Psychiatrised childhoods

Abstract

As the ‘psy’ complex comes to exercise an ever-greater grip on our lives, we have an even greater need for critical resources to interrogate and resist its presumptions.

– Burman (2008: viii)

‘Psychiatrisation’ describes the process by which an ever-expanding assemblage of human life experiences have come to be observed, understood, enacted and acted upon through the language, theories, technologies and institutional practices of Western biomedical psychiatry. Ever since the medical profession seized its opportunity to profit in the ‘mad trade’ during the late 18th and early 19th centuries and ‘psychiatry’ established itself as a new sub-specialty of medicine, various cognitive, behavioural and emotional states have been governed by ‘illness’ and ‘disorder’ categories which draw boundaries around ‘normality’ and ‘abnormality’ (Coppock and Hopton, 2000). The normal/abnormal binary is the organising mechanism for psychiatrisation, while diagnosis is the process by which individuals are marked out as ‘mentally ill/disordered’; an exercise operationalised by the use of professional manuals such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) of the American Psychiatric Association (APA, 2013) and the World Health Organization’s International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) (WHO, 1992). Those who meet specified criteria can be classified as having a mental disorder, thus ‘marking certain mental and emotional states and experiences as different, abnormal and pathological against preconceived notions of ‘normal mental health’ (Liegghio, 2016: 114).

Biomedical psychiatry is underpinned by the assumption that psychiatric diagnosis simply involves the identification and accurate naming of an objective disease process (Bracken and Thomas, 2000). However, critical research contests this assumption, demonstrating that the diagnostic process is unreliable, heavily influenced by the subjective interpretations of clinicians (Caplan, 1995; Double, 2002; Kutchins and Kirk, 1997), and that diagnostic categories are permeated with bias derived within and reinforcing of relational, structural and systemic forms of power and domination (Fernando, 2017; Rogers and Pilgrim, 2014). Moreover, diagnostic classification systems are unstable, constantly under negotiation, reflecting prevailing ideological, socio-cultural and political conditions. The contents of both the DSM and ICD are determined through a process of periodic review and consultation by a panel of ‘expert’ psychiatrists. Some ‘disorders’ have ‘disappeared’ altogether, notably as with the de-classification of homosexuality in the DSM in 1973 and the ICD in 1992. However, the trend over time has been towards exponential growth in the overall number of classified disorders, meaning that many behaviours, thoughts and feelings that were once considered to be within the ‘normal’ range of human experience are now deemed to be ‘pathological’. From an initial list of 128 ‘disorders’ in 1952, the DSM has been revised five times and now contains in excess of 300.

The implications and consequences of psychiatrisation for the lives of those who come into contact with mental health systems are as complex and controversial as they are varied. From its earliest days psychiatric intervention was experienced as alienating, stigmatising, coercive and, as such, resisted (Porter, 2006). Indeed, over time there has been remarkable continuity with which encounters with mental health systems are reported negatively, whether interventions are directed at the body or the mind or both (Johnstone, 2000; Rogers et al., 1993). Significant developments in critical social theory and epistemology within social science in the 1960s and 1970s, alongside the flourishing of social activism and consciousness-raising among various social groups, gave impetus to challenges to psychiatric discourse, systems and practices, opening up possibilities for new meanings, resistances and calls for substantive change (Chamberlin, 1978; Morrison, 2005)¹. It is in this context that the term ‘psychiatrised’ has come to be associated with, and used by, activists within adult mental health service user movements around the world, many of whom identify as ‘psychiatric survivors’ of sanist² and ableist³ normativity and oppressive mental health systems (Burstow et al., 2014; Daley et al., 2019; LeFrançois et al., 2013). In this sense, ‘psychiatrised’ not only signifies the process of being acted upon by psychiatry (i.e. being diagnosed with a ‘mental illness’ or ‘disorder’ and/or ‘treated’), but also the scope for individual and/or collective agency within the constraints of diagnosis; whether that be, for example, demanding the right to be taken seriously, to own and define one’s own distress and to have a decisive influence in finding solutions to that distress, or engaging in political acts of resistance to psychiatric authority.

