During childhood two factors become highly relevant to the question of mental health. The first is the emotional life of young people. The second is ‘primary socialization’: the ways in which new- comers learn how to become accepted and acceptable members of their parent society. Both of these factors are relevant for our purposes, because the field of mental health implicates distressed experiences and distressing conduct on the one hand and deviance from norms on the other.
As far as emotions are concerned, sociologists have drawn largely upon psychoanalysis.
Freudianism has influenced a variety of social theories from structural functionalism to neo- Marxism (the ‘Frankfurt School’). Psychoanalysis (see Chapter 1) offers a theory that connects the individual’s inner life to their external social context. It provides an account of the emotional life of individuals, while at the same time offering an explanation of how mental ill-health is deter- mined by society. For Freud, civilization puts limits on the free expression and experience of emotions, particularly the instincts of sexual desire and murderous aggression. These limits lead to the need of the child to repress their antisocial feelings in exchange for family and societal acceptance. This battle between emotions and social conformity leads to the development of neu- rosis. However, Freudianism is a limited social theory. Freud’s emphasis is on civilization (Freud 1930) leading to repression and neurosis. According to Freud, we are all neurotic (to some extent) for more or less the same reasons to do with balancing our instinctual needs with the constraints of reality made clear to us by our parents. Consequently, differences between social groups were not addressed systematically by his theory, although later psychoanalytically orientated writers explored women’s issues with the establishment of feminist therapy (Mitchell 1974; Eichenbaum and Orbach 1982).
Freud offered an explanation for neurotic behaviour arising from anxiety. Later psychoana- lysts also tried to address the question of depression (Bowlby 1951) and psychosis (Winnicott 1958;
Laing 1967) by looking at the impact of poor care and separation on the infant (from birth to 2 years). However, as an example of the divergent views within psychoanalysis, the influential work of Melanie Klein is distinctive because it focused on the pathogenic impact of the infant’s inborn aggression (rather than poor care). By contrast, the work of Bowlby, Winnicott and Laing was heavily environmentally orientated; it emphasized parental privation and deprivation as the source of later mental health problems. Whereas Klein can be seen to blame the instincts for mental ill-health, the ‘environmentalists’ can be seen to point the finger at parents, particularly the mother.
Thus, variegated psychoanalytical accounts certainly emphasize a general social backdrop (‘civilization’) to emotional development, but the nuclear family then becomes its main frame of sociological reference. Mainstream clinical psychoanalysis tends to play down or ignore variables other than the family, such as the particular stresses associated with class, race, gender, age and sexuality. It also ignores the potentially powerful role of extra-familial social institutions, such as the school, in shaping the child’s identity and their emotional life.
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Turning to primary socialization, there is a strong consensus across theoretical positions in both sociology and psychology that childhood is a special part of the life-span. It is a time when most of the rules and mores associated with the society and particular class and culture which the child inhabits are learned. It is also a time when gender-specific conduct is acquired. The child learns what is expected of him or her both at their current age and in the future, through their exposure to adult models of conduct. They learn gradually to control their body and their emotions in order to perform competently and efficiently in the presence of others. They learn the impor- tance of a shared view of reality with their fellows in gaining security and in meriting credibility.
All these learned capacities are also bound up with an increasingly elaborate and defined sense of identity. Thus, socialization is about learning how to behave in a context-appropriate way in society and it is about a person gaining a confident sense of who they are.
The relevance of socialization for mental health is that children learn to behave confidently and appropriately, following rules and complying with norms. This competence can fail if the per- son lacks the intellectual capacity to grasp what to do (currently this is termed a ‘learning diffi- culty’ and used to be called ‘mental handicap’ or ‘mental subnormality’). It can also fail if the person lacks confidence in their performance as a social actor (this might be a way of thinking about
‘phobic anxiety’) or if they are too sad to participate in everyday activities (‘depression’). The com- petence can also be adjudged to have failed by others if the person fails to comply with everyday expectations of appropriate behaviour in context or they make idiosyncratic claims about reality.
We will return to this later when discussing ‘schizophrenia’.
