioeconomic and political
changes associated with industrialization encouraged ideals
of orderliness, self-control and adaptation to the changing
political and economic circumstances that were necessarily
also inculcated in middle-class children, in particular, and
difficulties by children in accommodating these values
were increasingly regarded as problematic.
One constant in the concern regarding hyperactivity and
inattention in children has, in fact, been their impact on
learning by otherwise intellectually capable pupils. At the
same time, the natural ‘volatility’ of childhood attention
had long been accepted both as prerequisite and hindrance
to their rapid capacity for learning, as noted by no less than
the great English philosopher John Locke in Some thoughts
concerning education (included from the 4th enlarged
edition of 1699):
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P. B. Foley
It is a Contradiction to the natural State of Childhood
for them to fix their fleeting Thoughts. Whether this
be owing to the Temper of their Brains, or the
Quickness or Instability of their animal Spirits, over
which the Mind has not yet got a full Command; this
is visible, that it is a Pain to Children to keep their
Thoughts steady to any thing (Sect. 167).
No pedagogic success can be attained against this inclina-
tion with punishment or rebuke: Calmness is instead
required on the part of teacher. Nearly two hundred years
later, the Toronto philosopher Frederick Tracy commented
in a similar vein:
The child’s attention is comparatively weak and
intermittent. He cannot attend to the unimpressive,
the stimulus must be strong, must be on the motor
side, and must be frequently renewed. His attention is
very easy to obtain, but very hard to retain (Tracy
1896, p. 118).
A key feature of their discussions published between these
two statements—primarily the subject not of medical
literature, but of pedagogic journals and handbooks—was
that there was little perception of problem children, but
rather of a spectrum of distractibility in children, and
variation in the competence of teachers respecting these
differences. One of the basic goals of education was, in
fact, to gradually channel and focus the quicksilver minds
of children: The distracted child was neither defective nor
bad, simply untrained. Philosophical and medical thought
concerning consciousness and attention also contributed to
increased interest in disorders of these faculties during this
period.
The focus of educational discussions in Germany until
the early twentieth century generally concerned attention,
with motor restlessness regarded more as its corollary than
a separate feature. Zappeligkeit (‘fidgitiness’) was the term
usually applied to children presumed consumed by inner
restlessness; it was regarded as both normal and necessary
in infants, but inappropriate in older children, obliged to
self-control (Siegert 1910). It could be presented as
uncontrolled motor activity (including chorea) or as Vie-
lgeschäftigkeit: hectic, uncoordinated activity, where much
as initiated, but little brought to a satisfactory conclusion
(Siegert 1909).
Krankhafte Unruhe des Kindes (‘pathological restless-
ness in children’) could also be observed in restless, hys-
terical, or neurasthenic children, as well as in more serious
psychiatric disorders. The movements of these children are
restless and more hurried than in the healthy, but by no
means clumsy. They make always fiddling with objects
unnecessarily, attacking everything, flicking through their
books, opening drawers, playing with the pencil box,
Sons and daughters beyond your control
twisting scraps of paper, fumbling with their hair, etc.
Striking remains the great tendency to fatigue and
depression (Bergmann 1917). The psychomotor irritation
exhibited by these children was seen as lying on a con-
tinuum that ranged from that in healthy children to invol-
untary motor tics and even tremor (see also Fuchs 1896;
Ziehen 1909).
Unstätigkeit der Kinder (‘instability of children’) was
described by the Encyclopädie der Pädagokik as a deficit in
maintaining attention, especially in livelier children, there
is a restless, drifting bustle; the lad commences something
with passion, but soon abandons it and starts something
new. The author attributed the problem to parents or
teachers constantly switching between activities and noted
that the situation was difficult to correct in those over
9 years of age (Anonymus 1860).
Attention was, not unexpectedly, addressed at length in
pedagogic handbooks throughout the nineteenth century.
Inattention was also specifically discussed: Zerstreutheit
(‘distractedness’, ‘absentmindedness’) denoted the inabil-
ity to voluntarily focus attention, particularly upon the
subject of the teacher’s interest. Such attention deficits
were not invariably associated with hyperactivity and could
refer to both dreamy lack of focus on school lessons, or to a
general lack of sustained concentration. In his classic
definition of the term, the Austrian philosopher–physician
Ernst von Feuchtersleben (1806–1849) described it as:
… an indecision of attention … that corresponds in
mental life to the trembling of the muscles in the
corporeal: an oscillation that indicates that the power
of the soul is not sufficient to act persistently in one
direction, so that rest, relaxation, constant change is
necessary (von Feuchtersleben 1860, p. 47).
Th. Klähr provided a detailed sketch of the distracted child
in an 1886 essay for the Deutsche Blätter für erziehenden
Unterricht (‘German pages for educational instruction’):
Even the external appearance of such a child reveals
the deficit requiring correction. The mercurial rest-
lessness of the entire body, the wandering and
uncertain gaze, the facial features that betray strange
moods are the features of a distracted child that ini-
tially catch one’s eye. Their mental life certainly
shows no tendency to indolent inactivity or reverie, as
seen in lazy children: on the contrary, the mind reg-
isters too many novel impressions without allowing
them to persist, so that the new impression quickly
pushes its fleeting predecessor back below the
threshold of consciousness. Thoughts spring quickly
from one object to another, and even in interesting
activities they dwell only a short time upon the same
points. … No game is initiated without being
abandoned after a short time, no instruction is fol-
lowed without forgetting something. Critical parents
and teachers, for whom such children with their
careless, their hastily executed, carefree, playful
behavior, with their restless sitting and demeanor, are
a constant source of concern and sorrow, sometimes
describe its essence as flightiness, sometimes as
nonsense, at other times as negligence. All these
different expressions can be summed up with the one
word: ‘distractibility’…. [This] volatility of spirit
does not arise periodically, … it is not limited to a
particular activity, but … it gives lends all the doings
of the child a certain character that has become
habitual, or is close to becoming so (Klähr 1896).
Klähr regarded the phenomenon as reflecting a failure of
will: it must be numbered among the moral defects, against
which upbringing is obliged to organize countermeasures-
action. Indeed, where attention is lacking, not only is
achievement of the intellectual aspects of schooling
threatened, but also the goals of moral education. While
congenital or acquired organic factors were probably
involved, as they were in the development of the person-
ality in general, the roles played by the child’s social
environment and by their parents and teachers were at least
as significant: Both those parents who spoiled their child
with excessive indulgence and those whose discipline
disregarded the child’s physical and mental nature were
liable to encourage poor attention. Some of Klähr’s
comments could, in fact, be drawn from the more recent
sources: The craving for pleasure, the desire for the new
and the exciting also draws the world of the children into
their demonic circles. Can we then be surprised if children,
mentally poisoned by premature visits to theaters and all
kinds of exhibitions, by participation in adult amusements,
and by stimulating reading, become incapable of collecting
and controlling their thoughts, of the regular strenuous
work required by their lessons? (Klähr 1896).
One author explained the situation by reference to the
‘psychological mechanism,’ the constant changes in con-
scious perception and thought elicited by sensations that
underlays all mental activity, but which occurs as uncon-
sciously as does breathing or digestion. The child, as a still
only partially developed mental person, is still bound
tightly to the unsteady psychic activity at this lower level
… their mental life is controlled via thousand threads from
the sensory world. It is the goal of the teacher to free the
child from this constant buffeting by their senses (Anon-
ymus 1890; see also Strümpell 1892, pp. 63f.). Münch
(1842), on the other hand, had earlier emphasized the
importance of home life: The higher classes tended
to provide their children with too many diversions, dis-
couraging the development of focused attention and
123

discipline, while children from the lower classes were
dulled by their poor environment or by their employment in
mindless jobs from an early age.
Hermann Grünewald (Herborn, Nassau) published a dis-
cussion of this aspect in 1902 that encapsulated much of what
had been published over the past half century in Germany,
linking pedagogic insights with philosophical consider-
ations. Attention varied across the day, so Grünewald, even
in adults, but even more in younger children, where intrinsic
motor restlessness discouraged focused application; the
construction of the school day must recognize this by not, for
example, switching rapidly between activities, or expecting
children to immediately settle down to work after the
excitement of playtime. The fantasy of the child, combined
with their more immediate response to sensations, required
taming for structured learning to be possible. The home
environment plays a similarly critical role: Grünewald
offered the case of a 10-year-old boy constantly exposed to
the activities of his father’s tavern, so that he was uncon-
sciously trained in distractedness. The discussion in this
paper mostly concerned ‘incidental distractedness’ in
otherwise healthy children, so that Grünewald comments
that it is dubious to even regard it as a problem, but he did
note that in rare cases, it could become ‘habitual’ if steps
were not undertaken to correct the situation; in the one
serious case he had encountered it was combined with
unmistakable symptoms of mania (Grünewald 1902).
Inattention in the medical literature
The nineteenth German educational literature was thus well
acquainted with problems of poor attention and excessive
activity in pre-pubescent pupils, but they were largely
regarded as developmental problems, as issues to be
addressed in the classroom and the home, rather than as
psychiatric conditions.
Similar problems were also seeped gradually into the
medical literature. Scottish physician Alexander Crichton
(1763–1856) provided one of the earliest references to
attention problems in children in 1798, noting that it could
be congenital or acquired; although poor concentration was
attributed to unnatural or morbid sensibility of the nerves, it
was not an insurmountable obstacle to education, even were
it evident from an early age; further, what is fortunate, it is
generally diminished with age (Crichton 1798, p. 271; see
also Palmer and Finger 2001). The English physician John
Haslam (1764–1844) described a spoiled child who had
been raised to be a creature of volition and the terror of his
family, as he wanted the power of continued attention, and
was only attracted by fits and starts, it may be naturally
supposed he was not taught letters, and still les that he
would copy them. His behavior, which so disturbed the boy
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P. B. Foley
himself that he sometimes spoke of suicide, nevertheless
improved after 9 years of age (Haslam 1809, pp. 198–206).
The Breslau psychiatrist Heinrich Neumann (1814–1884)
wrote particularly graphically of the ambiguous feelings
that the hectic child could arouse in their parents:
But one knows another kind of precocious develop-
ment that is more reminiscent of hypermetamorphosis
… Such children have something restless about them,
they are in perpetual motion, highly volatile in their
inclinations, unsteady in their movements (including
chorea!), difficult to get to sit down, slow in learning
the positive, but often dazzling with rapid, brazen
replies. This condition, which conceited mothers
describe as witty, anxious mothers as excited of
course, is certainly not itself a mental illness, but it
must be regarded as a morbid tendency, the conse-
quences cannot be foreseen, and must be seriously
examined with regard to physical and moral educa-
tion (Neumann 1859, pp. 143f).
Neumann’s neologism, hypermetamorphosis, described the
inability to resist a shift in focus elicited by each. The term
was later associated with Wernicke; according to his
concept of the ‘motility psychosis,’ hypermetamorphosis
induced an excessive urge to move (Bewegungsdrang)
(Wernicke 1906, pp. 203f.), but neither Wernicke nor his
successors (Kleist, Leonhardt) appear to have addressed the
issue of hyperactivity in nonpsychotic children.
The German psychiatrist Wilhelm Griesinger, who
famously declared in 1845 that mental disease was brain
disease (1817–1868), described a spectrum of mania-like
behavior in children, at the lower end of which scale was a
form that he distinguished from both folie raisonnante and
moral insanity (to be discussed below):
Sometimes it is also a persistent state, but more
intense: there is greater restlessness, a constant aim-
less roaming, confusion of the intelligence, perver-
sion of the emotions, with excitement which
sometimes passes (with greater impairment of mental
development) into profound mental debility. It is
impossible to categorically distinguish this from the
versatile form of infantile dementia: these are the
children who are never at rest for even a moment,
who chatter incessantly and in a confused manner,
exhibit no attentiveness, always wandering around,
laughing, screaming, etc. (Griesinger 1867, 146f).
These children were at the mercy of sensory impressions;
the prognosis, however, was not bad. The general impres-
sion indeed remains throughout the nineteenth century that
hyperactivity and attention deficits could rarely be consid-
ered pathologic, and were expected, in any case, to regress
with age, so long as the children were not indulged in their
Sons and daughters beyond your control
vices. This contrasts with moral insanity, a concept
introduced by James Cowles Prichard (1786–1848) as an
approximate equivalent to Pinel’s (1806) folie raisonnante:
Moral Insanity, or madness consisting in a morbid
perversion of the natural feelings, affections, incli-
nations, temper, habits, moral dispositions, and nat-
ural impulses, without any remarkable disorder or
defect of the intellect or knowing and reasoning
faculties, and particularly without any insane illusion
or hallucination (Prichard 1835, p. 6).