While the subject of psychiatrisation is well-established and articulated in the arena of adult mental health, as it relates to knowledge of the lived experiences of children diagnosed with psychiatric disorders, it remains relatively underexplored – both in terms of critical research and scholarship across disciplines and in the activities of service user/survivor movements (LeFrançois and Coppock, 2014). Such oversight owes much to the way in which adultism,⁴ or institutionalised ‘age patriarchy’,⁵ bolstered by Western essentialist theories of child development (Burman, 2008; Nieuwenhuys, 1998), has pervaded knowledge about children’s emotional lives, obscuring understandings of the experiences and impact of sanism on children and ‘childhoods’⁶ (Coppock, 1997; Liegghio, 2016). Theoretical and epistemological developments from the ‘new sociology of childhood’ facilitated a strong critique of how adultism and developmentalism have excluded children from the production of knowledge about their own lives (Prout and James, 1997; Qvortrup, 1994). This marked a crucial ‘transition towards recognizing children as ‘knowers’ – able to generate knowledge (Foley, 2001: 99). As such, it paved the way for research studies to emerge in child mental health that began to give new insights into children’s emotional lives and to offer provocations to think, research and practice differently. And so, over the past two decades, research and scholarship has begun to document the psychiatrisation of childhood and children’s lived experiences of psychiatrisation in diverse contexts (see for example, Bergnher and Zetterqvist Nelson, 2015; Brady, 2014; Breggin, 2014; Coppock, 1997, 2002, 2005; Kvist Lindholm and Zetterqvist Nelson, 2014; Laws et al., 1999; LeFrançois, 2008; LeFrançois and Diamond, 2014; Liegghio, 2016; Mills, 2014; Rabaia et al., 2014; Runswick-Cole et al., 2016; Singh, 2013; Skovdal, 2012; Timimi, 2002; Van Daalen-Smith et al., 2014; Wickstrom, 2013). Much of this work speaks to the institutionalised adultism and sanism that characterises and informs oppressive adult-professional-child encounters globally. Crucially, however, it also facilitates the reframing of children’s psychiatrised identities from passive victims of ‘adult-psy’ authority to capable, creative, agentic human beings.

It is with the above context in mind that the subject of Psychiatrised Childhoods was chosen for this Special Issue of Global Studies of Childhood; in order to further make visible, politicise and critique ‘the assumptions relating to children who have been diagnosed within mental health services’ (LeFrançois and Coppock, 2014: 165). The call for papers invited contributions from authors committed to interrogating how processes of psychiatrisation are observed, understood and experienced in the lives of children. The aim was fourfold. First, to facilitate critical examination of how researchers, policy makers and practitioners in diverse contexts ‘see’, make sense, categorise and respond to children’s emotional distress. Second, to disrupt essentialised Western, medicalised, pathologising conceptualisations of childhood and children’s mental health/distress by reframing diagnosis and treatment as a children’s citizenship question rather than a biomedical condition. Third, to promote fuller and more nuanced understandings of children’s social relations, culture and meaning making in relation to their own mental health and emotional distress and/or that of others. Fourth, to contribute to interdisciplinary theorisation, policy and practice that is strengths rather than deficits orientated and that recognises and respects children as a heterogeneous population of creative human actors capable of imagining and executing strategies for managing their emotional lives, despite structural and discursive constraints arising from their generational position in society.

