Keywords

6.1 Children and the Welfare State

Unlike poverty and unemployment, childhood is not a social problem; rather, it is simply a part of the human life course. However, upon closer inspection, childhood is rarely conceived as something that merely unfolds and it is instead approached as a problem that needs to be analyzed and managed. Rousseau’s (1911 [1762]) Émile, ou De l’éducation, for instance, serves as a reminder that providing children with the right upbringing has occupied science and philosophy for decades. Over the course of the nineteenth and the beginning of twentieth centuries, medicine and psychology gained considerable authority over childhood, particularly—but not only—when it was considered problematic. Nolan (1998), for instance, exemplified how the legitimation of American public education moved from religious ideas and values to the psychological needs of children and their healthy development. Rafalovich (2001) traced the conceptual history of attention deficit hyperactivity disorder (ADHD) and demonstrated that medicine created various labels to categorize the disorder since at least 1877. In a more recent historical comparison, Clarke (2015) revealed that advice for mothers in Canada’s most read woman’s magazine was equally medicalized in the period from 1945 to 1956 as in the period from 1990 to 2010. These historical analyses indicate that the medicalization and psychologization of childhood are by no means new phenomena. Over the course of the twentieth century, medicine and psychology established themselves as two primary disciplines for dealing with childhood issues in contemporary societies. This characteristic was shown in an analysis of the scientific discourse on childhood problems in which medicine and psychology were found to have the greatest publication output in this area compared with all other disciplines covered in the Social Science Citation Index since the mid-twentieth century (Brase et al., 2022). However, if medicalization and psychologization have been historic phenomena and if both fields have such an established position today, why did we select childhood problems as a topic for this book?

One reason for our choice is that problems in childhood serve as a prime example for better understanding the link between medicalization, psychologization, and the welfare state. Children spend a large amount of their childhood in institutions that are funded and regulated by the welfare state. Public education is one of many ways in which the welfare state (e.g., family policy, children’s and youth services, healthcare, minimum income for families) impacts children’s lives in advanced, industrialized nations. Moreover, welfare states take a special interest in children whose lives are considered problematic. For these children, the welfare state usually offers additional programs, such as child protection services, assisted living, special education, and therapies. Thus, considering this collection of child-related programs and services, the welfare state has a strong influence on childhood and plays a key role in managing childhood problems.

Secondly, the role of children in the welfare state has changed dramatically over the last two decades. This change is strongly connected to the growing influence of the social investment paradigm. At the core of the paradigm is the idea of investing in human capital for future returns (i.e., in the form of productivity, social participation, and lower welfare expenditures), with investing in children “as an emblem of the future” (Adamson & Brennan, 2014, p. 47) being seen as most profitable. For instance, Esping-Andersen (2002, 2005) prominently supports a “child-centred social investment strategy.” This perspective has also been taken up by the European Commission, which issued a 2013 recommendation entitled “Investing in Children: breaking the cycle of disadvantage”:

(2) Children1 are more at risk of poverty or social exclusion than the overall population in a large majority of EU countries; children growing up in poverty or social exclusion are less likely than their better-off peers to do well in school, enjoy good health and realise their full potential later in life; (3) Preventing the transmission of disadvantage across generations is a crucial investment in Europe’s future, as well as a direct contribution to the Europe 2020 Strategy for smart, sustainable and inclusive growth, with long-term benefits for children, the economy and society as a whole. (European Commission, 2013)

This statement from the European Commission illustrates that children play an instrumental role in terms of how the social investment concept is used by the European Union to justify benefits and services that influence children’s lives.

In the United States, economic Nobel laureate James J. Heckman is a prominent advocate for investing in early childhood. In his paper “Skill Formation and the Economics of Investing in Disadvantaged Children,” which was published in Science in 2006, Heckman argues that “[m]any major economic and social problems can be traced to low levels of skill and ability in the population” (Heckman, 2006, p. 1901). He further suggests that these abilities are character skills, such as “motivation, perseverance, and tenacity” (Heckman, 2006, p. 1901), which disadvantaged children often lack because they are exposed to broken families and bad parenting. Heckman’s work highlights the tendency of the social investment perspective to use psychological concepts such as motivation or resilience to tackle social problems. This psychologization of childhood problems is also visible in the expansion of parenting programs across advanced, industrialized countries (Betz et al., 2017).

In sum, children have become a central target of social investment initiatives (Esping-Andersen, 2005; European Commission, 2013; Kjørholt, 2013). Along with—and as a part of—educational reforms, fostering children’s health and psychological competences has served as a cornerstone of these initiatives. Thus, we can identify a growing importance of medicine and psychology in the welfare state’s monitoring of—and intervention in—children’s lives (Ecclestone & Brunila, 2015). This monitoring includes the use of medical and psychological ideas to objectify childhood problems and to justify interventions (Gillies, 2005; Heckman & Kautz, 2013; Macvarish et al., 2015). Monitoring and intervening in children’s lives can also mean managing childhood through medicalized and psychologized categories and interventions (institutions) (Odenbring et al., 2017; Ramey, 2020). Finally, this monitoring and intervening in children’s lives can involve an increasing reliance on the expertise of medical doctors and psychologists (actors) (Liebsch, 2020).

In the present chapter, we investigate how the medicalization and psychologization of childhood have unfolded in Germany over the last two decades. In the following section, we provide an overarching perspective on how these processes have evolved based on existing literature and the analysis of policies and governmental reports. In the following part of the chapter, we present evidence from three studies that provide more information on how the processes of medicalization and psychologization work and how they compare and interact with other approaches of childhood and children’s behavior (e.g., social or moral explanations). The first study illustrates how collective actors—specifically the German Professional Association of Pediatricians and the German Education Association—engage in or resist the medicalization or psychologization of problems in childhood. In the second study, we present the public’s view on ADHD and the importance that the German public attaches to medical and psychological accounts of hyperactive behavior in children as compared with other explanations. Finally, we examine how learning difficulties are addressed in Germany and we provide examples of medicalization and psychologization in all three dimensions (i.e., ideas, institutions, actors). We end with an overarching conclusion from these three studies and provide some thoughts on how the COVID-19 pandemic might have impacted the medicalization and psychologization of childhood in Germany.