‘Moral’ originally referred to the ‘passions’ enjoying socially
inappropriate free rein, not to a faculty of conscience, so that
‘moral insanity’ more closely translates as ‘conduct disorder’
in modern parlance, although this distinction had been
gradually occluded by the late nineteenth century. Equally
important was that intellectual defects were explicitly
excluded by the definition. These children, in contrast to
the inattentive and restless, did not grow out of their
condition. Many reviewers of the history of ADHD include
the ‘morally insane’ and other ‘evil’ children (and, in some
cases, hyperactivity in the mentally handicapped) as well as
the hyperactive but morally competent child as earlier avatars
of the ADHD concept (for instance, Rafalovich 2001).
Challenging children relevant to our discussion may indeed
have been included in this category, but discussions by major
authors, particularly in England (where the ‘moral insanity’
concept was particularly strong), but this is not evident to any
significant degree in the European literature.
It is significant that the Freiburg psychiatrist Hermann
Emminghaus (1845–1904) did not depict an ADHD-like
condition in his Psychischen Störungen des Kindesalters,
the first handbook of pediatric psychiatry (1887), although
he did include several pages on ‘moral insanity’ (Em-
minghaus 1887, pp. 231–243). In 1899, the Scottish psy-
chiatrist Thomas Clouston described states of over-
excitability, hypersensitiveness, and mental explosiveness
in children, a state he located on the borderland of psy-
chiatry, and which he linked with an explosive tendency in
cortical brain regions, similar to that of epilepsy and per-
haps linked with asynchronous development, leading to
loss of inhibition by higher centers. The result was exces-
sive responsiveness to internal and external stimuli. The
prognosis was good, but Clouston nonetheless advocated
high-dosage bromide therapy to manage the situation,
together with good nutrition and exercise (Clouston 1899).
Early twentieth century: the rise of neurological models
of behavioral disorders
The major step in the direction of recognizing hyperactivity
and attention deficits as a medical condition more than an
object of psychological analysis has generally been regarded
as the three Goulstonian Lectures presented by George
Frederic Still (1868–1941), the first British professor of
children’s diseases (1906, King’s College, London), to the
Royal College of Physicians in March 1902. Still reported his
systematic study of abnormal psychical conditions in chil-
dren, principally disorders of moral conduct and increased
emotional lability (passionateness), describing antisocial
behavior in three groups of children: those with intellectual
handicaps, those who had suffered an acute febrile disease or
brain injury, and others who had suffered neither. Still
regarded all three groups as displaying similar deficits in
moral conduct, defined as immediate gratification of self in
opposition to the control of action in conformity with the idea
of the good of all, behavior marked by aggression, defiance,
and incorrigibility. In his view, moral deficits were primarily
related to more general disorders of intellect, ‘moral control’
requiring the interaction between three factors—a cognitive
relationship with the environment (in order to develop a
‘moral sense’); the ability to rationally forecast the conse-
quences of an action; volition—and it was a morbid failure of
the last to which Still ascribed the moral deficiencies of
children who retained a moral consciousness, this in turn
perhaps related to exalted irritability of nervous centres,
resulting from cell-modification dependent upon interfer-
ence with cell-nutrition rather than morphological irregu-
larities, for which reason childhood behavioral symptoms
could presage psychiatric disease in the adult. He did,
however, note that physical stigmata suggested early,
otherwise unapparent physical changes. Proposing a physi-
ological basis for behavior was nothing new, being consis-
tent with the, in principle, linkage of psychological processes
with brain function that had commenced in the late nine-
teenth century. Further, there is nothing Darwinistic about
this thought, other than the observation that, as the highest
and latest product of mental evolution, moral control was
also the most fragile (Still 1902).
Some caution is warranted in identifying Still’s
observed conditions with ADHD. Firstly, he was primarily
interested in moral deficits in behavior: His twenty patients
without general impairment of intellect and without phys-
ical disease were not so much hyperactive as inappropri-
ately active, so that it would be more apt to speak of
‘conduct disorders’ or impulsiveness. Attention deficits
were indeed found to be fairly constant, but were only
mentioned in passing as a possible alternative to deficient
‘moral consciousness’ as an explanation for bad behavior.
He described one example of a quite abnormal incapacity
for sustained attention, causing school failure even in the
absence of intellectual retardation:
Another boy, aged six years, with marked moral
defect was unable to keep his attention even to a
123

game for more than a very short time, and, as might
be expected, the failure of attention was very
noticeable at school, with the result that in some
cases the child was backward in school attainments,
although in manner and ordinary conversation he
appeared as bright and intelligent as any child could
be (Still 1902, p. 1166).
The immediate impact of Still’s lectures is also dubious.
He himself did not refer to them in his highly regarded
Common disorders and diseases of childhood (five editions
between 1909 and 1927), where moral defect is only
discussed in connection with epilepsy and convulsions, nor
were they often cited during his lifetime, and then usually
with reference to his description of post-infection character
change. His major aim seems to have been to raise
awareness of the fact that ‘bad behavior’ should not be
automatically condemned as willful or evidence of bad
character, nor should the intelligence of such children be
underestimated; that is, he pleaded for a more differenti-
ated treatment of ‘problem children,’ in order to save those
who could be saved. While recognizing the value of his
observations, they must nonetheless be regarded as part of
the prehistory of ADHD, not as the beginning of its history.
The work of Alfred Frank Tredgold (1870–1952), an
English authority in mental disease, with respect to the
‘moral sense’ essentially expanded upon that of Still
(without citing it), although his more deeply biological
viewpoint saw less of an environmental influence on its
development, consistent with his eugenicist stance. In the
second edition of his much cited work Mental deficiency
(amentia) (1914), he introduced the following in his dis-
cussion of the ‘feeble-minded’, the mildest form of mental
retardation:
In the lethargic, inert type of feeble-mindedness there
is a defect of spontaneous attention; but this is never
so marked in this degree as in the more serious grades
of amentia. The general stir and excitement aroused
by a visitor is much more pronounced in the special
school than in the imbecile ward. On the other hand,
active or voluntary attention is commonly in defect,
both with regard to its intensity and its duration. The
most trifling thing serves to distract these children
from their occupation, so that even where the atten-
tion is readily gained, it is with difficulty held
(Tredgold 1914, p. 167).
The result was impulsiveness and impeded schooling, but
hyperactivity was not a feature of these children. Further,
Tredgold specifically defined these children as typically
requiring life-long specialized care—they are unable to
swim against the stream, or even to keep their heads
above water (p. 172)—so that these were not children of
123
P. B. Foley
normal intelligence. Like Still, he envisaged the possibil-
ity of both congenital (‘psychopathic’ or ‘neuropathic
diathesis’) and acquired defects (in utero and perinatal
injury, infection) and is therefore seen by some as a
harbinger of the 1940s ‘minimal brain damage’ concept of
ADHD-type disorders. While more influential than Still
(Amentia continued to appear in new editions until 1952),
his contribution to the prehistory of ADHD was similarly
minor.
In 1908, Adalbert Czerny (1963–1941), one of the pio-
neers of modern pediatrics, published the first edition of his
popular handbook on the role of the physician in raising
children; neither this nor the following editions refers
specifically to hyperactive or distracted children. The 6th
edition (1922), however, included the description of a
group of difficult to educate children with familiar char-
acteristics: a great need for movement, lack of sustained
application in play and other activities, disobedience, and
deficient ability to concentrate during lessons (Czerny
1922, pp. 107f.). Czerny discerned an interaction of con-
stitution and education in these cases, which he did not
regard as psychiatric in nature.
After the Great War, the Heidelberg psychiatrist August
Homburger (1873–1930) and the Karlsruhe pediatrician
Franz Lust (1880–1939) each similarly underscored inter-
actions between constitutional, psychological, and social
factors in the development of irritability, lack of concen-
tration, and behavioral restlessness in children; excessive
sensory stimulation and poor teaching methods continued
to be cited as contributing factors, so that antisocial
behavior need neither be purely inborn, nor the result in
inadequate parenting (Seidler 2004). In his Vorlesungen
über Psychopathologie des Kindesalters, Homburger also
discussed deficiencies and volition and self-control in
adolescents. The very basis of this instability was the
inadequate emotional core of the personality, the result of
which is a lack of inhibition, cohesion, perseverance.
Instead of reasoning, interests, obligations, principles,
views of the future are supplanted by stubbornness,
impulsiveness and vague desires, all at the mercy of fleet-
ing impressions (Homburger 1926). The solution for these
children primarily involved appropriate training; as Franz
Kramer commented in 1925: the better our parents and
educators [Erzieher], the fewer psychopaths we will have
(in discussion of von der Leyen 1926).
Mikhail Gurewich (1878–1953), director of the Pediatric
Psychiatric Clinic of the Children’s Medical Institute in
Moscow, similarly described in 1925 a frontal motor
condition in infants (3–5 years) that lacked extrapyramidal
signs, including excessive liveliness (excess of drive),
which can be explained by the disinhibition (the frontal
systems subordinate) motor centrality, a crass deficiency of
active attention and a general intellectual insufficiency,
Sons and daughters beyond your control
elevated mood and moria-like conditions, as well as speech
production deficits (Gurewitsch 1925). Hypermotor
syndromes had been recognized as both medical and ped-
agogic problems during the 1920s, and a ‘psychoneuro-
logical sanatorium’ school had provided special programs
since 1919. The authors regarded the problem as having
increased by the 1950s due to a series of factors, including
increased survivability of difficult births and therapeutic
possibilities, as well as improved detection; further,
hyperactivity is not only a school problem: it often becomes
the source of rapidly advancing maladjustment within
the family, the school, and society, and thus is an impor-
tant social problem as well (reviewed: Isaev and Kagan
1981).
Infection and behavioral disorders: encephalitis
lethargica
Awareness of the potential impact of specific external
factors upon behavior via neurologic changes increased
during the 1920s following descriptions of conduct disor-
ders associated with post-vaccination and post-infection
encephalitis, as well as, most dramatically, following
encephalitis lethargica (EL). Between 1917 and the late
1920s, EL was an epidemic, probably viral, neuropsychi-
atric infection. The acute disorder was characterized by
different combinations of cranial nerve palsies, sleep dis-
turbances, and involuntary motor symptoms; mortality was
about 15 %. In children (and some adults) who survived
the acute phase, the following pseudo-neurasthenic phase
was characterized severe psychiatric and behavioral chan-
ges, including impaired voluntary attention, impulsiveness,
emotional lability, precocious sexuality, self mutilation, a
tendency to wander, and delinquency, often to a degree
requiring confinement in psychiatric or penal institutions,
appeared in various constellations in children who had
previously not attracted attention in this way. Neither
intelligence nor memory were impaired, but sleep was
commonly affected: The children tend to be overactive
through the night but slept through most of the day. In the
few cases that came to autopsy, neuropathology was con-
fined to the brainstem and was not markedly different to
that associated with post-encephalitic parkinsonism in
adults; that is, the cerebral cortex was spared (reviewed:
Stern 1936). There was also later some suggestion that
involvement of the region implicated in ‘sham rage’ in
animals might be implicated (Le Gros Clark 1938).
Disobedience, rudeness, constant silliness and lack of
seriousness, brazenness: such symptoms might be dis-
missed as ‘children being children,’ but their significance
in EL children was their combination with more serious
conduct problems: erethism, amoral tendencies, the
continuous irritation of all around them, none of which
were more than momentarily reduced by the harshest dis-
cipline or the most passionate pleading. The severity of the
behavioral symptoms often exceeded anything that could
be dismissed as ‘youthful energy’ or simply ‘difficult
children,’ or even as defiance of social conventions. The
spectrum of behaviors regarded as ‘abnormal’ may have
been broader in the 1920 than in 2014, and many cases
were less criminal than irritating, but these behaviors were
not simply disagreeable for parents and medical practitio-
ners, but also for the child who had never previously
behaved in this manner and who even now often experi-
enced them as foreign to their ‘selves.’ Doctors also noted
that although children suffering post-encephalitic psychi-
atric disturbances could exhibit the cruelest behavior—
removing their own eyes or killing a sibling—they exhib-
ited genuine remorse after the fact, and claimed to have
been compelled to act as they did. The ultimate fate of such
children could hardly be more tragic: their behavioral
problems receded during their early 20s, only to be
replaced by rapidly advancing parkinsonism from which
there was no recovery (reviewed: Anderson 1923; Leyser
1924; Homburger 1926, pp. 451–462; Thiele 1926;
Borthwick 1927; Proby 1939; Fairweather 1947; Vilensky
et al. 2007).
