The Goulstonian Lectures of Sir George Frederic Still in 1902 are by many authors considered to be the scientific starting point of the history of ADHD (Barkley
2006a; Conners
2000; Palmer and Finger
2001; Rafalovich
2001; Rothenberger and Neumärker
2005). Still was a British pediatrician who was born in Highbury, London, in 1868. He became involved in research into childhood diseases and wrote several medical textbooks about his findings (Farrow
2006). The most widely known findings are his descriptions of “a form of chronic joint disease in children” (Still
1897), which today is called “Still’s disease” (Farrow
2006). In 1906, Still became the first professor of pediatrics in England at King’s College Hospital London (Farrow
2006). In 1933, he was president of the first international pediatric congress (Hamilton
1968). Still has therefore frequently been called “the father of British pediatrics” (Dunn
2006).
In his Goulstonian Lectures, a series of three lectures to the Royal College of Physicians of London “On Some Abnormal Psychical Conditions in Children” (Still
1902), Still discusses “the particular psychical conditions (…) which are concerned with an abnormal defect of moral control in children” (Still
1902, p. 1008). He defines moral control as “the control of action in conformity with the idea of the good of all” (Still
1902, p. 1008). Still states that “moral control (…) is dependent upon three psychical factors, a cognitive relation to environment, moral consciousness, and volition” (Still
1902, p. 1077). Since both “cognitive relation to environment”, which implies a “capacity for reasoning comparison”, and moral consciousness are intellectual capacities (Still
1902, p. 1008), Still states that defective moral control as a morbidity can often be observed in cases of mentally retarded children (Still
1902). However, “there are other cases which cannot be included in this category” (Still
1902, p. 1008) and which, as he points out, “in particular (…) call for careful observation” (Still
1902, p. 1008). They comprise the cases considered as historical descriptions of ADHD, i.e. children with a defect of moral control but without a “general impairment of intellect” (Still
1902, p. 1077). Still divides these cases in two further groups, children with a “morbid defect of moral control associated with physical disease” (Still
1902, p. 1077), such as a cerebral tumor, meningitis, epilepsy, head injury or typhoid fever, and children with a “defect of moral control as a morbid manifestation, without general impairment of intellect and without physical disease” (Still
1902, p. 1079). Some of the latter group, however, showed a “history of severe cerebral disturbance in early infancy” (Still
1902, p. 1081). This differentiation was the origin of later concepts of brain damage, minimal cerebral dysfunction, and hyperactivity as historical precursors to ADHD (Rothenberger and Neumärker
2005).
Still described 20 cases of children with a “defect of moral control as a morbid manifestation, without general impairment of intellect and without physical disease” (Still
1902, p. 1079). Interestingly, Still observed 15 cases of boys and five cases of girls. This is “a disproportion which [in Still’s opinion] (…) is not altogether accidental” (Still
1902, p. 1080) and which is consistent with the commonly observed uneven male to female sex ratio of 3:1 in child and adolescent ADHD (Barkley 1990, cited by Palmer and Finger
2001). Most children for whom the first manifestation of the defect was determined showed symptoms before the age of 7 (7 out of 9 cases), which currently is a diagnostic criterion of DSM-IV-TR. Still furthermore recognized that a morbid manifestation of a child’s moral control can be considered only when the child does not meet the standard for moral conduct at a certain age within a “range of variation which we arbitrarily recognize as normal” (Still
1902, p. 1009). The American Psychiatric Association also states that for a diagnosis of ADHD, symptoms have to be present “to a degree that is maladaptive and inconsistent with developmental level” (American Psychiatric Association
2000). Still argued that a “lack of moral control may be shown in many ways” (Still
1902, p. 1009). The symptoms listed are:
(1) passionateness; (2) spitefulness – cruelty; (3) jealousy; (4) lawlessness; (5) dishonesty; (6) wanton mischievousness – destructiveness; (7) shamelessness – immodesty; (8) sexual immorality; and (9) viciousness. The keynote of these qualities is self-gratification, the immediate gratification of self without regard either to the good of others or to the larger and more remote good of self. (Still,
1902, p. 1009).
