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Psicologia USP

Print version ISSN 0103-6564On-line version ISSN 1678-5177

Psicol. USP vol.29 no.3 São Paulo Sept./Dec. 2018

https://doi.org/10.1590/0103-656420180107 

ORIGINAL ARTICLES

Medicalization of childhood: between care and medication

Luciana Jaramillo Caruso de Azevedoa  * 

aPontifícia Universidade Católica do Rio de Janeiro, Departamento de Psicologia. Rio de Janeiro, RJ, Brasil


Abstract

From psychoanalytic clinics with children, a close relation can be observed between care and medicalization. Studies on medicalization are extremely relevant today, considering not only the capture of forms of psychical suffering, but also the massive production of diagnoses and the pathologization of childhood. In these terms, this study, in light of psychoanalytic theory, intends to perform an articulation between the notion of care and the medicalization of childhood. To do so, at first, a theoretical discussion is presented on the impact of medicalization on the care given to children. Then, we highlight the importance of care for the psychical constitution and its connection with the medical discourse. At last, we emphasize that medicalization is increasingly becoming a mechanism that tampers with diversity. It is essential to rethink the advances of medicalization as a major form of therapeutic intervention and the extent of its reach in the contemporary scenario.

Keywords: medicalization; childhood; child care; contemporaneity

Resumo

A partir da clínica psicanalítica com crianças, nota-se a estreita relação entre os cuidados e a medicalização. Os estudos sobre a medicalização são de extrema relevância na atualidade, tendo em vista não apenas a captura das formas de sofrimento psíquico pelo discurso médico como a produção massiva de diagnósticos e a patologização da infância. Este artigo propõe uma articulação, à luz da teoria psicanalítica, entre a noção de cuidado e a medicalização da infância. Para tanto, inicialmente, será apresentada uma discussão teórica sobre o impacto da medicalização nos cuidados dispensados às crianças. Em seguida, destacaremos a importância dos cuidados para a constituição psíquica e seu enlace com o discurso médico. Por fim, enfatizamos que a medicalização se torna cada vez mais um mecanismo que tampona a diversidade. É indispensável repensar os avanços da medicalização como forma majoritária de intervenção terapêutica e a dimensão do seu alcance no cenário contemporâneo.

Palavras-chave: medicalização; infância; cuidados infantis; contemporaneidade

Résumé

Dans la clinique psychanalytique avec des enfants, une relation étroite est observée entre les soins et la médicalisation. Les études sur ce sujet sont extrêmement pertinentes aujourd’hui, en considérant non seulement la capture des formes de souffrance psychique, mais aussi la production massive de diagnostics et la pathologisation de l'enfance. En ces termes, cette étude, à la lumière de la théorie psychanalytique, vise à articuler la notion de soin et la médicalisation de l'enfance. Pour ce faire, une discussion théorique est présentée sur l’impact de la médicalisation sur les soins donnés aux enfants. Ensuite, nous soulignons l'importance des soins pour la constitution psychique et sa connexion avec le discours médical. Enfin, nous soulignons que la médicalisation devient de plus en plus un mécanisme qui altère la diversité. Il est essentiel de repenser les avancées de la médicalisation en tant que forme majeure d’intervention thérapeutique et sa dimension dans le scenario contemporain.

Mots-clés: médicalisation; enfance; garde d'enfants; contemporanéité

Resumen

A partir de la clínica psicoanalítica con niños, se percibe el creciente cruce de la atención y la medicalización de la infancia. En el escenario contemporáneo, son extremamente importantes las investigaciones sobre la medicalización, puesto que contribuyen en gran medida a entender las formas de sufrimiento psíquico y a fomentar la producción progresiva de diagnósticos y de la patologización de la infancia. En este estudio, se pretende lograr una articulación acerca de la atención a los niños y de la medicalización de la infancia. Para efectuarlo, siguiendo la perspectiva psicoanalítica, en un primer momento, se formularán consideraciones teóricas sobre el impacto de la medicalización de la infancia. En segundo momento, se hará hincapié en la importancia de la atención para la constitución psíquica y la relación con el discurso médico. Por último, se enfatizará que la medicalización ha sido una manera de obstaculizar la diversidad presente en el sujeto. Es necesario reconsiderar los avances de la medicalización como terapéutica más utilizada y su alcance en la contemporaneidad.