The behavioral syndrome was all the more frightening
for all concerned because it sometimes included features of
congenital psychopathy, a term then supplanting ‘moral
insanity’: the combination of unimpaired intelligence with
apparent ethical nihilism meant that the children pursued
their anti-social activities with a certain refinement and
sometimes managed to astutely conceal their misdeeds …
such patients can become the worst of vexations with which
one must contend. The onset of largest epidemic of the
disease which makes criminals (The Times: Medical cor-
respondent 1924), in the United Kingdom in 1924, caused a
great deal of public and political concern, building on
previous disquiet in nations as different as the United
Kingdom, Germany, and the Soviet Union that delinquency
in general had increased since the War. EL was cited in the
defence of youths arraigned for various crimes during the
1920s, and its effect on adolescents was the subject of
parliamentary debate and government enquiries. Special
institutes for the care of such children, with varying suc-
cess, were established in various countries, including
Germany, France, the United Kingdom, and the United
States. On the other hand, EL-related character change of
degree that seriously threatened the safety of others was not
as common as some literature suggests. Even Arthur Hall
(1886–1951)—who coined the denomination ‘apache type’
to describe such children—noted that they were atypical,
but were all the more visible because of their potential for
criminal activity (Hall 1925). The most common type,
123

however, consisted of his ‘super-difficult’ children, who
could also engage in activities that brought them to the
attention of the police, but were more likely to be patho-
logically unsocial creatures.
The EL behavioral syndrome was described wherever
EL was encountered, but the most systematic investigations
were conducted in Germany, particularly at the Charité in
Berlin under Karl Bonhoeffer (1868–1948), who suggested
that a discordance between cortical and subcortical func-
tion underlay the unprecedented character change (Bon-
hoeffer 1922), presaging more recent models of reduced
impulsive control, despite differences in the details.
Important studies were undertaken here by Rudolf Thiele
(1880–1960), who explained the problem in terms of
Drang:
By Drang we mean a primarily utterly amorphous,
objective and non-directional discharge tendency that
represents, with regard to its mental representation,
an impassionate restlessness and tension, and that
only in its impact through its manipulation of the
object or as the result of interference with directed,
intentional actions assumes the form of a specific
action with content. … One can formulate this rela-
tionship briefly in this manner: The will selects its
object, the drive [Trieb], due to its inherent direct-
edness, seeks its object, and the inherently goal- and
directionless, ‘‘blind’’ Drang finds its object, i.e. it
interacts with whatever object is available. It lacks, at
least primarily, an imagined or otherwise mentally
represented motive. The most primitive manifestation
of Drang presents itself as a general, chaotic motion
unrest (Thiele 1926, pp. 55f.; see also Thiele 1953).
In any case, EL triggered behavioral changes in children
that are not duplicated by any other neurological condition,
with the possible exception of traumatic brain injury; in
particular, the dark fissure that opened between the EL
sufferer and their urges was rarely again described, an
puzzling separation of the person from their actions (which
does not exclude the possibility of its being encountered
but not acknowledged). It was this phenomenon that
endowed the syndrome with its sinister eeriness, the baleful
malignity that horrified the powerless parent who asked the
marginally less helpless neurologist whether they would
ever see ‘their’ child again, with much the same trepidation
that parents once sought the services of an exorcist.
Therapeutic approaches ranged from special training in
dedicated institutions to frontal leucotomy. The EL expe-
rience of the 1920s inspired a multifaceted discussion of
the role played by the brainstem in psychological processes
as well as in psychiatric disorders, including psychosis and
hysteria in adults. as well as providing a large number of
children and adolescents exhibiting excessive psychomotor
123
P. B. Foley
activity, thereby shaping emerging the concept of the
‘hyperkinetic child.’
Charité, Berlin: The Kramer–Pollnow hyperkinetic
syndrome
The EL epidemic had largely ebbed by 1930, when Franz
Kramer (1878–1967) and Hans Pollnow (1902–1943),
also of the Psychiatric-Neurologic Clinic at the Charité,
described a ‘hyperkinetic syndrome’ in children, charac-
terized by persistent movement, climbing, handling of
objects, reduced concentration, and delayed speech
development; epileptic fits were also common at the
onset. The disorder commenced between the ages of 3
and 4 years and then declined gradually from the age of
six, whereafter the previous intellectual and speech defi-
cits were largely compensated. The authors presented
several examples, including a monozygotic twin whose
brother was free of the disorder, suggesting that it was
probably caused by infection or other external agent; the
only autopsy had found evidence of EL-like brainstem
changes (Kramer and Pollnow 1930). Nearly 2 years later,
Kramer and Pollnow published their results in detail,
including reports on 45 children seen between 1921 and
1931, 15 of whom had been followed for several years.
They noted that Wernicke had presented a similar case in
1901 as an example of his ‘motility psychosis’ (Kramer
and Pollnow 1932).
The symptoms of the syndrome were very similar to
those of the EL syndrome, and the authors conceded that
most differences were more quantitative than qualitative;
some cases even included typical somatic symptoms, such
as hypersalivation. But there were also subtle differences:
The restlessness of the Kramer–Pollnow syndrome was
more chaotic, for example, and hyperactivity was similar
throughout the day rather than nocturnal. Critical, however,
was the absence of neurological signs in the Kramer–
Pollnow children, particularly the absence of both oculo-
motor and extrapyramidal phenomena. Their hyperactivity
could give the impression of severe intellectual deficits, but
the observations of Kramer and Pollnow suggested to them
that the intellect was less severely affected than it
appeared; their perception and memory were, in fact,
excellent. The Kramer–Pollnow report thus further sup-
ported the concept that antisocial behavior need not be
inborn, nor the result in inadequate parenting. While dis-
tractibility, hyperkinesia, and impulsiveness were key
features, other characteristics are not as easy to reconcile
with more recent view of ADHD: the strong association
with convulsions or epilepsy during epilepsy, early speech
production deficits, the regression of symptoms by age
seven.
Sons and daughters beyond your control
Immediate reaction to the Kramer–Pollnow report was
mixed. The Zentralblatt review of the 1932 paper by Julius
Hallervorden was extensive and neutral (Hallervorden
1933), but Hans Heinze (1895–1983), Assistant Physician
to Paul Schröder (1873–1941) in Leipzig—recently
described as the centre of European child and adolescent
psychiatry (Angermeyer und Steinberg, cited by Rothen-
berger and Neumärker 2005, p. 110)—argued that Kramer
and Pollnow had seen nothing but a reaction elicited by any
of a number of organic brain processes (Heinze 1932),
missing the point of the Kramer–Pollnow paper that there
existed a distinct, reversible childhood hyperactivity syn-
drome, the number of cases of which had remained fairly
constant across the 1920s, uninfluenced by the rise and fall
of EL. Wilhelm Lange (1894–?) in Chemnitz was more
sympathetic, declaring that Kramer-Pollnow children were
easier to identify when, as in his unit, their presentation
could be directly compared with EL (Lange 1933).
The further reception of the concept was somewhat
confused: When it was cited over the next quarter century
was often misinterpreted as a form of encephalitis, epi-
lepsy, or schizophrenia—Lay (1938) devoted two pages of
his paper on childhood psychosis-like disorders to their
‘hyperkinetic disease,’ while Parsons and Barling’s Dis-
eases of infancy and childhood (Parsons et al. 1954)
mentioned it as a form of childhood psychosis, their only
discussion of hyperactivity (see also Strömgren 1947;
Creak et al. 1952) or as a variant of Heller’s dementia
infantilis; there was even one report of possible Kramer–
Pollnow syndrome without hyperactivity (Everberg 1957).
As late as 1961, however, the British Medical Journal
recognized their contribution, although conflating it with
‘moral insanity’:
In the hyperkinetic syndrome, first described by F.
Kramer and H. Pollnow, the child may be cold, cruel,
ruthless, destructive, and difficult to contact emo-
tionally, but the condition is distinct from schizo-
phrenia: about 50 to 60% have epileptic fits or
electroencephalographic evidence of focal lesions,
and many of the remainder probably have some more
subtle cerebral anomaly. The disturbance often
becomes attenuated with advancing age and the
prognosis is better than in autistic children (Anony-
mus 1961).
This situation is partly explained by the vicissitudes visited
upon by the two Jewish authors after 1933, impeding their
further research, and neither returned to their syndrome
(see Neumärker 2005; Rothenberger and Neumärker 2005),
partly by the fact that the new syndrome was overshad-
owed by the seemingly more numerous EL cases. From the
1930s, ‘post-encephalitic behavior disorder’ was indis-
criminately employed, particularly in the United States for
any behavioral disorder that followed childhood infection,
thereby pooling completely different types of neuro- and
psychopathology (see, for example, Anderson and Mambar
1939; Levy 1959).
The sociologist Adam Rafalovich, amongst others, has
argued that this period consolidated an increasing drive to
medicalize unconventional childhood behavior (Rafalovich
2001); Lantéri-Laura and Gros (1982) argued that the
‘hyperkinetic syndrome’ was essentially invented by child
psychiatrists in the 1920s as a means for distinguishing
their nascent field from other areas of medicine. The social
aspects of both the origins and consequences of the EL
syndrome, in particular, were, however, far from neglected.
The suggestion that physicians never asked about the
social variables (Rafalovich 2001) affecting childhood
behavior ignores the pools of ink devoted to describing the
social backgrounds of affected children and discussing the
impact of crowded housing, the parents’ mental and social
problems, the child’s prior diseases, and other factors.
Further, consideration of social factors played critical roles
in the medical and legal approaches to behavioral prob-
lems. Although the children were diagnosed in institutions,
EL children were transferred to institutions specifically
because they had proved intolerable in their homes; their
conduct often improved during institutional care, but
deteriorated once discharged. Further, the examples cited
by Rafalovich also give the impression that merely naughty
children were being institutionalized. This ignores several
critical features of their behavior: that it represented a stark
contrast with their pre-EL personality; that it was regarded
as so extreme that parents sought official help in an era
when there were less restrictions on the punitive actions
they could legally adopt; that the children themselves were
often distressed by their behavior and their lack of control
over it; that this behavior could escalate with age to include
violent crimes, including rape and murder; that these
children ultimately succumbed to parkinsonism. To regard
these children as victims of a need to ‘medicalize’ deviant
behavior is to miss the point entirely: These were unhappy,
driven children who derived little or no pleasure from their
misadventures. It may be unpalatable, but neurological
disease can so radically modify both cognitive functions
and personality that the pre-disease personality of the
sufferer can be difficult to recognize, or recover.
The hyperkinetic syndrome in older children
and adolescents
Shortly after Pollnow and Kramer reported their syndrome
in detail, Emil von Lederer and Stephan Éderer (University
Pediatric Clinic, Budapest) described a hypermobility
neurosis of childhood that resembled in many features the
123

Kramer–Pollnow syndrome, but curiously affected those
between 7 years of age and puberty; without apparent
reason, the child was suddenly restless, their schoolwork
suffered, their mood changed, and their speech was
impaired, while intelligence was untouched; extrapyrami-
dal symptoms could also be presented:
Apart from nighttime rest, which is usually undis-
turbed, the child does remain quiet for even a second.
They scuttle back and forth, they don’t walk but run,
instead of sitting quietly they shuffle around on their
chair, they kick against the table, chair etc. Even their
hands are never still, touching everything unneces-
sarily and without thought. Facial expressions are
lively, their speech hasty and unconsidered. … the
previously more or less industrious, obedient student
does not follow his lessons, they make no progress,
and their constant restlessness and talkativeness dis-
turbs both teachers and classmates. The parents also
notice that the child is unable to apply themselves to
any task for an extended period, that the usual street
noise suffices to lure him to the window, that his
attention is distracted by the slightest disturbance. …
He likes to run around aimlessly, climbs on furniture,
fences, trees; sometimes he almost breaks his neck
because his awkwardness has increased. … Their
mood has also changed: The formerly friendly, easily
controlled child is ill-tempered, impatient, moody; it
has a tendency to tears, but can abruptly switch to a
sunny mood (von Lederer and Éderer 1934).
The incidence of the syndrome was found in 424 urban
school children to be 9 %, but in most instances, the
symptoms disappeared by puberty at the latest; in others,
symptoms were so mild as to attract little attention, while,
in contrast, Lederer and Éderer warned that the complaints
of the parents are exaggerated, as they are irritated even
by the natural mobility and exuberance of their healthy
child.
