School Daze
A bird’s-eye view of why mental health diagnoses keep rising, particularly among students.
Hi All,
Quick-hitter for today while we’re taking a holiday break from longer posts. A few weeks ago, the New York Times ran an article titled America’s Children Are Unwell. Are Schools Part of the Problem? At its core is a question many people are asking: why have mental health diagnoses—especially among children—risen so rapidly?
The numbers are pretty striking. As the article notes:
“One million more children were diagnosed with A.D.H.D. in 2022 than in 2016.”
“Nearly 32 percent of adolescents have been diagnosed at some point with anxiety; the median age of “onset” is 6 years old.”
“In the early 1980s, one in 2,500 children had an autism diagnosis. That figure is now one in 31.”
The article’s answer is that schools themselves should be considered a culprit. We at Living Fossils don’t disagree—in fact, we highly recommend Is Schooling a Damaging Evolutionary Mismatch? by Michael Strong.1
But reimagining schools, while worthwhile, won’t solve the mental health crisis on its own, because schooling is only one piece of the puzzle. Over the past two years, I’ve been trying to identify and articulate the other pieces. When assembled, the picture that emerges has less to do with bad actors or conspiracy theories than with ordinary people responding predictably to abnormal environments—environments we made, and could theoretically change.
So why have mental health diagnoses risen? Here’s how I see the pieces fitting together:
A baseline increase in mental illness is plausible, mainly because of evolutionary mismatch.
The modern world places novel demands on our Stone Age mind—demands it is not always equipped to handle. Modern childhood is an obvious example. Many readers will be familiar with the argument, popularized by Jonathan Haidt and others, that “the loss of ‘play-based childhood’ and its replacement by ‘phone-based childhood’” hasn’t been great for the mental health of children and teens.2 In my view, modern technology has almost certainly contributed to many cases of ADHD, in both children and adults.
From the article:
“Screens have thoroughly invaded childhood, supplanting the sleep, exercise and socializing in person that can ward off depression and anxiety.”
Relevant Living Fossils articles:
Diagnostic boundaries have expanded, mainly in good faith.
A second explanation is that the boundaries of mental illness have widened. New diagnostic categories have materialized; old ones have been stretched. Conditions that once described severe impairment increasingly encompass milder, more ambiguous forms of distress or difference, ushering more and more people under their expanding umbrellas.3
This expansion has understandable and mostly well-intentioned causes. Here is how the chair of the DSM-IV task force, Allen Frances, explained the decision to include Asperger’s syndrome:
My task force approved the inclusion of…Asperger’s syndrome, which is much milder in severity than classic autism and much more common. In doing so, we were responding to child psychiatrists’ and pediatricians’ concerns for children who did not meet the extremely stringent criteria for classic autism, but had similar symptoms in milder form and might benefit from services.
So, criterion creep is not necessarily the result of fraud or faddishness. In many cases, it reflects good-faith attempts to recognize real suffering. But when diagnostic thresholds are lowered and categories broadened, prevalence rises even if the underlying population has not changed.
Perverse incentives drive diagnosis rates.
The rise in mental health diagnoses is propelled by a set of large, mutually reinforcing incentives. Schools, parents, clinicians, and students are all responding—often rationally—to pressures that push in the same direction:
School-level incentives reflect Goodhart’s Law, which states that when a measure becomes a target, it ceases to be a good measure. Schools funded on test scores are incentivized to over-diagnose so students receive extra time, disruptive students are medicated, or low-performing students’ scores are excluded altogether.
From the article: “With school funding now on the line, there were unmistakable incentives for children to be diagnosed…Getting a child treated, potentially with medication, could help an entire classroom achieve higher scores, especially if the child’s behavior was disruptive to others. And in some parts of the country, children with disabilities were not counted toward a school’s overall marks, a carve-out that could boost scores.”
Relevant Living Fossil article: The Teen Mental Health Crisis
Parent-level incentives resemble a public goods problem. Everyone would be better off with fewer diagnoses because it would allow scarce resources to flow to those who need them most, but individual parents are incentivized to advocate early and often because if they don’t, others will, placing their child at a relative disadvantage.
From the article: “The people clamoring loudest for a diagnosis of A.D.H.D. or autism are often parents.”
Clinician-level incentives reflect a classic principal–agent problem, in which the person entrusted to make decisions (the agent) has incentives that differ from those who bear the consequences (the principal). Mental health professionals are supposed to improve mental health, but they must also make a living. This discourages recommending low-cost, non-professional alternatives—exercise, friendship—and encourages identifying more ways to intervene. None of this need be ill-intentioned, and most of it probably isn’t.
Relevant Living Fossil article: Returning to Ivan Illich
Student-level incentives reflect what has been called the gentrification of disability. Reducing stigma around mental illness was a good idea, but in some contexts it has overshot the mark by actively rewarding identification with mental illness and penalizing normalcy. (One of my teen clients recently told me that the new diss is “neurotypical.”) A diagnosis can mean more time on tests, reduced workloads, access to a tight-knit community, and positive attention from the social world—often at little to no cost. Who wouldn’t want that? And who would ever want to be cured?
Per Frances: “Whenever having a diagnosis carries a benefit, it will be overused.”
Relevant Living Fossil articles: The Art of Suffering Well and Insults, Challenges, and Insults
Social contagion/memification/copycat effects drive the spread of diagnoses.
I see this as closely related to incentives, but importantly distinct. Think of fashion, the fact that suicides spike after being covered in the news (the so-called Werther effect), or the curious habit among educated people of beginning answers to questions with “So.” In each case, visibility and imitation—not direct reward—drive adoption. In the same way, social contagion helps explain how symptom narratives and identities move through the population, often faster than incentives alone would predict.
Solutions themselves have a habit of generating problems (the “solution problem”).
Solutions often create new problems in addition to solving old ones. As a result, the more mental health solutions we develop, the more mental health problems we’re going to generate. This can be as mundane as someone seeking help for everyday stress, acquiring a clinical anxiety diagnosis, and then taking medication that causes insomnia.
Relevant Living Fossil article: The Solution Problem
There is no stop mechanism because the brain is too complicated.
Diabetes is confirmed by elevated blood glucose. A broken bone is confirmed by an X-ray. But because the brain is the most complicated thing humans have ever encountered, no such tests or biomarkers exist for most mental illnesses. This means that almost anything can be asserted without fear of falsification. In the realm of mental health diagnosis, everyone has a blank check.4
Per Frances: “It is difficult to accurately diagnose autism spectrum disorder. There is no biological test.”
Relevant Living Fossil article: The Art of Suffering Well
So let’s put it all together. The rise in mental health diagnoses doesn’t require bad actors, conspiracies, or mass delusion—only a modern environment, elastic definitions, misaligned incentives, social transmission, and no effective braking mechanism.
I think the solution is no more complicated—or simple—than cultural recalibration. At the moment, we grant the mental health industry more power than it deserves, while granting alternatives like exercise and community less power than they deserve. That balance could change, although how to accomplish it—other than writing more Living Fossils articles—is anyone’s guess.
We’re open to other guest-written articles, just saying.
The quote is from Here are 13 Other Explanations for the Adolescent Mental Health Crisis. None of Them Work by Jean Twenge.
For example, see this article on the growing percentage of Harvard students claiming a disability.
No, sadly, the experts don’t really know what they are talking about.