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

What do two Russian satellites launched in 1957 have to do with the skyrocketing rates of attention deficit hyperactivity disorder (ADHD) diagnoses in recent decades? Quite a lot, as it happens. Many such surprises await readers of Matthew Smith’s Hyperactive: The Controversial History of ADHD, a book that makes important contributions both to contemporary debates about ADHD and to the wider 20^th-century history of creeping medicalization. Drawing upon a wide range of medical, educational, historical, and popular literature relating to hyperactivity, Smith’s accessible and insightful book should find its way onto the reading lists of not only historians of medicine (particularly of mental health) and of youth, but also health professionals and parents of hyperactive children.

Throughout the book, Smith chips away at the supposed “universalism and essentialism” of ADHD and its treatment (155). He argues that although hyperactive behaviour may be linked to biological factors, the relative prevalence of the medical diagnosis of ADHD and its predecessor disorders in any given time and place is “a product of culture” (155). The introduction lays a strong foundation for the argument, surveying the key literature in a way that highlights the “polarized views, strong opinions and little compromise” (16) that characterize so much of it. Such all-or-nothing approaches, subsequent chapters reveal, have helped bring us to our current fixation on stimulant treatment. Smith emphasizes the complexity of mental illness and implies that diagnosis and treatment should rise to that challenge instead of opting for one-size-fits-all approaches.

Chapter 1 takes aim at histories that reproduce a Whiggish tale of unchallenged progress from the initial identification of hyperactivity, through various refinements, to the triumphant discovery of Ritalin and its peers. Smith quickly pokes holes in these assumptions and shows that although there may always have been fidgety children, the discoveries of the 1920s and 1930s usually trotted out in such accounts are not the unassailable forebears (and therefore historical legitimizers) of today’s diagnoses and treatments they purport to be. He later effectively marshals the ever-shifting terminology and associated symptoms of ADHD to support this attack.

Sputnik surfaces in Chapter 2, in which Smith ties the dramatic growth of ADHD diagnoses (centred in the United States) to the Cold War and changes in the American economy. The scientific prowess displayed by Sputnik shocked Americans into reassessing children’s behaviour: bookish introverts gained status; academic under-achievers became a problem. Simultaneously, the manual labour that had traditionally absorbed underachievers began to dry up. Rather than blaming teachers or parents for these children’s troubles, “‘he’s hyperactive’ quickly became a catch-all explanation for problematic behaviour” (153).

The impact of mid-20^th-century shifts within American psychiatry is the focus of Chapter 3. Both psychoanalytical and social psychiatric treatments foundered on the shoals of practicality–the talking cure and altering American society were hard and slow; the biological psychiatrists’ stimulants, on the other hand, were quick and easy. These arguments are further supported by Chapters 4 and 5, which respectively survey Ritalin and diet-based alternatives. Both worked for some, but not all, hyperactive children; Ritalin’s convenience gave it an advantage. Dietary treatments suffered from medical hostility and the difficulty of proving their effectiveness in double-blind clinical trials, and they went the way of psychoanalysis and social psychiatric treatments.

In Chapter 6, Smith combines case studies from Canada and Britain with anecdotal evidence from other countries, in order to suggest the importance of social and cultural contexts in shaping how the same hyperactive symptoms are understood and treated. The discussion is somewhat unsatisfying because of the limited nature of Smith’s evidence from non-English-speaking countries, but it highlights the difficulty of determining who needs treatment and who is simply a nuisance. His success in showing that the answers vary by time and place drives a stake in the heart of the essentialists’ and universalists’ approaches to ADHD and will sit well with historians of medicine.

The fact that Hyperactive...