Similar cases were described in Italy by Sante de Sanctis
as ‘dysthymic children,’ including symptoms such as
undirected behavior, slowness, apathy, inactivity, absence
of emotional delicacy, and also by positive signs: impul-
siveness, psychomotor agitation and choreiform move-
ments, general restlessness, excitability going up to
compulsive talking, refusal to work, tears and laughs pro-
voked by the slightest stimulants, sleep troubles, erotism,
wandering (de Sanctis 1923, 1934). Both Pollnow/Kra-
mer’s and de Sanctis’ cases, which he interpreted as an at
least partially hereditary metabolic disorder, were cited by
Austrian psychiatrist Hans Hoff (1897–1969) in his article
on ‘hyperkinetic disorder’ in his 1956 textbook of psy-
chiatry (Hoff 1956, p. 544).
123
P. B. Foley
Interestingly, Kramer had previously reported a disorder
under the name haltlose Psychopathen (‘unstable psycho-
paths’) characterized by indecision and impulsivity that
was typically manifested as the person commenced work-
ing life: The unstable person is drowned in the momentary
situation and he changes purpose with the slightest change
of external situation. Sufferers initiated plans of action, but
could not lead them to completion, as automatic series
required constant and considerable voluntary effort, and
this could not be maintained. Internal restlessness also
caused a need of activity, but lacking in direction; impul-
sivity and momentary decisions led to ill-considered
actions. This was combined with internal sense of superi-
ority to others that was, however, combined with feelings
of insufficiency, and together with their heightened sensi-
tivity, this typically resulted in failure in employment and
social withdrawal (Kramer 1927).
The ‘hyperkinetic child’ (and persistence of certain
aspects of the syndrome into early adulthood) was thus a
recognized phenomenon in Europe by the early 1930s, but
was clearly not yet regarded as a major problem for psy-
chiatry (it rarely rated a mention in handbooks prior to the
1950s, while German neuropsychiatrist Theodor Ziehen
(1862–1950), for example, discussed attention deficits in
his Outline of physiological psychology (Ziehen 1924)
without referring to their occurrence in children, although
he had previously contributed a handbook article on
‘pathological restlessness’: Ziehen 1909), but rather as an
issue that was resolved by puberty or, in more difficult
cases, by specific educational, ‘character-forming’ mea-
sures. It is nonetheless somewhat surprising that it did not
attract more attention, given the great interest during early
twentieth century in psychomotor function and correlations
(see, for instance, Kleist 1908; Dupré and Merklen 1910;
Kleist 1927).
In the United States, Eugen Kahn and Louis Cohen
(Yale University School of Medicine) described the same
phenomenon in 1934 as organic drivenness, or a surplus of
inner impulsion, and similarly saw it as a symptom that was
not pathognomic for any one disorder (two of his three
examples were children, 8 and 11 years). Its biological
basis was brainstem dysfunction, one of the two regions
(the other being the cerebral cortex) they regarded as most
important for superior mental functioning; extrapyramidal
symptoms were also presented (tics, choreiform move-
ments) (Kahn and Cohen 1934). Wilmot Schneider
(Cleveland, Ohio) was also familiar with the hyperkinetic
child in 1944:
It matters not whether we are teacher, parent, school
or private physician—we are all familiar with the
hyperkinetic child. Many of you may not recognize
Sons and daughters beyond your control
him by that name. Some of you may know him as the
‘‘nervous’’ child, or as the one who ‘‘never sits still’’;
others call him hypomanic or the ‘‘fidgety child.’’ …
restless, overactive, aggressive, distractible children
whose behavior includes inattention, flightiness of
ideas, an explosiveness of motor output; those whose
behavior in the school, home, and doctors’ examining
rooms includes unpredictable, impulsive behavior,
hair-raising ‘‘getting into everything’’ (Schneider
1945, p. 559).
Schneider emphasized the organic roots of this behavior,
but nonetheless recognized social and psychogenic
contributors:
We must know him or her as a psychobiologic unit;
an integration of the psyche (emotions and intelli-
gence) and soma (physicochemical components,
endocrine, allergy) being acted upon by the total
environment (home, school, society) and in turn
having an effect, as a personality, on this environ-
ment (Schneider 1945, p. 560).
While the focus was on hyperactivity, its association with
poor attention was also noted by some authors: A.
T. Childers (Cincinnati, Ohio), for example, found that
neurological signs were not always present in hyperactive
children, but that difficulty to hold his attention, short
attention span or excessive divertibility was evident in 22
of 30 cases; part of the child’s over-activity as he
constantly sought new experiences or gave himself up to
uninhibited curiosity. Other prominent features included
talkativeness, boastfulness, and poor sleep. Childers main-
tained that social and environmental factors were insuffi-
ciently considered in the discussion of the nature of
childhood overactivity (Childers 1935).
Minimal brain damage
Tredgold had noted that in milder cases [of asphyxia dur-
ing birth], the initial symptoms may rapidly pass off and it
is only when the child begins his schooling that deficiency
is noted (Tredgold 1914, p. 229). This was largely over-
looked until the mid-1920s, when EL raised awareness of
the potential impact of brainstem injury upon personality
and behavior, and major publications provided diverse
examples of both specific and less specific impacts of
different types of head injury incurred during the First
World War. A number of major examinations of perinatal
brain injury were also published during this period (for
example, Ehrenfest 1922; Doll et al. 1932).
The argument that brain damage released lower brain
regions from inhibition by higher control, leading to the
presentation of more primitive, uninhibited behavior, had
been suggested by the EL behavioral syndrome, and applied
to hyperactivity in children in general. Interest moved to the
cerebral cortex during the 1940s, with comparisons of
hyperkinetic behavior in children compared with that of
monkeys following frontal lobe ablation, or in children who
had suffered frontal lobe trauma (Levin 1938). Further,
Kramer and Pollnow were not alone in their association of
the hyperkinetic behavior with epilepsy: abnormal or ‘epi-
leptoid’ type EEG patterns had been identified in more than
half the children with behavioral disorders but no other
evidence of CNS dysfunction or insult (Jasper et al. 1938;
see also later publications by Bradley, reviewed by Bau-
meister et al. 2012), a finding confirmed by later studies (for
example, Ingram 1956; Knobel et al. 1959; Anderson 1963;
Satterfield 1973; Loo and Barkley 2005).
During the 1940s, the American educationist Alfred
Strauss (1897–1957) and colleagues explored personality
and problems of mental processing in the brain-injured
child, initially in patients with marked intellectual deficits:
A brain-injured child is a child who before, during, or
after birth has received an injury to, or suffered an
infection of the brain. As a result of such organic
impairment, defects of the neuromotor system may be
present or absent; however, such a child may show
disturbances in perception, thinking, and emotional
behavior, either separately or in combination (Strauss
and Lehtinen 1947, p. 4).
That is, ‘brain damage’ was determined on the basis of test
performance, not upon neurological evidence of an insult.
Deficient attention and hyperactivity were only briefly
touched upon in the volume generally cited as establishing
the ‘minimal brain damage’ concept—Strauss was more
interested in learning and perceptual deficits—but it none-
theless led to increased interest in ‘hidden’ brain damage as
underlying not only hyperactivity in children, but all
childhood learning, perceptual, and behavioral difficulties.
The major problem with this model was that Strauss and
colleagues proposed that all brain lesions, wherever
localized, are followed by a similar kind of disordered
behavior (Strauss and Lehtinen 1947, p. 20), and that the
various behavioral and learning difficulties they had
described were merely variants of this one response; con-
versely, another commentator opined that there was a
striking similarity in the behavior of all hyperactive chil-
dren regardless of the cause of the hyperkinesis (Russell
1942). Gesell and Amatruda (1941) similarly commented
that The concept of minimal injury has been gradually
forced upon us by our clinical experience with atypical
infants. … In obscure or doubtful cases the following is a
safe rule: Do not assume that there has certainly been a
cerebral injury, but assume that every child who is born
123

alive has run the universal risk of such injury (p. 231).
Further, there was no neurophysiological explanation that
provided a link between the presumed ‘brain damage’—it
is notable that the term ‘brain damage’ in this context was
used primarily by psychologists, not neurologists—and
specific learning difficulties or behaviors. The concept of
‘minimal brain damage’ was, however, not quite as
abstruse as it might first appear: It was, in principle, a
natural extension of the search for neuropathology under-
lying major psychoses and other psychiatric disorders,
combined with the evidence provided by encephalitis
lethargica, wartime injuries, and other phenomena causing
brain injury are often associated with attention deficits and
motor activity. Further, the catastrophic psychiatric and
neurological symptoms had occurred following ‘silent’
infections with EL and epidemic polio; Ramsay and Young
(1963)argued similarly that EEG changes following rubella
and measles were more common than would be suspected.
Even today, it has been suggested that most instances of
encephalitis remain undiagnosed (Davison et al. 2003). In
1959, Knobloch and Pasamanick wrote in compromise, on
the basis of a study of 500 behaviorally challenging chil-
dren that found a higher presentation of neurological
abnormalities than in 350 control children, that a a con-
tinuum of cerebral damage ranging from severe abnor-
malities, such as cerebral palsy and mental deficiency, to
minimal damage. This haziness was reflected by the
absence from major child psychiatry texts of the hyperki-
netic syndrome as late as 1969.
In any case, the assumption that mental, emotional,
motor, and behavioral abnormalities in children were
attributable to undetected brain damage was widely
explored during the 1950s, whereby it was not applied only
to the hyperkinetic syndrome: It is protean but the form
that it most commonly takes is seen in the child who is
clumsy, writes badly and slowly, lacks concentration and
has slow reactions (Editorial 1964). The problem, indeed,
arose that the specific ‘hyperkinetic syndrome’ was partly
subsumed into this ‘brain damage’ syndrome, leading to an
confused, undifferentiated view of such disorders
(reviewed: Kessler 1980). There were certainly reports that
hyperkinetic behavior was often associated with preterm
births, and other complications of pregnancy were partic-
ularly common in the history of hyperkinetic children (for
example: Knobloch et al. 1956), but were not specific
indicators. As American child psychiatrist Leon Eisenberg
(1922–2009) later commented (1964), one is tempted to
conclude that brain damaged is the expletive uttered by the
clinician vainly trying to restrain for examination a
writhing whirling miniature dervish.
This is not to say that there was no evidence for brain
abnormalities in hyperkinetic children: Mauricio Knobel
and colleagues (Kansas), for example, reported EEG and
123
P. B. Foley
psychoneurologic test findings that were interpreted in
favor of frontal lobe dysfunction, possibly of biochemical
rather than neurological nature, resulting in release from
inhibitory input (Knobel et al. 1959). Knobel (1959) argued
that a purely diencephalic problem would produce a more
complicated symptomatology than seen in ‘acting out’
(impulsive, aggressive hyperactivity), perhaps remember-
ing the picture seen in EL children.
The surprising effects of amphetamines: the roots
of an unresolved controversy
The quasi-neurological approach was reinforced by the
initially little heeded findings of Charles Bradley
(1902–1979) regarding the seemingly paradoxic effects of
amphetamines in children with behavior problems at the
Emma Pendleton Bradley Home on Rhode Island (USA).
The effects of Benzedrine (racemic amphetamine; 10 mg
as single daily dose) were trialled in thirty children (5–14-
years old) over 3 weeks, presumably because of the
recently reported effects on mood in performance in adults
(stimulation of choroid plexus function would be an unli-
kely motivation). The scholastic performance of 15 of the
29 school age children improved in spectacular manner
while taking the drug, with a notable increase in drive; 15
children who had previously burdened their environment
with noisy, aggressive, domineering behavior were now
less moody (subdued) and more sociable, but of these only
eight were those whose schoolwork improved. Bradley
extended his study to 100 children over subsequent years,
most diagnosed with behavior disorders of psychogenic
origin but also including neurological cases, with the
median dose raised to 20 mg/day; 54 children were sub-
dued and 19 stimulated; 50 of the 84 school children
improved in scholastic performance. Bradley recom-
mended the drug as useful for some children with behav-
ioral problems for improving their sense of well-being and
voluntary control, but also commented that it could not
replace alleviation of the child’s environment or psycho-
therapy (Bradley 1937; Bradley and Bowen 1941; recent
review: Strohl 2011).
