Problem behaviour in children is not always a mental disorder
Children are increasingly being given drugs by doctors to help teachers and parents cope with their troublesome behaviour. Certain behaviours or actions by children, such as not sitting still, are being judged as evidence of mental disorders and used to justify an official diagnosis. This has led to an increase in diagnoses of children with conditions such as attention deficit hyperactivity disorder (ADHD) and drug treatment with stimulants, antipsychotics and antidepressants.
(Readers should be aware this piece was first shared in 2014)
The problem with giving children such diagnoses is that it obscures other interpretations of children and their behaviour.
It detracts from considerations of what is best, educationally, for individual children. And it encourages a reliance on definitions of mental disorder to account for childhood normality or abnormality. In a new book, Valerie Harwood and I have called this trend psychopathologisation.
In the UK, around 5% of children of school age are said to have ADHD. The growth in mental disorder diagnoses seems to be a global phenomenon, with estimates of the worldwide prevalence of ADHD at 5.29% and an average in Europe of 4.6%. Figures are much higher in Australia (11.2%), America (11%) and Africa (8.5%).
In our research, we interviewed child mental health psychiatrists, educational psychologists, teachers providing additional educational support and youth work professionals in Australia, England and Scotland. All voiced major concerns about increases in both the diagnoses and the prescriptions of drugs. Recent press debates, in The Conversation and elsewhere, about whether ADHD is “real” deflect from a more striking – and “real” – enthusiasm for labelling more and more children as mentally ill.
The risk of psychopathologisation is greatest for particular ethnic groups and for children from disadvantaged backgrounds. In the UK, children and young people living in poorer circumstances are four times more likely to be diagnosed with ADHD.
Boys outnumber girls in diagnoses of ADHD by four to one, as is the case in most neuropsychiatric conditions. But there is a referral bias, where boys are more frequently referred than girls because of their aggressive behaviour. This takes the ratio of boys to girls within mental health clinics or hospitals to between six and nine, to one.
Girls are considered more likely to exhibit the characteristics of the less prevalent attention deficit disorder, which include sluggishness and anxiety. But because, by its nature, it does not involve hyperactivity, they may not be referred or may be misdiagnosed.
Catch and treat them young
There is great enthusiasm for resolving the mental health problems of very young children (or the risk of these) under the rubric of “intervention”. Some of these interventions are even directed at unborn children, for example, by minimising maternal stress and promoting healthy behaviour by the mother during pregnancy.
The earliest times of life are key times of intervention for future healthy minds. The newborn, as well as the prenatal (or antenatal) periods, are viewed as times in a child’s life that hold the most potential for when mental health problems can be avoided, detected or corrected.
This potential decreases as age increases, on a downward sliding scale from the unborn, newborns, infants, toddlers and preschoolers. The “developing brains” of very young children are perceived as important in the prevention of mental problems.
For the child entering primary school, scrutiny is intensified and directed at whether he or she will “fit” into school and be accommodated in its expectations and practices. For those children who cause concern, psychopathologisation begins in earnest.
The acceptance that things have now been “set on course” generates a period where practices such as separation using different schools and classrooms, pharmaceuticals, and behavioural management programmes for parents at home or for teachers within schools, swing into full-scale operation.
At secondary school, a more sombre tone emerges that reveals an acceptance that older children’s behaviour disorders are unlikely to be resolved. The secondary-aged mentally abnormal youngster is seen as presenting danger and risk to the teachers and other students. The measures introduced at this stage are “palliative” and are aimed at controlling the young person’s condition and minimising its impact. The purpose of this control and containment is to protect the security of others and of society at large.
In colleges and universities, psychopathology becomes linked to the troubled student with depression, and with a concern for the dangerous potential for potency and violence. Higher education establishments are seeking to learn from incidents such as the Virginia Tech massacre.
Diagnosing potency has become a regular practice within institutions, together with drives to detect danger through “connecting the dots” and threat assessment. There is far less interest in those other forms of behaviour disorder that received attention during earlier phases of schooling.
Are there alternatives?
Several of the professionals we interviewed described explicit efforts to resist diagnosing children with ADHD or other behavioural disorders and described three lines of resistance. These focused on the language used by teachers and parents. One interviewee, an educational psychologist, said: “We’re trying to change the language and get people away from what they think is the bad child and helping people to understand that there’s a context here, the reason we’re getting the behaviour might be this experience or that experience”.
Others tried to encourage teachers to look beyond the child’s difficulties to the family situation and to change the perceptions of those families who came “looking for a prescription”. These professionals succeeded in interrupting referrals for diagnoses by showing teachers and parents better ways of understanding and responding to children’s behavioural problems.
Good teacher education could also help to reduce the numbers of diagnosed children. If teachers were helped to find children’s behaviour less of a threat and more of an interesting challenge, with resources and support to enable them to respond effectively, a diagnosis of disorder may become less attractive. It would require a form of teacher education that emphasises meeting the needs of all children in the classroom and helps teachers to develop an enthusiasm for the diversity that the children bring.
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