This process generated six scholarly contributions. In the first article, Timo Beeker, China Mills, Anna Witeska-Młynarczyk and Sanne te Meerman emphasise the conceptual and agentic complexities at play in the idea of ‘psychiatrisation’. Two case study vignettes, based on two previous empirical research studies undertaken by one of the authors in Poland, serve as a point of focus for a detailed, critically reflective theoretical discussion that aims to ‘demonstrate the messiness of psychiatrization in practice’ (in this issue, p. 16) and ‘to flesh out the nuanced ways in which psychiatrization operates in the everyday lives of children and youth’ (p. 16). For these authors, psychiatrisation consists of ‘heterogeneous, not centrally controlled sub-processes, which are driven by different agents, for diverse and sometimes even contradicting motives’ (p. 14). Rather than a one-directional and one-dimensional trajectory for psychiatrisation, Beeker and colleagues identify both ‘top down’ and ‘bottom up’ processes, illustrating how ‘psychiatrisation can be ‘done to’ children, ‘with’ children or even ‘by’ children’ (p. 17). In this, one vignette is used to illustrate a child’s ‘resistance to psychiatrization through their ADHD label’, while the other illustrates ‘young people embracing and positively identifying with bio and psy-knowledge in relation to depression’ (p. 12). Together, these vignettes illustrate ‘that children have nuanced understandings of their behaviour, distress and of psychiatrization; and may both resist and sometimes strategically enact psychiatrization’ (p. 16). The authors conclude that ‘young people’s accounts of psychiatrization may challenge dominant adult-centred assumptions’ (p. 16), highlighting the central importance and value of ‘knowing as situated inquiry’. Such an approach offers the potential to provide much fuller and nuanced understandings of children’s lived experiences, in diverse contexts, and to contribute to theorisation that is strengths rather than deficits focused.

In similar vein to Beeker et al. (in this issue), Sofia Kvist Lindholm and Anette Wickstrom are keen to demonstrate how children and young people are creative agents in using and adapting formal psychiatric concepts. In their article, they draw on empirical research with 15-year-old Swedish young people to explore how they interact with dominant discourses regarding their mental health, as articulated in mainstream epidemiological self-report surveys. The authors begin by outlining processes of psychiatric labelling in the use of international standardised epidemiological survey instruments for measuring children’s mental health and emotional wellbeing (such as the World Health Organization’s four-yearly cross-national survey, Health Behaviour in School-Aged Children). They identify ‘leaps in reasoning’ in the interpretation of survey data and observe that, ‘attempts to measure and interpret data about young people’s wellbeing draw on a medical model in which young people’s experiences of various problems are decontextualised and considered signs or symptoms of psychopathology’ (p. 27). Using Hacking’s theoretical concept of ‘looping effects’, they explore and analyse ‘how young people appropriate, reject and give new meaning to the psychiatric labels anxiety and depression’ (p. 29).

An important finding in this research is that, rather than simply reproducing the dominant biomedical discourse that locates emotional distress ‘within’ themselves, the young people shifted the focus to the ‘social and structural context of managing school, their social relations and norms and ideals of society and their peer groups’ (p. 35). That is, they transformed pathologising psychiatric labels from diagnostic into cultural categories. In this sense, the authors argue, ‘psychiatric labels stop being categories for suffering and start being cultural categories applicable to dealing with the ups and downs of life’ (p. 36). Nevertheless, the authors observe how this shift in focus is nullified when adult interpreters fail to pick up on the nuances of meaning in young people’s transformative use of psychiatric concepts in their self-reports. They conclude that if standardised epidemiological surveys are to accomplish their intention of providing valid interpretations of children’s self-reports of their mental health and wellbeing, they must be cognisant of such discursive changes, or ‘looping effects’; reinforcing further the importance of ‘knowing as situated inquiry’.

In the third article, Allison Moore draws on and further develops theorisation from within the field of Critical Autism Studies to explore critically the diagnostic category of pathological demand avoidance (PDA) in children. She traces the emergence and development of PDA interrogating its theoretical and discursive contours as a contested terrain. She begins by outlining the conceptual origins of the term, developed initially as a behavioural description in clinical practice but later recognised formally as an individual behaviour profile within the autistic spectrum, defined as ‘an extreme resistance to the ordinary demands of everyday life’ (p. 40). Moore’s central argument is that ‘we must exercise extreme caution in accepting the validity of PDA’, suggesting that ‘it can be seen as an attempt to psychiatrise autistic children’s resistance which, in so doing, restricts their agency’ (p. 40). She suggests that ‘PDA is better understood as Rational Demand Avoidance (RDA); an understandable and rational response’ from autistic children as they attempt ‘to navigate their way through a neurotypical world that is not designed to acknowledge, let alone meet, their needs’ (p. 40). Furthermore, she identifies PDA as part of a wider ‘normalisation agenda’ involving ‘treatments and interventions designed to support or, in some cases force, autistic individuals to ‘adapt’ to the neurotypical world around them’ (p. 43).