This approach was little applied elsewhere until the
1950s; while ethical reservations regarding the use of
psychotropic agents in children were not unknown in the
1940s, the general abuse potential of amphetamines in
adults had also caused sufficient alarm to provoke restric-
tion of their availability (Staehelin 1941). The dominance
of psychoanalysis in post-1945 American psychiatry also
played a role.
The effectiveness of amphetamines in dampening
hyperkinetic behavior played a significant role in the
ongoing investigation of this symptom. For example, when
Sons and daughters beyond your control
Maurice Laufer and colleagues published their investiga-
tion of the ‘hyperkinetic impulse disorder’ and the benefits
of amphetamine therapy (see below), it was at a time when
poor parenting was regarded as the major problem in
poorly behaved children (Knobloch and Pasamanick 1959
pointedly commented that Behavior problems in children
have been ascribed to tension in their mothers, but the
likelihood that an infant with difficulties produces tension
in his mother needs serious consideration). Laufer sus-
pected that abnormal activity of the reticular activation
system might be involved, and applied Gastaut’s photo-
metrazol stimulation test to test this hypothesis: He found
that hyperkinetic children were more sensitive those with
emotional disturbances to metrazol, and that this difference
was abolished by administration of amphetamine. The
authors concluded that poor sensory filtering at the level of
the thalamus flooded resulted in overactivity (Laufer et al.
1957).
A number of other agents had been recommended by
this time, including methamphetamine, tranquilizers, and
several antihistamines, but none had proved as satisfactory
as amphetamine (Laufer and Denhoff 1957). One, how-
ever, would ultimately prove to be the most popular option:
methylphenidate, or Ritalin, first synthesized in 1944, but
commercially released in 1954 as an alternative to Ben-
zedrine with fewer untoward side effects (Panizzon 1944;
Meier et al. 1954). Following a successful trial in 108
children and adults (mean age of 15 years) with emotional
problems, it was approved by the FDA for the treatment of
childhood behavioral disorders in 1961. The first clinical
study restricted to hyperkinetic children (Knobel 1962:
infantile hyperkinetic syndrome) and a double-blind, pla-
cebo-controlled study in which parents and childcare
workers rated behavior (Conners and Eisenberg 1963)
provided further support for its employment as an adjunct
to psychotherapy and family counseling. Most research in
the following years was sponsored by the NIMH, as
pharmaceutical firms were uneasy about perceptions of
pediatric psychopharmacology; Ritalin was, indeed, one of
the first agents specifically examined in this age group. It
was not until the 1970s that it displaced amphetamine as
the first choice agent in this regard; Wender commented in
1971 that it was more expensive than Dexedrine, and that
its duration of action was shorter; on the other hand, some
children responded to Ritalin and not to Dexedrine, and
vice versa (Wender 1971, p. 105). Access to the agent,
however, was tightened at this point following reports of its
misuse as a recreational drug; this coincided with increased
restrictions being imposed upon amphetamines for the
same reason (Diller 1996; Mayes and Rafalovich 2007).
The effectiveness of stimulants on certain aspects of
problem behavior contributed to focusing upon these
aspects that became key features of ADHD as it is now
defined, but, as we have seen, both hyperactivity and
attention deficits were objects of psychiatric and other
medical discussion before stimulant therapy achieved
widespread acceptance. Further, the long-held impression
that the benefits of stimulant therapy were restricted to
those with non-neurological hyperactivity (Knobel et al.
1959) was long dubious, and was finally dismissed by the
close of the 1980s (Rapoport et al. 1980). Their employ-
ment remains controversial, some arguing that they repre-
sent the application of medical knowledge for purposes of
social control; this argument also flows into doubts that
ADHD itself is nothing but a political construct for de-
monizing inconvenient childhood energy. From Bradley
onwards, however, even advocates of stimulant use
emphasized their roles as adjuncts to psychotherapy (see
Eisenberg 1971 for discussion at the beginning of the
ascendancy of methylphenidate). These issues cannot be
further discussed here and can certainly not be settled by
appeal to history (review of amphetamine therapy until
1970s: Schmutz 2004).
Renaissance of the hyperkinetic syndrome
A return to the brainstem in different guise was proposed
by Maurice Laufer during the 1950s, whose investigations
suggested that in the ‘hyperkinetic impulse disorder,’ as he
dubbed it—characterized by hyperactivity; short attention
span and poor powers of concentration; irritability;
impulsiveness; variability; and poor school work (Laufer
et al. 1957)—insufficient sensory filtering at the dience-
phalic level led to overactivity in the reticular activation
system and hence to flooding of the cortex with
impressions:
… hyperactivity is the most striking item. This may
be noted from early infancy on or not become
prominent until five or six years of age. There are also
a short attention span and poor powers of concen-
tration, which are particularly noticeable under
school conditions. Variability also is frequent, with
the child being described as quite unpredictable and
with wide fluctuations in performance. The child is
impulsive and does things ‘‘on the spur of the
moment,’’ without apparent premeditation. Out-
standingly also these children seem unable to tolerate
any delay in gratification of their needs and demands.
They are irritable and explosive, with low frustration
tolerance (Laufer et al. 1957).
Laufer was aware that there was no evidence for brain
damage apart from the behavioral syndrome in many of
these children, and emphasized that amphetamine therapy
was only appropriate in combination with psychotherapy.
123

In the same year, Leon Eisenberg (Johns Hopkins
Hospital, Baltimore) singled out hyperkinesia and attention
deficits among the most fundamental features of behavior
in his description of the psychiatric implications of brain
damage in children (Eisenberg 1957), while in 1962, Heinz
Prechtl (Groningen; b. 1927) described a choreiform syn-
drome consisting of specific muscle contractions, as well as
behavioral problems, including hyperactivity and specific
learning difficulties (Prechtl and Stemmer 1962; see also
Lemke 1953; Wieck 1957).
There were thus two separate but overlapping concepts
by the end of the 1950s: that of mild brain damage, and that
of the hyperkinetic child. Both Laufer and Eisenberg have
been credited with the introduction of the concept of the
‘hyperkinetic child’ or ‘hyperactive child’ (including
Barkley 2006), but even Laufer’s ‘hyperkinetic impulse
disorder’ can only be seen as the provisional culmination of
developments underway in Europe and elsewhere since the
1920s. Part of the confusion arises from the terminology:
‘hyperkinetic behavior’ itself was interpreted both as a
symptom and as a specific (in the minds of those who used
it) syndrome, the former view having predominated in the
USA until the early 1960s, the latter reflecting more the
European viewpoint. Further, Laufer, for example, regar-
ded his syndrome as typical for [all] those with mild brain
damage, whereas Europeans regarded the hyperkinetic
syndrome as more distinct. ‘Minimal brain dysfunction’
(MBD; the successor concept to minimal damage) and
hyperactivity apparently widely confounded as late as the
mid-1970s:
… despite the interchangeable use of MBD and
[hyperactivity] in public discussions, the two cate-
gories are not identical. For one, MBD children are
not always hyperactive, although most are. Secondly,
hyperactive children do not always have a learning or
perceptual disability, although most do (Safer and
Allen 1976, p. 6).
The very concept of ‘hyperactivity’ differed between North
American perceptions, where it referred to a unusually high
levels of motor activity that disturbed those around the
child, while in Europe drivenness and extreme excessive-
ness were required (see, for example, Barkley 2006).
A specific hyperactivity syndrome without etiologic
assumptions
In 1960, Stella Chess (1914–2007) noted that Hyperactivity
is one of the common manifestations of disturbed child
behavior. … Even when it is not mentioned initially by the
individuals offering complaints about the child, hypermo-
tility often is numbered among the prominent issues which
123
P. B. Foley
bring a youngster to a psychiatrist for diagnosis and
treatment. Chess explicitly placed more emphasis on
behavior instead of brain damage in defining the physio-
logical ‘hyperactive behavior syndrome’—where the child
carries out activities at a higher than normal rate of speed
than the average child, or who is constantly in motion, or
both—and at the same regarded the prognosis as less dark
than had been usual since the War; Chess associated the
syndrome with neither brain damage nor poor parenting.
Behavior modification techniques, special education, and
psychotherapy, as well as stimulant medication as last
resort, were appropriate, but the disorder could simplify
rectify itself by puberty. She was not, however, specifically
referring to ADHD, but rather to a syndrome of hyperac-
tivity presented in a range of children with different
underlying problems (Chess 1960).
Concepts of ‘minimal brain damage’ were largely
introduced in an educational–psychological context and
referred more to perceptual and performance deficits than a
specific neuropsychiatric syndrome. It would, however, to
be mistaken to believe that the ‘hyperkinetic child’ was
overly vague: The picture gleaned from the literature
changes little over 50 years, as exemplified by a descrip-
tion in 1972:
The ‘‘syndrome of the hyperkinetic child’’ may thus
be summarized as a youngster, usually male, who is
overly active for his age and whose actions are often
impulsive, random, purposeless, and at times per-
severative. His attention span is strikingly short; he
appears to flit from one task to another, completing
few. He is easily distracted, seemingly responding to
each and every stimulus in his environment. His
emotional swings are great, so that he is overly
affectionate one moment and biting and kicking the
next. He appears to test continually the limits of his
environs and seems oblivious to punishment (Gro-
over 1972).
The issue of whether hyperactivity should be seen as the
cornerstone of a specific syndrome, or rather as a symptom
encountered in a variety of contexts, remained nonetheless
unresolved. The contours of a specific hyperactivity syn-
drome were hazed by the broader, not unreasonable concept
that a range of minor neurodevelopmental defects could
have consequences ranging from subtle sensorimotor and
behavioral consequences to profound mental deficits. This
lack of definition was perceived as increasingly unsatisfac-
tory during by the early 1960s, as the desire for definitive
catalogs of defined psychiatric conditions, analogous to the
International Classification of Diseases (ICD) of the World
Health Organization, became louder. The ICD had included
the category ‘primary childhood behaviour disorders’(item
324) since 1948 (the 6th edition: the first to classify diseases,
Sons and daughters beyond your control
not causes of death; World Health Organization 1948,
p. 124), while the American Standard classified nomencla-
ture of disease (1933, 1935) had allowed the possibility of
including ‘over-activity’ as a specifier in the diagnosis of
‘primary behavioral disorders in children, neurotic traits,’ a
diagnosis applicable to children of any age to 19 years,
alongside tics, stammering, nail-biting, and similar (cited in
Helmerichs 2002, p. 36). This latter formulation was
essentially adopted in 1952 by the American Psychiatric
Association (APA) for the first edition of the Diagnostic and
statistical manual (DSM) in its definition of adjustment
reaction of childhood; attention deficits were not mentioned
(Committee on Nomenclature and Statistics of the American
Psychiatric Association 1952, pp. 41f.).
Minimal brain dysfunction
On the other hand, the term ‘minimal brain damage’ was
itself regarded with increasing scepticism, not merely
because of the unsubstantiated supposition of ‘brain dam-
age’ on the basis of behavior (see, for instance, discussion
in Birch 1964), but because even the assumption that all
children with brain damage presented the ‘brain damaged
child syndrome’ was dubious. Schulman and colleagues
examined the issue in mild retarded children in 1965 and
found that distractibility was the only sign consistently
associated with brain damage (regardless of scale or loca-
tion), and that hyperactivity certainly was not (Schulman
et al. 1965); further, the children were not more active than
other children per se, but rather unable to suppress activity
when required to do so (Kaspar et al. 1971), foreshadowing
a shift in focus from hyperactivity to attention in inter-
pretation of such behavior.
The term ‘minimal brain dysfunction’ was introduced by
Sam Clements and John Peters in their 1962 discussion of a
syndrome including attention deficits and hyperkinesis in
school children, explicitly avoiding the term ‘damage’ in
order to allow for the possibility of deviation on a genetic
basis or on the basis of a central nervous system matura-
tional lag (emphasis in original), while also noting that it
referred to the same phenomena as organic learning and
behavior disorders and minimal brain damage. They also
specifically rejected the false dichotomy [that] has placed
most workers in the position of being able to think in terms
of only psychogenesis or only organicity (Clements and
Peters 1962).
In Europe, the Oxford International Study Group of
Child Neurology concluded in 1962 that one should refer to
‘minimal cerebral’ or ‘brain dysfunction’ rather than
‘damage’, and this semantic shift was widely adopted in the
literature (‘minimal brain/cerebral damage,’ it should be
noted, had not normally been employed as a clinical term).
The 56 participants had been invited to submit their
understanding of the phrase ‘minimal brain damage’: 25 %
did not even approve of the term, while only one (London
pediatric psychiatrist Guy Michell 1963) described the
‘hyperkinetic syndrome’ as being associated with this term.
