Doughnut psychiatry as a living community model for sustainable development of children

The National Health Service in England recently announced a major review of attention-deficit hyperactivity disorder (ADHD) and autism services.¹ This statement followed ‘an avalanche of need’ characterised by steep increases in referrals, waiting times and drug prescriptions since the Covid-19 pandemic. In December 2023, there were 172 022 patients with an open referral for suspected autism – the highest number ever reported. Related press releases stated that experts are undecided about whether the increase in diagnoses is due to more children having autism and ADHD or a rise in overdiagnosis, or whether there were previous unmet needs. This debate is not new; ongoing increases in the prevalence of neurodevelopmental problems and conditions have been noted ever since their conception in the psychiatry DSM.²

Our standard reflex to these rises is to prevent poor long-term outcomes, such as increased prevalence of mental health disorders and greater risk of school exclusion. But perhaps we need a far more critical appraisal of the rise itself, one that takes environment and context much more seriously as its most logical contributors. Kate Raworth, an economist from Oxford and author of the book Doughnut Economics, made a seminal statement to stimulate such a rethink ‘We have an economy that needs to grow, whether or not it makes us thrive. We need an economy that makes us thrive, whether or not it grows.’³ It is not farfetched to paraphrase this statement into one for ‘doughnut development’: we have a society in which children have to contribute and perform, regardless of whether that makes them flourish. We need a society in which children can flourish regardless of their achievements or contributions. Indeed, the parallels between economic neoliberal pressures and youth mental health crises have become increasingly apparent. How is it possible that we pay so much attention to climate threats to nature and our habitats but not more explicitly link them to the surge in developmental problems?

Raworth described the economics doughnut as ‘the safe and just space for humanity’ where no one falls short on life's essentials, while ensuring that we do not overshoot our pressure on Earth's life-supporting systems. We see a fruitful adaptation to psychiatry by safeguarding ‘the fair and sustainable space for development’ between the social and biological needs on the inside and the limits of care and welfare systems on the outside. Such a model could facilitate a shift from diagnosing and judging development to nurturing and supporting development as a dynamic living system – like a garden, which constantly evolves in response to its environment and context.

Indeed, one's garden of development needs strong roots and a fertile soil and must be maintained together by the gardeners of upbringing, care and education in a favourable and adaptive environment. The right to development formulated in the international Convention on the Rights of the Child is an important instrument to safeguard these conditions. Indeed, there are growing concerns about exposure to several (toxic) substances and influences that have been attributed to neurological disorders in the elderly,⁴ which have not yet been thoroughly considered with respect to developing children during pregnancy as well as in childhood. In addition, there is a range of new environmental influences, such as the social and sensory pressures that screens and social media present. These are unambiguous in their effects on development and cannot be seen as separate from other health aspects, such as (poor) nutrition and (too little) exercise. Systemic ecological investigations on pregnancy and developmental outcome are emerging but mainly outside clinical practice.^5,6 If we want to take all these influences and factors into account, we need to expand current diagnostic concepts and move beyond linear suppositions of cause and effect.⁷ At present, professionals in children's mental health and education mostly cannot care for development as an ecosystem. Rather, the fragmented system forces them to focus on individual parts of the garden, which prevents a coherent perspective on the problems they face. Thus, increasing recognition of viewing human development through the lens of complex systems underscores the need for a multisector and holistic approach to addressing developmental disorders.

As outlined in Fig. 1, the doughnut development model expands on the original social inner ring elements with biological determinants such pregnancy, genetics, learning ability and early conditions. The outer ring represents the ceiling of available care and welfare as the equivalent of the planetary boundaries that must not be exceeded. In between, the doughnut is the sweet spot that represents the space (garden) for children to thrive via fair and sustainable development.

Fig. 1. Doughnut development model (a) graphic and (b) schematic to foster a community driven systems approach to developmental conditions.

We propose doughnut development as a living, evolving community systems model. Similar to the initiatives of the Donut Economy Action Lab and the Donut Coalition in Amsterdam, we want to involve as many sectors and as much lived experience as possible in the elaboration and implementation of the concept of doughnut psychiatry.⁸ This is the starting point for a symbiosis of sharing ownership and responsibility for the garden of development. Some parts of the model will lend themselves more easily to scaling or measurement, whereas others will require a more qualitative narrative.

The aim of the doughnut development model is to bring and keep the development of the child within the capacity of its societal environment, with attention to the existing biological and social basic conditions. Let's work together to become gardeners for the most important biotope there is: a place where children can thrive and flourish within their own possibilities and a society that surrounds them.