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Transcript of Vivian Hill
DECP Conference 2013 The Medicalisation of Childhood Behaviours: The Need for a Paradigm Shift
British Psychological Society Division of Educational and Child PsychologistsManchester June 2013The Medicalisation of Childhood Behaviours: The Need for a Paradigm ShiftVivian Hill
ioe.ac.ukThe debateToday 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 childrens 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 ConcernsOver 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 ChallengesThe 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 ConditionsOver 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 357This 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 OrientationsIn 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 ContextThe 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 influencesThe 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 LearningDisabilities, 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.
Contextual influencesThe 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.
Bronfenbrenners Eco-systemic ModelMACROSYSTEMAttitudes, Politics and Ideologies of the CultureEXOSYSTEMExtended FamilyFriends of FamilySocial Welfare ServicesMassMediaNeighboursLegalServicesMESOSYSTEMCHILDSex AgeHealth etcMICROSYSTEMFamilySchoolHealthServicesFaithGroupPeersNeighbourhoodPlay Area 12The 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. ParadigmsParadigms 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 impactInfluences 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
15Paradigm ConflictThe 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.Helen Upton, Professional & Academic Tutor 201117Social constructionism and social constructivism are sociological theories of knowledge that consider how social phenomena or objects of consciousness develop in social contexts.The 20th century saw the emergence of interest in language as being an important representation of reality. - The idea that human beings in some measure construct the reality they percieve. There was also an interest in how theory involved within the natural sciences. The ideas were used to research scientific theory. For scientific theory to be accepted as valid - generally accepted that the result obtained had to be replicable. Social constructionists argued against the notion of objective reality proposing that scientists actions are always a matter of discretion, I.e. what is identified as priorities for study, what methods are chosen, tools used etc. In terms of natural sciences Alexander Librucks distinguishes between discursive constructions and material constructions (basic natural order - the constituents of the world)When social constructionists say that facts are socially constructed - while talking about discursive constructions (theories, models, concepts) they assert that factual knowledge is the product of a creative interpretation process that is carried out in social interaction (Liebrucks)A social construction (social construct) is a concept or practice that is the construct (or artifact) of a particular group. When we say that something is socially constructed, we are focusing on its dependence on contingent variables of our social selves rather than any inherent quality that it possesses in itself. The development of social constructionist i