British Psychological Society Division of
Educational and Child Psychologists
Manchester June 2013
The Medicalisation of
Childhood Behaviours:
The Need for a Paradigm Shift
Vivian Hill
ioe.ac.uk
The debate
Today we will consider:
The influence of philosophical paradigms and the legislative
context on how services are currently delivered to children;
The complex interplay between individual characteristics and
wider social factors on children’s behaviour;
Are current paradigms fit for purpose or leading to
inappropriate assessments, diagnoses and interventions?
How to ensure fair and equal access to EP services for all
children in a legislative context of change.
Professional Concerns
• Over the past decade there has been growing professional
concern about the numbers of children being diagnosed
with a range of mental health problems and prescribed
psychotropic medication;
• Children living in adversity and those with learning
disabilities are over represented in this group;
• Children as young as 3 have been prescribed medication
to manage their behaviour; Hsia & Maclennan 2009 report
a 96 fold increase in prescriptions for children under six
between 1992 and 2001;
• The interaction between social context, poverty and
psychological well-being is well established yet largely
ignored when: organising and providing services, or
making a diagnosis and considering interventions.
Professional Challenges
• The changing legislative context brings new challenges;
• Is this the start of the privatisation of SEN?
• With devolved budgets and resources schools will be able
to buy the services they want but are they the services that
they need? Who will critique what is on offer? Who will
fund the full extent of multi-professional working with the
most needy;
• What of the unsponsored child? The troubled and
troublesome, low achieving, time consuming, and difficult
to engage?
• How will we ensure fair and equal access for all children?
• Can you differentiate the statutory and non-statutory role?
The Growth of Mental Health Conditions
• Over the past four decades there has been growing
professional concern about the proliferation of mental
health categories and their lack of evidence base.
• In 1952 there were 106 diagnostic categories in DSM 1.
• In 1994 DSM-IV described 357
• This reflects the influence of the Biomedical Model which
tends to view mental health needs as constitutional in
origin and therefore encourages a medical response.
Philosophical Orientations
• In the past four decades there have been emerging
different philosophical orientations to mental health
including:
• Critical Psychiatry;
• Anti-psychiatry;
• Post Psychiatry;
• Social Constructivist Movement.
• These movements question the biomedical perspective
and advocate enhanced consideration of psychological
and social explanations using a biopyschosocial approach.
Goldstien and Goldstien (2006)
There is compelling evidence that
well-being and mental health needs
are strongly influenced by wider
social factors, and that the links
between social context and behaviour
are complex and bi-directional.
National Context
The Department of Health (2004) indicates that 10% of 5-15
year olds have a diagnosable mental health condition but that
up to 40% of them are not accessing any form of specialist
support, they also suggest that a similar number of children
experiencing less serious difficulties, may also benefit from
support.
Stallard et al (2007) reported that health agencies could not
respond the level of demand for that could come from
schools.
This data indicates a considerable profile of need but a dearth
of resources to respond.
Contextual influences
The Office of National Statistics (2004) reports that the
incidence of mental health problems in the learning
disabled population is around 40%, with those with severe
learning difficulties experiencing an incidence rate that is
three to four times higher, further studies have consistently
verified this finding, Einfeld and Tonge, (1996), Dykens
(2000) and Cormack, Brown and Hastings (2000).
The Child and Adolescent Mental Health and Psychological
Well-Being Working Group (2004) found that 1 in 10 of all
children referred for mental health problems has a learning
disability, and that 50% of those live in poverty.
Context
The Mental Health Services for Children with Learning
Disabilities, a National Care Pathway (2006),Reported:
‘At the time of the project only 45% of child mental health
services were accessible to children and young people with
learning disabilities, and three Strategic Health Authorities
were without any specialist LD CAMHS provision.’
Emerson (2006) suggests that health, including mental health
is in part determined by social factors including socioeconomic status. He argues that as a consequence
children with learning difficulties are at increased risk of
exposure to all forms of social exclusion, and emotional
and behavioural problems. He speculates that 25-30% of
this risk relates to poverty.
Contextual influences
The evidence suggests that to date these well established
contextual factors have been largely ignored when planning
the strategic delivery of CAMHs services. Those children with
the highest levels of need have been poorly catered for and
pattern of provision requires an urgent review.
Hill (2006) proposes that given the strong links between
poverty, learning disability and mental health needs there is a
clear rational for making mental health provision, and wider
parental support, including social work support, available as
part of the routine provision within all special schools for
children with learning disabilities. The role of the EP in these
contexts should be significantly enhanced to facilitate a more
therapeutic and intervention focused approach.