6.2 Medicalization and Psychologization of Childhood in Germany

Families have always been a focus of welfare statepolicies. However, since the end of the 1990s, children as an independent group have become increasingly important in the social policy discourse of the EU, in many international organizations, and in individual nations (Lister, 2006; Schiettecat et al., 2015), including Germany (Betz, 2016; Olk & Hübenthal, 2009). These discourses exhibit two main characteristics: (1) a new emphasis on the notion that child poverty is a central issue in advanced, industrialized countries (European Commission, 2013; Nygård & Krüger, 2012; Olk & Hübenthal, 2009) and (2) increasingly frequent references to the social investment model (Lister, 2006; Nygård & Krüger, 2012). Investing in children is considered instrumental for economic growth and for breaking the cycle of social disadvantage. For instance, in the draft of the so-called Good Daycare Law, the German government stated the following:

For years, the OECD has pointed to the importance of early childhood education in cognitive and emotional development as well as in mitigating social inequality and promoting better overall student performance. […] The Federal Ministry of Economics suggests that spending on early childhood education has high rates of return. For example, it has been shown that the real fiscal rate of return on quantity- and quality-enhancing spending in this area is roughly eight percent. […] In the long term, the future employment opportunities of children improve, […] and there are also further effects of investments in early childhood education, such as increased life satisfaction, reduced crime, and a greater willingness to engage in social activities. (Bundesregierung, 2018, pp. 11–12)

This quote demonstrates the high expectations set in policies which invest in children which should translate in improving society in various ways (economic growth, employment, life satisfaction, crime, civic engagement). While international organizations such as the OECD which is referenced in this legislation have promoted this view, social policy researchers have criticized these expectations as exaggerated (Cantillon & van Lancker, 2013).

In Germany, which has traditionally focused on a male-breadwinner model and familial childcare before the age of three, the social investment discourse has been accompanied by a fundamental change in policies. Early childhood education and care (ECEC) has been substantially expanded ([Daycare expansion act] Tagesbetreuungsausbaugesetz, 2004), and in 2008, the government installed the social right of parents to receive childcare for children at the age of one ([Child promotion act] Kinderförderungsgesetz, 2008). Following the expansion of childcare, a debate and several initiatives for improving the quality of care were set in motion. Health promotion and child development were identified as key areas for the quality promotion initiatives in early childcare and education (Bundesregierung, 2022; [Daycare Quality and Participation Improvement Law] KiTa Qualitäts- und Teilhabeverbesserungsgesetz, 2018). In the accompanying discourse, quality childcare has been conceived as a strategy for combatting child poverty because it enables parents to be employed—which is considered the most effective way of overcoming material deprivation—and because childcare centers are supposed to provide stimulating environments that compensate for less stimulating environments in disadvantaged families (Lister, 2006; Olk & Hübenthal, 2009). In addition, parenting has become a focal point in discourses and policies. Parenting is considered the major factor that drives the successful development of children (Betz, 2016; Gillies, 2005), and a wide range of measures and initiatives have therefore been put in place to educate parents and improve their parenting skills (Betz, 2016).

While this new orientation toward children has been widely analyzed in the social policy literature (Cantillon & van Lancker, 2013; Lister, 2006; Schiettecat et al., 2015), little emphasis has been placed on the role of medicine and psychology in this development. The basis of the social investment paradigm is the human capital model, which is an economic theory. However, in the application of the social investment idea, medicine and psychology play an important role and provide individualistic perspectives that resonate well with the human capital model. Governmental reports and laws reveal how medical and psychological concepts and technologies are woven into these discourses and programs (Ariaans & Reibling, 2021; Wissenschaftlicher Beitrat für Familienfragen beim BMFSFJ, 2005). For instance, health and healthy development are central in this discourse and in policies that address the quality of childcare. Psychological concepts and evidence play a key role when it comes to justifying parenting programs that center around the psychological concept of parents’ educational competence (“Erziehungskompetenz”) (Wissenschaftlicher Beitrat für Familienfragen beim BMFSFJ, 2005). Similarly, psychological evidence is used to justify the necessity of services for improving the life of children who live in disadvantaged situations (Wissenschaftlicher Beitrat für Familienfragen beim BMFSFJ, 2005). Betz (2016) has also highlighted the fact that despite the investment perspective, there is a strong deficit orientation in childhood discourses, and epidemiological evidence is frequently used to justify the need for state monitoring and intervention. However, medicalization and psychologization have not only occurred on the level of ideas: Indeed, regular screening examinations with pediatricians have been offered since 1971. However, the range of—and tasks associated with—these screenings has been expanded to include screening for psychosocial preventive needs and child abuse. While these screenings are considered important for reasons of surveillance and monitoring children’s development, they have created anxieties and led to a low tolerance for deviations from the norm (Liebsch, 2020). Pediatricians have become consultants and gatekeepers for educational decisions (e.g., regarding whether a child is ready for primary school) (Liebsch, 2020). Moreover, medical doctors and psychologists as well as other health professions have taken on a new role in child protection and have been approached as partners in several initiatives, such as early childhood intervention and prevention programs (e.g., Frühe Hilfen (“Early Childhood Intervention”)—a national early parenting and intervention program). A specifically stated aim in such initiatives is to use the healthcare system as a door opener and gatekeeper for managing childhood (Deffte et al., 2018).