Palabras clave: medicalización; infancia; atención a niños; contemporaneidad

Introduction

Medicine intake is part of the contemporary subject’s life, becoming the subject of deep research from different fields of knowledge. A central point in the medicalization study is the intrinsic association between subject and discontent. According to Birman (2007), the body became a crucial place where the discontent evades through complaint, which allows the individual to state that something is wrong with him. In this sense, medicalization has emerged as a way of managing and diagnosing psychic discontent.

The idea that everyday events can be diagnosable and treatable by medicine is not new. Even before modernity, we got used to understand and explain the psychic life - including ethical conducts - by knowledge on the body materiality (Figueira & Caliman, 2014). The experience of the self has been slowly contaminated by this knowledge on diagnostic criteria from disorder qualifying manuals, which sometimes may seem new readings of old personal difficulties (Lima, 2005)

The notion of medicalization emerged aiming at reporting the expansion of medicine jurisdiction to new areas, especially those regarding moral, legal or criminal matters. With this in mind, medicine has become a social control device, by taking over regulatory function before exerted by the church and the judiciary (Brandão, 2012). For Aguiar (2004), medicine can create new realities, practices and speeches that allow new ways for individuals to understand, regulate and experience their bodies and feelings.

Regarding care, which previously came from different contexts, such as family members, and transmitted among generations, Lasch (1983) points out that the family has lost the ability to create and take care of their children without the help of specialists. According to the author, the time plot has been constantly broken and torn, erasing the traces between generations. As a consequence, family bonds loose strength as experts start to take over tasks previously assigned to the family. Lasch (1991) also points out to the “bourgeois family anomie”, which is the emptying of parental care functions concerning kids and its technical appropriation by health and welfare professionals. When giving away most of its responsibilities to the school and welfare specialists, the family aimed at exclusively becoming a space of fellowship and friendship, a refuge from the hardships of the working world. However, the concept of home as a safe environment became inviable as relationships followed the logic that guides personal relationships in the outside world - the logic of survival and immediate gratification.

Guarido (2010) states that the need for childhood management was established. To do so, technical preparation aimed at raising healthy and productive individuals would be indispensable. On the other hand, Lima (2005) points out to one of the vicissitudes of contemporary times: the progressive displacement of a number of human discontents. Several approaches that attempted to explain individual vicissitudes were reduced to physicalist conceptions on its biological dimension. This way, behaviors that caused discomfort could be interpreted as a result of medical causes, and how family, school, relationships, conflicts, among other factors, affect people. Today, these forms of analysis are readily dismissed as misguided and, above all, not scientifically founded.

Given this panorama, Whitaker (2016, 2017) states the existence of a diagnostic epidemy, which makes clinical work increasingly complex. Excessive restlessness during the identification and classification process of diseases seems to outweigh concerns with the one undergoing suffering.

Combined with a process of biologization of everyday life, we can see the dissemination of speeches encouraging the medicalization of society. The dissemination of diagnoses, its setting, the multiplication and inaccuracy of biomarkers give way to childhood pathologization and medicalization to an extent that anything other than normal is seen a disease to be treated with medication (Melo, 2016). Lima (2005) indicates that the diagnostics have been usually performed in a very quick way, which compromises precision, as it ignores the child’s context.

However, according to psychoanalytic theory, care is fundamental to the subject’s psychic constitution. There is need to carry out an in-depth study on children from a biological perspective that addresses with the current trend of assigning the responsibility for children’s care to professionals. It is important to investigate how and to what extent medical knowledge - especially from the psychiatric field - has been answering to the social demands in question by simply diagnosing behavioral deviations in an attempt to contribute to normalization.

