Why Do People Think ADHD Is A Moral Deficiency?

Today, we’re continuing our discussion on the history of ADHD in the early modern era, working from the 1850s through the 1980s. After this episode, when you hear someone say ADHD, you’ll have some idea of the historical and cultural context behind it, and you’ll know why some people think ADHD is just the result of us “not trying hard enough.”

Want to listen? This post is based off of Episode 70 of the Neurodiverging Podcast! Listen on Apple Podcasts | Spotify | Youtube

Show Notes & Sources:

• Get ad-free podcast downloads by joining us on Patreon: http://patreon.com/neurodiverging
• Read Still’s “Goulstonian lectures on some abnormal psychical conditions in children.”
• Robert B. Kugel, Robert G. Scherz, Henry M. Seidel, Jean L. McMahon, Andrew Rinker, Dale C. Garell, David W. Van Gelder, Effie O. Ellis, Sarah H. Knutti, John R. Poncher
  Pediatrics Apr 1975, 55 (4) 560-562;
• “The Story of Fidgety Philip.” The Evolution of A Disorder. Edward M. Hallowell, M.D. and John J. Ratey, M.D.

• History and Medication Timeline of ADHD, By Vincent Iannelli, MD 

Transcript of Episode 70: Why Do People Think ADHD Is A Moral Deficiency?

Introduction

Hello friends! Welcome to Neurodiverging, Danielle here. Today, we’re continuing our discussion on the history of attention deficit disorder. We’ve talked some about how we have good evidence that ADHD is a normal neurodivergence. The presentation or traits of ADHD are due to genetic variation, and has been present in the human population for thousands of years.

So in the last episode of this series, I discussed the Obtuse Man, a Greek caricature of an ADHD-seeming person from the 3rd century CE. Then we talked briefly about the idea, through the 18th century in the West, that ADHD, along with other neurodivergences AND mental health challenges, was considered a sign of moral deficit. That is, if you had ADHD traits, you must have done something bad to “earn” them.

Finally, in the early 1800s, a physician called Crichton published a series of volumes that began to call this into question. Crichton suggested that mental illness, and neurodivergences as well, were based in physiology, and he was the first person to have any traction with this theory. 

So today, we’re going to spend more time on the history of attention deficit disorder in the early modern era, working from the 1850s through the 1980s.

Again, this is not meant to be a thorough exploration – there are many, many books out there, and I have some resources listed in the notes if you’d like to explore further. But this is just an overview, so that when you hear someone say ADHD, you have some idea of the historical and cultural context behind it.

ADHD In The Late 19th Early 20th Century

Once Crichton introduces this idea that neurodivergence and mental illness are not related to sin or moral character, but are rather physiological in nature, we see several other prominent physicians start to jump on the bandwagon.

In 1844, almost 50 years after Crichton published his books, the German physician Heinrich Hoffmann, who later went on to found the first mental hospital in Frankfurt, created some illustrated children’s stories including “Fidgety Phil” (“Zappelphilipp”), who is nowadays a popular allegory for children with ADHD.

Like Crichton, Hoffmann rejected the common opinion that psychiatric patients were obsessed or criminal. Instead, he saw mental illness and neurodivergence as medical issues stemming from something in the physical body.

Hoffman wrote a children’s book called “Struwwelpeter,” which he had created for his 3-year-old son, Carl Philipp, who may or may not have been his inspiration for the stories. The poem of “Zappel-Philipp,” or “Fidgety Philip”, is probably the first written mention of something that looks very like ADHD by a medical professional.

In the story, the father asks his son to sit at the dinner table and be calm and eat. But the son is not able to sit still. He rocks back and forth on his chair until he loses his balance, taking the table cloth and all of the dinner down with him. As a parent of a child with ADHD, this story is a pretty familiar one to me!

Despite being the first medical professional to describe ADHD, and being progressive in his treatment of mental illnesses for the time, Hoffman’s depiction of ADHD in Zappel-Philipp still focuses blame on the child, and although Philipp gets off relatively lightly, the children in the other stories in the collection fair much worse.

The stories were very popular at the time, to the point that ZappelPhilipp is still used today in German-speaking countries to refer to a child who fidgets, is restless, or constantly on the move.

