The conception of man decides – psychiatry versus pedagogy

“I don’t understand why so many children today have mental health problems,” said a colleague recently. “People always say they’re under so much pressure, at school and at home, and then there’s climate change and our world situation. I know that they face many challenges on their way to adulthood. But isn’t that a task that all children face worldwide? And wasn’t it the same for us, albeit with different issues?” she continued.
  Unfortunately, my colleague’s question is well-founded. The published figures speak for themselves. A study by UNICEF reports long waiting lists and overcrowding in child and adolescent psychiatric centres. Unfortunately, my colleague’s question is well-founded. The published figures speak for themselves. A study by UNICEF reports long waiting lists and overcrowding in child and adolescent psychiatric centres. She refers to the Zurich Child and Adolescent Psychiatric Service, which reports a 40 per cent increase in emergencies and a lack of places in the inpatient sector in 2021. This concerns behavioural problems (ADD/ADHD), autism spectrum disorders (ASD), anxiety disorders, depression, suicidal tendencies, etc.¹ – Diagnoses as listed in DSM 5, the American Manual of Psychiatric Criteria. At the end of 2022, the Swiss Federal Statistical Office (BSF) reported an unprecedented rise in mental disorders among children and adolescents. They were the most common cause of hospitalisation among 10–24-year-olds, more frequently than injuries, accidents or physical illnesses.²

Have mental health problems
become more frequent today?

This is a question that is increasingly being asked. The explanation often given is that we live in a world in which mental health problems are increasingly being addressed; people are more sensitised than before and want to take children and young people seriously. That’s right, they are also asked about their feelings in certain teaching projects in schools. They are asked to think about their feelings and express them using symbol cards.
  It has become common among some young people today to express their feelings, often with a certain amount of dramatization. Some then find their task and also their validity in counselling friends. The media address the issue with reports, interviews, films etc. and at the same time provide guidance for media-effective role models. Social media are also important, especially TikTok, where people exchange ideas in problem-specific groups, compete in a negative way at best and give each other (usually questionable) tips. (The European Union has rightly opened a formal investigation against TikTok for allegedly failing to protect minors). This promotes a supposed sense of togetherness on a sick level.
  It is forgotten that unhappiness is part of life’s experiences and does not automatically have to end in depression. There is also rarely an anxiety disorder behind it when a child does not tackle a task that is set for it, refuses to go to school or withdraws from its social environment. An awkward eating behaviour does not have to be the beginning of anorexia or bulimia, and a teenager with a doomsday mood is not close to suicide. Of course, a keen interest in children’s problems is the right thing to do, especially if they last longer and have a lasting impact on their lives. However, overly concerned attention may inadvertently intensify and reinforce the child’s behaviour.