Finally, while the social investment paradigm casts a positive, future-oriented light on childhood, its narrative is accompanied by the analysis of problems in childhood and by the identification of children who are “at risk” (Betz, 2016). As a result, the new emphasis on children in the social policy discourse and the selected measures for intervention in children’s lives may have contributed to a greater awareness of—as well as to the persistence of problems in—childhood. First, the focus in policymaking has been intentionally placed on emphasizing education and services as well as on activating parents to work rather than on redistributing resources (Olk & Hübenthal, 2009). Despite the stated hopes of these policies, structural inequalities and child poverty have hardly been affected: Indeed, child poverty has remained mostly stable over the last 15 years, with around one in five children at risk of poverty (Schmitz-Kießler, 2022), and the poverty risk of single parents—and particularly of families with three and more children—has even increased in recent years (Schmitz-Kießler, 2022). Moreover, there is no indication that the expansion of early childhood education has reduced the influence of social origin on educational success (Hußmann et al., 2017).

Second, the increased surveillance of childhood—combined with the high expectations associated with investing in children has led to an increased attention toward childhood problems. This heightened problem awareness exists because children who are not happy, healthy, and successful constitute a threat to social investment logic (Lister, 2006). If such childhood problems arise, medicine and psychology are professions that are regularly approached to deal with these problems (by parents, teachers, and policymakers). The right of these professions to provide diagnoses is essential, as these diagnoses constitute official explanations for childhood problems. Moreover, medical doctors and psychologists serve as gatekeepers to treatment and access to specialized services that are provided by the German welfare system, such as logopedic, physical therapy, and educational training for children with learning difficulties. In a focus group in our research project conducted with professionals who work with children in Germany, one pediatrician stated:

From the perspective of pediatricians, our work has changed a lot in the last few decades. We deal much less with acute illness and infectious diseases than we used to, and we are consulted by parents regarding educational problems, behavioral problems, learning problems, and […] and social and psychological problems. And […] we are paid by health insurances, [so] we of course can only take action if a diagnosis is made […]. [W]e always have to have a justification for creating costs. (Pediatrician, focus group, 25 June 2021)

In line with this assessment, diagnoses of mental illnesses in children and adolescents rose in Germany between 2005 and 2015, with more than one in four children having received a diagnosis within the previous year (Grobe, 2017; Steffen et al., 2018). Moreover, there was also a steep upward trend in the consumption of methylphenidate (i.e., the most common medication for treating ADHD) between 1993 and 2012 (Bundesinstitut für Arzneimittel und Medizinprodukte, 2015). However, this development was perceived critically and led to a debate on over-medicating children in Germany (Karsch, 2018). In reaction, the prescription guideline for stimulants for children became more restrictive in 2010, which led to the stabilization and partial reduction of prescriptions for stimulants that had commonly been prescribed for ADHD (Grimmsmann & Himmel, 2021). However, in 2017, a new treatment guideline was issued that referenced existing UK recommendations provided by National Institute for Health and Care Excellence (NICE). The new guideline lowered the clinical criteria for prescribing stimulants and suggested using these stimulants for moderate-intensity ADHD based on evidence on the relative effectiveness of pharmacotherapy and psychotherapy. The implications of these changes cannot yet be identified with available data (Grimmsmann & Himmel, 2021).

This debate on the diagnosis and treatment of childhood mental illness conditions reveals the dynamics in the role of medicine and psychology in the field of childhood problems. While the medicalization and psychologization of childhood in Germany can be detected in current discourses and policies, there is no indication that childhood is exclusively or primarily viewed from a medical or psychological perspective. Instead, medical and psychological ideas, categories, and actors are integrated with economic, social, and educational elements (NZFH Beirat, 2016). Moreover, over-medicalizing childhood (albeit not over-psychologizing childhood) has also met with critique and resistance. In the following section, we examine the role of two professional organizations in the discourse on childhood problems and discuss how medicalization—and the resistance to medicalization—can be identified in their public communication.

6.3 Childhood Discourses: How Pediatricians and Educators Construct Problems in Childhood

In our theoretical framework, we outlined three dimensions of medicalization and psychologization. In this section, we examine the dimension of ideas and specifically address whether and how medical and psychological ideas are used to describe and explain problems in childhood. In order to do this, we systematically analyzed the ideas that two specific actors—namely the German Professional Association of Pediatricians (Berufsverband der Kinder- und Jugendärzte—BVKJ) and the German Education Association (Verband Bildung und Erziehung—VBE)—have used in their public communication on childhood problems. We investigate these two associations because the existing literature has shown that pediatricians and educators are important agents in medicalizing childhood behavior (Brault et al., 2022; Klasen, 2000; Malacrida, 2004; Rafalovich, 2005a). However, the role of these groups has thus far been analyzed on the micro-level. For instance, studies have examined how teachers and pediatricians influence families in seeking a diagnosis for problematic childhood behavior (Brault et al., 2022; Klasen, 2000; Lavin, 2016; Malacrida, 2004; Rafalovich, 2005b). From these studies, we know that the influence of both groups can vary. In some cases and contexts, pediatricians and educators encourage the medicalization and/or treatment of children’s behavior, while in other cases, these pediatricians and educators actively resist this process and try to de-medicalize children’s behavior, for instance, by trying to convince parents with other explanations for the behavior, by refusing to make a diagnosis or referral, or by refusing to prescribe medication. However, what has been largely unexplored is the influence that pediatricians and educators have as collective actors on ideas about childhood problems through their professional associations. These professional associations are important since they are the mouthpiece of the profession. Through their public communication and lobbying work, the professions have the potential to influence public discourses and policy decisions.

Therefore, we investigate how these associations construct childhood behavior. Specifically, we examine when and how these associations medicalize/psychologize or de-medicalize/de-psychologize childhood. To shed light on this issue, we conducted a qualitative content analysis of 48 press releases made by the German Professional Association of Pediatricians and of 104 press releases made by the German Education Association that these organizations had published between 2009 and 2019. We would have liked to additionally examine the ideas put forth by one of the psychological associations in the field, but sufficient data were not available to conduct a comparable analysis.

