Editor’s Note: Over the next several months, Mad in America will publish a serialized version of Sami Timimi’s book, Insane Medicine. This week, he explores the “McDonaldisation” of growing up—how changing attitudes toward childhood have led to an epidemic of childhood “depression.” Each Monday, a new section of the book will be published, and all chapters will be archived here.
When I was training to be a child psychiatrist in the early to mid-1990s in the UK, childhood depression was considered to be rare, related to adversity, and generally unresponsive to pharmaceutical treatment. Sure, children got sad, became irritable, upset, and anxious, but these were thought of as generally understandably reactions to what was happening in their life.
Since then, much has changed in a very short period of time. Even day-to-day language seems colonised by medical terminology, with youngsters describing their feelings using clinical (“I feel depressed”) as opposed to more ordinary language (“I feel unhappy/sad/miserable”).
Trainees in child and adolescent psychiatry today, like most child psychiatry consultants trained in the new millennium, routinely dole out selective serotonin reuptake inhibitors (SSRIs—the most common type of “anti-depressant” prescribed) like fluoxetine or sertraline to children and adolescents.
This medicalisation of our ordinary and understandable emotional lives has led to a horrific cultural shift, leading us all, but particularly our youngsters, to become alienated from and suspicious of our emotions. The proliferation of the concept of childhood depression has led to a steady chipping away at our youths’ natural resilience, as they, and those around them, become alarmed at the power of feelings and preoccupied with monitoring the self for signs of being broken.
Like medicalised childhood behavioural problems, medicalising mood creates great commercial opportunities. From books to therapies there is no shortage of products that can be sold to the concerned parent or stressed teenager. Just as when they promoted the idea that behaviours that stress parents out can be solved by the simple act of taking a pill, the pharmaceutical industry understood the potential money to be made by promoting the concept of depression as something that affects kids in the same way as adults.
The problematising of kids’ emotional lives also opens up the world of therapies from emotional first aid to mindfulness. The marketplace is teaming with remedies jostling for access to the shop windows of the mental health arcade with offers of cure and pain relief.
In the same way that our ideas about what is expected in kids’ behaviours and how to interpret perceived problems is changed by labelling them with a “diagnosis,” so our ideas about, and perception of, suffering and resilience can be affected by medicalising mood, potentially alienating the young of today from the possible learning and insight that can come out of experiences of distress and adversity, at the same time as distancing us from seeing the social and political real-life potential sources of suffering.
Mainstream construction of childhood depression
Here is the definition in the UK National Institute for Clinical Excellence, from when they first produced guidelines for childhood depression in 2005. These guidelines were last updated in 2019 and they are still using the same basic definition:
Clinically, the term depression refers to a group of symptoms and behaviours clustered around three core alterations in experience: changes in mood, in thinking, and in activity, sufficient to cause impairment in personal and/or social functioning. Mood changes typically include sadness and/or irritability accompanied by a loss of pleasure, even in cherished interests. Cognitive changes generally lead to inefficient thinking, usually with a pronounced self-critical focus. Physically, depressed people become less active, although this may be concealed by the presence of anxiety or agitation.
Although there are many similarities between adult depression and depression in younger people, there are important developmental differences in each of these three areas.
As with adults, there is a change in mood from pleasant to unpleasant, that is relatively pervasive, persisting over time and place and sufficiently severe to interrupt every day functioning. Some children will deny feeling sad but will admit to feeling ‘down’, others will admit to feeling ‘grumpy’ or ‘irritable’. In a significant proportion of cases the depressed young person no longer derives as much pleasure from life (anhedonia). This feature occurs in around 15 to 20% of depressed adolescent females.
Typically, young depressed patients have poor self-esteem with little to say when asked about their good points. They may indicate that they are ‘no good’, and that life events and difficulties in their social world are their fault. They may see no future for themselves, consider life hopeless and themselves helpless to effect any change for the better. They may complain of a loss of concentration, poor attention and an inability to make decisions. This may be due to a loss of confidence in their abilities or a difficulty in thinking. In severe cases the patient may feel guilty, or even wicked, and state that they deserve to be punished for past misdemeanours. Some such cases will have suicidal ideas, which are particularly serious. It should be noted that it is normal for children and young people to feel guilty about parental separation. Very rarely young patients will describe delusions or hallucinations.
By the way have you noticed the general rule of thirds when you create a psychiatric category? ADHD has 3 core symptoms, so does ASD, and so does depression!