Moore goes on to explore critically the intersections between autism and childhood and then autism, childhood and gender. She locates PDA within a wider discursive critique of developmentalism – or as she puts it ‘the pathologisation of self-advocacy’ (p. 42), ‘the pathologisation of competence’ (p. 44) and ‘the pathologisation of transgression’ (p. 47), respectively. In this, she identifies how ‘autistic children who attempt to engage in independent decision-making that may resist or challenge neurotypical norms are especially vulnerable to attracting the label of PDA, simply because they are children’ (p. 44, my emphasis). She argues that ‘there is nothing inherently pathological about the behaviours classified as such under PDA’ rather, ‘it is simply behaviour interpreted as extreme or pathological by parents, carers and professionals based on developmental, adult-centric and neurotypical assumptions of how children should behave’ (p. 49). Furthermore, she concludes that ‘the intersection of developmental models of childhood, the normalisation of sex/gender differences and compulsory neurotypicality places female autistic children at particular risk simply because they do not, or cannot, conform to what others expect of them’ (p. 49).

Sarah Golightley presents findings from research with former students of US-based ‘therapeutic boarding schools’, described as comprising a disparate range of privately run, poorly regulated, residential institutions which are marketed as facilities that deliver therapeutic and/or socio-educational programmes aimed at ‘treating’ so-called ‘troubled teens’. ‘Troubled teens’, she explains, ‘are young people who are labelled as having emotional, behavioural, or substance misuse problems’ (in this issue, p. 53). The author describes a thriving ‘troubled teen industry’, within which therapeutic boarding schools ‘have a reputation as interventions for wealthy families with power and privilege’ (p. 54). This underscores the political economic context of therapeutic entrepreneurialism within which psychiatrisation is enabled to grow and flourish (Frances, 2014; Whitaker and Cosgrove, 2015). Typically, referrals to these facilities are initiated by parents, with or without the young person’s consent, and may include forcible removal from home by ‘transporters’ who convey the young person to the receiving institution. This illustrates not only how children and youth often have little agency over their own health-related decisions, but also the ease with which their fundamental right to bodily integrity can be overridden by adults claiming to be acting ‘in their best interests’ (Coppock, 1997, 2002).

Golightley self-identifies as a former therapeutic boarding school student. As such, her epistemological approach is in the tradition of survivor-led research which disrupts dominant ‘expert’ narratives, facilitating silenced voices to be heard and ‘leading to the generation of new, transferable knowledges’ (p. 55). In this, her ‘central aim is to centre the perspectives of former students and critique social control of young people in therapeutic boarding schools’ (p. 53). Using the lens of Mad Studies and drawing on data from in-depth case study interviews, she explores critically ‘the role of sanism, adultism and epistemic injustice in constructing and regulating the ‘troubled teen’ (p. 53). An important positive message to emerge from this research is that although the personal accounts in the case studies testify to disturbing oppressive practices and ‘negative experiences’ (p. 56) of psychiatrisation in institutions claiming to provide ‘therapeutic care and treatment’, even so, ‘the schools’ strict structure and surveillance culture could not override students will and their ability to find means to resist’ (p. 53).

Anita Franklin, Geraldine Brady and Louise Bradley turn their attention to important issues that are largely absent from existing childhood studies literature. Specifically, the powerful role of and interplay between medical and psychiatric discourse in the lives of abused disabled children that gives rise to negative experiences for such children within services that are purportedly designed for their protection. Drawing on qualitative data derived from three UK research studies which sought the views and experiences of disabled children and young people who had experienced abuse, the authors identify two core themes. First, the dominance of a medical model of disability that determines how disabled children are defined and seen as victims of abuse. Second, the medicalisation and psychiatrisation of disabled young people’s experiences of abuse leading to inappropriate responses by professional services in which children are potentially victim-blamed, silenced or inappropriately labelled, and which fail to meet their needs for support (in this issue, p. 70). Overall, the findings illustrate how medicalising, categorising, psychiatrising and ‘othering’ ‘prevents disabled children from being seen, heard, listened to and understood, and to receiving a child centred, children’s rights approach to protection and provision’. (p. 75).