6.3.1 German Professional Association of Pediatricians, 2009–2019

The German Professional Association of Pediatricians issues press releases on a wide variety of issues, including social problems such as poverty, child protection, early education, problematic childhood behavior, and learning difficulties. In part of the press releases, the association unequivocally advocates for a medicalized perspective of childhood problems, for example, in its position on ADHD:

ADHD is a predominantly biological and genetic disorder that is modified by environmental and social factors. […] Pharmaceutical treatment for ADHD has been established for over 60 years and has been scientifically validated by countless studies. The therapy is highly effective, with serious, undesirable side effects being rare [as well as] reversible and tolerable with careful monitoring. (Berufsverband der Kinder- und Jugendärzte, 2012c)

Moreover, the association is committed to prevention and health promotion in childhood, for instance, by calling for more health professionals in schools (Berufsverband der Kinder- und Jugendärzte, 2017a, b) and by more extensively including health topics in school curricula (Berufsverband der Kinder- und Jugendärzte, 2017b, 2018).

In contrast, in other press releases, the association has argued that social problems such as poverty are the cause of many problems that are encountered in their clinical practice. For instance, the association claims that poverty leads to health issues such as respiratory infections (Berufsverband der Kinder- und Jugendärzte, 2016). Moreover, in several press releases, the association has highlighted how children in poor or socially disadvantaged families more frequently have developmental disorders due to their low-stimulus environment (Berufsverband der Kinder- und Jugendärzte, 2009b, 2011c, 2012a, b, 2013a, 2014, 2015b). The association thus demands more, earlier, and better early childhood education in order to help these children (Berufsverband der Kinder- und Jugendärzte, 2009a, 2010a, b, 2011a, 2013b, 2015b, 2019).

In several press releases, The German Professional Association of Pediatricians has constructed the medicalization of children as a result of the failing educational system. For instance, the association has found inadequate educational structures and teachers to be responsible for sending these children to the medical system. Pediatricians claim that teachers are quick to refer children to medical help (Berufsverband der Kinder- und Jugendärzte, 2014, 2015d) and that children are increasingly often “pathologized” in the facilities of the educational system. For example, children with behavioral problems are not treated with educational methods and are instead advised by teachers to go to the medical doctor (Berufsverband der Kinder- und Jugendärzte, 2011a). Due to insufficient social and pedagogical measures and interventions, physicians respond with the tools of their own system—namely diagnosis and therapy—(Berufsverband der Kinder- und Jugendärzte, 2011a) even though these immanent tools have not been evaluated to be effective in most cases (Berufsverband der Kinder- und Jugendärzte, 2010c, 2011a, 2015b, c). Thus, physicians argue that they have no other option than to medicalize children:

If we had a quantitatively and qualitatively adequate pedagogical system of socially compensatory early childhood support, such children would certainly be better off there than in the medical system. Those who denounce the increase in spending on prescription drugs for treating children must ask themselves why society does not provide sufficient early intervention facilities and does not equip childcare facilities in such a way that they can fulfil their educational mandate. (Berufsverband der Kinder- und Jugendärzte, 2011a)

Overall, the German Professional Association of Pediatricians views problems in childhood as both medical and social problems. To some extent, the association resists medicalizing childhood by explicitly discussing the phenomenon of medicalization and criticizing the educational system’s quick tendency to look for help from the medical system. However, the association has also argued that pediatricians have no other choice than to diagnose and treat children due to the lack of alternative strategies—thus legitimizing medicalization of childhood problems.

Moreover, our analysis of the association’s press releases additionally indicates an implicit form of medicalization that derives from two mechanisms: (a) Boundary expansion: The German Professional Association of Pediatricians comments on many topics that lie far outside its professional boundaries (e.g., the quality of the educational system), which can be interpreted as an extension of the boundaries of the association’s jurisdiction. This development has also been described in the United States, where scholars have shown how pediatricians extended the scope of their practice in the second half of the twentieth century to also include childhood behavior and the psychosocial needs of children, which today constitute major components of their work (Halpern, 1990; Pawluch, 1983). In comparison, educators have addressed the healthcare system far less frequently, which reveals how medical expertise can often be leveraged to comment as experts on many topics while medicine can mostly be critiqued within its own professional circle. (b) Medical framing: The language used in the press releases is interspersed with medical terms. Thus, even if the association calls for social measures, the framing of an issue is often medical due to the references to medical diagnoses and treatments.

6.3.2 German Education Association, 2009–2019

The German Education Association encompasses a wide range of professions and institutions, including educators in early childhood centers and kindergartens as well as schoolteachers in various tracks. The existing medicalization literature has highlighted the importance of educators and schools in the initiation and implementation of medicalizing childhood behavior (Brault et al., 2022; Malacrida, 2004; Rafalovich, 2005b). One of the reasons for the prominent role of these of educators is that they interact with the same group of children on a daily basis and have “the opportunity to constantly compare a student’s behaviors to those of other students” (Brault et al., 2022, 3). However, cross-national comparisons of the role of teachers in labeling ADHD have indicated that in North America (USA, Canada), teachers’ tendency to medicalize children’s behavior is much more pronounced than in Europe (UK, Belgium), where teachers are often critical of medicalizing children’s behavior (Brault et al., 2022; Malacrida, 2004).

Our analyses of press releases made by the German Education Association indicate that the association’s conceptualization of children’s problems is similar to what can be found in teachers’ practices in other European nations. If the association writes about problems in childhood, these problems are most often attributed to the socio-economic context of the children’s family, such as poverty or migration background. The solutions that the association advocates predominantly focus on the educational system and include structural measures, such as (financial) investment in pre-school education, more hours of education in schools, and smaller class sizes (Verband Bildung und Erziehung, 2016a, b, d). More often, however, individual measures are proposed as solutions, such as special classes and educational counseling for children with problematic behavior or support for difficult circumstances (Verband Bildung und Erziehung, 2009a, 2010, 2015, 2016a).