The childhood definition uses the adult depression definition and then adapts it to an idea of what those equivalents might look like in children. Take any sentence you want from the above and see how many “objective” measurable features there are. It’s so vague, it has the potential to scoop up most adolescents at some point in their growing up years. Who wouldn’t sometimes feel irritable, grumpy, sad, have mood changes, be self-critical, have difficulty making decisions etc.? Do we really want our youngsters to grow up without experiencing these things?
Depression and growing up
Before the onset of the Second World War, Western society viewed relations between parents and children primarily in terms of discipline and authority. This behavioural approach stressed the importance of forming the habits and “good” behaviours needed for a productive life.
After the Second World War there was concern about the impact of discipline and authority on children. A debate about what caused the nightmare society of Nazi Germany, influenced by the growing respect for psychoanalytic theory, suggested that authoritarian behavioural approaches could cause a person to become aggressive, hostile, and murderous.
Professional and scholarly opinions, which spoke about the child as an individual and favoured a more democratic approach to child-rearing, started to percolate. A movement away from harsh discipline, toward more humane forms of discipline through guidance and understanding, gradually became more popular in political circles and everyday culture.
In addition, whilst the pre-war model prepared children for the workplace within a society of limited resources and consumer goods, the post-war years of economic boom meant that children were growing up in a society where pleasure-seeking consumerism was soon to become the new “normal.”
The post-war “permissiveness” model saw parent-child relations increasingly in terms of pleasure and play rather than obedience and respect. Parents now had to relinquish traditional authority in order for children to develop their own capacity for making choices and to support their sense of self-worth.
This cultural shift also meant that as these post war generations become parents themselves, they too had less of an emphasis on parental duty and responsibility and wanted opportunities for fuller expression for themselves. Parental obligations were paving the way for the cultural expectation of fun and permissiveness for all.
Changing economic structures also led to important changes in the organisation of family life. More mothers entered the workforce and a renegotiation of power within the family was taking place. The growth of new “suburban” communities and the economic demands of market economies were resulting in greater mobility, less time for family life, and a reduction in geographically connected extended families rooted in community networks.
Many families (particularly those headed by young women) became isolated from traditional sources of childrearing support and information. As a result, various childrearing guides increased in importance and childrearing advice started migrating from being primarily the domain of extended communities and older generations to being the domain of the professional classes.
The backlash against the culture of permissiveness that took place during the 1980s and ‘90s in the West continued to put the individual at the centre. More parents were forced to work for longer hours, and state support, particularly for children and families, was cut, resulting in widespread child poverty, a situation that was to be replayed after the 2008 financial crash. As I write this, we are yet to see how this will affect the post Covid-19 world.
With this growing sense of insecurity about how best to raise children, parenting advice and interventions became big business. Cloaked in the language of science, ownership of knowledge on how to be a “good” parent was acquired by the professional classes. There was now a right way to love your child, standards by which children are judged to be correctly developing, and a set of (white, middle-class) rules that parents, teachers and other adults had to adhere to in order to avoid “damaging” children. The injunction that childhood should be free from strife and full of fun remained, but became harder to achieve.
Books and classes on parenting abound, and multiple methods for surveillance of our young populations have become institutionalised. In the world of smaller families, less community and extended family support, two working parents often stressed with keeping a secure source of income, and a high demand on parents to ensure their children have fun, it’s not surprising that the professionalisation of parenting results in many parents fearing that engagement with the pains of growing up should be left to experts.
The increase in levels of anxiety amongst parents who may fear the consequences of their actions has reached the point where the fear for many is that any influence that is visible could be viewed as undue influence. This increases the likelihood that some parents will feel it safer to leave essential socialising and guidance to the expertise of professionals as, surrounded by this narrative that paints childhood and child rearing as loaded with risks, they lose confidence in their own abilities.
The growth of the popularity of the concept of childhood depression from a rare to a common diagnosis reflects these broader cultural dynamics. Here we have an individualised notion of little adults (autonomous individuals who should be able to manage their feeling states) falling prey to internal mental diseases that resemble those that affect adults, in a culture where it’s felt that something has gone wrong with you if you are not having fun. Medical and other healthcare professionals are then seen as the experts who understand these problems, and parents are advised to turn to them for an “objective” opinion about their children’s mental state, as these professionals are thought to have the right skills to know best how to solve their children’s difficulties.