The medicalization and its impact on childhood

Initially, the term “medicalization” was proposed by Irving Zola, in 1972, when referring to the increase in the jurisdiction of the medical profession to new working fields, especially when it comes to regulatory functions (Ab, 2004). Despite being a descriptive term to indicate something that guided by medical knowledge, most authors have used it when implying an excessively negative review of the medicalization process (Conrad, 2007). These criticisms addressed the increase in the influence of medicine in fields that up until now were not its responsibility, creating conflicts about the medical, social, epistemic or ontological status of certain diseases and, therefore, the need for control and therapy (Gaudenzi & Ortega, 2012).

According to Conrad (1992), medicalization is when an issue ends up being conceived in medical terms, described from medical language, and understood from this logic, and even dealt with through medical intervention. From this idea, science has been describing these categories by adjusting them to the already existing ones. Such categories are relatively flexible, as they are conceptually and clinically vague, its scope depending on the doctor’s perspective.

From another perspective, the text “Laços e desenlaces na contemporaneidade”, by Birman (2007), points out that changes occurred in the family belong to the biopolitics field, which constitutes western modernity. Based on Foucault (1976), the author says that medicalization of the social space is an outcome of biopolitics, through which medicine began to regulate individual and collective bodies. It aimed at fostering the quality of life of the population as the major sign of wealth of nations. From birth to death, different age ranges became the object of biopolitics. This way, populations turned both into objects and subjects of power, understanding children as the representation of the future.

This complex global process called “medicalization” consists of a way to turn experiences previously managed in other ways, sometimes within family and social environment, into medical needs that involve interpretation and care techniques. In this juncture, we can consider that medicalization restricts therapeutic perspectives, by dismissing the subjective and social aspects of the health-disease process (Tesser, 2006). One can not ignore the fact that diseases are understood in a culture at any given time.

For example, concerning the attention deficit disorder and hyperactivity (ADHD), Lima (2005) points out there are no criteria or reliable markers to differentiate pseudo-ADHD of Hallowell, culturally biased, from the biological frame given as “true”. Lacet and Rosa (2017) understand that the consequences of ADHD diagnostic epidemy affect children in several ways, such as in school, which implies a demand for disciplined behavior on behalf of a good performance at school. However, these demands often conceal obstacles regarding the educational institution itself. Parents feel the need to cope with medical knowledge, which refers to ADHD organic etiology, finding themselves clueless on how to approach their children’s symptoms. Thus, both the school and the family converge to silence the child of its “uneasiness”, by opting for a drug treatment.

Caliman (2016) explains that giving students with learning difficulties a medical or psychological referral is a common practice among most professionals in the education field. However, if on one hand the protocols and diagnostic evaluations allow the early tracking of diseases, on the other hand, it also favors the understanding of children’s issues as of individual order and due to faults in the child’s neurological activity.

According to Caponi (2016), despite mothers of children with ADHD not liking the idea of medicating their children with psychotropic medication, they do it. Firstly because medical recommendations are usually considered irrefutable. Secondly because the school pushes parents to get their children evaluated and undergo medical follow-ups, when identifying any behavioral changes.

We understand that this educational practice denotes a way of ensuring the child’s development, by asking parents to take part in the care, and aligning it to medical interventions. Parents are concerned with their children’s adequacy in society to make sure they will have the same opportunities as everyone else. Taking care of a child has turned into following the school’s advice on specialist follow-up. It is worth noticing that the ability of care transcends the “referral to the specialist”, despite including this professional. Thus, at this point of discussion, it is important to note the existence of a wide range of factors involved in the difficulties within the school environment, these not being only reduced to disorders. Would school performance be a fair measure of evaluation?

The presented evidence implies this combination of factors and produces tension. The need for early diagnosis of clinical frameworks and proper medical intervention is undeniable. However, the obsession to identify each disorder seem to rise as an attempt to overcome the difference between the several ways of being a child. This way, generalization stems from the concept of pathological, in which the analysis of each small difference points to anything other than normal or considered standardized.