Although social and educational reasoning and measures for problematic childhood behavior are promoted, some press releases relate to medical and psychological descriptions and measures. Similar to pediatricians, educators advocate for more health competencies and prevention (e.g., measures against obesity) in schools as well as for individual care and assistance of chronically ill children, which should be done by healthcare workers who are employed at schools (Verband Bildung und Erziehung, 2017a, 2018a, b). Furthermore, low social and emotional development in children should be given greater importance and should be supported by additional special-needs education (Verband Bildung und Erziehung, 2017b).

The state must therefore also ensure [that] basic medical care [is provided] by school health professionals in all schools. […] School health professionals should make preventive offers and thus contribute to a healthier lifestyle for [their] students. (Verband Bildung und Erziehung, 2018b)

However, educators are also concerned about the medicalization and pharmaceuticalization of childhood problems, as demonstrated by the following quote from 2012, which was the peak year in the strong upward trend of methylphenidate consumption in Germany:

Children should be allowed to remain children; they should be allowed to romp around and be loud without it being immediately interpreted as an illness. Only in severe cases and in the event of behavioral problems should medication be reached for. Before that, Beckmann [Chairman of the VBE] demands, children with behavioral problems should be treated with smaller classes and better support. (Verband Bildung und Erziehung, 2012a)

Nevertheless, the association additionally uses psychological categories—such as “burnout” and “stress”—to draw attention to increased performance pressure in schools (Verband Bildung und Erziehung, 2009b, 2010, 2016c). According to the German Education Association, “The pressure on the children must not be allowed to get out of hand. Students who are burned out are no longer a rarity” (2016c). This statement indicates that while educators in Germany seem to be mostly opposed to the medicalization of childhood behavior, they nevertheless engage with psychological explanations. This finding is in line with the existing literature, which has highlighted how the educational system has embraced psychological concepts and technologies (Alexander, 2018; Ecclestone & Brunila, 2015).

Table 6.1 summarizes the main results of the analyses of the press releases by the German Education Association and the German Professional Association of Pediatricians. The table displays the diverging general approaches of both organizations and presents a concept of problematic childhood behavior from the perspective of educators that stresses social and educational causes while pediatricians focus on medical causes. Educators mainly demand more social and educational measures and investment in children and view medical, psychological, and pharmaceutical treatment as a means of last resort. In contrast, pediatricians portray pharmaceutical treatment for ADHD as a common, non-dangerous solution. These medical actions for deviant childhood behavior prevail in the German Professional Association of Pediatricians but also highlight the fact that more social and educational investment in children is needed. Nevertheless, as long as this greater investment remains lacking, children are diagnosed and treated within the healthcare system.

Table 6.1 Medicalization and resistance to medicalization by the German Education Association and the German Professional Association of Pediatricians
Full size table

6.4 Medicine and Psychology in the Public’s View of Children with Problems

The welfare state is more than merely a conglomeration of policies, programs, and institutions: Indeed, its influence is also exerted through ideas and narratives from welfare discourses. These ideas are shaped by many different actors, including professional associations, such as the ones analyzed in the previous section, as well as by policymakers, journalists, scientists, social movements. However, ideas not only circulate among these elite discourses, but also form part of the understanding and beliefs of individual citizens. The public’s attitudes are critical for the public legitimacy of the welfare state and also shape the experiences of welfare recipients, who encounter these ideas in social interactions (van Oorschot et al., 2017). Therefore, welfare state research has been increasingly interested in examining the public opinion of welfare policies and the target groups of such policies (van Oorschot et al., 2017). There are many ways in which we can investigate the ideas of the welfare state and its recipients. One prominent way has been through the study of public opinions of welfare policies and target groups. However, despite the growing influence of children as a target group of the welfare state, the social legitimacy literature has not yet examined the public’s views on children and their problems as a way of understanding ideas about childhood and the welfare state.

Therefore, in this section, we investigate the public’s views on children with problems. To do so, we developed several vignettes of children with problematic behavior. These vignettes were launched as a self-designed factorial survey that was fielded in an online access panel from YouGov Germany in September 2019. The sample was quota-based and represented the German adult population in terms of sex, age, education, and region. We presented respondents with hypothetical case descriptions of children. Here, we compare the descriptions of a child with normal (albeit not perfect) behavior and a child who represents a characteristic case of behavior that would indicate a diagnosis of ADHD. The case descriptions were developed and pre-tested with three trained psychologists. In the descriptions, both children were eight years old and attended a public elementary school. The description of the children, however, varied with respect to gender and ethnicity as well as in terms of the characteristics of their families (i.e., educational status, one-parent/two-parent family, sexual orientation of parents). The varying vignettes were assigned to respondents via randomization. One vignette of the child with hyperactive behavior appeared as follows:

Ben is 8 years old, attends 2nd grade in elementary school, and lives with his mother, Sandra, who did not graduate school. Ben is a bright and intelligent boy. Nevertheless, he has been having more and more problems in school, especially because he finds it difficult to concentrate on individual tasks, which he often does not complete. On Parents Day, Ben’s class teacher reported that Ben is easily distracted and needs to be reminded frequently to focus on his task. He often gets up from his seat without being asked, walks around the classroom, or suddenly starts talking loudly to classmates. Ben has a couple of friends in the neighborhood with whom he meets regularly to pursue common hobbies, but he finds it difficult to make new friends. Sandra has also noticed that Ben increasingly often forgets his homework and loses his toys. He also has frequent problems with getting up in the morning and going to sleep on time in the evening.

After presenting the vignette, we first asked respondents what they thought were the likely causes of the described child’s behavior. Figure 6.1 displays the percentage of respondents who indicated that the given reason was very likely, likely, or at least had a 50-50 chance of being a cause of the behavior. Overall, we can see that psychological and social reasons were more frequently selected than medical and moral reasons as causes of the child’s behavior. Thus, the behavior of both children was attributed by most respondents to psychological reasons, such as “low self-esteem” or “stress,” and social reasons, such as the “family situation” or “a difficult social context.” Except for “low self-esteem,” these causes were considered equally or similarly likely for both children. In contrast, medical reasons—such as a “chemical imbalance in the brain,” a “genetic predisposition,” or a “mental illness”—were perceived as likely by more respondents for the child who was described as showing hyperactive behavior than for the child with normal behavior. Thus, about half of the respondents considered biomedical reasons to be a potential cause for the child’s behavior. Additionally, about half of the respondents thought that the behavior might be the result of a bad parenting style, while only one in five respondents thought that the reason could be due to the child’s bad character.