The political and economic self-interest of the medical profession, the pharmaceutical industry, psychologists, therapists, and a whole ragbag of opinionated opinion-givers have found an ideal set of cultural preconditions that could be used to promote an ahistorical, culture-blind, individualised, biomedical interpretation of childhood unhappiness. This now brings relatively common growing up experiences previously regarded as ordinary, which children themselves, or their parents, would deal with, into the sphere of medical problems requiring a medical opinion and possibly a medical procedure known as “treatment.”
Natural human reactions (even if they are undesirable ones) have become too dangerous to allow, and parents and their wider social networks are less inclined to believe they have the knowledge and skills to help their young withstand, grow, and develop through (and sometimes because of) emotional turmoil.
Most cultures understand emotional suffering to be part and parcel of what it means to live and develop as a human being. Suffering has the potential to inform and deepen our connection, experience, and understanding of human potential and resilience. Suffering is thus not something we should assume to be of no value that we have to find a way to remove. But there is money to be made in the infantile fantasy that we can live our lives without suffering.
In addition to the cultural tendency for distancing ourselves from engagement with our children’s emotional lives and our cultural fear of suffering, the concept of depression is itself a product of the human imagination. “Depression,” as a diagnosis, has not developed out of scientific insights that have located a disease in our biology or psychology, but out of a culturally specific set of ideas. Many of the key psychiatric symptoms in depression (such as the focus on how we think and feelings of guilt) refer to concepts that are influenced by Western philosophical ideas. These experiences may be absent, nonsensical, or have different meanings in cultures where different philosophical traditions have been influential.
Just as our ideas about growing up have changed, so have our concepts of childhood problems. It was only relatively recently, beginning in the early to mid-1990s in the US, that our understanding of childhood depression began a far-reaching transformation. Prior to this, childhood depression was viewed as a very rare disorder, different from adult depression, and not amenable to treatment with antidepressants. This was what I was taught in my training to become a consultant child and adolescent psychiatrist. In most of my training placements, the idea of childhood depression as a diagnosis was never mentioned.
In the 1990s, influential academics and practitioners started writing articles and books that claimed that childhood depression was more common than previously thought, resembled adult depression, and was amenable to treatment with antidepressants. Media articles talked about the hidden suffering that was taking place under our very eyes, but that we hadn’t seen. We were told that this silent suffering was of children who were not just sad, but had an illness, just like adults, only because they were kids, we were dismissing their pain and neglecting to help them with proper safe treatments like “antidepressants.”
Reflecting the broader cultural changes that have taken place in our views of childhood, child rearing, and parenting, childhood depression had arrived. We were ready to scale up the marketisation of childhood problems.
The McDonaldisation of growing up
I often wonder how many of us are aware of how our understanding of children, childhood, child development, family life, and education have changed as we have succumbed to the “McDonaldised” notion that the challenges and uncertainties connected with growing up can be placed into neat categories of things “wrong” with individual children, which can then be fixed with simple, one size fits all, interventions. Like McDonalds, a market economy and culture preys on our desire for here-and-now satisfaction of our cravings, provided in a fast, timely manner, and that requires little engagement with the product beyond its consumption. Get your products and messaging right and you can entice your consumers when they’re still young and then have them as potential customers for life.
Children are ultimately dependent on adults to make most decisions on their behalf. But now we have professionalized the process of growing up to such a degree that many parents and other adults in caring positions (such as teachers) are afraid of actively intervening to guide children in their care. They may feel they need an “expert” to best understand what the right thing to do is, while others feel judged and embarrassed by their children’s behaviour. Parents (particularly mothers) are often blamed for poor parenting with “tut-tuts” and raised eyebrows, but rarely praised for good parenting. Others have been forced to work long hours leaving little time to be with their family, and often with little support as a result of diminishing local community and extended family connections.
It’s hard to be a “normal” parent these days. If you are judged too close to your children you are enmeshed, too distant you are too cold and don’t know how to love your children in the right way. Of course, abuse and harm does happen, whether deliberate or accidental, but being a parent has become an anxiety provoking experience with much confusion and often little emotional and practical support, particularly for mothers who continue to carry the majority of the burden of bringing kids up. There is much money to be made from exploiting this anxiety and the inevitable desire parents have to make things better for their kids, as well as soothing the anxieties they feel.