Guarido (2007) and Caponi (2012) underline the wide range of symptoms and diagnoses in the manuals, mainly in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which promotes medicalization. According to Caponi (2016), in the days that followed its publication, the fifth edition of the DSM received criticisms regarding the new diagnostic classification based on different fields of knowledge, such as public health, psychoanalysis, social sciences and the psychiatry. For the critics, the DSM-V increased the feeling left by its previous editions, a group of disorders with no epistemological consistency and with a strong tendency to multiply psychiatric diagnoses. These criticisms have multiplied in recent years. Severe criticisms were made by researchers from the psychiatric field, such as Bruce Perry, Leon Eisenberg, Nancy Andreasen, Robert Spitzer, Marcia Angell and Allen Frances.

The growing number of medical-pedagogical interventions from the proliferation of diagnoses and prescriptions of medications is significant among adults and children. By indicating a pathological framework, diagnoses and therapies oversimplify the pains of childhood, thus increasing the amount of children who allegedly need to receive medication (which happens earlier and earlier in their lifetime).

About a different aspect, Sassolas (2012) states:

Recent pedagogical perspectives had a remarkable impact on psychiatric practices when exemplifying different relationships between teachers and students and active teaching methods that use mediations and group work. The new psychiatry became dynamic enough to influence opinions and the political power, which allows its proposals to be translated into laws and financing initiatives- i.e. in structural reforms: the sectoral organization of care. (p. 524).

According to Sassolas, one can both observe the influence of Psychiatry on Pedagogy, and of Pedagogy on Psychiatry. Hence, there is need to question the close relationship between these two fields and its possible repercussions by approaching the school and the production of laws and policies. According to Sassolas (2012), new psychiatric culture emphasizes technical acts, as well as evaluation and predictability, supported by allegedly objective markers. It does not ignore the relational care,it only reduces its operating aspects, namely, the implementation of protocols.

With this in mind, it is worth to highlight that the care needed for child proper development, including its main characteristics for the subject’s constitution, has been misunderstood with technical and regulatory measures, often more inclined to childhood homogenization than to actual concerns with a healthy development.

Child care and psychic constitution

According to Figueiredo (2009), the arrival of a newborn in the human world is marked by a complex web of events that establish their conditions and ways of becoming a human being. In this field of study, Winnicott was a celebrated psychoanalyst and pediatrician who devoted his work to the importance of care in children’s development. Winnicott (1988) states that, in a family structure that waits for the newcomer, parents offer continuity in time for their babies, whose beginning dates back from their conception and background, until achieving independence. In this sense, the mark of the presence of the other transforms care in a fundamental element in the process of subjectivation, giving it a structural function.

In traditional studies such as “Through Paediatrics to Psycho-Analysis” (2000), “The Maturational Processes and the Facilitating Environment” (2007/1983), “Playing and reality” (1975), among others, Winnicott notes that care description maintains a close relationship with the environment and the presence of the good-enough mother in the psychic constitution of the subject. It is valid to point out that, in the author’s conception, the mother is the one that exerts mothering, i.e, caring, since the beginning. The good enough parenting, in its early critical stage, would refer to continuity (in time) of the emotional environment of specific elements and external physical environment, which cannot be reduced to medical interventions. Therefore, we consider fundamental care is beyond medical rationality, being more associated with the meeting of the baby’s needs than to technical procedures.

However, there is need for the doctor to give up on the illusion of omnipotence which implies that for each question, doubt and lack of knowledge, there would be a response or a procedure. Based on that, Figueiredo (2009) highlights that the caregiver - family members, doctors or teachers - must renounce their own omnipotence to repair manic fantasies By treating the child with medication, the caregiver does not allows them to undergo childhood freely and to develop their singularities. Hence, medicalization does not meet the particularities of each case, as it promotes homogenization, which does not corroborate with psychoanalytic theory and practice.

If, on the one hand, the individual lacks an environment that is good enough for their development and formation through care, on the other hand, when achieving maturity, they become responsible for this environment and develop the ability to care. Adult health is conceived as a construction process held over the several childhood phases, mental health care resulting from an incessant care that allows the continuity of emotional growth (Winnicott, 1952/2007).