Fig. 6.1
4 bar graphs of the responses to 4 reasons for 2 behaviors. Medical and psychological have genetic disposition and low self-esteem at the top for normal, and mental illness and stress for hyperactive. Social and moral have family situation and bad parenting style at the top for both behaviors.

Weighted share of respondents who assessed the various reasons provided as 50/50, likely, or very likely causes of the described child’s behavior. Categorization into medical, psychological, social, and moral reasons based on theoretical reasoning. Source: vignette study, Wave 1 (in 2019) (N = 2093), own calculations

Full size image

Subsequently, the respondents were informed that the parents were concerned about the child’s behavior but were unsure what to do. The respondents were then asked what they would recommend to the parents. Figure 6.2 reveals how many respondents (fully) agreed with each recommendation. In both cases, the majority of respondents thought that the parents should do something to deal with the child’s behavior and not wait and see what would happen. Agreement with the recommendation that the parents should not simply wait to see what happens was higher for the child with the hyperactive behavior. Parenting strategies and educational support received high agreement for both cases. “Love and encouragement” and “talking to the teacher” were recommended by most respondents in both cases, “setting rules” was supported by about half of the respondents, and “warning to ‘shape up’” was chosen by one in four respondents. Again, the major difference between both descriptions can be seen with respect to the medical and psychological options. While only one-third of respondents suggested that the parents consult a child psychologist or a pediatrician for the child with normal behavior, about half of respondents chose the same recommendation for the child with hyperactive behavior. Interestingly, support for consulting a child psychologist was even higher than for consulting a pediatrician.

Fig. 6.2
4 bar graphs of the responses to 4 recommendations for 2 behaviors. Wait and see, parenting strategies, educational support, and medical or psychological support have, do nothing, love and encourage, talk to teacher, and consult child psychologist, at the top, in order, for both behaviors.

Weighted share of respondents who agreed or strongly agreed with different parental recommendations. Source: vignette study, Wave 1 (in 2019) (N = 2307), own calculations

Full size image

Finally, we aimed to obtain a better impression as to how much respondents would support potential welfare entitlements and obligations for the described children and their families (see Fig. 6.3). Support for entitlements—namely an “entitlement to free educational counseling (8 sessions)” and an “entitlement to free family therapy (1 year or longer)”—were supported by a greater share of respondents than were obligations. Support was higher for the child who was characterized by hyperactive behavior, with 58% of respondents supporting “short educational counseling” for this child compared with 53% for the normal child description, and 54% of respondents supporting “long family therapy” for the child with hyperactive behavior compared with 42% for the normal child description. Requirements such as “being obligated to attend family counseling,” “being obligated to consult a pediatrician,” and “being obligated to take medication” were supported by between one-fourth and one-third of respondents, with support for all options being somewhat higher for the child with hyperactive behavior. Support for sanctions in the form of removing the child from school until a medical examination has been performed was low, with only one in ten respondents agreeing with this option. Support for sanctions did not differ between the two descriptions.

Fig. 6.3
2 bar graphs of the respondents who agreed with 2 categories for normal and hyperactive behavior. Short educational consultation tops under entitlements and family counseling tops under obligation and sanctions for both behaviors.

Weighted share of respondents who agreed or strongly agreed with entitlements, obligations, and sanctions. Source: vignette study, Wave 1 (in 2019) (N = 2289), own calculations

Full size image

Our analyses indicate that psychological explanations—such as stress and low self-esteem—are popular and are among the most frequently selected options for explaining childhood behavior. On the other hand, medical explanations are much less popular but are seen as being much more relevant in the case of hyperactive behavior. Medical doctors and psychologists are clearly considered important professions in dealing with childhood problems. However, parenting and educational measures receive even greater support. About half of the respondents support providing parents who are concerned about their child’s behavior with access to (even potentially costly) therapeutic options, while only a minority of the respondents support medical or psychological obligations or removing children from school. In sum, medicine and psychology are clearly part of the societal repertoire for dealing with childhood problems. Nevertheless, they are neither the only nor the collectively shared answer to childhood problems. However, the greater support for medical and psychological explanations and interventions in the case of hyperactive behavior indicates that this childhood diagnosis has become part of the public discourse.

6.5 Learning Difficulties and the Medicalization and Psychologization of the German Educational System

Behavioral problems among children—and specifically ADHD—have long been a central topic when it comes to understanding medicalization and psychologization in childhood (Conrad & Schneider, 1992; Malacrida, 2004). Learning difficulties are another interesting issue with a specific link to the educational system (Holmqvist, 2020; Katchergin, 2012). Medical diagnostic categories in the ICD-10 (F81.0, F81.1, and F81.2) and the DSM-5 (Kaufmann & Aster, 2020) as well as clinical practice guidelines have been developed for dyslexia and dyscalculia in many countries, including Germany. Unlike for ADHD, however, no medical or psychological treatments exist for dyslexia and dyscalculia; instead, treatment consists of special educational measures and programs that are designed to foster competencies in writing, reading, and mathematics (Kaufmann & Aster, 2020; Schulte-Körne, 2010). Assessing a student as not having generally low intelligence is important for diagnosing these learning disorders. Therefore, previous studies have investigated learning disorders as examples of “positive stigmas” (Katchergin, 2012) or even as “consecrating medicalization” (Holmqvist, 2020). This labeling means that the diagnosis of a learning disorder often allows children from privileged families to maintain their status despite their low educational performance in specific areas and even gives them appreciation by others that they can succeed despite this impairment (Holmqvist, 2020). Hence, the diagnosis of learning disorders can contribute to the reproduction of social stratification. In a recent study from the US, for instance, Suhr and Johnson (2022) reported that not only has test-seeking for learning disorders increased, but the results of these tests have also led to inequalities:

There are disparities in who receives accommodations. For children, receipt of diagnosis and high stakes test accommodations has increased more, and is overall much higher, among students attending high performing districts in communities with high socioeconomic status relative to middle class or lower-income school districts. (Suhr & Johnson, 2022, p. 1)

In the following section, we reveal how learning difficulties have resulted in medicalization and psychologization in different dimensions (i.e., actors, institutions, and ideas) in Germany. Moreover, we discuss how the institutional setup in Germany shapes whether, when, and where learning difficulties are medicalized/psychologized. In so doing, we highlight (a) how learning disorders are socially constructed and (b) how diagnostic categories become linked to social rights in the educational system.