Children, meanwhile, are measured, tested, ranked, and commented on in schools, sports, appearance, social media, and so on, such that they, from a young age, learn that they get value from what they do, rather than for just being. Like living in an on-going X Factor contest, they may feel scrutinised for how they perform as individuals, more than how they contribute to the common good or being part of the family and community around them. They may have full timetables and then plenty of distractions such as TV, smart phones, junk food, and an array of colourful toys. It’s also hard to be a “normal” kid these days.
If you’re judged too lively, you’re “hyperactive,” too quiet you may be “depressed,” a bit shy, you may be “autistic.” Of course, kids do suffer abuse and trauma and communicate this through their behaviour, but, in many Western societies, to be a kid these days is to be closely monitored and scrutinised for your level of performance. When things are judged “not right” by someone, you can then become exposed to a variety of assessments and procedures to determine what’s wrong, broken, and dysfunctional in you. There is much money to be made from identifying your dysfunction and the marketing promise that this will lead to something (a label, a treatment) that will make things better.
Childhood depression is one of these successful modern brands that helps monetise and entrench states of alienation from self and others that arises out of both the reframing of the ordinary struggles and sufferings that accompany growing up, and the increased gap and tension that arises in a culture that fears ordinary intervening in children’s lives (lest it upset their autonomy) and so professionalizes this. It takes its place next to the two other successful categories of ADHD and autism as brands with great commercial success.
Whilst ADHD and autism started as childhood disorders that soon grew into marketable brands and so spread upwards into markets for adults; childhood depression is the result of the opposite trend. Depression is a big market amongst adults and so its eventual marketisation downward into childhood was inevitable.
Back in 1996, the World Health Organisation predicted that by 2020, depression will be the second-leading cause of disease burden globally. Since then there has been relentless messaging that we are experiencing a rising tide of mental health problems—with depression leading the way—such that today, much of Western society shares an idea that we are facing an epidemic of mental illness and psychiatric emergencies. Young people are often picked out as a particularly vulnerable group, whom, we are told, are ravaged by undiagnosed and untreated mental disorders.
Schools have become a prominent site of concern and focus for this propaganda, as mental health problems are said to start early in life. This way of thinking keeps the focus on the idea that it’s individuals that have the disease and so it’s individuals who need to be identified and treated. The role of systems around them is to adjust to help them with managing their disorder. A population/community-wide approach is only that which improves detection rates and provides more services that should give early intervention. Consciousness of the way schools are set up, testing regimes, job security, financial security, community support, and so on, are banished when we are trained to be sympathetic to our “ill” children.
The creation of epidemics happens when we liberally throw around headlines like “one in eight people aged under-19 in England have a mental health disorder” and “50% of all mental health problems are established by the age of 14” and read about a “striking increase,” “sharp rise,” or “crisis” in the prevalence of mental health problems amongst young people and a lack of services for them.
Yet in these articles from both media and the scientifically illiterate professional bodies that represent mental health professionals (like the Royal College of Psychiatrists that I am a fellow in), they don’t make clear what is meant by the term mental health “disorder,” “problem” or “illness.” Mental disorders are what these experts define them to be and, as you have been discovering, are open to wildly differing interpretations because of subjectivity that cannot be escaped. You don’t make something objective just by saying it is and because you claim to know what that is.
Young people, their parents, and their teachers read these headlines and have a growing “awareness” that these illnesses are all around us, and you could be one of those affected. You start to notice how bad you feel sometimes and wonder why you feel like this. Could it be that you are developing a mental disorder?
As I write, sitting at home in the middle of the Covid-19 epidemic, I hear warnings going out with every newscast. There is an epidemic of mental health problems erupting all around us. Defining understandable anxiety, loneliness, and fear of losing your job as a “health condition” individualises and leads down the path towards thinking there is something wrong in you and then looking for a health-based solution.
What if the news was also full of stories of how, since the lockdown, many people felt that the rat race was put on hold and they could notice the world and people around them more, about how parents and children forced to spend time together, learnt to talk to each other and do things together again, and how the internet has helped us reconnect through video links with family and friends we rarely have time to talk to?
In tandem with this media coverage, mental health has also risen up the UK government education agenda as it has, throughout the last decade, dedicated more time and funding to programmes, initiatives, and support, particularly in schools, to “improve” young people’s mental well-being. In 2018, the UK government announced that an additional £1.4 billion was being made available to “transform” children and young people’s mental health services with the primary emphasis being increasing training and access that builds upon what is already done by schools and colleges.