Although most of these symptoms are not directly associated with the current concept of ADHD, the keynote identified by Still fits an important finding of modern ADHD research. Delay of gratification appears to be “a major problem for children with ADHD” (Barkley
2006b) and reactions without regard to consequences, whether “to the good of others or (…) [the] good of self” (Still
1902, p. 1009), are strongly associated with impulsivity, a main symptom of ADHD. The most common symptom observed by Still in these cases was “an abnormal degree of passionateness” (Still
1902, p. 1009). Passionateness did not mean affection (Barkley
2006b), but some “impulsivity regarding some immediate goal” (Conners
2000, p. 176) and a kind of “quickness to display all emotion and especially those of frustration, anger, hostility, and aggression” (Barkley
2006b, p. 137), for example expressed “in outbursts of rage” (Still
1902, p. 1165). Similarly “jealousy” does, according to Still, not mean “the mere emotion but its uncontrolled expression” (Still
1902, p. 1009). Still attributes these symptoms to “a morbid failure to control (…) emotional activities” (Still
1902, p. 1165), which is due to an “exaggeration of excitability” (Still
1902, p. 1165). These descriptions are similar to the current concept of impulsivity. Although not explicitly mentioned in DSM-IV-TR, impulsivity as a main symptom of ADHD is often associated with a lack of emotional impulse control, a low frustration tolerance and some abrupt outbursts of rage (Barkley
2006b). Still describes some cases with signs of impulsivity,
for instance, the case of the boy, aged 11½ years (…): his mother stated that in the midst of playing quietly with other children he would suddenly seize two of them and bang their heads together, making them cry with pain and (…) he seems unable to resist it. (Still,
1902, p. 1165).
Still also mentions that many of his depicted cases showed “a quite abnormal incapacity for sustained attention. Both parents and school teachers have specially noted this feature in some of my cases as something unusual” (Still
1902, p. 1166). An attention deficit is a main symptom of ADHD and, according to the current DSM-IV-TR criteria, a child with ADHD “has difficulty sustaining attention in tasks or play activities” (American Psychiatric Association
2000). Difficulties at school are frequently observed in children with ADHD. In particular, the notion of children with a significant attention deficit, but “without general impairment of intellect” (Still
1902, p. 1079) fits modern-day ADHD. Recent studies have shown that the IQ of children with ADHD is within the normal range (MTA Cooperative Group
1999; Schuck and Crinella
2005). Some of the cases cited by Still showed remarkable symptoms of inattention, for example,
the case of a boy with moral defect who would repeat the process of saying ‘Good-night’ several times before he was aware that he had done so; the same boy would often put his boot on the wrong foot apparently without noticing it. Another boy, aged six years, with marked moral defect was unable to keep his attention even to a 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).
Many of Still’s descriptions appear to indicate that children in the early twentieth century showed clear symptoms of ADHD. However, most of the symptoms listed by Still and described in his cases do not refer to ADHD. Still also reported children who “seemed to take a delight in tormenting the other children” (Still
1902, p. 1080), for example by throwing other children’s toys in the fire and laughing at their grief. He furthermore described children who pathologically stole or lied with extraordinary insensitivity to any punishment, children who were aggressive and attacked strange children or threatened to hurt their mothers (Still
1902, p. 1081), “lawless” children with “a reckless disregard for command and authority” (Still
1902, p. 1009), children with “a complete lack of natural affection” (Still
1902, p. 1165) even to their parents, and children who showed cruelty to animals for example by attempting to put a cat in the fire (Still
1902, p. 1081) or by “cutting a rabbit alive (…) smothered in blood” (Still
1902, p. 1081).
Still’s concept of a “defect of moral control” is not consistent with the concept of ADHD. Still did not predominantly refer to inattentive-impulsive children, but rather described several types of deviant behavior observed in children. “His description included the full range of externalizing behavior disorders” (Conners
2000), presumably many cases that would meet today’s criteria for conduct disorder, oppositional defiant disorder, learning disabilities, or antisocial personality disorder (Palmer and Finger
2001; Barkley
2006b; Conners
2000). All these cases were combined in the concept of “defect of moral control”. Among these cases, there were probably also some cases of ADHD such as the ones depicted above. Although the signs described by Still are consistent with some symptoms of ADHD, they are not sufficient for a clinical diagnosis of ADHD. Hyperactivity as a main symptom of ADHD is hinted at in one case, i.e. a girl who showed “marked fidgety, almost choreiform movements” (Still
1902, p. 1082). Still’s work, nevertheless, “represents a break from the more general medical discussions of morality” (Rafalovich
2001) and his original notion of an impulsive syndrome which was distinguishable from general intellectual retardation and symptoms caused by physical diseases is pioneering (Conners
2000). He discusses both nature and nurture as possible factors underlying a lack of “moral control” and includes an elaborate description of family history in his cases. Still’s Goulstonian lectures can be considered “the groundwork for a category of mental illness that is (…) specific to child deviance” (Rafalovich
2001) and a historically significant moment for child psychopathology in general (Barkley
2006b). Regardless of whether or not Still’s descriptions include some cases of ADHD, his work is nevertheless important in the analysis of historical ideas concerning ADHD. Still’s demonstration of a connection between brain damage and deviant behavior in children was highly influential regarding the further conceptualization of ADHD.