In Germany, about 5% of school-aged children are diagnosed with dyslexia (Schulte-Körne, 2017), while the more recently acknowledged dyscalculia is only diagnosed in 1–2% of children (Wyschkon et al., 2009). Learning disorders are accepted diagnoses in the ICD-10 and the DSM-5, and children receive the diagnosis from psychiatrists and psychologists (medicalization/psychologization in the dimension of actors). Nevertheless, these diagnostic categories are not acknowledged by the German public healthcare system as a disease (Gemeinsamer Bundesausschuss, 2020; Schulte-Körne, 2010). This regulation means that all forms of therapies for learning disorders are explicitly not covered by health insurance (Gemeinsamer Bundesausschuss, 2020). Only if learning disorders are accompanied by other diagnoses such as depressive symptoms or ADHD can psychological and/or medical treatment be accessed (Schulte-Körne, 2010). This institutionalization of learning disorders reflects the core controversy surrounding this issue in which certain actors argue for medicalizing/psychologizing learning disorders while others resist this process.

In Germany, for instance, the Federal Association of Dyslexia and Dyscalculia (Bundesverband Legasthenie und Dyskalkulie)—an advocacy organization for people with learning disabilities—adopts a biomedical framing. By referring to the ICD-10 and the DSM-5, genetic and neurological predispositions are viewed as the primary causes of dyslexia and dyscalculia (Bundesverband Legasthenie und Dyskalkulie e. V., 2018a, b). In contrast, the German Education Association (VBE) and the German Professional Association of Pediatricians (BVKJ) both argue that social background is mostly a factor for children who have difficulties in reading (Berufsverband der Kinder- und Jugendärzte, 2010d; Verband Bildung und Erziehung, 2012b). While the German Professional Association of Pediatricians acknowledges possible neurological causes of dyslexia (Berufsverband der Kinder- und Jugendärzte, 2015a) and uses the medical term learning disorders (Berufsverband der Kinder- und Jugendärzte, 2011b), the German Education Association exclusively employs exclusively the term learning weakness, which does not implicate a biomedical framing (Verband Bildung und Erziehung, 2016a). The biomedical and non-medical framing of learning difficulties in the discourse reflects the general scientific debate on learning difficulties, which has not yet reached a firm consensus as to the origins of these difficulties and has highlighted diagnostic problems (Elliott & Gibbs, 2008; Elliott & Grigorenko, 2014; Suhr & Johnson, 2022).

As mentioned earlier, from a welfare state perspective, it is interesting that a diagnosed learning disorder does not entitle the diagnosed individual to a benefit in the German healthcare system. However, a diagnosis can imply entitlements in the educational system (i.e., medicalization/psychologization in the dimension of institutions). In Germany, the entitlements granted for learning disabilities in the educational system vary across the 16 federal states because educational regulations are state-specific. Thus, in essence, 16 different rules and regulations on how to deal with learning disorders exist. In other words, federalism shapes how learning difficulties are acknowledged and dealt with and thereby creates variation in the degree of medicalization and psychologization of learning difficulties within Germany. This variation notwithstanding, there are two main options for schools to respond to students with learning difficulties: compensating for disadvantages (“Nachteilsausgleich”) and safeguarding grades (“Notenschutz”) (Schulte-Körne, 2017). Compensating for disadvantages is based on the principle of equal treatment. Thus, the compensation aims to establish equal conditions for all students during the test. For example, a student may receive compensation (e.g., more time, access to a dictionary) for a test, but the test would then be graded the same as all other tests. In contrast, safeguarding grades means that the parts of a student’s performance that can be affected by a learning disorder are not taken into account in the grading scheme. For example, a student might take the same test as everyone else, but the grading would be adjusted (e.g., orthography may not be graded). Compensating for disadvantages is not allowed to be mentioned in school reports, whereas safeguarding grades usually must be mentioned in reports and school graduation certificates.

However, it is not only the federal states and the educational policies on the state level that shape how learning difficulties are dealt with: Indeed, court decisions also play a role. Court decisions shape how compensation for disadvantages is handled and also play a critical role in safeguarding grades for the federal state of Bavaria, the second-most populous state in Germany. Court decisions have been reached on cases concerning safeguarding grades for students with dyslexia by the Munich Administrative Court, the Bavarian Administrative Court, and the National Administrative Court, the latter of which made changes to the Bavarian Law on Education and Schooling (BayEUG). Based on all of these courts’ rulings, the Bavarian state amended its federal education and schooling law by including a new section (Art. 52 Abs. 5 BayEUG) that proclaims that safeguarding grades is permissible under certain circumstances (e.g., approved disorder, request by parents) and that it must be noted in all reports and diplomas. In general, schools decide whether and how compensating for disadvantages and safeguarding grades for a child are carried out (§ 35 Abs.1 BayScho). In order to prove dyslexia, children are required to submit a school psychological statement (§ 35 Abs.2 BayScho). An assessment by a school psychologist is now required when families wish to receive an acknowledgment of their child’s dyslexia by the school. In essence, the court ruling stimulated the psychologization of reading and spelling difficulties by tying educational benefits to a psychological expert opinion. However, although court decisions led to this psychologization, this development cannot be evaluated as an intentional process by the involved courts. The courts’ decisions only call for clarifying the existing law for safeguarding grades, but exactly how this clarification is done and whether it involves a psychological assessment are decisions that were made by the Bavarian government. Therefore, this example reveals that legal institutions shape medicalization and psychologization processes, though this effect was not intended by the courts. Nevertheless, the Bavarian government probably would also not have changed the existing law and included psychological assessments for cases of dyslexia, but it did so because it had been required to create an explicit law.

