Fifty years ago, a disruptive child was exactly that: disruptive, unruly, a candidate for the naughty corner.
A grimly anti-social teenager was just that too: grim and anti-social, best left to his or her own devices.
Today, we are alert to the possibility that such behaviours may reflect mental health problems of one sort or another, some dysfunction that needs a medical intervention. The disruptive child could be diagnosed as ADHD, the withdrawn teenager as depressed.
Both could receive some sort of treatment (or, more likely in these days of strapped resources, be on the waiting list for it) – a treatment certainly expected to involve some sort of psychotherapy, and maybe (in both cases) drugs.
This is progress. Where once those who didn’t fit our notions of standard behaviour were judged, punished and then pretty much left to stew in their own juices, our vigilance for mental health issues at least leads to a much more compassionate and supportive view.
And that is good: whatever one may conclude about the nature and origins of troubling behaviour, the young are too naïve to cope with such problems without help of some sort. No-one would advocate a return to the insensitivities of the past. But have we gone too far in applying a medical model to the troubled?
At the time of the most recent major survey (2004), 10 per cent of children and teenagers, around three in every classroom, were diagnosed as having a mental health problem.
Professional practitioners report that the incidence has risen still further in the past decade, and that such problems are now more widespread, occurring not only in youngsters from deprived or difficult backgrounds, but also in increasing numbers from “good” and affluent homes. Youth mental health is a serious concern.
What drives this crisis in mental health? Is it simply that we recognise problems today that we did not understand in the past? Or are we over-vigilant for such problems, too quick to reach for a medical explanation and so over-diagnosing troubling behaviour, and hence over-pressuring resources?
We are far more aware today of major mental illness (MMI), forms of dysfunction that are plainly outside the normal sphere. Classic examples would be the psychotic delusions and hallucinations typical of schizophrenia; the wild, irrational mood swings of manic depression; the perceptual distortions associated with anorexia, body dysmorphic disorder, OCD.
As our mastery of neuroscience and genetics advances we are finding chemical, neurological and genetic bases for such disorders – and we are finding effective medical treatments.
MMI was not understood in the past, though it was certainly present. It is only in recent years that we have begun to realise that such illnesses can begin in early childhood or adolescence – which has led to more diagnoses.
Our vigilance and medical approach to MMI is obviously appropriate. But it is far less clear that such a ready recourse to medical diagnosis is best practice for lesser forms of troubling behaviour.
When is it appropriate to diagnose a disruptive child as having a medical problem? When does depression slip from a normal response to something requiring medication?
We are far more ready than in the past to diagnose a mental health problem in such situations, and the tendency is to do so. But there are concerns about this approach.
The first is that there are generally no clear diagnostic criteria, no definitive diagnostic tests for many forms of mental health problem falling outside MMI. The borderline between the normal and the abnormal is extremely fuzzy, resting as much on social convention as medical foundation. Diagnosis is consequently often a tricky, somewhat questionable affair. The danger is that we “medicalise” what is actually in the normal range.
Medicalising the normal would not matter, if the result was effective intervention – but that is far from sure. The evidence that medical treatments are effective across the broad spectrum of cases now diagnosed as mental health problems is surprisingly weak.
Drug treatments have limited impact in many cases (for example, reviews of research suggest that, while very effective in serious depression, antidepressants have little or no more effect than a placebo in lesser levels of depression), and they involve side effects.
Likewise, psychotherapy and counselling are less effective than is popularly supposed, and have been shown in some cases to do more harm than good.
The most effective approach is cognitive behavioural therapy, but this too is no magic bullet and does not work for all.
By medicalising the normal we may be subjecting children and adolescents to inappropriate and ineffective interventions. We may also be inadvertently undermining powerful resources for mental health.
For example, recent research suggests that when we “medicalise” normality we create a conceptual framework that is counter-productive in various ways.
We have long known that labels have the potential to be damaging. Even in our enlightened times, an individual labelled as having a mental health problem is perceived and treated differently, in ways that may entrench the problem rather than alleviating it. Older children and teenagers are still bullied for being different.
Worse: the new research shows that how one conceptualises the nature of an emotional or behavioural problem has a direct impact on the efficacy of interventions. For example, believing that your troubles reflect a disorder that needs medical treatment can disempower, undercutting the normal processes through which we develop resilience to, and recovery from setbacks – which is what we all need, in this troubled world.
Obviously, rowing back from a medical view of troubled youth would be a retrograde step if it blunted our success in early identification of MMI. But the evidence we have suggests that, in lesser cases, emphasising normality and normal coping mechanisms is beneficial.
Various experiments of this kind have been made over the past century (for example, in a community in Belgium recently reported in The Psychologist, where those we would describe as mentally ill have been enfolded in the local community and treated as “normal” with good effects stemming from the acceptance and social support this provides, an emphasis on individual coping).
In sum: there are grounds for arguing that we are too ready to medicalise troubling behaviour in the young, and that this can be counter-productive.
Implications for schools
So, what implications might this discussion have for best practice in schools?
- Continuing vigilance for the early signs of MMI is obviously crucial. Continuing training to recognise such signs is important, as research progressively uncovers more practical clues.
- Equally, it is prudent to watch for signs of distress that may signal that a child or teenager is struggling with some situation and needs help, whether practical or emotional, whether from school, family, social services or the NHS. Far better to head problems off than to let them develop.
- Raising the threshold at which we begin to think of a troubled individual as having mental health problems rather than a normal reaction to the stresses of life need not reduce our efforts to offer support. It should merely redirect those efforts toward empowering the attitudes and strategies that foster resilience to, and recovery from setbacks, as a normal part of development for the individual and the school community as a whole.
- Dr Stephanie Thornton is a chartered psychologist and former lecturer in psychology and child development.