The takeover of
pedagogy by psychiatry

Today, it has become common practice to assign psychiatric diagnoses to conspicuous behaviour of children and adolescents – a drastic intervention in their lives. This development is the result of a paradigm shift that has shifted the authority to interpret and treat such problems from education to medicine. Until the last decades of the 20^th century, the explanation and treatment of problematic developments of children and adolescents was based on the carefully compiled research results and experiences of the personalistic humanities, which emerged from the European scientific tradition. These are anchored in a personalistic conception of man and focus on the individual’s mental state and life-history development. The human relationship becomes the starting point for complex educational work.
  Then the trend of explaining psychological problems primarily in neurobiological terms was adopted from the USA. This ushered in the psychiatrisation of education that continues to this day. What was even a point of discussion at a political level for a short time back then is hardly ever discussed today.
  In 2006, three female cantonal councillors submitted a postulate to the Zurich Cantonal Council with the following wording: “Child and adolescent psychiatry in the Canton of Zurich is undergoing a paradigm shift. A biologistic conception of man is replacing the humanistic and sociological view, and this is changing the ways in which developmental disorders, illnesses and behavioural problems are treated. Mental disorders are increasingly understood as biochemical disorders in the brain, and treatment is increasingly carried out with the administration of chemical substances that influence the neurobiological brain functions in such a way that the undesirable behaviour disappears. Less and less attention is being paid to the psychosocial causes and environmental conditions that promote the occurrence of certain behavioural abnormalities and mental disorders.”³
  The postulate was related to the worrying increase in the prescription of methylphenidate (then known under the brand name Ritalin) to children with ADD, ADHD. A development that also concerned the National Ethics Commission (NEK). In 2011, it warned against dispensing methylphenidate to children: “This is because taking pharmacological substances for the purpose of enhancement changes the child’s behaviour without any contribution on their part. This constitutes an encroachment on the child’s freedom and personal rights. Because pharmacological agents cause behavioural changes, but the child does not learn how to achieve such behavioural changes itself, the child is deprived of an important learning experience for independent action: namely, to influence its behaviour through its own decisions – and not (solely) through external means – and thus to be able to assume responsibility. In this sense, enhancement severely restricts the child’s freedom and inhibits its personal development.”⁴
  The study commissioned by the ZHAW (Zurich University of Applied Sciences) did not come to a conclusive answer as to whether there was unjustified medicalisation⁵, and the “Neue Zürcher Zeitung” reported no need for action because most parents felt well advised and the federal government was already monitoring the development of ADHD case numbers after several parliamentary initiatives.⁶ However, the question of the paradigm shift in the view of humanity, which was raised in the postulate of the three cantonal councillors in 2006, was not answered.

A paradigm shift in the conception
of man – what does that mean?

A paradigm shift means a different approach to explaining the psychological problems of children. In our case, the following example may be explanatory and helpful. It’s about Leona, a girl we often meet in our schools. She already stood out in kindergarten. Leona could hardly stay quietly on a task; she would run around the room and disturb the other children. Then she started first grade and her problem became more obvious. The impression was that she was a clever girl. At the same time, she performed poorly and stood out due to her erratic behaviour. The lessons were organised in such a way that the children had to work independently according to a weekly plan. It was often restless in the classroom, and Leona was part of this unrest. She completed her worksheets sloppily and seemed overwhelmed. She soon had gaps in her learning material. She didn’t like practising and often resorted to guessing or cheating. The very hard-working teacher tried everything to calm Leona down. Without success. After some time, she suspected that Leona had ADHD and advised her parents to seek counselling from a child psychiatrist. This was followed by various interviews, questionnaires that the parents and school had to fill out and an enquiry into the social environment. In the end, the suspected diagnosis was confirmed and the use of methylphenidate was recommended on the basis of the distress expressed by the parents.

Leona’s problem –
from a biological point of view

Behind this approach is a certain view of human nature that explains ADHD against the background of a neurobiological-genetic theory and categorises the symptoms as the result of a disruption of biochemical control circuits in the brain. Oskar Jenni (Co-Head of Department and Senior Physician of Developmental Paediatrics at the Children’s Hospital Zurich and Associate Professor of Developmental Paediatrics at the University of Zurich) notes that making a diagnosis of ADHD is very challenging and is also the subject of controversial debate. On the one hand, there is uncertainty because there is no generally recognised disorder model, no reliable ADHD test is available and the disorder sometimes overlaps considerably with other illnesses and reactive behavioural problems. In practice, it is sometimes difficult to distinguish between immature behaviour and a disorder and, finally, ADHD symptoms are distributed continuously throughout the population.⁷
  In any case, pedagogical considerations that are orientated towards the strengths of the children are a wallflower. This is because the ICF-CY (International Classification of Functioning, Disability and Health for Children and Adolescents) is the guiding principle in (curative) educational theory and practice today. It divides people into individual areas (physical functions, activities, participation, environmental factors and personal factors), which are described and should be addressed therapeutically. It is closely linked to the ICD-10, the European equivalent of the American DSM classification system.
  According to ICF-CY, the child’s problems are recorded in a support plan cycle that encompasses the above areas. From this, support goals are defined by observation, measurement and counting and a support plan is drawn up. In progress reviews, it is checked whether or to what extent the goals have been achieved and new ones are agreed.
  The procedure, which is reminiscent of technical control systems, was actually adopted from systems engineering. The ICF-CY was adopted by the General Assembly of the World Health Organisation (WHO) in 2016. This meant that the psychiatrisation of education had become a fact. Instead of pedagogical considerations, superficial measures based on behavioural therapy concepts were now the order of the day, with the aim of reducing children’s unfavourable behaviour – which was understandably rarely successful.
  Back to the example: It was suggested that Leona be given a place in the classroom where she could easily leave the classroom if she felt restless or angry. She should also be relieved of the pressure of the material by adapting her learning objectives (i.e., reducing the amount of material). In later years, she would be able to count on compensation for disadvantages, for example more time to solve exams, or possibly a workstation in a separate room.
  All of this is based on the biologistic view of human nature, which focuses (too) narrowly on the individual child and their symptoms. This approach to mental health problems, which was illustrated here using the example of ADHD, is common practice in many places today, is taught and learnt in curative education courses and is also used in a comparable way for other mental health problems.