Exploring The Cause Of ADHD In The 20th Century

Hoffman’s Fidgety Phil was important for being the first time a medical professional described ADHD, but it’s sort of an incidental description, being more prescriptive for how children should and should not behave. Most historians seem to consider the real scientific starting point in the history of attention deficit disorder to be the Goulstonian Lectures of Sir George Frederic Still in 1902, about 60 years after Hoffman.

“The Goulstonian lectures on some abnormal psychical conditions in children” were presented  before the Royal College of Physicians in London in March 1902, and then released by The Lancet in April that year.

Still described a group of twenty children he’d encountered in his pediatric practice who were defiant, extremely emotional, chaotic, spiteful, and who didn’t seem able to control themselves. He noted they had been raised in good homes to decent parents, but that this behavior still appeared early on in their lives. 

In his address, Still discusses this group as having an “abnormal defect of moral control in children,” which he refers to as morbid, just meaning “diseased”. Still asked several questions of his audience, which basically boil down to:

Does this set of symptoms together make a thing? And, if this is a thing, is this set of symptoms I’m seeing caused by some underlying condition, or is it something that exists on its own, unrelated to any other co-occuring medical issue?

Now, Still described the set of behaviors he observed in his pediatric practice as being “defects of moral control,” where moral control was defined as “the control of action in conformity with the idea of the good of all.”

One of Still’s overall categories of moral deficiency is basically mischievousness, or misbehavior – children who repeatedly do things they’re not supposed to do, even if a parent or another adult warns them against it.

We know, of course, that many children labeled “trouble-makers” nowadays commonly struggle with impulsivity. To anyone with an impulsive child, or who experiences impulsivity themselves, all of Still’s examples will be very familiar!

Still’s work is important to the history of attention deficit disorder because he’s the first doctor to recognize a collection of traits now known as ADHD as being related to each other, and one of the first to say that ADHD was likely biological in origin.

That said, most of his conjectures as to the nature of their relationship were flat-out wrong. With his theory of “defect of moral control,” he’s referring to a group of children as being disinterested in the good of the community, and more interested in their own goals and pursuits.

He’s calling these kids selfish, at the root of it, and in a lot of his lecture, he seems to view them as almost malevolent. 

Most of Still’s work is deeply ableist from our modern perspectives, and it is not fun to read for that reason. That said, it is still possible to recognize that, overall, the group of kids he’s talking about do seem to have traits of what we’d know call ADHD, and this is the first time a physician called that out.

Additionally, the realization that these ADHD traits were biological in origin also created the beginnings of the realization that punishing kids for these behaviors wouldn’t “fix” them. Recognizing that clinical treatment was needed was the beginning of creating a better, kinder type of child rearing.

Still’s work really caught on, and after his 1902 lecture, there’s a spurt of activity around figuring out the biological mechanisms of ADHD. For example, William James, the father of American psychology, read Still’s work and was very intrigued.

James believed that the deficits in what he called “inhibitory volition, moral control, and sustained attention” were somehow caused by an underlying neurological “defect”, or difference in the brain.

He thought ADHD brains might have a decreased threshold for inhibition of response to various stimuli, OR that there might be some disconnection within the cortex of the brain, where intelligence was dissociated from willpower.

James’ work added to the growing idea that ADHD was biological, not psychological, in nature. 

The Advent Of ADHD Medication

Then, in 1936, the U.S. Food and Drug Administration approved Benzedrine as a medicine. Benzedrine was the first amphetamine marketed in the United States to treat conditions like depression. 

In 1937, Dr. Charles Bradley was trialing Benzedrine for behaviorally-disordered kids who had severe headaches, when he accidentally learned that his patients’ behavior and performance in school improved when he gave it to them. This discovery wasn’t well-understood at the time, because doctors didn’t get why a stimulant would improve these behavioral symptoms. 

But, throughout the 1940s and 50s, these kids were sometimes treated with Benzadine, as well as two other stimulants called Ritalin and Cyler. It’s in the 1950s that we start to see the use of hyperkinetic emotionally disturbed children, and Hyperkinetic impulse disorder, as diagnoses. Which diagnosis was used seems to have depended largely on the doctor and the primary trait of concern.  

In the 1960s, “minimally brain damaged” became the popular way to refer to kids who had  ‘various combinations of impairment in perception, conceptualization, language, memory, and control of attention, impulse, or motor function’.

All of these diagnoses probably lumped together folks we would distinguish between today, but scientists and doctor are starting to zoom in on ADHD and its specificities. All of these issues are still considered childhood problems, though. There’s hardly any research done in this time period on what happens to children like this as adults.

