Who speaks for the bad boys (and girls)?

In a way, we are in a golden age for attitudes to young people’s mental health. Just this week, no less a figure than Prince Harry talked about his own help-seeking, both he and his brother and sister-in-law have campaigned for better services and more positive societal attitudes. Theresa May has discussed the issue in a not-entirely-bad speech.

But what if I was to ask you what the most common mental health condition is in the UK? Most people guess at anxiety, or depression. If pushed they might go for eating disorders. But it’s none of these. By a considerable distance, it’s conduct disorder.

Conduct disorder is, roughly, an established and disruptive pattern of anti-social behaviour, which impairs the young person’s life. The commonest objection is that this is not really  a mental health disorder, but that in itself betrays quite a restrictive attitude to what emotions and thoughts we regard as worthy of help, and which we reject and condemn.

Imagine two girls of 14.

One, Amelia, is lonely and sad a lot of the time, she doesn’t think her friends like her, and self-harms by cutting her forearms.

The other, Charlie, is angry and alienated. She thinks her mum hates her and they row a lot, and she self-harms by drinking in the park and getting into fights.

Which girl is more worthy of our concern and care? I would argue that they are both, equally worthy of our compassion and to receive the help that they need.

However, the narrative around mental health is exclusively about the type of problems that Amelia has, and puts Charlie in the ‘broken Britain’ bin of delinquents and ‘problem families’. And it isn’t just the media- I’ve been to discussions of young people’s mental health at the Department of Health, NHS England, the Royal College of Psychiatry and innumerable charities, think tanks and parliamentary groupings. I have never seen a young person with conduct problems attending, and no-one (other than me) has ever, ever mentioned this condition which, just to remind you, is the most common mental health condition in young people. When I do mention it, everyone nods, mumbles, and goes back to what they were talking about. Usually mindfulness, or apps.

Why is this? It’s not because people in the field are stupid, or uncaring.

One problem is that these kids do not have socially acceptable mental health problems. They are routinely rude, they often undermine attempts to help them (mainly because they don’t believe they are worth helping). They are not eloquent, typically, and are often ashamed of their feelings in a way that we encourage with our condemnation.

One big focus in mental health has been the role of schools in supporting pupils with mental health problems, but hand in hand with moves to train every teacher to deal with anxiety and depression is a hardening of attitudes to anything remotely anti-social, and the return of the disciplinary culture of the 1950s will do far more damage to mental health than any amount of amateur CBT can compensate for.

Anxiety and depression are, demonstrably, no respecters of social class. Conduct disorder, on the other hand, very much is- it is vastly more common in poorer families, and so society’s attitudes to poor families are transferred to their troubled offspring.

The help they require is complex, and requires co-ordination across multiple agencies, support for the whole family, and above all, patience. They can be helped, and there is a lot of evidence of effective interventions, but ultimately they are too difficult, and give too little political reward, to be the priority.

Conduct disorder is associated with every kind of negative outcome you can think of. It is a major, treatable, public health problem. Why are we not talking about it?

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