Hyperactive: The Controversial History of ADHD by Matthew Smith (review)

In October 2012, the New York Times reported that diagnoses of attention deficit/hyperactivity disorder (ADHD)—with accompanying prescriptions for stimulant medication—were being used as performance enhancement for disadvantaged kids in poor socioeconomic circumstances (Alan Schwarz, “Attention Disorder or Not, Pills to Help in School,” October 9, 2012). Readers of Matthew Smith’s engagingly written Hyperactive will recognize this phenomenon as yet another stage in a history of diagnosis (and treatment) in children that ties up social and cultural problems and circumstances in a purportedly medical package.

As Smith explains, hyperactivity is a controversial concept. Some believe that hyperactive diagnoses are not real and reflect poor parenting (or socioeconomic or educational disparities), while many insist that hyperactivity is the result of neurochemical and/or genetic defects. Smith gets beyond the polemic by exploring the social, economic, and professional roots of the emergence and flourishing of the diagnosis. Hyperactivity did not appear as a major problem of interest to pediatricians or psychiatrists in the United States until the 1950s. Further, the concept of a mental disorder of hyperactivity did not evolve through scientific discovery. Instead, in the context of increasing pressure on American school systems in the wake of Sputnik and the education race with the Soviet Union, it became less acceptable for some children to perform poorly in school.

Although the nature of hyperactive behavior was contested among psychoanalysts, biologically oriented psychiatrists, and social psychiatrists in the 1960s and 1970s, a growing number of practitioners found appeal in a diagnosis of hyperactivity. In turn, many appreciated the blame-free, quick-fix approach offered by stimulant medication. As Smith points out, pharmaceutical companies increasingly marketed interventions advertised as wonder drugs to solve all kinds of social and academic problems. Agents such as Ritalin became easily accessible, and a pharmaceutical intervention increasingly made sense to both educators and mental health professionals. Hyperactivity entered psychiatric nomenclature as “hyperkinetic reaction of childhood” in the 1968 DSM-II, and then became “attention deficit disorder” in DSM-III (followed by “attention deficit/hyperactivity disorder” in DSM-IIIR in 1987). Happily for pharmaceutical companies—who helped “educate” physicians and parents about this—the symptom of inattention became as important as hyperactivity as a sign of illness, and an expanded diagnosis translated into an expanded market for stimulants.

Smith does a nice job of showing us that this progression was not inevitable. There were alternatives, such as diet interventions in the 1970s that could have provided a different path. Further, the American embrace of diagnoses such as ADHD and stimulant medication was not matched in time or fervor in other countries such as Canada or the United Kingdom. Smith’s book is a good compliment to Nicholas Rasmussen’s On Speed (NYU Press, 2008) that explored the international story of amphetamine. While Rasmussen focused on the drug, its effects, and its fans and detractors, Smith examines the relationship between a diagnosis and a drug treatment. Both of these books help problematize the too easy relationship between an ADHD diagnosis and a stimulant prescription.

One of the major contributions of Smith’s book is that he examines the history of education as an important context for the emergence of medical interest in hyperactivity. This is a critical story, as educational imperatives (and limitations) have been a central feature in the explosion of diagnoses of hyperactivity. He also demonstrates that biologically oriented psychiatrists had a strong professional motive to embrace a neurochemical (rather than environmental) diagnosis of hyperactivity (and later ADD/ADHD) as they endeavored to reshape psychiatry in the 1970s and beyond.

Hyperactive tells a compelling story of the confluence of interests of psychiatrists, pharmaceutical companies, educators, and parents, and Smith also raises questions that hopefully future scholars will explore. We need to know more about the relationship between psychiatrists and pediatricians, since the latter have become the main prescribers of stimulant medications for ADHD. And as Smith states, the story of gender and the...