Views & Reviews Review

Has Ritalin replaced the rod?

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8532 (Published 19 December 2012) Cite this as: BMJ 2012;345:e8532
  1. Iain McClure, consultant child and adolescent psychiatrist, Royal Hospital for Sick Children, Edinburgh, UK
  1. iain.mcclure{at}ed.ac.uk

The current construct of attention-deficit/hyperactivity disorder (ADHD) may not be helping us understand hyperactivity. Iain McClure finds this book a good starting point for inquiry

Psychiatric conditions are best fit constructs, informed both by science and the society within which they are observed. Some have stood for centuries, owing to their persistence through subjective human internal experience and observed external behaviour. Thus melancholia has transmuted into depression. Matthew Smith’s Hyperactive argues that it is by no means certain that similar longevity will be accorded to attention- deficit/ hyperactivity disorder (ADHD).

Instead, argues Smith, a lecturer in the history of medicine at the University of Strathclyde and a 2012 BBC Radio 3 “new generation thinker,” if more attention were applied to the complex underpinnings of ADHD, a less impulsive social and scientific understanding of this aspect of human behaviour might result.

Hyperactive shows that hyperactivity, and how it is defined and construed, is a touchstone of psychiatry’s increasing identity confusion since the 1950s. In place of the ascent of ADHD as a child psychiatric condition to a position of prominence in much of the Western world, Smith suggests that the international community should now create a thoughtful dissolution of its current conception (to be found in the American Psychiatric Association’s draft of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)1) and reform it into something that does more justice to the complexity of human behaviour. Smith’s historical explorations, and his consequent questions and conclusions, have important implications for psychiatry, for education, and for society in general.

This fascinating book opens with a short history of ADHD, or “hyperactivity” as Smith prefers to call it. He unearths new facts that crush the notion that ADHD has a historical foundation, with one fascinating exception. The Scottish physician Alexander Crichton helpfully explored so called “mental restlessness” for the first time in 1798. Crichton attributed the resulting symptom of hyperactivity as being the result of oversensitivity to environmental stimuli. Instead of the deterministic, fixed, and lifelong debility that modern physicians increasingly attribute to ADHD, Crichton believed that “attention was highly variable” both within humanity and within the individual, and that the patient’s response to lack of attention was, with maturity, increasingly a matter of free will. Such 18th century philosophical considerations have not, seemingly, entered the American Psychiatric Association’s 21st century thinking.

Smith then summarises the social and educational history of postwar America and the history of the three main psychiatric movements—psychodynamic, social, and biological—of 20th century psychiatry. At different times each of these approaches has seemed dominant, until giving way to one of the others. This baton passing has, we learn, not been helpful for Western psychiatry’s development. Failure to hold onto the baby while at the same time enthusiastically emptying the bath water has meant that the best lessons from each of these schools have not been merged into something richer. Now, Hyperactivity argues, psychiatry is at a vital crossroads, evidenced by the mounting controversy over the draft version of the DSM-5. Biological psychiatry’s 30 year dominance is being challenged by new versions of social psychiatry and psychotherapy. Can we hold onto the baby this time?

Many key issues connected to the phenomenon of ADHD are explored here, and numerous discoveries are made along the way. Thus, I learnt that, throughout the 1950s, methylphenidate (Ritalin) was marketed as a pick me up for the aged and mildly depressed. Then in 1957 Russia launched Sputnik and America panicked. How could a communist state overtake the world’s most powerful nation in scientific technology? The military and political conclusion was that America’s education system was at fault, particularly in regard to students with potential who dropped out. Newly commissioned school counsellors identified the three symptoms that such failed students had in common—attention-deficit, hyperactivity, and impulsivity (ie, ADHD). In 1961, Ritalin’s advertising images morphed from weary old grannies into troublesome grandsons. Clear new evidence, if more was needed, of pharmaceutical compounds hanging around disorder parties, eyeing up the most lucrative condition to go home with.

Hyperactivity is a riveting read, and will entertain anyone interested in the history of medicine. I wondered, for completeness, if Smith might have covered ADHD symptoms, as they undoubtedly present, in other psychiatric conditions such as autism or schizophrenia. Research into the history of this aspect could be helpful, as, in my opinion, the draft version of the DSM-5 seems totally confused as to why such conditions can and cannot be conceived of as being comorbid with ADHD.1 Also, the book predominantly covers the history of hyperactivity as a purely behavioural condition. It would be interesting to discover the history of subjective accounts of hyperactivity, if any such exists.

Thus, although excellent, Hyperactive feels like a thoroughly explored starting point for further inquiry. As Smith concludes, we need to learn more about gender differences in hyperactivity (does this have an evolutionary aspect?), about hyperactivity being a possible consequence of exercise deficit in Western children, and about whether ADHD represents a new phase in parent-teacher-child dynamics. Has Ritalin simply replaced the rod?

Notes

Cite this as: BMJ 2012;345:e8532

Footnotes

  • Hyperactive: the Controversial History of ADHD

  • Matthew Smith

  • Reaktion Books; 248 pages; £25.00

  • ISBN: 978 178023031 3

  • Rating: ****

  • Conflict of interest: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References