Leona’s problem – on the basis
of a personalistic conception of man

The theoretical frame of reference for a psychological-pedagogical approach, on the other hand, is formed by the personal human sciences, including depth psychology and (cultural) anthropology. Individual psychology, founded by the Viennese doctor Alfred Adler in the first half of the 20^th century, is particularly well suited to understanding Leona’s problem in depth. It enables a differentiated, individualised anamnesis of her social and cultural environment and how Leona moves within it. Alfred Adler called it Lebensstil (lifestyle). The key points are Leona’s relationships in her family environment, her sibling situation, her parents’ parenting style and her previous (learning) biography. How did Leona understand these circumstances and what inner conclusions did she draw from them? How is she internally connected to her fellow human beings? Such an anamnesis opens up a different approach to understanding a problem like Leona’s, and for a long time it was also the basis of (curative) educational work.

A scientifically based working model

The personal image of the human being, which is inherent to individual psychology but also forms part of the foundations of Johann Heinrich Pestalozzi’s pedagogy, led to the development of value-based (curative) education in Switzerland. It saw itself as an independent science and set itself apart from medicine. Pioneers were personalities closely associated with practice such as Heinrich Hanselmann, Paul Moor, Hermann Siegenthaler, Emil E. Kobi and others – but the research work continued. What Alfred Adler, his students and the pioneers of curative education had developed has now been confirmed and expanded by the findings of anthropology and developmental psychology and by psychotherapeutic practice. They researched the evolutionary, social nature of human beings, focussed on the social and cultural influences on a child’s personality development and investigated the quality of bonding experiences, which is crucial for social-emotional and intellectual development. As a result, we now have a scientifically sound working model for educational practice that is based on the latest research findings.⁸

Back to Leona

It became apparent that she had little support in her family relationships. Weakened by a pampering style of upbringing, she lacked the courage to face up to the demands of the subject matter. She covered up her insecurity with her restless behaviour. In doing so, she fell back on the coping patterns she had learnt in early childhood and expected relief from those fellow beings around her.
  The teacher therefore needed to do more emotionally corrective relationship work. This meant encouraging and guiding her, encouraging and challenging her and sharing in her difficulties and successes in learning. The prerequisite for this was a well-structured, instructive lesson in which the children worked through the subject matter together – a form of teaching that places high demands on the teacher as a person. But this provided the basis for motivating educational success and an environment in which exchange was cultivated and friendships with peers were possible. This opened the door to more inner flexibility for Leona. She seized the opportunity to make a constructive contribution to what was happening in the classroom. It was a successful process, but it took time.
  At the end of year six, she wrote to her teacher: “It will soon be the holidays and my time at your school will be coming to an end. When I first came to this school two years ago, I was a real whirlwind and caused a lot of trouble. I sometimes didn’t understand the world when you stopped me and disagreed with me. But when I think about it now, I have to laugh. I look at the younger children and remember what we were like back then. I am very grateful today for what you have done for me and I will take what I have learnt and experienced with me into the sixth form [after primary school].”