A reinforcing loop of “moral panic” has developed where the problem effectively inflates itself. The more we, in the mental health professions, talk about there being a crisis in the mental health of the young, the more we notice it, and the more we talk about it as a result. Media then reports this, calls it a scandal, so government responds with more funding, which further highlights this epidemic. Young people, their parents, and teachers are exposed to this so they start noticing their emotions and behaviours in a new way, searching for signs of this epidemic, having been sensitised to its existence and the importance of early intervention.
Expanding our ideas of what mental health problems, such as childhood depression, are affects people’s self-understanding and behaviour. Changing ideas will change people. In a kind of social self-fulfilling prophecy, new demand that didn’t previously exist is created, meaning more people talking about depression, more evidence of the epidemic, more media attention, and so on.
In 2019, my daughter Zoe carried out a piece of research as part of her undergraduate dissertation. She interviewed secondary school teachers about their beliefs and practices in relation to the mental health of their students and how this had changed in their schools over the last 10 years. Her findings were a startling expose of how rapidly things have changed. All the teachers she interviewed felt that awareness of mental health and mental disorder had increased and that this has led to an expansion in the numbers of students thought to have mental health problems that required professional intervention.
Whilst she also found that there had been a substantial increase in mental health provision both within and outside the school system, teachers perceived these services as still woefully inadequate. Teachers identified many behaviours and experiences they would previously have thought of as ordinary and/or understandable as likely mental health problems that required professional expertise they lacked.
Even ordinary interactions, like spending time talking to a distressed student, were seen by their line managers as potentially problematic, as the student could be developing a mental disorder and they didn’t have the expertise to know what the right thing to do is.
Many teachers were unsure where the boundaries for a mental disorder lay and how to differentiate that from “unruly” behaviours or “putting it on” to get some extra perceived benefits. Most teachers, when asked about what causes mental health problems, referred to everyday challenges such as exam stress, relationships, family, social media, and bullying. Despite the fact that teachers were oriented towards this environmental model of causation, when it came to how best to help these children, teachers subscribed to a more medical model view that relied on “trained experts” who could diagnose and treat the resulting disorders.
Lack of discussion or understanding in media, government policy, or even academic papers on what sort of a “thing” constitutes mental health and where/when special expertise might be helpful, coupled with this increased sensitivity toward identifying mental disorders early, leads to an increase in the number of students being deemed to require professional help that teachers, parents, and friends can’t provide. More referrals are then made and, despite external services expansion, they then have trouble dealing with the number of referrals, leading to access problems that leads to more media coverage of a “crisis” in services, thus further increasing the volume of the “mental illness in the young scandal” coverage and so on.
It should be no surprise, then, that a survey in 2019 of one thousand young people found that 68% thought they have had or are currently experiencing a mental health problem and, of those, 62% thought that “de-stigmatisation” campaigns helped them identify it. It also found that there had been a 45% increase in mental health referrals of under-18s in the previous two years.
These are dizzying numbers, but not that far off from a 2019 academic paper that, using a child self-report questionnaire methodology, came up with a prevalence figure for mental health problems in 11- to 15-year-olds of 42%.
This alienation from, and fear of, the emotional turmoil that growing up brings is the terrifying result of this moral panic about mental health. A 2020 study from New Zealand suggests these figures may be an underestimate! They reported that 86% of people will have met criteria for a psychiatric diagnosis by the time they’re 45 years old, and 85% of those will have met criteria for at least two diagnoses. Exactly half of the population will have met the criteria for a “disorder” by age 18. The medicalisation of the ordinary has truly arrived.
The scene has been perfectly set up for transforming the challenges, confusions, intensity, and changes that happen as we grow and develop, particularly in our adolescent years, into potential obstacles, dysfunctions, dysregulations, and disorders, that can be neatly packaged and given “treatments” to get rid of them. This ideology is ripe for the growth of childhood depression as a simplistic brand that our young are encouraged to identify and consume, along with simple remedies that they may wish to take, intermittently or continuously, for the rest of their lives.
Depression has become the leading brand for adolescents and their carers to shop for, looking for the McDonaldised solutions that will stop them feeling so bad. The crumbs of comfort they get by identifying with this label opens the door to a potential lifelong struggle with the consequences of this consumption. What a tragedy.
Next week, in Part 2 of Chapter 5, Sami Timimi will investigate the evidence for “antidepressant” drugs and their use in children.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.