A final aspect of socialization relevant to understanding mental health is that children learn to control their emotions. The strong emotional expressions tolerated in childhood become less and less acceptable as the person matures into adulthood. Consequently, if an adult becomes more exuberant or sad than is deemed appropriate for the context by others, they may acquire the label of ‘manic depressive’. In modern industrial societies, which are regulated by versions of rational- ity, adult conduct is marked by a capacity to comply with both moral propriety and rational rules.
By young adulthood, those of us who act either immorally, incompetently or irrationally will be deemed by others to be either bad or sick (Pilgrim et al. 2011).
Most psychologists assume that problems in childhood make the person susceptible to later mental health problems. Likewise, sociological models of depression in adulthood emphasize developmental vulnerability factors as well as current stressors (Brown and Harris 1978, discussed in Chapter 4). The social causationist model of depression from Brown and Harris involves a multi- factorial approach. As far as childhood is concerned, a strong case has been recently made for a uni-factorial causationist model, which links a variety of mental health problems to sexual abuse in childhood. Because of the strong evidence for this relationship, we will look at this in some detail below.
What is important to note here are the competing values underlying these approaches and an awareness of the socially negotiated ideas and theories about children and young people. The latter is important if knowledge about children and mental health is dominated by an adult-centric view of the world and the views of children are not taken into account. Those undertaking a cor- rective to this adult-centric position by using a participatory approach with children themselves, such as Liegghio and colleagues (2010), lay out the themes and qualities of a sociology of child- hood perspective, as shown here in Table 5.1.
Sociology, childhood and adversity
The relationship between age and mental health has only occasionally been addressed directly by sociologists. This may, in part, reflect the relatively low status that children have had within main- stream sociology. As Mayall (1998) has pointed out, children have been ‘regarded unproblematically,
Age, Ageing And menTAl heAlTh over The liFe course 73
as socialization projects within the private domain’. It is only relatively recently that a sociology of childhood has begun to be established, which focuses on understanding children’s social position as a minority group and as ‘embodied’ health care actors (see Table 5.1). This sociological inquiry explores inter-generational relationships and the ways in which children’s identities are constituted in and through particular places and spaces. Adolescents and children identify more with, and make distinctions between, groups of people in relating back to their own sense of self and place in the world, rather than identifying with a particular locality or national identity (Scourfield et al. 2006).
Identity, which in the young is strongly bound up with peers, leads to an age-bound and highly specific view of mental health and help-seeking. For example, suicide and depression were not always conceptualized as a ‘problem’ for which help-seeking from formal or informal sources is required (Biddle et al. 2007). The use of the Internet and mobile phones has also increasingly become central to the latter (social networking sites, MSN communication, Facebook, etc.), with consequences for understanding the configuration, and expression, of mental health topics. For example, the Internet increasingly acts as a forum for suicidal identities to be tested out, authenti- cated and validated by individuals. The same is true of the Internet’s support of anorexic tenden- cies in young people (Horne and Wiggins 2009).
There has been some interest in people’s conception of health and illness through subjectively defined stages of the life course (Backett and Davison 1995) and in the impact of mental health risk at different points in childhood, adolescence and adulthood (Power et al. 2002). However, there has been little integration of the different dimensions of ageing within sociological thought (Arber and Ginn 1991). An exception is the work of Backett-Milburn and colleagues (2003), who explored the social and cultural processes in different accounts of childhood, health and inequal- ities provided by children. They found that children display considerable emotional resilience and tend to play down the effects of relationship and material factors. At the same time children highlight how familial and personal challenges, such as bullying, divorce or learning difficulties, constitute a set of commonly held childhood experiences which cut across differences of class and gender.
This type of study on childhood processes is important because of the emergence of roles and norms during primary socialization (both traditional topics of interest for sociology as well as Table 5.1 A participatory framework for studying childhood
Themes Qualities
values individual agency/social responsibility
ontology/epistemology social constructionist views of child, development
competence, differences models of children situated in socio-historical context and challenging deconstruction traditional models of mental health and distress
Agency and power in
adult–child relationships children have unique roles and positions in relation to power children have inherent rights
children need opportunities to develop competencies and access to valued resources, and opportunities to participate and have influence
intervention/change focus need to focus on an expansion of contexts from individual and family to a broader social context and social policy where children play an active role in the intervention and change process
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social psychologists). For example, children, adolescents and adults who follow a certain sequenc- ing of their social roles are assumed to be better adjusted than their counterparts who follow other life-course patterns. In early adulthood this normative order is defined as first entering the paid labour force, then getting married, and later having children. Both men and women seem to benefit from following the normative course of role transitions. However, there are differences for differ- ent population groups. For example a US study suggests that African-Americans who work first, then have children, and later get married report better mental health than their peers (Jackson 2004).