More importantly, however, the group urged that this rather
amorphous group of conditions should be analyzed into
specific clinical types, with Prechtl’s choreiform syndrome
nominated as one candidate form (Mac Keith 1963a, b; see
also pp. 95f).
In the United States, however, the term was officially
defined by a taskforce established to restrict its compass in
such a manner that in practice it included all those
encompassed by the older concept, including all manner of
learning, cognitive, and conduct disorders, of whatever
etiology:
The term ‘‘minimal brain dysfunction’’ refers … to
children of near average, average or above average
general intelligence with certain learning or behav-
ioral disabilities ranging from mild to severe, which
are associated with deviations of function of the
central nervous system. These deviations may mani-
fest themselves by various combinations of impair-
ment in perception, conceptualization, language,
memory, and control of attention, impulse, or motor
function (Clements 1966, pp. 9f).
The same author identified no less than 38 different
currently employed clinical descriptors that fell within its
purview, ranging from Organic Brain Disease, Diffuse
Brain Damage, Neurophrenia, Organic Behavior Disorder,
Minimal Cerebral Palsy and Cerebral Dys-synchronization
Syndrome in the organic sphere to Hyperkinetic Behavior
Syndrome, Character Impulse Disorder, Psychoneurologi-
cal Learning Disorders, Dyslexia, Clumsy Child Syndrome,
Hypokinetic Syndrome, Attention Disorders and Interjacent
Child in the psychological, while no less than 99 symptoms
were accommodated under its umbrella. This inevitably led
to criticism that nothing having been achieved (it was, for
example, described by Ross and Ross (1976), p. 13, as an
umbrella term that failed to distinguish what it defined from
other problems) and that the emphasis remained unduly
restricted to neurological rather than environmental factors.
It was important, however, that the definition applied to
children not classified as mentally defective.
The task force was also more optimistic: Of the 99
symptoms, ten occurred more frequently (including
hyperactivity [1.], emotional lability [4.], disorders of
attention [5.], and impulsivity [6.]); moreover, Order is
somewhat salvaged by the fact that certain symptoms do
tend to cluster to form recognizable clinical entities,
amongst which was the ‘hyperkinetic syndrome’ (Clements
1966, p. 13).
123

The term and the abbreviation ‘MBD’ was then adopted
by Paul Wender in his influential 1971 handbook, explicitly
because he wished to accommodate a large number of
psychiatric conditions of children … under one conceptual
roof (p. 2) and wished to avoid a name that elevated one
symptom or implied a particular etiology. The hyperkinetic
form was in his concept perhaps the ‘classic form,’ but not
the only clinical type; indeed, hyperkinetic behavior was
typical but not necessary for the behavior pattern associ-
ated with MBD (p. 3), a pattern he regarded as distinct and
easy to recognize. Wender argued that the primary psy-
chological factors in MBD were decreased experience of
pleasure and pain, high, poorly modulated activation levels,
and extroversion; he further cautiously suggested that the
first two factors, in turn, were related to altered catechol-
amine metabolism in critical brain regions (Wender 1971).
Like ‘minor brain damage,’ minimal brain dysfunction
primarily comprised the presentation of sensori-motor
symptoms and a presumptive organic basis, sometimes
evidenced by ‘soft neurological signs,’ such as EEG
abnormalities, altered motor reflexes, speech defects, or
gait disorders (Satterfield 1973), and was applied to chil-
dren with various types of conduct disorder; hyperkinetic
syndrome was a subclass that included around 60 % of
cases (Stamm and Kreder 1979).
The end of prehistory: new names for hyperkinetic
disorders
In 1967, the WHO Seminar on Psychiatric Disorders,
Classification and Statistics held in Paris as part of the
process, begun in 1965, for preparing the 1975 revision of
the ICD (ICD-9). One of its findings was that there was a
need for a category such as ‘hyperkinetic syndrome,’ to be
provisionally included in the section on ‘developmental
disorders,’ as it was often encountered by child psychia-
trists. It was characterized by:
extreme over-activity which was poorly organized
and poorly regulated by the usual social controls,
distractibility, short attention span, impulsiveness,
and often also, marked mood fluctuations and
aggression. Such disorders were much commoner in
boys than in girls; there was often a characteristic
response to drugs such as amphetamine, and fre-
quently, too, there were associated perceptual diffi-
culties and problems at school. While these
conditions were sometimes associated with organic
brain pathology, it was generally agreed that this was
often not the case and that certainly this could not
constitute any part of the diagnostic criteria (Rutter
et al. 1969).
123
P. B. Foley
A year later, the ‘hyperkinetic reaction of childhood’ was
included in the expanded DSM (DSM-II), defined as a
disorder being characterized by overactivity, restlessness,
distractibility, and short attention span, especially in young
children; the behavior usually diminishes by adolescence.
The term ‘reaction’ reflected dynamic view of the disorder
held by Leo Kanner (1896–1981), founder of American
child psychiatry, and was included in all DSM-II childhood
condition names (Committee on Nomenclature and Statis-
tics of the American Psychiatric Association 1968,
pp. 49–51). It did not, however, immediately supplant
‘minimal brain dysfunction’, and Paul Wender’s 1971
volume with precisely that title indicated that the nomen-
clature problem had not yet been settled, even within the
United States, but also specifically established, by the aid
of then new Venn diagrams, that MBD, brain damaged, and
hyperactive were not congruent but rather overlapping
classes. In this comprehensive discussion of all aspects of
the concept (except its history!), Wender also underscored
the fact that while identification of MBD in the pre-
adolescent child was relatively straightforward, its diagno-
sis in older children was culturally dependent, as most
patients in this category were referred because of their
antisocial behavior patterns:
The archetypal all-American (or Australian) boy,
independent, stubborn, self-willed, other-directed,
would be a miserable failure as a traditional Japanese
child. If a child has MBD proclivities, he is well
advised to be born as a male, and as the son of a
nineteenth century frontiersman with past prison
sentences (Wender 1971, p. 35).
The DSM-II definition allowed maximum latitude to the
diagnosing physician. The new category of ‘hyperkinetic
syndrome of childhood’ (314) ultimately introduced into
the ICD-9 in 1975 was, in comparison, more restrictive:
Disorders in which the essential features are short
attention-span and distractibility. In early childhood
the most striking symptom is disinhibited, poorly
organized and poorly regulated extreme overactivity
but in adolescence this may be replaced by under-
activity. Impulsiveness, marked mood fluctuations
and aggression are also common symptoms. Delays
in the development of specific skills are often present
and disturbed, poor relationships are common (World
Health Organization 1977, p. 210).
This definition reflected in part a shift in emphasis that had
occurred in the meantime, a shift to the position that
attention, a psychological faculty, might be more central to
the problem than the observable behavior of hyperactivity,
and that hyperkinetic children were perhaps not innately
more active than others, but less able to control this
Sons and daughters beyond your control
activity. From the psychological viewpoint, Roscoe Dyk-
man and colleagues (Arkansas) had advanced the model of
an ‘attentional deficit syndrome’ with an developmental,
organic basis that could be expressed as either an excess or
deficit in motor activity (Dykman et al. 1971); Wender
similarly noted that the most striking and constant
perceptual-cognitive abnormality of the MBD child is
shortness of attention span and poor concentration ability
(Wender 1971, p. 14). The Canadian Virginia Douglas
(Montreal) not only regarded attention deficits and impul-
sivity as more central to the construction of the disorder,
these were also the problems that responded best to
stimulant therapy. Her research at McGill University
indicated that hyperactive children were not especially
distractible under appropriate conditions, particularly if
immediate and continuous reinforcement was provided;
this in turn suggests that reward processing is abnormal in
these children, going some way to explaining the benefits
of amphetamine therapy. Further, it appears that it may be
just as important to consider the quality of the hyperactive
child’s behavior as its quantity. Because of his short
attention span, he tends to flit from one goal to another. As
a result his behavior is often fragmented and disorganized,
and these qualities may contribute to the impression of
excessive activity (Douglas 1972). She thus identified
deficits in direction and maintenance of attention, elevated
need for reward, inadequate modulation of arousal levels,
and reduced capacity for inhibition of impulsivity as the
key features of the syndrome. Douglas also found,
however, that this impulsivity could persist into adoles-
cence and beyond, even if, as was typical, motor restless-
ness declined.
The circle had thus been completed, returning to atten-
tion problems as the central focus. Douglas’ insights are
generally credited with influencing the revision of DSM
title and criteria, pushing it towards a more testable and
attention-focused definition. The new orientation was
acknowledged in the change in name in DSM-III (1980) to
‘Attention Deficit Disorder(ADD) (with or without hyper-
activity).’ DSM-III also established more specific symptom
lists for the three key symptoms (attention deficits,
hyperactivity, impulsiveness) and also demanded for the
first time the exclusion of other childhood psychiatric
conditions. Further, there was no longer any explicit
assumption of an underlying brain pathophysiology:
Attention was a purely psychological concept, and the
definition of ADHD descriptive and behavioral, not etio-
logic (psychoanalytic explanations were also abandoned).
‘Oppositional defiant disorder’ and ‘conduct disorder’, still
part of ‘hyperkinetic reaction’ in DSM-II, were also
removed from the ADHD group of disorders (although all
were still clustered together in DSM-III-R under ‘disruptive
behavior disorders’) (American Psychiatric Association
1980, pp. 41–45; American Psychiatric Association 1987,
pp. 49–58).
The introduction to the definition in DSM-III conceded
that for most of the categories the diagnostic criteria are
based on clinical judgment, and have not yet been fully
validated by data (1980, p. 8) and that alterations were
inevitable. In the 1987 revision, however, the symptom
lists were pooled, and the two subtypes effectively merged
into ‘Attention Deficit Hyperactivity Disorder (ADHD).’ It
still allowed leeway for interpretation, and this has been a
subject of criticism, as has the focus on attention deficits at
the expense of other mental symptoms. Further clinical
research restored subtypes in DSM-IV (1994)—predomi-
nantly inattentive type, predominantly hyperactive-impul-
sive type, or a combination of both—and also elevated its
status by renaming the group to which ADHD belongs
‘Attention Deficit and Disruptive Behavior Disorders.’
Further, the DSM-IV definition had broader support from
field trials than previous versions (American Psychiatric
Association 1994, pp. 78–94).
Hyperactivity remains the dominant concept in the next
revision of ICD (ICD-10, 1992), with the category F90.0
‘Hyperkinetic disorders: Disturbance of activity and
attention’ including ‘attention deficit disorder or syndrome
with hyperactivity’ and ‘attention deficit hyperactivity
disorder.’ This phrasing has been preferred to ‘attention
deficit disorder’ because the latter implies a knowledge of
psychological processes that is not yet available, and it
suggests the inclusion of anxious, preoccupied, or ‘dreamy’
apathetic children whose problems are probably different.
However, it is clear that, from the point of view of
behaviour, problems of inattention constitute a central
feature of these hyperkinetic syndromes (World Health
Organization 1992, p. 206). ICD-10 and DSM-IV had
significantly converged in the definition of the disorder,
diverging primarily with respect to its title and, more
importantly, in the stringency of the guidelines stipulated
for its diagnosis, particularly with respect to the presenta-
tion of all symptoms in all relevant life contexts. Never-
theless, key differences in their defined populations
remained, with one study finding that only 11 % of those
satisfying diagnosis of ADHD also met the criteria for
hyperkinetic syndrome (Lee et al. 2008).
The ICD-10 criteria for hyperkinetic disorder remain
stricter than those for ADHD in the latest DSM version,
DSM-5 (2013), in that ICD-10 demands both hyperactivity
and attention deficits; ‘hyperactivity’ in DSM-5 includes
behaviors not listed in ICD-10, such as excessive talking
and difficulties in waiting in turn; lack of persistence plays
a more prominent role in the ICD concept of the attention
deficit; the upper age limit for the presentation of symp-
toms is 7 years in ICD-10, but 12 years in DSM-5 (7 years
in DSM-IV); ICD requires observation of symptoms by the
123

clinician, whereas parental and teacher reports are accor-
ded equal weight by DSM.
Nevertheless, the two syndromes share a common def-
initional core in terms of symptoms; the major difference
lies in the freedom of interpretation of these definitions.