MACROSYSTEM
Attitudes, Politics and Ideologies of the Culture
EXOSYSTEM
Extended Family
MESOSYSTEM
MICROSYSTEM
Friends
of
Family
Family
School
Neighbours
CHILD
Sex Age
Health
Services
Mass
Media
Faith
Group
Health etc
Peers
Neighbourhood
Play Area
Legal
Services
Social Welfare
Services
Bronfenbrenner’s Eco-systemic Model
The evidence suggests that the social and
psychological world of the child also has a
critical influence on their well-being and these
issues require a more systemic approach.
Consider common life stresses: exposure to
domestic violence, gang culture, reduced
opportunities for free play. A change of
paradigm might help to better support children
facing these challenges. NIMH and MHE have
already clearly signaled that current paradigm
is no longer fit for purpose.
Paradigms
• Paradigms are a set of assumptions, concepts, values and
practices that constitute a way of viewing reality for an
intellectual community that shares them.
• Kuhn (1970) in The Structure of Scientific Revolutions
described how science progresses through alternating
periods of stability, when an existing model of reality
dominates for a protracted period, followed by revolution,
when the model or reality itself undergoes sudden drastic
change. He notes that these preconceptions often embody
hidden assumptions and can vary amongst individuals.
Paradigm impact
• Influences the factors considered to effect behavioural
functioning;
• Influences what is considered adaptive and maladaptive;
• Influences what is considered to be an appropriate foci for
intervention
Paradigm Conflict
• The constructivist biopsychosocial, model common in
applied psychology embraces broader conceptualisations
of the origins of complex behaviour;
• The medical model has a very much more constrained
within person focus, with implications for management and
intervention.
• The conceptual paradigms used by different members of
the multi-professional network influence understandings,
language and action differently and create tensions in
effective communication.
Social Constructivism: What is it?
• Any approach or theoretical orientation which has at its
foundation one or more of the following key assumptions:
• A critical stance towards taken for granted knowledge.
• Historical and cultural specificity.
• Knowledge is generated and sustained by social
processes.
• Knowledge and social action go together.
Four versions of constructivism
Objective
There is an external reality
Social
Knowledge is
constructed socially
CoConstructivism
Knowledge is negotiated
through conversation and
conversation is in turn the
external reality
Cognitive
Constructivism
Knowledge is an external
reality that is constructed
through internal conflicts
within the individual
Situated
Constructivism
Knowledge is negotiated
socially, though everyone
has different social
experiences resulting in
multiple realities
Radical
Constructivism
Knowledge is constructed
individually based on an
individual’s unique
experiences; there is no one
objective reality
Subjective
There are multiple realities
From: Heather Kanuka and Terry Anderson (1999)
Individual
Knowledge is
constructed
individually
Social Constructivism
• Challenges us to examine the way that we perceive the
world - the ‘real’ world is different for each of us.
• Proposes that the way we perceive and understand the
world depends on where and when in the world we live
rather than any objective reality - it therefore challenges
some of the traditional dominant models of psychology.
• Social processes, interactions and language influence the
way we think.
“Reality is constructed inter-subjectively,
that is socially negotiated between
significant others who are able to share
meanings and social perspectives of a
common life world”
Berger and Luckman 1966
Discourse
• When people talk to each other, the world gets
constructed. Our use of language can therefore be thought
of as a form of action by some social constructionists.
• ‘A discourse refers to a set of meanings, metaphors,
representations, images, stories, statements and so on
that in some way together produce a particular version of
events. Surrounding any one object, event, person etc.,
there may be a variety of different discourses, each with a
different story to tell about the object in question, a
different way of representing it to the world.’Burr 2003
Constructivism - a search for meaning
• Meaning is not assumed to exist ready made, awaiting
discovery by expert observers
• Meaning is a continually emerging outcome of interactional
processes
• Communicating meaning is never a direct process.
Individuals are always engaged in a process involving
interpreting and sense making
Attention Deficit Hyperactivity Disorder
This description of behaviour
challenges the biomedical model,
and yet this diagnosis is the one
most likely to lead to the prescription
of psychotropic medication for
children. ONS (2004)
Attention Deficit Hyperactivity Disorder
There is no definitive medical assessment for the
condition
• Diagnosis is often through check lists
• Family /developmental history
• Educational commentary
There are concerns that diagnosis is subjective. Does the
person have ADHD or is the over activity an appropriate
response to adversity: abuse, trauma or indeed learning
disability? Who decides and how?