It is widely recognized that the point at which young people become adults is historically and socially constructed. Changing views about when a person is a child and when they become an adult has been evident in recent mental health research. For example, it has been found that early pubertal timing is associated with increased mental health problems (Kaltiala-Heino et al. 2003).
Additionally, the point at which children are considered to become adults has implications for iden- tifying mental health trends. A study found that malaise symptoms in the age group 11–16 seemed to have a similar pattern to young adults, suggesting that the boundary between childhood and youth might need to be set at an earlier age (West and Sweeting 2004).
Societal values also seem to define to an extent what is acceptable treatment and manage- ment of children and adolescents with mental health problems. For example, substantial media attention has been focused on the issue of psychiatric medication use and ECT for children.
While the use of medication has increased dramatically since the early 1980s, for both children and adults, the vulnerability and special social status attributed to childhood means that this group receives more emotive and controversial coverage. This change has led to concerns about the long-term impact of medication on the immature brain (Carlezon and Konradi 2004) and the ethical implications of parents consenting to treatment on their children’s behalf (Breeding and Bauman 2001).
Lay people express mixed views about the use of medication in childhood. In a study of the acceptable use of Prozac, specifically for children, a survey of US public opinion found that just over half of the adults interviewed considered it appropriate to use Prozac for children or adoles- cents expressing suicidal intentions, but there was growing opposition to the use of such medica- tion for hyperactivity and other behavioural problems (McLeod et al. 2004).
Among lay people, strong and consistent correlates of willingness to give psychiatric medica- tions to children include trust in doctors and the respondents’ own expressed willingness to take psychiatric medications. However, it seems that most people consider that psychiatric medica- tions affect child development, give children a flat, ‘zombie’-like affect, and delay resolving ‘real’
behaviour-related problems. The view that physicians overmedicate children for common behav- ioural problems is also widespread. Women and those with more education tend to report more negative views on medication (Pescosolido et al. 2007).
Finally in this section, a methodological challenge about studying adversity is highlighted by mental health research about young people. Measuring a cumulative effect is seen as the most meaningful way of measuring the impact of adversity, rather than the sum of the number of occur- rences of distinctly experienced events. For example, a recent US study found that total cumula- tive childhood adversity is related to depressive symptoms, drug use and antisocial behaviour;
there is thus an incremental impact on mental health which increases as a range of adversities accumulate over time (Schilling et al. 2008).
A cycle of disadvantage is also apparent with evidence of the effects of childhood social adversity impacting on developing parent/child attachments and on learnt parenting styles. Symp- toms of depression in parents who had themselves suffered adversities in childhood were asso- ciated with an ‘insecure’ attachment style in relation to their own children. Both material and emotional deprivation are associated with low levels of expressed parental warmth. By contrast,
Age, Ageing And menTAl heAlTh over The liFe course 75
high parental warmth is associated with decreased risk of insecure attachment styles (Stansfeld et al. 2008). Similarly Kiernan and Huerta (2008) found that economic deprivation and maternal depression separately and together diminish the cognitive and emotional well-being of children.
Part of this impact arises from the less nurturing and engaged parenting style of those with fewer economic and emotional resources.
This interaction of (lower) class position and emotional resources highlights that models of mental health causation based either on material or psychological explanations are less persua- sive than ‘both/and’ models. Poverty increases the risk of mental health problems but not all poor people develop the latter; mediating psychological factors are therefore important to consider.
This links with the next section, which starts with the point that the psychological construction from victims about their adverse conditions in childhood is variable. Moreover, the presence of the adversity of abuse can happen in all classes, which highlights the need to consider family peculiari- ties not just social group membership.