Addendum:
a discussion that is still pending

The above would have been a possible answer to the three cantonal councillors’ question as to how we want to deal with problems that can arise in the development of children. It is about the paradigm shift that has led to the psychiatrising of curative education. Do our problem children have to put up with what is described as a neurobiological-genetic “disorder” (which is stylised in some places as a neuroatypical variant of being human)? Or are they fortunate enough to meet people who understand that their behavioural problems have become part of their life story, who draw on the latest, well-validated research findings and use them to develop a path that opens up ways to a more optimistic future for the children and their relationship partners? The question of the meaning and goal of a paradigm shift must not be “forgotten”. The (curative) education colleges would have to accept the question of the basis and content of their training programmes. Today, a change is needed towards a pedagogy that is orientated towards a personal conception of man and a scientifically based working model.  •

¹ Hadatsch, Florian. “Psychische Gesundheit von Jugendlichen. Studienergebnisse. Unicef Schweiz und Liechtenstein” (Mental health of adolescents. Study results. Unicef Switzerland and Liechtenstein). 2023. https://www.unicef.ch/de/unsere-arbeit/schweiz-liechtenstein/psychische-gesundheit
² Bundesamt für Statistik. Medienmitteilung. “Behandlung von psychischen Störungen bei jungen Menschen in den Jahren 2020 und 2021. Psychische Störungen: beispielloser Anstieg der Hospitalisierungen bei den 10- bis 24-jährigen Frauen” (Federal Statistical Office. Media release. “Treatment of mental disorders in young people in 2020 and 2021. Mental disorders: unprecedented increase in hospitalisations among 10- to 24-year-old women”). https://www.bfs.admin.ch/asset/de/23772011
³ KR No. 202/2006. Postulat Abgabe von Psychopharmaka in Kinder- und Jugendlichentherapien (Postulate on the dispensing of psychotropic drugs in child and adolescent therapies). Submitted by Silvia Seiz-Gut (SP Zurich), Gabriela Winkler (FDP Oberglatt), Heidi Bucher-Steinegger (Grüne Zurich), 25 October 2006.
⁴ NEK-CNE. “Über die Verbesserung des Menschen mit pharmakologischen Wirkstoffen. Schweizerische Ärztezeitung” (On the improvement of humans with pharmacological agents. Swiss Medical Journal). 2011; 43. https://www.nek-cne.admin.ch/inhalte/Themen/Stellungnahmen/NEK-CNE_Enhancement_d.pdf
⁵ Rüsch, Peter et al. “Behandlung von ADHS bei Kindern und Jugendlichen im Kanton Zürich” (Treatment of ADHD in children and adolescents in the Canton of Zurich). ZHAW 2014, p. 71f. https://www.zhaw.ch/de/gesundheit/ueber-uns/news/news-detailansicht/event-news/adhs-studie-der-forschungsstelle-gesundheitswissenschaften-ist-veroeffentlicht/
⁶ Müller, André. “1 von 40 Schulkindern in Zürich nimmt Ritalin” (1 out of 40 schoolchildren in Zurich takes Ritalin). In: Neue Zürcher Zeitung of 19 April 2014, p. 17
⁷ Jenni, Oskar. “Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung: Warum nicht ADHS-Spektrum?” (Attention deficit/hyperactivity disorder: Why not ADHD spectrum?) In: Monatsschrift Kinderheilkunde. (Journal for paediatrics and adolescent medicine). Volume 164 Number 4, (2016) (https://www.zora.uzh.ch/id/eprint/182694/1/ADHS-Spektrum.pdf)
⁸ Names such as Michael Tomasello, Lew Vigotsky, John Bowlby, Mary D. S. Ainsworth, Karin and Klaus Grossmann, Colwyn Trevarthen, Peter Hobsen, Paul L. Harris, Henri Julius and others are associated with this research.