Winnicott (1975) states that:

success in child care depends on devotion, and not on intellectual inclinations. The good-enough mother starts promoting her full adaptation to the needs of her baby, and, as time goes by, she adapt herself less and less gradually, according to the baby’s ability to deal with her failure. (p. 25)

According to the author’s perspective, primordial relationships and first care are fundamental for the psychic constitution. The care aimed at children would set the foundations of their mental health. The ego would become as strong as the support given by a good enough mother, who gives her best to adapt herself to the needs of the baby. Therefore, the prototype of the care experience is the initial relationship between the baby and the motherly Other, characterized by both the baby’s dependency condition and maternal willingness. At first, care would imply the other’s willingness to devote themselves in favor of the baby’s first adaptations to the world (Winnicott, 1955/2005, 1952/2007).

When referring to the word “infant” or infans (speechless), Winnicott (1952/2007) points out that the corollary of this period refers to the period when the infant depends on the care based on maternal empathy than on rational understanding of what is or could be verbally expressed. The so-called disorders would be due the failures occurred in environmental provision (Winnicott, 1963/2007).

Plastino (2009) points out that care inadequacy or care failure, and the frustration that it causes, is the main reason behind the so-called “new pathologies”. Considered new for being more recently disseminated, they express the pains of the subject’s narcissism, therefore more radical and archaic than the pains due to transference neuroses. It is noteworthy that even in cases in which there was proper environmental provision, there is no way to ignore the context of the child’s symptoms, being necessary to consider the moment of the child’s life, their development, and their relationship with the school and family. Other essential factors in child care are ambivalence, fantasy and the relation that each child has with reality.

In the case study on little Hans, described in the text “Analysis of a phobia in a five-year-old boy” (1909/1969), Freud teaches that despite neurosis usually stemming from anxiety, not every childhood symptom will be extended for their lifetime. According to Freud (1909/1969), Hans was not the only child struck by phobia during childhood; some transient symptoms are extraordinarily frequent, even in children who received proper care and education. Over months or years, the child seems to recover. However, it can not be said that medical measures are required for such recovery or that it implies changes in character.

In the same text, Freud (1909/1969) states that Hans’ phobia may have been triggered, including for its own benefit, as it drawn parent’s attention to the inevitable difficulties that children face when, during the formation of their cultural background, they need to overcome innate pulsional components. The boy’s problem led his father to give him assistance. Thus, one can consider that Hans might have had some advantage over other children for not carrying within themselves which, in the form of repressed complexes, might mean something for his future.

With this in mind, we can think that the children’s psyche builds itself through the care, reflecting significantly throughout their life. Cultures, societies and time periods are characterized by specific care procedures, these being psychological foundations that allow and permeate the development of the subject. It is difficult, indeed - albeit important - to look at the current cultural context not ignoring the need to consider the context around care, as the caregivers and the objects of their care have a determined background (Figueiredo, 2009).

Childhood medicalization

Historically, between the 19th and 20th centuries, the traditional idea on family constitution and children could not sustain itself. This rupture also occurred due to the fact that women wanted to be seen as individuals, and not only as mothers. Women left home in the search for an identity, on the other hand, men did not come back home to make up this maternal absence. For this reason, children have been attending nurseries and schools too early, as they have to compensate the lack of parental figures. This set of structural transformations particularly focused on children’s narcissism economy, producing new forms of subjectivation and psychic disorders. The lack of parental figures in the family environment and anonymity in childcare - especially of infants - can have a direct association with the emergence of disorders. Thus, we can consider narcissistic disinvestment as a condition that contributes to new forms of psychic pain (Birman, 2007).

In contemporary societies, Ehrenberg (2010) points out to cult to performance, in which entrepreneur has been seen as a model of heroic life for summarizing a lifestyle in which the individual build their own story. Individual success was promoted to the ideal code of conduct of the masses, and to achieve it there is need for us to conquer a place for ourselves in the world. Thus, being successful means to have autonomy to develop itself. According to this author, the capitalization of behavior implies the need for everyone to contain themselves, as a way of seeing self-management as a way of overcoming the evils of competition and the obsession to detect the zero error.

For Ehrenberg (2010):

The individual is undergoing the process of life capitalization. The obsession to win, to become somebody, and the mass consumption of psychotropic medications are closely connected, because a new culture of achievement is necessarily a culture of anxiety at the same time. Happy pills are the cocoon profile at the core of the training profile, the reintroduction of well-being in a lifestyle in which risk-taking, the prioritization of the search for individual singularities and self-control define the standards of conduct of each (p. 139).