The coming together of the two over the past generation is
expected to continue with the release of ICD-11 (forecast:
2015): The draft proposal sees the current F90.0 replaced
by ‘Attention deficit hyperactivity disorder’:
Attention deficit hyperactivity disorder is a disorder
that is characterized by a variable mixture of persis-
tent inattention, hyperactivity and impulsivity of a
degree that significantly deviates from what would be
expected given the individual’s general develop-
mental level, and that begins during childhood or
adolescence. Inattentiveness is the inability to keep
one’s mind focussed on a task. Hyperactivity mani-
fests as excessive movements and difficulty to remain
still. Impulsivity is a tendency for rushed action
without reflecting (World Health Organization 2012).
Together with the new, currently provisional ‘Attention
deficit disorder without hyperactivity’ (persistent, signifi-
cant difficulty sustaining attention on tasks that do not
provide a high level of stimulation or frequent rewards), it
will constitute the group ‘Attention deficit disorders’.
French psychiatry and the ‘unstable child’
The French approach to ADHD-like conditions followed a
somewhat different track, focused on the psychological
concept of ‘instability,’ and adopted in part from Kraepe-
lin, rather than the more neurological ‘hyperkinesis.’
French reviewers have attributed this divergence, at least in
part, to the fact that French psychiatrists have traditionally
been concerned with patients of all ages, whereas in other
countries children have been examined by pediatric spe-
cialists; further, a psychosocial approach to the organism as
a whole has been preferred in France. The difference has
been epitomized as regarding childhood behavior as either
a matter of social adaptation (France) or physiological
maturation (elsewhere), as the contrast between French
psychodynamic holism and Anglo-Saxon pragmatism
(reviewed: Micouin and Boucris 1988; Joly 1996; Welniarz
2011).
This interpretation is somewhat, but it is true that French
interpretations pursued a separate path for much of the
twentieth century. The French literature includes numerous
descriptions of hyperkinetic behavior in children with
intellectual disabilities from at least as far back as Edourd
Seguin’s 1846 Traitement moral, hygiène et éducation des
idiots. There was some suspicion that hyperactivity in
123
P. B. Foley
children might, however, also be the prelude to psychiatric
disease in adulthood, particularly ‘manie raisonnante’
(here: hypomania), a view shared with Griesinger:
Children intended by nature to suffer manie rai-
sonnante attract attention through their great liveli-
ness. Wayward, distracted, mobile, unruly, they owe
to their good memory the little progress they make in
schools or the lyceum is attributable to their good
memories. They are always at the bottom of their
class; the efforts they sometimes undertake to escape
the lower ranks are usually in vain (Campagne 1869,
p. 184).
The term instabilité méntale—like ‘psychopathy’ at this
point, settled somewhere between normalcy and psycho-
sis—was applied to these children in 1892 by Charles
Boulanger, student of neurologist and Charcot editor
Désiré Bourneville (Bicêtre):
They are distinguished by a lack of balance in the
faculties of the mind. They cannot fix their attention
for long, they have no attachment, they must do
otherwise than others. They are intelligent but their
repeated inconsistencies, their constant eccentricities
soon attract attention. It seems that an unknown force
pushes them to periodic behavioral lapses that they
cannot explain when asked (cited in Welniarz 2011).
Bourneville adopted the term himself, writing after his
retirement that it was more common in the mildly feeble-
minded than in idiots or imbeciles, and described their lack
of impulse control:
The unstable possess an exuberant physical mobility.
They never remain in one place, they repeatedly
leave the table without a reason. If they play, they
quickly pass from one game to another. Their intel-
lectual mobility is similar. No sooner do they begin
reading than they want to write or count, etc. They
are disobedient. … They have sudden impulses, they
run away from school, from their father’s house …
They are lavish with their promises, often making
them with the best of intentions … but some hours
or some minutes later do exactly what they had
promised to no longer do (Bourneville 1897,
p. LXXXVIIf).
Bourneville distinguished between the ‘unstable’ and the
merely undisciplined child in Les enfants anormaux au
point de vue intellectuel et moral:
The unstable child can dwell on nothing: the
impressions that he receives via his senses follow one
another, through lack of attention, so fleetingly, that
they do not give rise to a persistent idea. The
Sons and daughters beyond your control
dynamogenic power of his ideas manifests itself
abruptly, but its transience increases with its strength.
… If he moves in class, it is because he cannot
remain still; his physical instability is correlated with
his mental instability. While the undisciplined child
can achieve something in the long term if it wants to,
especially something it has not been told to do, the
unstable child achieves nothing. Before executing
any decision, another emerges, which in turn will be
displaced by a third.
The unruly is dangerous.—The unstable is useless
(Bourneville 1905, p. 18).
Jean Demoor (1867–1941), physician at a school education
school in Brussels, similarly reported a condition that has
received insufficient attention from psychiatry that he
termed mental chorea:
Mental chorea is clearly a disease of attention, during
which the process [attention] does not acquire suffi-
cient strength to become an inhibiting factor. Under
these conditions, the sick child remains essentially
reflexive, variable, unstable and unconscious. The
lack of attention causes … the lack of will and
therefore the fatal defect of pre-attention (Demoor
1900).
These children experienced a constant need for movement
and change as well as lability of mood. This disorder,
uncommon in children with marked intellectual handicaps,
was linked by Demoor to deficient muscular proprioception
(in more recent terms)—according to the Flechsig model of
volition, If sensations are defective in their intensity or
their quality, attention phenomena are fleeting and con-
fused, and volition will be without energy and defective—
and his therapeutic approach involved ‘progressive mus-
cular discipline’. Jean Philippe and Georges Paul-Boncourt
(Paris) noted in the same year that:
The unstable schoolchild is a mentally abnormal
child, who cannot fix his attention either to listen, or
to answer, or to understand. It is in vain that he is
brought back to subject: forever and in spite of
himself his mind turns elsewhere, and it should be
noted that physical instability is often not less pro-
nounced than mental instability (Philippe and Paul-
Boncour 1905, p. 46; see also Paul-Boncour 1919).
The authors excluded children with marked intelligence
deficits, hysteria, epilepsy, or developmental delays from
this definition, and warned that it was not a diagnosis, but
rather a symptom encountered in a number of conditions.
In 1909, French psychiatrist Ernest Dupré (1862–1921)
included instabilité psychomotrice as a form of his broader
integration of motor and mental function in his concept of
débilité motrice; it was characterized by instability of mood
and motor function, and difficulty in maintaining attention
(Dupré and Merklen 1910); the term ‘debilité psychomot-
rice’ was still be used as the French pendant to the English
‘minimal brain dysfunction’ during the 1960s (Bax and
Mac Keith 1963, p. 97). Georges Heuyer (1884–1977)
pursued this psychomotor instability model further in his
1914 thesis Les enfants anormaux et les délinquants juve-
niles, although his interest was more in those who would be
described as ‘moral imbeciles’ in England, delineating
three key identifying symptoms in these children: attention
deficits, hyperactivity, and perverse, incorrigible behavior
(Heuyer 1914).
Following the First World War, Guy Vermeylen was
among the first to employ psychological testing in these
children, and concluded that those with attention deficits,
paired with excellent memories and vivid imaginations,
were essentially the result of unharmonious development
of different mental functions, retaining the same mobility of
impressions and desires, the same scattering of attention,
the same discontinuity in thought and action, the same
fickleness of feelings (Vermeylen 1922, p. 70) appropriate
to preschoolers: His interest cannot be sustained in one
direction for long, and requires immediate and repeated
satisfaction to justify continuation of the action (p. 75).
This neurodevelopmental interpretation was pursued fur-
ther in the monumental 1925 thesis by Henri Wallon
(1879–1962), L’enfant turbulent, who defined several
anatomically based levels of instability in children, each
affecting different aspects of psychomotor function, thus
providing a neurophysiological basis for the disharmony of
Vermeylen, while at the same time emphasizing that this
was an evolving, dynamic brain situation, not a static
condition (Wallon 1925). His model also emphasized the
close association of psychiatric function with abnormalities
of both voluntary and involuntary movement that were
widely explored in the context of psychomotor integration
during the 1920s, a direction that had arisen prior to the
outbreak of EL, but was nonetheless heavily influenced by
the experience of this neuropsychiatric disorder.
The culmination of this line of thinking was the 1940
monograph by Heuyer’s former student, Jadwiga Abram-
son, L’enfant et l’adolescent instables. Études cliniques et
psychologiques, a volume seen as sealing the parting of the
ways between French instabilité and the ‘hyperkinetic
child’ concept. Abramson was particularly interested in the
psychology of the unstable child as assessed by laboratory
testing. Abramson argued that disequilibrium between
emotional, intellectual development can produce instability
in the child (‘instability’ that was natural at certain stages
of personality development, such as infancy, the com-
mencement of schooling, and puberty), and her testing of
these functions indicated that the unstable child possessed a
123

good memory and could complete tasks requiring only
short-term attention but not those requiring more sustained
application, temporal or spatial coordination, and speed;
their actions and reactions were impulsive and deficient in
continuity and connectedness, their swinging moods and
heightened suggestibility were combined with an opposi-
tion to the stable and organized. Voluntary direction of
attention was poor, with the child being distracted by any
external stimulus, or fixated upon a particular detail; ana-
lysis of complex situations or stimuli was also deficient.
While organic factors could not be ignored, the dynamic
nature of the instability, and its dependence upon social
and other environmental factors were also emphasized
(Abramson 1940; see also similar by the Nijmegen author
Chorus 1942/1943). Heuyer himself later emphasized that
these factors could, in fact, foster ‘conditioned psycho-
motor instability’ (Heuyer and Lebovici 1951).
The ‘unstable child’ in French literature was thus
broader than current ADHD, encompassing all those in
whom age-appropriate psychomotor development was
disturbed, regardless of etiology, and was thus similar to
the Anglo-Saxon ‘brain-damaged child’ in the 1950s in its
scope, including the mythomaniac, the imaginative, the
impulsive, the simulator; but we also see him among the
instinctive perverts, among the hysterical, the epileptics
and the erratic (Abramson 1940, p. 12). The concept,
however, declined in use from the early 1960s, presumably
under the impression of discussions of hyperactivity in the
English language literature. In 1968, Nicole Dopchie 1968
reviewed the international literature concerning the
‘hyperkinetic child,’ thereby introducing the term into
French employment; in 1973, neuropsychiatrist Julian de
Ajuriaguerra (1911–1993) published a detailed comparison
of the instable and hyperactive child models, wherein he
criticized both the American ignorance of the French
model, and their assumption that response to stimulant
medication was specific to hyperkinetic children: we still
believe that the dual polarity as we described in psycho-
motor instability remains valid as a heuristic point of view,
and is valid in the case of hyperkinetic syndromes. For us,
psychomotor instability is the psychomotor aspect of a
disorganized core (de Ajuriaguerra 1973). He averred that
the French concept involved both motor and psychological
aspects, and that both were modified by interaction with an
adult environment that did not tolerate instability.
In view of continued perceived shortcomings of both the
DSM and ICD classifications of psychiatric conditions in
children and adolescents, Roger Misès and colleagues
introduced in 1988 the Classification française des troubles
mentaux de l’enfant et de l’adolescent (CFTMEA),
including under ‘Disorders of instrumental functions and
learning’ the clinical type hyperkinésies, instabilities
psychomotrices, corresponding to the hyperkinetic
123
P. B. Foley
syndrome of ICD-10. The CFTMEA places greater
emphasis upon social and psychological than neurobio-
logical factors, with clear consequences for therapy.
‘Hyperactivity’ has, indeed, been criticized by many
French authors not primarily for its own sake, but because
of its association with stimulant therapy (for example,
Diatkine and Fréjaville 1972), an approach still regarded
with scepticism by French psychiatry. The rapprochement
between the two concepts was nevertheless advanced by
the revision of 2000, which listed Troubles hyperkinétique,
with subtypes defined by the presence or absence of
attention deficits; these syndromes had also been trans-
ferred to the new class of ‘Conduct disorders’ (current
edition: Misès 2012, pp. 56–58). The rapprochement of the
two directions was thus undertaken by the beginning of the
new century, although a major 1997 French textbook on
pre-adult psychiatry omitted mention of either the instable
or hyperactive child. Ritalin was approved for the treat-
ment of hyperactive children in France in 1995, but con-
tinued opposition has constrained its adoption.
There is no space here to enter into discussions of
whether the divided path hereto was the result of the
imperialist hegemony of Anglo-Saxon theories and retreat
into protectionism by some French specialists in the
apparatus of the soul (Joly 2005), but much of this litera-
ture is unfamiliar to most non-French readers (all the more
striking given the positive reception of the work of Binet,
Piaget, and others regarding child development). The main
explanation is ultimately rather that French authors long
regarded hyperactivity/instabilité as a psychological–
developmental issue, whereas their non-French colleagues
were focused on the neurological aspects of the question.
