Overmedicalisation of childhood: what paediatricians and child health professionals can do

Introduction

In the sociological literature, medicalisation is when a problem ‘is defined in medical terms, described using medical language, understood through the adoption of a medical framework, or ‘treated’ with medical intervention’.¹ While applying a medical lens is at times appropriate to understand underlying causes of childhood behaviours, we are here focusing on medicalisation as an overextended and inappropriate phenomenon, that is, overmedicalisation. Distinguishing between these requires careful assessment.² Child health professionals are involved in overmedicalisation’s iatrogenic effects. There are high expectations that clinicians will provide medical diagnoses and treatment for children presenting with behavioural complaints, but the complexity of family, psychosocial stress and vulnerability, which exaggerate or even cause symptoms, is often ignored. Given the lack of accessible and tailored interventions, tensions arise when a diagnostic label is sought to access substitute support, even if this does not directly meet the child and family’s core needs. Here we describe factors that perpetuate the overmedicalisation of childhood and its harms, and outline how child health practitioners and families can avoid overmedicalisation and take constructive steps moving forward.

Why overmedicalisation?

First, overmedicalisation arises from a set of ideas, primarily in societies influenced by the insight that systematic application of the empirical method can control the natural world (eg, steam engines, antibiotics). Overmedicalisation is an outgrowth of this empirical-interventionist trend in health.³ Systematic detailing of norms around development and behaviour (eg, milestones) is used to identify what is abnormal (or undesirable). In overmedicalisation, the empirical method is used inappropriately, establishing not just what is but what should be.

Second, overmedicalisation has grown because it is facilitated by medical and educational establishments.³ Medical recommendations are disseminated across institutions in society through educational and screening programmes, and they point back to the medical system. Preschools and schools surveying a myriad of children cooperate with this model insofar as those who diverge from norms are told to see a physician (eg, ‘Your child doesn’t interact with others … have you considered seeing a paediatrician?’). Development is thus overmedicalised, and a loop is created as physicians are then expected to do something for a child with a ‘medical’ problem.

Third, manuals like the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) reshape conceptions of mental illness to encompass everyday experience. For example, youth can have ‘mild’ major depression, which is a ‘peculiar contradiction in terms’,⁴ rather than a non-diagnosis. Significant losses such as bereavement or illness should not exclude a depression diagnosis, again focusing more on diagnostic conclusions than, say, addressing contextual stressors in a holistic manner. Autism is reconceived as a spectrum, making it easier to frame behaviours as ‘autistic’ and place children somewhere along the spectrum in inherent grey zones. This has led some caregivers to seek autism spectrum disorder diagnoses for services, even though functional impairment in many contemporary autism diagnoses is less severe than decades earlier, and diagnostic thresholds are evolving.⁵ Newer clinicians are then trained with tools intended to be sensitive to newer diagnostic categories, already inundated with medical knowledge and understandably without a historical or critical perspective to counterbalance cultural practices within medicine. In addition, corporate interests in treatments for medical conditions and the rise of private clinics, incentivised to diagnose and treat conditions based on lower diagnostic thresholds, contribute to overmedicalisation.

Overmedicalisation in paediatrics is especially striking because children are subjected to the medical system in ways adults are not.⁶ Children are brought to appointments, and their consent is not generally obtained until adolescence. A 7-year-old girl cannot consent or disagree about a diagnosis in the way a 27-year-old adult can. Similarly, children are parented, meaning the quality of parenting and contextual factors such as instability or domestic violence can profoundly impact a child’s behaviour. Overmedicalising such behaviours is to mistake family stress for pathology. Finally, children are monitored in private by families and in public by schools, unlike any other segment of the population, again providing the substrate for overmedicalisation to develop.

Why the overmedicalisation of childhood matters: harm to children, families and society

Children are at greatest risk of immediate harm from overmedicalisation. A preschool scuffle leads to an incident report and a physician visit focusing on behavioural disorders. Play is redefined with a technical overlay (eg, a child who dislikes sticky hands has a sensory aversion, while a child who enjoys lining up toys has stereotyped behaviour), firmly placing it as a phenomenon requiring expertise or oversurveillance as opposed to a natural, fun and even appropriately risky activity that is pivotal to child development without necessarily involving adults.⁷ By defining such behavioural concerns in medical terms, intervention becomes a logical next step. Psychotropic medications, now commonly used in childhood for conditions like attention deficit hyperactivity disorder, autism spectrum disorder, depression or anxiety, have short and long-term side effects. These range from mood fluctuations and sleep issues to dyslipidaemia and extrapyramidal effects. The extensive use of these medications, especially without careful assessment of psychosocial risks and environmental conditions, is dangerous.⁸ Overmedicalisation may disempower children by making them rely solely on external factors such as pharmacological supports. Countering this requires understanding children in holistic terms and avoiding the reflex to prescribe medicine. See tips A and C.

Even non-pharmacological interventions can be problematic. Unnecessary diagnostic ‘labels’ can lead to self-fulfilling prophecies. After a child is diagnosed, expectations change such that teachers, parents and children themselves interpret behaviour through the lens of the ‘label’ rather than focusing on building resilience in coping mechanisms or adjusting to one’s surroundings.⁹ It is not unusual to hear the word ‘oppositional’ in reference to a child diagnosed with oppositional defiant disorder, as if this obviates the need to consider that he may be opposing something with good reason. See tip B.

