On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.98 n.8 Cape Town Aug. 2008
MEDICINE IN ART
Richard E KastI; Eric Lewin AltschulerII
IMD, is Clinical Assistant Professor in the Department of Psychiatry, College of Medicine, University of Vermont
IIMD, PhD, is Assistant Professor in the Department of Physical Medicine and Rehabilitation at the University of Medicine and Dentistry of New Jersey, Adjunct Clinical Instructor in the Department of Rehabilitation, Mt Sinai School of Medicine, and a Member of the Brain and Perception Laboratory, University of California, San Diego. He does clinical work and studies clinically applied and basic cognitive neuroscience, and also has a deep interest in the history of medicine and medicine in art
Attention deficit hyperactivity disorder (ADHD) is currently thought to affect between 5% and 10% of school age children.1 Yet, curiously for such a common disease, ADHD was described in the medical literature only a little more than a hundred years ago.2 It is therefore worth searching historical sources to look for older descriptions of the condition. Thome and Jacobs3 note a description of the mixed inattentive and hyperactive subtype of ADHD in 'The Story of Fidgety Philip' ('Zappel-Philipp') from the second edition (1846) of the children's book Struwwelpetef4 by German psychiatrist Heinrich Hoffmann (1809 - 1894):
But Philip he did not mind
His father who was so kind.
And then, I declare,
Swung backward and forward
And tilted his chair ...
Auster5 noticed the inattentive subtype of ADHD in a child who could not concentrate and learn his lessons despite hundreds of attempts, described more than 1 700 years ago in the Babylonian Talmud:
"What', the Master asked, 'is the matter today?' 'From the moment', the pupil replied, 'the Master was told that there was a religious matter to be attended to I could not concentrate my thoughts, for at every moment I imagined, Now the Master will get up or Now the Master will get up.'
Further consistent with the notion that ADHD is an old disorder, we note here the earliest known example so far of the hyperactivity subtype of ADHD in the remarkable painting 'The Village School' (c. 1670) (Fig. 1) by Dutch master Jan Steen (c. 1626 - 1679).
A modern diagnosis of ADHD,6 hyperactivity subtype, requires that six of nine criteria (six hyperactivity criteria and three impulsivity criteria) be met. The children in the painting illustrate all six of the hyperactivity criteria: (i) often fidgets with hands or feet or squirms in their seat; (ii) often leaves their seat in classroom or in other situations in which remaining seated is expected; (iii) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults this may be limited to subjective feelings of restlessness); (iv) often has difficulty playing or engaging in leisure activities quietly; (v) is often 'on the go' or often acts as if 'driven by a motor'; and (vi) often talks excessively. The three impulsivity criteria - blurting out answers, not waiting one's turn and interrupting others - cannot be met, but only because there is not sufficient order in the school to interrupt! These criteria are evident in children under 7 years of age, clearly cause academic dysfunction, and are not associated with other psychiatric or developmental disorders.
Despite its meeting criteria for the hyperactivity subtype of ADHD, we are still compelled to consider in the 'differential diagnosis' of the picture the normal state of childhood. Does the painting represent not ADHD, but 'boys being boys'? Steen's painting has the wonderful ambiguity of great art, and a view of the painting as exaggerated play certainly comes to mind when looking at it. However, contrast with another Steen painting (Fig. 2) from approximately 5 years earlier, also (confusingly) now known as 'The Village School', provides perhaps the strongest evidence that something is seriously wrong and amiss in the 1670 painting. Indeed, all the children save one in the 1665 painting are impeccably behaved, and the child who is being punished seems to have insight and regret for his transgression, or at least for his punishment. Alternatively, could the 1670 painting simply represent Steen's 'style' and not ADHD? Indeed, a certain amount of mayhem is not uncommon in Steen's paintings, for example in Fig. 3. However, as we can see in Fig. 3 this mayhem is circumscribed in a way that the goings on in the 'Village School' (1670) are not. Furthermore, as also illustrated by Fig. 3, disorder in Steen's paintings is typically associated with drunkenness and lasciviousness - which are of course not found in the 'Village School'.
In summary, Jan Steen's remarkable painting 'The Village School' (1670) is the oldest known depiction or description so far of the hyperactivity subtype of ADHD. Like all great art it is most provocative and thought provoking and as such not only illustrates for all time this segment of the human condition, but also introduces some ambiguity as it charges us to consider the boundary and distinction between ADHD and normal boyhood. Steen's painting, combined with observations of the inactivity subtype of ADHD in literature and history,3-5 show that ADHD is not a disease new to the 20th and 21st centuries. Further searching of historical sources for cases of ADHD is warranted.
1. Katragadda S, Schubiner H. ADHD in children, adolescents, and adults. Prim Care 2007; 34: 317-341. [ Links ]
2. Still G. The Goulstonian Lectures on some abnormal psychical conditions in children: lecture I [II, III]. Lancet 1902; 1: 1008-1012; 1077-1082; 1163-1168. [ Links ]
3. Thome J, Jacobs KA. Attention deficit hyperactivity disorder (ADHD) in a 19th century children's book. Eur Psychiatry 2004; 19: 303-306. [ Links ]
4. Hoffmann H. Slovenly Peter (Der Struwwelpeter, translated into English jingles from the original German of Dr Heinrich Hoffmann by Mark Twain, with Dr. Hoffmann's illustrations adapted from the rare first edition by Fritz Kredel). New York: Marchbanks Press, 1935. [ Links ]
5. Auster S. Attention deficit disorder. Pediatrics 1999; 104: 1419. [ Links ]
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. (DSM-IV). Washington, DC: American Psychiatric Association, 2004. [ Links ]
E L Altschuler