The convergence of the two directions lies in the recog-
nition that ADHD is indubitably a multifactorial and
multidimensional disorder, where the impossible choice
between plague and cholera, between the rejection of any
genuine psychopathologic option and the obliteration of
the complexity of levels and systems of human functioning
(Joly 2005) is no longer necessary nor desired.
Overview of more recent developments
The essential nature of ADHD was by no means settled by
naming it in the DSM or ICD catalogs, and during the
1970s, the explosion of literature provoked controversy as
much as it illuminated the subject. Only the major features
of this literature can be discussed here: While annual
number of items concerning ‘attention deficit disorders’ or
‘hyperactivity disorder’ listed by MedLine was less than
100 during the 1970s, it had grown to 300 annually in the
mid-1990s, and nearly 2,000 today, a figure that does not
include most conference presentations or books.
Sons and daughters beyond your control
A catecholamine hypothesis of hyperactivity was first
proposed in 1970—catecholamine hypotheses had been
successfully introduced for Parkinson’s disease, schizo-
phrenia, and depression in the course of the 1960s—but did
not prove as fruitful as originally hoped. Nonetheless, the
involvement of catecholamine systems is central to current
neurophysiological models of ADHD, although, as Bau-
meister and colleagues have recently commented, the
models proposed are entirely consistent with ideas that
were put forward by researchers in the 1930s (Baumeister
et al. 2012). The 1990s witnessed an increase in research
consistent with older assumptions of localized brain dys-
function. A number of specific brain abnormalities have
since been identified in the brains of ADHD children,
including localized dopamine and noradrenaline abnor-
malities, altered fronto-cortical and striatal perfusion and
metabolism, and EEG dysfunction, but a comprehensive
neurophysiological model of ADHD remains a hope for the
future. This contributes to the fact that only one major new
medication has been introduced since methylphenidate,
atomoxetine (Strattera), a noradrenaline re-uptake inhib-
itor that also hinders dopamine re-uptake and antagonizes
NMDA receptors. Its absence or abuse potential is highly
regarded, but its precise mechanism of action in ADHD
remains to be determined.
Neuropsychological instruments has been developed for
the standardized assessment of behavior, allowing greater
comparability between studies in different laboratories.
Further, investigations since the 1980s have suggested that
motivation functions played a more fundamental role than
attention in the disorder; while this possibility was implicit
in Douglas’s work, newer research investigating specific
aspects of attention (particularly with regard to perception
processing and filtering) indicated that deficits could not be
detected in these areas. Further, it had long been recog-
nized that hyperkinetic behavior was often manifested to
varying degrees in different environments, and this led to
both neurological (association with reduced cortico-limbic
perfusion; effect of stimulant drugs) and psychological
models of deficient stimulus response control (reviewed:
Barkley 2006; review of motivation studies: Modesto-
Lowe et al. 2013).
That mental disorders tend to cluster in certain families
has been documented since the early twentieth century, and
that this also applies to hyperactivity and attention deficits
has been recognized since the 1970s (see, for example,
Morrison and Stewart 1971), but only more recent genetic
investigations have enabled the disentangling of heredity
and environment in the development of ADHD (recent
review: Caylak 2013). Although it has now been reported
that the former may explain 75 % of the variance in its
incidence (Faraone 2005), it is recognized that genes alone
do not account for the phenomenon ADHD: What is
inherited appears to be a set of traits rather than an illness,
and a set of dispositions to react to the environmental
associations of ADHD (Taylor 2011).
It is now recognized that so-called co-morbidity—the
presentation of other behavioral, affective, or motor dis-
orders by those suffering ADHD—is more common than
formerly thought, co-morbidities being identified in nearly
70 % of cases in one large study. The developmental
relationships between these conditions are complex and
remain an important feature of ongoing pathophysiological,
psychological, and therapeutic research. DSM-5 explicitly
allows diagnosis of co-morbid ADHD and autism
(reviewed: Taurines et al. 2010).
In 1976, Borland and Heckman reported that half of the
men who had been hyperactive continued to show a num-
ber of major symptoms of hyperactivity. … despite normal
IQ scores and levels of education, men who were hyper-
active had never achieved a socioeconomic status equal
their brothers. … Our findings suggest that emotional
problems in everyday living may result from the persistence
of symptoms of hyperactivity (Borland and Heckman 1976;
see also Mendelson et al. 1971). This was among the ear-
liest acknowledgements that the attention deficits and
associated psychological features might persist into adult-
hood, even if hyperactivity of childhood type diminished
during puberty. This has been the subject of a burgeoning
literature on this since 2000, with some finding evidence
that ADHD may be a life-long condition. This is recog-
nized in DSM-5, but remains controversial (reviewed:
Doyle 2004; Blondeau et al. 2009; Nylander 2011; Guld-
berg-Kjär 2013).
Final comments
The 1970s witnessed the first major upsurge of public
scepticism regarding the ‘reality’ of ADHD as a medical
condition, with vigorous proposition of the viewpoint from
some quarters that hyperactivity was simply part of the
normal range of childhood energy (for example, Conrad
1975: psychiatry and public health have always been
concerned with social behavior and have traditionally
functioned as agents of social control; as well as popular
books such as The myth of the hyperactive child and other
means of child control: Schrag and Divoky 1975). Accu-
sations that inadequate parents and teachers are demanding
medical approval and support for the pharmacologic con-
trol of unruly children (at a time when overindulgence of
adults in pharmacologic solutions of their own problems
attracted less attention), as well of conspiracy theories
alleging that pharmaceutical profits are the driving force
behind the rapid increase in the diagnosis of hyperactivity
disorders and the prescription of stimulant therapy over the
123

past half century have in the meantime, if anything,
increased rather than diminished. Consensus statements on
the nature of ADHD by medical experts (Taylor et al.
2004; appendix A to Barkley 2006) have not resolved these
differences, and the divide between the camps comparable
in stability with the trenches of the First World War (dis-
cussed in Mayes and Rafalovich 2007). These arguments,
however, are generally rooted in concerns about the treat-
ment of children with stimulant medication, and can only
be sensibly addressed by separating the two issues.
The figure of the ‘hyperkinetic’ or ‘hyperactive child’
has been remarkably constant for at more than a century.
The incidence of hyperactivity in children, however, has
long been a matter of controversy, and rates of hyperactivity
in children as high as 10 % prior to the Second World War
were noted above. In a review of several British studies,
Bax commented in 1972 that he believe[d] in the existence
of the relatively rare hyperkinetic syndrome and do not
believe it is usually too difficult to distinguish between the
hyperkinetic and the over-active child. … The child with
true hyperkinesia has a short attention span and excess
motor activity, characteristics which are consistently
observed by all adults who come into contact with the child,
and the presence of a familiar adult has little effect on his
behaviour (Bax 1972). In his view, there were numerous
other reasons that a child might be especially active—other
psychiatric disorder, unrecognized learning difficulties,
cultural or language differences, boredom, high energy
levels—that were not genuinely ‘hyperkinetic’ in sensu
strictu. The latter point is important, and is reflected in
differences between North American and European of
hyperactivity: The latter emphasizes the fact that unusually
high motor activity can be presented as part of a number of
disorders (or simply as a character trait), but only qualifies
as hyperkinetic disorder when combined with attention
deficits. According to recent studies cited in DSM-5, the
international incidence of childhood ADHD was about 5 %,
with no significant difference between North America and
Europe, and that of adult ADHD is 2.5 % (American Psy-
chiatric Association 2013, pp. 59–66).
The fact remains that ADHD is perhaps the best
investigated pediatric disorder of any kind. Faraone
reviewed the evidence for ADHD being a syndrome that
meets the standards set by Robins and Guze (1970),
essentially the criteria employed in the construction of
DSM-III, concluding that all six were clearly satisfied:
The diagnosis has well-defined clinical correlates and can
be distinguished from other diagnoses; the disorder has a
characteristic course and outcome, shows evidence of
heritability (family and genetic studies), and exhibits a
characteristic response to treatment; laboratory studies
have identified other neurobiological correlates of the
disorder (Faraone 2005).
123
P. B. Foley
This naturally establishes the usefulness/validity of the
nosologic entity ‘ADHD’ in the context of current psy-
chiatric thought: It does not mean that there is not more to
learn, nor does it validate the application of any particular
therapeutic approach; equally importantly, it does not
avoid the careless or inappropriate extrapolation of the
diagnosis of ‘ADHD.’ It does not establish that ADHD is a
syndrome with a single etiology (cf. Furman 2005), but nor
does anybody seriously maintain that it is anything but a
behavioral syndrome that can result from any of a number
of primary causes, the effects of which converge on pro-
cesses of attention and motivation. Individualized care is
therefore necessary. The tendency is towards viewing
ADHD as a multivariate entity, each component of which
is distributed within the community, and only extreme
values are perceived as problematic, and then only where
familial, social and medical contexts both register and
assess these values. On the other hand, the evidence for
underlying genetic and neurological bases for this behavior
is similarly clear. ADHD is ultimately a classic example of
the interaction between genetic, environmental and social
factors in determining the development and assessment of
personality and behavior; in the end treatment must,
however, focus on the welfare of the child and not only on
the convenience of those who interact with them, and, for
this reason, be specific for a given individual.
Attention deficit and hyperactivity disorder (ADHD)
may not be a psychiatric disorder of the same quality as, for
example, schizophrenia, and is not directly life threatening.
Attention deficits nevertheless indubitably cause distress to
the child of normal or near-normal intelligence. Both
attention deficits and hyperactive behavior exert negative
effects on their schooling, on their relationship with their
family, and on their broader social development, and
therefore requires remediation. This is particularly true
now that the chronic nature of the problem has been rec-
ognized: Even if the hyperactivity becomes less external,
the internal restlessness and its attendant impact on mental
functions may represent a major impediment to a fulfilled
life, and needs to be addressed when it is most amenable to
correction, in childhood. The assistance should as gentle as
possible, with pharmacologic therapy, as in all areas of life,
a last resort to reduce frictions between the child and their
world. Decisions as to what constitutes appropriate support
in these cases will be a question that involves conscience
and ethical considerations as much as it does medicine.
It behooves us to remember why the concept of the
‘hyperkinetic child’ entered medicine: The concern has
always generally related to the impact of the condition on
the child’s scholastic and social development; it has indeed
been argued that the discovery of attention disorders and
hyperactivity was the direct result of the expansion of state-
sponsored mass education at the turn from the nineteenth to
Sons and daughters beyond your control
the twentieth centuries (Brancaccio 2000). This is inaccu-
rate, but it reminds us that the focus must be on helping the
child master their psychological difficulties for their own
sake, while not ignoring those around them:
With forty-five to fifty children in a classroom, it can
be unbearably disruptive to have among them a child
who, despite seemingly good intelligence, cannot sit
still, cannot keep his mind on his work, minds other
pupils business instead of his own, hardly finishes the
work assigned, and yet, unpredictably, may turn in a
perfect paper. As a result, the teacher tends to put
increased pressure upon the child to conform and to
live up to apparent capabilities. Since he is unable to
comply, strife and unhappiness result (Laufer and
Denhoff 1957).
Many are uncomfortable describing attention deficits as
constituting a ‘disorder,’ and it might be wise to avoid
doing so, as advised in 1938 by Paul Schröder (1873–1941;
Leipzig) with respect to what were then described as
‘psychopathies’: after noting that it was impossible to
define ‘disease’ and ‘pathologic’ precisely, he argued that
the boundaries of character development were wide:
It is essentially advisable not to regard all abnormal
children (apart from those few who, in contrast, are
clearly mentally or neurologically ill) as patients or
that they should be evaluated and treated as such
(Schröder 1938).
For the same reason, he noted, the term ‘child psychiatry,’
he wrote, was at this point struggling to replace the older
term ‘special education’ (Heilpädagogik).
Despite growing consensus on the definition of ADHD,
cultural differences, including those between modern
Western states, will determine how this definition is
interpreted, and will also influence which consequences,
including choice of therapy, will follow this interpretation.
I hope that the prehistory I have presented in this paper has
illustrated how these questions have been addressed since
the birth of ‘scientific medicine’ in the early nineteenth
century, but I would not presume to prescribe how a parent
or physician should respond to a child in 2013. The general
precept of medicine—above all, do no harm—remains the
guiding principle, but this does not justify not providing
assistance to a child when such assistance is required for
their personal security and social development.
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