Child mental health: who is responsible? An overextended remitBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7083.813 (Published 15 March 1997) Cite this as: BMJ 1997;314:813
- Robert Goodman, reader in brain and behavioural medicinea
Parents and teachers are seriously dissatisfied with the behaviour of many children. Other children experience considerable stress, misery, or anxiety. Epidemiological studies suggest that roughly 20% of all children and teenagers are maladjusted or distressed,1 with some estimates being substantially higher.2 In the child psychiatric literature and government strategy documents these maladjusted and distressed children are referred to as having psychiatric disorders or mental health problems.3 4 I believe that this medicalisation of all maladjustment and distress is a serious “own goal” for the health service, generating unrealistic expectations of what child mental health services can deliver and diverting health professionals from their areas of expertise.
The medicalisation of maladjustment and distress is enshrined in the contemporary psychiatric classifications of the World Health Organisation and the American Psychiatric Association.5 6 Perhaps both these classifications were overinfluenced by the World Health Organisation's otherworldly definition of health as “a state of complete physical, mental and social wellbeing, and not merely the absence of disease and infirmity”7; falling short of this ideal is then a lack of health, and it is only a small step to define any serious shortfall as a disease. Cynics will also note that the medicalisation of maladjustment and distress generates employment for doctors and persuades health insurers to foot at least some of the bill. An overinclusive notion of child mental health may have encouraged health providers to fill the vacuum as successive funding crises have led social services and education to withdraw from much of their traditional child and family guidance work.
The folly of an overextended medical model can be illustrated with reference to conduct disorder, which is one of the commonest of the currently recognised psychiatric disorders of childhood and the one that probably accounts for the bulk of referrals to most child mental health services. Children with conduct disorder (including oppositional-defiant disorder) are naughty, awkward, disruptive, aggressive, and antisocial. I find it hard to see why this constellation is any more deserving of recognition as a psychiatric syndrome than love sickness, abrasiveness, or miserliness. Though conduct disorder is clearly a major problem for parents, teachers, and society in general, and though many of these children and their families need and deserve help, I do not believe that the problem is best seen as a mental health problem or that the help should usually come from the health service.
As citizens and doctors we should be concerned about conduct disorder in the same way that we are concerned about dangerous driving, homelessness, shoplifting, absenteeism, starvation, unemployment, or war. Take dangerous driving, for example. Doctors can sometimes identify predisposing medical causes such as dementia or hemianopia, and doctors are often confronted with the medical consequences of road accidents; yet no one would suggest that dangerous driving is a medical disorder per se or that the health service should take the lead in its detection and treatment.
In my view the same applies to conduct disorder: it sometimes stems from recognisable medical syndromes or has medical consequences but it is not a medical disorder. It is a social and educational problem that often has no identifiable health component. Social services and the educational system should share the responsibility for tackling conduct disorder. Social services have statutory roles in the management of severe parenting problems and juvenile delinquency. Since conduct disorder often stems from parenting problems and often leads to juvenile delinquency, social services should take the lead in assessing and managing conduct problems. Schools also have a key role to play since many children have conduct problems that are most evident in the classroom and playground, often reflecting school factors such as a laissez faire attitude to bullying or a failure to meet the needs of children with dyslexia or other learning difficulties.
Sharing the responsibility for treating a particular disorder between many agencies is all too often a recipe for proliferating meetings and diminishing action; the interests of children with “pure” conduct disorder would be better served if health bowed out. Social services and education need to be adequately staffed and funded to provide effective interventions such as parent training and school based programmes. This will leave child mental health services better placed to provide supplementary input for the minority of children whose conduct disorders have antecedents (such as hyperkinesis) or consequences (such as severe depression) that call for the special expertise of health professionals.
Empire building and decolonisation
Large areas of child welfare work have been inappropriately annexed into the medical empire; a planned decolonisation is long overdue. Beware of the tendency to assume that the “natives” cannot manage their own affairs. Who says that social workers or educational psychologists could not take over much of the work currently carried out by mental health professionals? With the empire gone, what will be left? There is a need for debate here, but even the most ardent decolonisers are likely to see a major continuing role for the health service in assessing and treating some varieties of childhood maladjustment and distress, including hyperkinesis, autism, obsessive-compulsive disorder, schizophrenia, and anorexia nervosa–though some of these disorders could arguably be labelled as developmental rather than mental health problems.
Children with these disorders need the sorts of input that only health service professionals are likely to provide. At present, many such children go undiagnosed and untreated, perhaps because limited health service resources have been diverted into general child welfare work. Proved treatments such as the use of medication for hyperkinesis or the use of behavioural therapy and medication for obsessive-compulsive disorder are greatly underused.8 9
My position could be misunderstood in several ways. While I believe that the money spent on helping maladjusted and distressed children could be used more effectively, I am arguing for a redeployment rather than a reduction in funding. Indeed, I would favour an increase in funding. Though medical imperialism needs to be reversed, decolonisation should not be instant; social services and education would obviously need enough time to train the necessary staff. Finally, I am not suggesting that the boundaries of the health service could ever be drawn once and for all: these boundaries will shift repeatedly as new treatments emerge and society's expectations change.