The authors see ‘social scientific understanding’ as a crucial counterbalance to dominant ‘medical discourse relating to disabled children [that] encourages categorisation, diagnosis and prescribed ways of understanding which does not enable reflection upon the ways that disability, childhood and victim status are constructed and interplay’ (p.74). They make a strong and persuasive case for urgent change in the form of a rights-based model of child protection premised on a shift in professional culture committed to greater understanding of disabled children’s lived experience from their own perspective. In this, they argue, ‘the inclusion of those who have lived experience of distress following child abuse is fundamental to increasing knowledge and understanding and in moving towards alternative ways of knowing’ (p. 68).

In the final article, Maria Liegghio poses two fundamental and interrelated questions of central significance to this Special Issue, namely,

What would it mean if ‘mental illness’ was not seen as a ‘limitation’, but rather as an ‘epistemological position’ from which the social world is experienced, understood, and acted upon? What would it mean for mental health practitioners if our theories about ‘distress’ and ‘helping’ were premised on the subjugated knowledges of the young people we serve instead of our objectified and professionalized knowledges? (In this issue, p. 79)

She explores these questions through a critically reflexive discussion of an evaluation of a participatory-action research (PAR) project on stigma undertaken with psychiatrised youth in Canada. Foregrounding the marginalisation and subjugation of psychiatrised youth theoretically within the mutually reinforcing discriminatory processes of adultism and sanism, Liegghio observes how the subjugated knowledges of psychiatrised adults have found expression in a way that those of children have not. Thus, the overarching aim of her article is to ‘critically examine the significance of psychiatrized youth setting and executing their own research and, ultimately, practice agendas’ (p. 80).

Liegghio explores critically the value of PAR as an approach that recognises ‘lived’ or ‘situated’ knowledge as valid/legitimate and that facilitates a context of inquiry within which the subjugated knowledges of psychiatrised youth can be made visible. Moreover, she envisages the potential of PAR as a progressive, emancipatory project through which psychiatrised youth can be mobilised to challenge adultist/sanist structures in mental health systems and to find ‘better solutions’ to their issues. Liegghio’s analysis suggests that the PAR was experienced as overwhelmingly positive and had a ‘de-pathologizing effect’ (p. 84). Nevertheless, the findings demonstrate that adult professional roles need to shift from being ‘agents’ working on behalf of, to ‘allies’ working in solidarity with, young people and ‘from a “therapy-driven” to an “emancipatory” practice in child and youth mental health’. (p. 87). In this, Liegghio is at pains to acknowledge the thorny question of whether ‘one off’ initiatives such as this are capable of counteracting institutionalised structures of adult domination in child mental health systems where policy-making and practices continue to be directed by what adults believe to be in the best interests of children. She recognises the enormity of the task of fundamentally shifting adult-centric structures and processes, concluding that the decolonisation of child mental health has a long way to go.

Together, the six articles that make up this Special Issue contribute to a growing body of scholarly literature committed to documenting the complex, multi-faceted nature and impact of adultism, ableism and sanism in the lives of children in diverse contexts. However, much remains to be done – particularly in relation to theorising, researching and documenting the lived experiences of children and childhoods in the Global South. It is my fervent hope that this Special Issue will provoke further interest among scholars so that we might observe and better understand experiences of psychiatrisation in the lives of all children.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Notes

Author biography

Vicki Coppock is Professor of Childhood Studies and Mental Health at Edge Hill University, Lancashire, UK. She is also a qualified and experienced mental health social worker. Vicki has an international reputation for research and publications involving critical social scientific analysis of childhood(s) and children’s rights in contemporary law, policy and practice contexts. Much of her work is characterised by a focus on ‘psychiatrised childhoods’ and promoting a positive rights agenda for children and young people in mental distress.

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