Upon investigating other states, we see that regulations for learning difficulties—and thus also the rights of individual students—can differ. In North Rhine-Westphalia (the state with the highest resident population in Germany), for instance, the diagnosis of dyslexia does not have to be proven by a psychological assessment, and an evaluation by a teacher is usually sufficient (Ministerium für Schule und Bildung des Landes Nordrhein-Westfalen, 1991). Nevertheless, compensating for disadvantages and safeguarding grades are both possible (Ministerium für Schule und Bildung des Landes Nordrhein-Westfalen, 1991). However, safeguarding grades is generally not possible for students after grade 10, i.e. for those aspiring to the highest schooling degree (Ministerium für Schule und Bildung des Landes Nordrhein-Westfalen, 1991).

Our analyses of state guidelines and laws also found medicalization and psychologization in the dimension of ideas: The guideline from the schooling ministry of North Rhine-Westphalia, for instance, uses the term “particular difficulties in learning to read and write” throughout its text and avoids the terms “disorder” and “weakness,” both of which are used in the Bavarian laws. A comprehensive word search of all federal schooling legislations found that many federal states have not yet integrated learning difficulties into their schooling legislations. However, the states might have done so in other directives and regulations. Of the federal states that have adopted passages on learning difficulties in their schooling laws, the adopted terms range from conveying no medicalization to conveying a high degree of medicalization. Some federal states have adopted the phrase “difficulties in reading, writing, and calculating” (Berlin, Brandenburg), whereas others use the term “weakness” (Bavaria, Saxony, Lower Saxony), and still others employ the medical term “disorder” (Bavaria, Hesse, Mecklenburg-Vorpommern).

Overall, the handling of learning difficulties in Germany indicates that political and legal institutions and policy legacies shape the extent to which—and the dimension in which—medicalization and psychologization unfold. The two cases of Bavaria and North Rhine-Westphalia indicate that rules and procedures for handling learning difficulties within Germany can vary substantially. However, for both states, national diagnostic guidelines apply, and their federal institutions provide for different pathways. In North Rhine-Westphalia, institutions support a resistance to medicalizing and psychologizing learning difficulties because these difficulties are mainly assessed by teachers rather than by medical doctors or psychologists. Furthermore, safeguarding grades is usually not employed after grade ten and is thus not performed for children aspiring to the highest schooling degree. On the contrary, Bavarian institutions have psychologized learning disorders by requiring both a psychological assessment and parental requests in order to safeguard grades. These rules might have repercussions on the individual level and might also lead to inequalities in access to safeguarding grades. As parents need to be highly involved in the process of having their children’s learning disorders (officially) acknowledged in Bavaria, parents with a higher social status might go through this process with their child more often than parents with a lower social status.

6.6 Conclusion

Medicine and psychology play a prominent role in how advanced, industrialized countries such as Germany address children. This role is visible in the current social investment discourse, which highlights health, character skills, and competences as forms of investment in the future of children and entire societies. These concepts have various disciplinary sources and can be interpreted from a biopsychosocial perspective that reveals how medicine and psychology are part of an interdisciplinary form of investing in children. In addition to this future-oriented and investment-focused adoption of medical and psychological perspectives and the integration of the two professions, medicalization and psychologization are also visible when children have, or, are perceived to have problems. While the discourse acknowledges the socio-economic origin (e.g., child poverty) of many of these problems, thereby showing a clear link to the two social problems discussed in the previous chapters, medical and psychological concepts are used to characterize and diagnose various childhood problems. Moreover, medical and psychological diagnoses and treatment are often the way that these problems are addressed in practice in the absence of alternative solutions, such as redistribution, social security, and adequate resources in the educational system.

The tendency to medicalize and psychologize childhood problems has been resisted by professional organizations and to some extent also by public opinion. However, high and rising rates of diagnosing mental illnesses in childhood suggest that in practice, there is still a tendency to medicalize and psychologize these problems. For instance, an analysis of the most comprehensive data sources that relied on ambulatory physician billing claims found that the proportion of children and adolescents with a diagnosed mental disorder within the preceding year had increased from 23% in 2009 to 28% in 2017 (Steffen et al., 2018). Nevertheless, there is a lack of comparable longitudinal data that would be necessary to investigate trends over a longer time period (i.e., over several decades).

In the second year of the COVID-19 pandemic, the implications of the situation for children became quite an important issue in the German discourse. While this discourse has been interdisciplinary, the recurring reference to epidemiological studies that “provide evidence” of the problematic situation that children face is one indication as to how medical and psychological accounts have been influential in this debate. Thus, childhood problems in the discourse have been quite often understood through the lens of medical and psychological concepts and interventions:

Two-thirds of the children and adolescents reported being highly burdened by the COVID-19 pandemic. They experienced significantly lower HRQoL (40.2% vs. 15.3%), more mental health problems (17.8% vs. 9.9%) and higher anxiety levels (24.1% vs. 14.9%) than before the pandemic. Children with low socioeconomic status, migration background and limited living space were affected significantly more. Health promotion and prevention strategies need to be implemented to maintain children’s and adolescents’ mental health, improve their HRQoL, and mitigate the burden caused by COVID-19, particularly for children who are most at risk. (Ravens-Sieberer et al., 2021, p. 879)

The long-term impact of the pandemic on discourses and policies on childhood remains to be empirically determined, but there are good reasons to believe that medicalization and psychologization have and will represent an important strategy in terms of how societies discuss and manage the long-term effects of the pandemic on children.