There is no doubt, at least in my mind, that childhood, and certainly teenage years, have become progressively harder over the last 30 years. There are many and varied reasons for this. Social media is undoubtedly a mixed blessing, benefitting some youngsters and harming others, but the pressures on children to conform are greater than ever. Being continually measured against your classmates, for the league table that the school’s reputation depends on, is another factor. Rates of anxiety and depression in teenagers are have been steadily rising, and this has got worse over the pandemic. Along with this increase, more children are being diagnosed as neurodiverse. This is partly because the parameters for the diagnosis have changed, but also because of increased recognition in children who aren’t seriously disabled by their condition.
Before we look at some of the pros and cons of labels, I should mention that there is a substantial literature on labelling theory which I don’t propose to examine here. I will simply look at a few common applications of labels and whether they are helpful, or otherwise, in practice.
Labels can be helpful…
Labels change the attitude of the observer. If a teacher knows that a child is neurodiverse, they may cease to use unhelpful labels such as ‘naughty’, and have ready plans that can be implemented. The label may also help the individual understand some of their own difficulties: “I am autistic, which is why I’m having to work harder to understand what someone is feeling, when my friends just seem to know.”
A mental health label can also help a youngster to feel validated. “I am depressed, I’m not just being difficult, so it’s valid for me to take time out”. The label can also suggest potential ways forward, such as engaging in therapy. A label is often a diagnosis, and NICE (The National Institute for Clinical Excellence) recommends treatments by diagnosis; looking at the evidence to recommend the best treatments and therapies.
Labels, therefore, can be useful: they can validate the individual, suggest treatments, and act as shorthand for others to begin to understand and help.
…or not so helpful
Labels also have many and various downsides. The harms and benefits depend on the type of label, so it’s worth addressing them separately
Identifying that a child is neurodivergent is helpful for that child. But what about the borderline between diagnosis and no diagnosis? Although we talk about a spectrum, and on the face of it we acknowledge that there is no hard and fast cut off, in reality the situation is treated as a clear binary: you are either neurodivergent or you are not. Someone may have many traits, but just miss the cut off. So despite having almost the same difficulties as the child who falls just the other side of the line, they will be treated entirely differently.
Schools often say that they treat the child not the label, but the reality is that without the label there may be no help forthcoming, and certainly no extra resources or exam breaks. This is not a problem of the label for the child who has one, but is a problem inherent in any label which has a relatively arbitrary cut off. It would be excellent if we were able to treat all children as individuals, who have traits along a spectrum, some of which needing more support than others. But the realities of our society and its resource allocation make this impossible.
More serious psychiatric labels can be more contentious, primarily because most psychiatric diagnoses are still based on an understanding of clusters of symptoms rather than underlying pathology. We know now, for example, that schizophrenia is probably the final manifestation of a number of underlying processes which may respond differently to treatment, and take different pathways through life. NICE does a good job of identifying which treatments are likely to be most effective for whom; their recommendations are based on large RCTs, but they are statistical, so don’t necessarily indicate which treatment will be best for any specific individual.
This difficulty can be seen in trials for antidepressants. Trials show them to be somewhat effective, while clinical experience suggests that they vary from being life-saving to being completely ineffective. With no way to differentiate between the groups, a large trial may find such a treatment, on average, moderately effective. Work is being done to understand more, but there are still many unknowns.
Talking therapies, social support, and psychological support are also important, but different people will appreciate different forms of assistance. A label can induce a lazy, “That person has X, I know what to do with X,” kind of approach. Yet one person’s experience, and what they found helpful, may not carry at all to someone else. It is common to hear that those who have been through something understand it best. But they may simply understand how it was for them, and then misapply that understanding to other people.
There is a risk that others will see the label, and not the person. This can lead to a lack of curiosity about why someone may be struggling, assuming that the label tells you everything you need to know about them. Medically it can lead to ‘diagnostic overshadowing’: new problems being overlooked or not investigated properly as they are assumed to be part of the diagnosis already known.
People, especially teenagers, can do this to themselves. It is fairly common now to see someone describe everything they do as being because of their label. “My ADHD made be do it” for example, when ‘it’ has nothing to do with ADHD. A harmless example on social media is self-described ‘empaths’, as if empathy wasn’t a normal human trait. This may just help someone feel a bit special. But more pernicious examples include the numerous ‘introvert’ memes, which in their extreme forms can lead to someone avoiding all social contact and, attributing it to their introvert status. In reality, these memes often characterise social phobia, and while they may appear to offer comfort, misidentifying a problem which they could get help with, and withdrawing from social contact, is unlikely to be the best way forward.
Identifying with an erroneous self-diagnosis also happens. Self-diagnosis can be helpful as a step towards getting more formal confirmation (where it is possible to do so), and getting help, where it exists. Commonly people make reasonably accurate observations about themselves, but not always. This can happen for teenagers, particularly those with a troubled or chronic trauma background, who are looking for explanations for their dysphoria. They may decide that they are autistic, or that they have bipolar disorder – labels which might make life more bearable, but might impede them receiving the kind of support they need. Upon learning that their self-diagnosis was erroneous, some people are relieved to learn they do not have a specific diagnosis, but it can leave others feeling bereft if they lose what they thought was the reason for their dysphoria.
The balance
It may seem that there are more downsides to mental health labels than there are advantages. But the advantages can be so significant that in practice they are not only here to stay, but useful. It is however important to bear in mind the downsides in order mitigate them as much as possible.