Corroborating with the line of thinking of abovementioned author, we observe that now children suffer from the logic that operates the adult universe, considering they are inserted in the same culture and are subjected to similar requirements. Birman (2007) understands that the absence of parental figures leads to excess of scheduled activities, when financial resources allow it. The children’s playing space has been restricted, having performance and shared socialization as its counterparts.

In addition, Birman (2012) indicates that certain medications and stimulants are part of the contemporary lifestyle as a response to the current discontent. In this context, the subject feel the need to keep up with the current accelerated life, giving way to hyperactivity. People often act without thinking about what the outcomes they seek with such action. Lima (2005) clarifies that the contemporary subject experiences an erratic world, with laws that change in the course of the game and values that loose strength after being announced.

Against the perspective proposed by diagnostic manuals, Ehrenberg (2010) states that the these medications work as silence drugs whose use quietly report the difficulties in living. Caponi (2012) understands medicalization as the need to silence suffering and singularities at all costs, as if it should not be part of the human development processes. While Perez and Sirelli (2015) indicate that if on one hand the medication response is common, on the other hand, psychoanalysis focus on subjectivity and the unconscious element that guides us throughout life, against the culture of medicalization and silencing of psychic.

Based on the psychoanalytic perspective, Tenório (2000) proposes the end of medicalization demands to promote the subjectivation of complaints. Which implies listening to the patients - the children - have to say about themselves and invite them to pay attention to reason behind their complains, and to be interested by the subjective dimension of what the affects them. The author emphasizes that “the reason behind the symptom is not only found in nosographic, featuring a meaning connected to the experience of the subjects, particularly in their the relationship with themselves. Thus, one can say that the symptom is not a strictly medical matter, being possible to consider it beyond medicalization. According to the medical perspective, the only way of mediating the problem is to translate it in terms of medical “semiological treasure” (Tenório, 2000, p. 85).

For Melo (2016), when it comes to the clinical context, which includes care and investments directed to children, psychoanalysis sustains a ethical and political questioning when recommending a treatment that considers the psychic suffering of children,their story, their social bonds within and outside of school, i.e., a treatment that considers their most intimate and unique features, namely, their symptoms.

Final considerations

As seen in this article, human existence is far from perfection and stability. Frustrating experiences threatens the meaning of the lives of subjects by mainly promoting discontent in contemporary individuals that find in medicalization a way to manage psychic discontent. This way, if advances in biomedical knowledge and its related technologies offer a better life to people who before would be doomed to suffering, sequels or even early death, they also associate people with a strict dependence on the medical institution, as only the submission to technically determined procedures is assigned to citizens (Tesser, 2006).

We are more and more encouraged to ensure the early diagnosis of diseases to provide good treatment. On the other hand, the obsession to detect early childhood mental disorders seems to be the neuralgic axis around which the DSM-V and ICD-11 articulate producing a significant tension. With this in mind, it is worth reflecting on the incidence of diagnostic inflation focused on adults and children. However, the excess of diagnostic categories contributes to medicalization, delimiting and standardizing individuals, and undermining their ability to position themselves historically and politically.

We must not forget that, in the current context of modernity, childhood became a target of the consumer culture, which led to a new conception of medicine intake. The positioning of “school-childhood” binomial seems to accentuate the explicit claim to know what befits the other, as an attempt to make it work “for-all” and suppress differences (Melo, 2016).

The care practice goes beyond what it is commonly taught and prescribed. Thus, it becomes urgent to recover the ability to deal with urgent and valuable tasks, which gives meaning and human value to our life and to the world (Forbes, 2009). It is essential to consider that child care also not only involves medical-pedagogical aspects. The imbrication of child-care from a biological perspective becomes a way of naming discontent, as has been seen, psychoanalysis has much to contribute to this study.

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Received: August 30, 2017; Accepted: August 09, 2018

*Corresponding address: lucianajaramillo@msn.com

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