Vivian Hill

1. British Psychological Society Division of Educational and Child PsychologistsManchester June 2013The Medicalisation of Childhood Behaviours: The Need for a Paradigm Shift Vivian Hill

2. 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.

3. 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.

4. 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?

5. 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.

6. 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)

7. 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.

8. 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. • Stallardet 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.

9. 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.

10. 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 socio-economic 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.

11. 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.

12. MACROSYSTEM Attitudes, Politics and Ideologies of the Culture EXOSYSTEM ExtendedFamily MESOSYSTEM MICROSYSTEM Friends of Family Family School Neighbours CHILD Sex Age Health etc Health Services Peers Faith Group Neighbourhood Play Area Mass Media Legal Services Social Welfare Services Bronfenbrenner’s Eco-systemic Model

13. 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.

14. 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.

15. 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

16. 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.

17. 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.

19. 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.

20. “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

21. 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

22. 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

23. 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)

24. 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?

25. Environmental Factors Family, school, life events,culture Toxins and Diet Foetal alcohol syndrome Hearing, vision, medication ADHD: Possible Causes Neuro Biological Impulsive Overactive Inattentive Behaviours Lead, Nutrition, Food intolerance Genetics, Congenital, Gender, Age, Acquired: trauma / Illness Instrumental Developmental History Cognitive Abilities Communication skills Learning difficulties Motivation Personal style Emotional status Child’s views Educational Judgement Individual psychological differences Clinical judgement, criteria, Measurement. BPS DECP 1996

26. Biological ADHD: Biopsychsocial Model Individual differences, Neurological aetiology, multiple causations Environmental Influences Poverty; Overcrowding; Quality of parenting and care; Opportunities for learning. Attention filter, inhibitory deficits, motivation, delay aversion, multiple mechanisms Psychological Behavioural Manifestations Impulsive, overactive, inattentive

27. 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.

28. “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

29. 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.

30. 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”.

31. 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.

32. 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. • Sabatinoand 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.

33. 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. Ways forward

34. Engaging in discussion and research activities across disciplines to help formulate a new paradigm for understanding children’s behaviour and emotional needs Most importantly….