Furthermore, technical language and the need for intervention have an impact on family dynamics. Whether through society more generally (eg, schools, neighbours, friends) or internalised narratives, overmedicalisation puts immense pressure on families to seek help from medical professionals and medications.¹⁰ Families may grow anxious because a child has frequent tantrums or because late-talking overwhelmingly equates to autism in their minds. This alters the fabric of the family, weakens the innate support networks that families are traditionally offered, and sometimes creates conflicts between different parenting styles. Additionally, this leads to increased dependence on health professionals. See tips F and G.

The societal understanding of ‘normal childhood behaviour’ is also constrained by overmedicalisation. Pharmaceutical solutions replace addressing the intricate social, educational, environmental or economic factors that contribute to children’s difficulties. Overmedicalisation also then removes other important lenses through which we understand childhood experiences, such as trauma or social distress. By encouraging conformity and reliance on medical authority, society runs the risk of losing sight of the value of varied childhood experiences, creativity and resilience.¹⁰ See tip D.

Finally, applying overmedicalised DSM/International Classification of Diseases-style diagnostic-driven psychiatry on childhood populations risks the undermining of existing cultural strategies for dealing with distress; more, not less, stigma; and the imposition of an individualistic approach that may marginalise family and community resources.¹¹ Indeed, the failure to address families’ socio-cultural understandings of children’s behaviour and development and to uncritically assume the validity of one’s own system is to apply the weight of the dominant cultural paradigm on communities without cultural power, not by careful reflection but by imposition, thereby exacerbating the cultural gap between physicians and patients in pluralistic societies.¹² By contrast, meeting culturally diverse families where they are is critical in positive neurodevelopmental assessment experiences.¹³

It is critical to highlight that such arguments are not justifications to suggest that all childhood diagnoses are somehow illegitimate or that funding for children should thus be reduced. This ought not to be politicised. To describe something as non-medical is not to suggest support is irrelevant. Rather, resources should be re-evaluated, considering where non-medical interventions play a role, with child health professionals empowered to provide both social and health prescriptions. Children need thorough evaluation and management using a bio-socio-ecological framework (figure 1); health professionals need education to mitigate overmedicalisation and its effects. See tips E and F.

Figure 1. Understanding the child within a bio-socio-ecological framework. Modified from Bronfenbrenner.¹⁵ DSM, Diagnostic and Statistical Manual of Mental Disorders.

Conclusion

Appropriate diagnoses and medicines are important, and this is why overmedicalisation of childhood is problematic. We are not advocating for a strict dichotomy between a diagnosis and something non-medical. Neurodevelopmental disorders, trauma and even behavioural manifestations of medical disease processes can co-occur, and medical management may be indicated as part of a holistic care plan. We need to empower clinicians to ‘uncouple’ diagnostic categories from management of the presenting problem, especially as diagnoses have become overextended.¹⁴ We also need to truly partner with children and families to engage in understanding the child’s presenting concerns, within a bio-socio-ecological and strengths-based framework. Various practices can help child health professionals best understand children in their contexts and avoid overmedicalisation. Fundamentally, we argue that we should use children’s rights as our guide and do what is in the best interests of the child.

Our tips to counter overmedicalisation in childhood

1. Seek to understand children and their contexts apart from clear diagnostic categories. Hear their stories without a need to overmedicalise.

   1. Consider family context and if dysfunction or other stressors are contributory.

   2. Use clinical judgement first, and diagnostic criteria as a supplement. Avoid checklist approaches.

   3. Consider conclusions that describe a child’s needs and function. For example, describe if inattention is situational and benign or is primary and impairing.

   4. Consider tools that clinicians can use to document the burden of developmental trauma, as interventions can be more effective than pharmacotherapy.

   5. Diagnoses and medicines should only be considered in cases of clear dysfunction and pathology that does not readily change with circumstances.

2. Consider the harms discussed above in making a diagnosis if it is not truly applicable.

   1. Be mindful of using diagnoses simply to access restricted funding or resources.

   2. Consider too if this detracts from providing resources to children with greater needs.

3. Decrease prescriptions of medicines.

   1. Consider if a medicine is truly necessary or if situational concerns should be addressed. Discuss nuances with families.

   2. Individualise care as much as possible versus reflexively seeking algorithms.

   3. Advocate for stronger primary/supportive care pathways (eg, allied health, family-based interventions).

   4. Regularly re-evaluate medicines and consider deprescribing trials.

   5. Distinguish between the narrow goal a medicine can achieve (eg, make a child calm) and the broader goal of a child’s flourishing. The former may not imply the latter.

4. Give space to children to grow and develop according to their unique trajectories.

   1. Allow behaviours/emotions that may be part of the learning process (much like falling is part of learning to walk and not pathological).

   2. Allow time for children to bounce back from stressors without pressuring recovery (medicinally or otherwise).

5. Seek training opportunities for clinicians to discern overmedicalised behaviours from pathological behaviour. Medical curriculum and continuing education should include:

   1. Deprescribing practices.

   2. An examination of how culture influences the interpretation of behaviour, and evaluative approaches that take these into account.

   3. Leadership in advocacy and collaboration that promotes contextually sensitive, culturally responsive, child- and family-centred care.

   4. Public health frameworks to understand drivers of child health inequities and strategies for population-based intervention.

6. Increase social prescriptions for children and families.

   1. Relational practices are part of basic human needs.

   2. These influence a child’s overall mood and engagement with others.

7. Re-empower families.

   1. Help them recognise that they know their children and contexts best.

   2. Reaffirm the unique ways in which a parent’s love and bond with a child are primary, irreplaceable and foundational.