ADHD: Possible Causes
Environmental Factors
Foetal alcohol
syndrome
Toxins
and Diet
Lead, Nutrition,
Food intolerance
Motivation
Personal style
Emotional
status
Family, school, life events, culture
Hearing, vision,
medication
Impulsive
Overactive
Inattentive
Behaviours
Developmental
History
Individual
psychological
differences
Child’s views
Cognitive
Abilities
Communication skills
Learning difficulties
Neuro Biological
Genetics, Congenital,
Gender, Age, Acquired:
trauma / Illness
Educational Judgement
Instrumental
Clinical judgement, criteria,
Measurement.
BPS DECP 1996
ADHD: Biopsychsocial Model
Environmental
Influences
Poverty;
Overcrowding;
Quality of
parenting and
care;
Opportunities for
learning.
Individual differences,
Neurological aetiology,
Biological
multiple causations
Attention filter, inhibitory deficits,
motivation, delay
Psychological
aversion, multiple mechanisms
Impulsive, overactive, inattentive
Behavioural
Manifestations
Subjectivity masquerading as science
• Many of the diagnostic categories in DSM-IV and DSM-5
draw on social norms rather than biological evidence,
making them subjective, lacking in validity, reliability, or
prognostic value;
• Moncrieff (2007) explains that the research evidence
suggests that diagnostic categories do not predict the likely
response to medication, or indeed to other interventions,
whereas specific and contextually informed formulations of
symptoms might.
“The point is not that decisions about
what is normal are riddled with
personal biases and political
considerations, but rather that, by dint
of a handful of influential professional
efforts, those subjective determinants
of diagnoses masquerade as solid
science and truth”
Paula Caplan (1995) former member of DSM panel
Critique of Medical Model
• Ultimately the concern is that in labelling worrying
or challenging behaviours as ‘illnesses’ the
context of the problem and the social factors that
underpin these behaviours is denied and the
problem is ultimately located within the child. This
has profound implications for the appropriateness
of the treatment of the child and the prognosis.
• Despite the 2009 NICE guidelines on the
treatment of ADHD few children are accessing
psychological interventions, most are prescribed
medication alone.
Critique of Medical Model
• Goodman and Poillion
• reviewed 48 articles and books on the topic of ADHD and
identified 69 characteristics and 38 causes for ADHD
evidencing little agreement either about the causes or
features of the condition.
• The challenge is in setting the boundaries for ‘clinically
significant behaviours’ at present there are only arbitrary
and subjective cut off points. Stranger & Lewis note the
weakness of rating scales as being “not sensitive or
specific enough to be used reliably as a diagnostic tool and
will inevitably lead to many false positives”.
Critique of Medical Model
• In 2001 the Maudsley Debate noted the prescription of
Ritalin increased from 183,000 in 1991 to 1.58 million in
1995.
• Recent figures estimate that 650,000 children aged
between eight and 13 are taking psychotropic drugs, up
from just 9,000 two decades ago.
• According to data obtained by Education Guardian in
2012 under the Freedom of Information Act there has
been a 65% increase in spending on drugs to treat ADHD
over the last four years. It is difficult to find precise figures
about the use of medication to treat ADHD in children
however, as currently no accessible national records are
kept, and there has been little research into the
consequences.
Critique of Medical Model
• The National Health Interview Survey, suggests that
roughly half of 6-11 year olds diagnosed with ADHD may
also have a learning difficulty.
• Sabatino and Vance re-evaluated 75 children aged 5-17
year olds diagnosed with ADHD where there had been a
poor response to medication or educational intervention
and found that one third were re-diagnosed with another
behavioural disorder that explained their symptoms. They
concluded that ADHD symptoms are shared with many
other mental health conditions as well as learning
difficulties and that the treatment and management of
ADHD should involve a complex analysis of the factors
influencing the child’s behaviour.
Ways forward
Universal access to EPs should be protected for all
vulnerable children and their families;
EPs should help ensure that all assessments,
formulations and interventions are based on
consideration of all relevant variables;
EP ratios should reflect not only the enhanced age
range, 0-25, but also the enhanced role;
EPs should engage in research to provide a secure
evidence based understanding for intervening with
complex and challenging behaviour.
Most importantly….
Engaging in discussion and research activities
across disciplines to help formulate a new paradigm
for understanding children’s behaviour and
emotional needs