ADHD Gets Officially Recognised 

Now, let me take a minute to mention the Diagnostic and Statistical Manual of Mental Disorders, or the DSM, which is still the major publication used to diagnose neurodivergence and mental health issues today. The first edition was published by the American Psychiatric Association (APA) in 1952, but didn’t include any mention of any of these earlier terms for ADHD. 

But in 1968, the second edition comes out, and that finally includes the disorders “hyperkinetic reaction of childhood or adolescence”, and “organic brain syndrome”. So the medical establishment has recognized these disorders and is beginning to codify how they should be diagnosed and treated.

The year after that, in 1969, the first Conner’s Rating Scale is published by C. Keith Conners. Revised editions of this questionnaire are still used to help diagnose ADHD today, for kids between 6 and 18 years-old.

So, by the late 1960s and early 1970s, there’s been enough research completed and enough consensus in the medical community about what’s going on that Conners is able to pull together a resource that is still in use 50 years later.

ADHD Backlash Of the 1970’s

Now, in the 1970s, there begins to be a pretty significant backlash to ADHD, and especially treatment of ADHD with stimulant medications. This is due mostly to one newspaper article in Washington Post which drastically misrepresented the number of kids in the US public school system being given stimulants, and also incorrectly implied that parents were being coerced into drugging their kids by the school systems.

This article did so much damage, and is still doing damage today, as we continue to fight the effects of misinformation published 50 years ago. This is important to the ADHD timeline, because this one article is where a lot of misperceptions about ADHD come from to this day, especially the idea that ADHD was created by drug companies to sell stimulants.

Fueled by the bad statistics in that article, a lot of anti-ADHD books came out in the 1970s, and a lot of them pushed “facts” that have now been disproven, like the idea that ADHD isn’t a real thing, or that if it is, then it’s just that food dyes cause hyperactivity, or sugar causes hyperactivity, or parents just aren’t parenting hard enough, etc.

These books are direct ancestors of modern-day “TV causes ADHD!” “Video games cause ADHD!” “Gluten causes ADHD” hysteria, and continue to cloud and mask the real biological causes of attention differences.

(A quick, clarifying note: you may personally find that food dyes or gluten or tv or whatever affects your ADHD. Cool, fine, I’m not here to invalidate your experience. I think there are probably a small number of people who are able to control their ADHD by changing their diet or their electronic habits or whatever.

But study after study has looked at this, and the vast majority of ADHD folks are not affected overmuch by sugar or food dyes or gluten or electronics, and I believe that pretending that they are just shames folks who are struggling instead of offering real support.)

This anti-ADHD backlash pushes the American Academy of Pediatrics to publish their first statement about ADHD in 1975, called Medication for Hyperkinetic Children. You can read that statement in full here.

So we can learn a couple of things from this statement. First, the AAP is recommending medication only when necessary, and not as a first step. Second, the AAP is straightforward about the fact that the mechanism by which the drugs work, and how to tell which drug to try when, is not well understood, and so drugs need to be used carefully and with oversight.

Finally, the AAP recognizes that what looks like “hyperkinetic child syndrome” might also be “an expression of basic personality, anxiety, subclinical seizure disorders, strictly in the eyes of the beholder, or true hyperkinesis” because the method of diagnosis is not yet particularly objective or trustworthy, so the doctor needs to be keeping an eye of the results of any drug trial.

ADHD In Modern Times

Finally, in 1980, we hear the words Attention Deficit Disorder for the first time, when the DSM-3 is published. The DSM includes the subtypes ADD with hyperactivity, ADD without hyperactivity, and ADD residual type.

So this is the evolution in the understanding of ADHD from the 1800s through the beginning of the 1980s. We see the movement away from the model of ADHD being purely mental or psychological, and into the idea of ADHD as being caused by biological mechanisms.

With this comes the understanding of a need for clinical diagnosis and treatment protocols, as what ADHD really is clarifies. In the near future, I’ll have a final episode covering the most recent history of ADHD from the 1980s through today. In the meantime, please check out neurodiverging.com for some other articles on the history of ADHD, parenting a child with autism or ADHD, or working with a partner with ADHD.

Conclusion

Next week we’ll be switching topics and doing an audience-requested episode about how I grew up with undiagnosed autism in the 1990s, and what that was like. So come back next week for that one! And please remember, progress comes as we learn more about who we are. We are all in this together.