Health and Social Care Committee and Education Committee
Wednesday 14th October 2026
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09:30
Speaker 1
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Speaker 1
Order, order! Welcome to this joint session of the Health and Social Care and Education Select Committees. This is the fourth session into our inquiry into Young People and Children's mental health Services, and it is a delight to have with us today, Professor Peter Fonagy and Professor Gillian Baird of the infamous. Now, because it's been a week since it's come out and it has been very widely reported, the Fonagy review.
Can I start perhaps just asking a very simple question how did you come to be the one to be asked to do this review? What is your background so that those who maybe are less familiar with it understand your expertise that you bear to this area? Professor Fonagy.
Can I start perhaps just asking a very simple question how did you come to be the one to be asked to do this review? What is your background so that those who maybe are less familiar with it understand your expertise that you bear to this area? Professor Fonagy.
09:31
Speaker 2
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Speaker 2
Thank you for asking and thank you for having us here. Really, really pleased to be able to present to you. I by background, I'm a clinical psychologist and I've been in child mental health for four decades, which is quite a long time. And I have , since 2011, been senior clinical adviser to NHS England in their child mental health policy team. And I've really enjoyed it. I think that was probably the reason that I was asked, because I had familiarity with the system and had clinical experience that seemed appropriate to the task.
09:32
09:32
Speaker 3
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Speaker 3
Thank you. So then I was asked to be vice chair, Kay, vice chair with Professor Sir Simon Wesley, who's not with us today. But I suspect many of you know. But by background, I'm a paediatrician. My specialised in paediatric neurodisability and was a consultant running a large service at Guy's and St Thomas's for a very rather more years than Peter has been, and have also was much involved with with nice and various guidelines and and research into areas relevant to this review as well.
09:33
Speaker 1
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Speaker 1
So very briefly, I mean, obviously people can read the over 600 page report too, if they want to, but Professor Fonagy, could you very briefly just outline the top recommendations that you made, but also while you do that, could you also perhaps underline at the same time the recommendations that you think are the low hanging fruit for the government and also which are the ones that you think might be the more challenging ones for them to implement?
09:33
Speaker 2
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Speaker 2
Thank you. The. Low hanging fruit will be a little bit challenging, but I will, I think, try and. So the review proposes a different model, a radically different model of managing children's mental health. And it's a shift from a diagnosis led system where people have to wait to get a diagnosis in order to get support to a system where as soon as they present with a need, that need gets addressed and they are then prioritised, if you like, for a diagnosis if needed, but in the hope that in many instances it will not be so.
What that means is that they would receive support earlier in relation to what they actually need. Because surprisingly, diagnosis doesn't tell you what people need. So after you have a diagnosis, it still needs to be figured out what it is that they require. So that seemed to us illogical. That it's also I want to emphasize that diagnostic assessment for us and specialist services remain essential in this system. We are not trying to downgrade the service and indeed to be protected, and it needs to be strengthened.
But we called for a number of other changes, which is. Perhaps ambitious, but a stronger focus on prevention. A public health approach to well-being, and tackling the social and environmental drivers that we identified for the increasing. Prevalence of common mental disorders in particularly young people, particularly children, young people, but across all ages seem to us to be important. And also we identified that the current system was actually incompatible with delivering effective prevention.
So the system that we are proposing is far more aligned to a system that targeted prevention can be aligned with offering support at the point when people present with need. So we argued that we need to create conditions for people to stay well, rather than relying predominantly on specialist services. Thank you. Just a couple of other things, if I may, because it's really essential to our logic that A be recommended because of the co-occurrence, the very high level of co-occurrence of neurodevelopmental disorders and common mental disorders.
Which do you mean
What that means is that they would receive support earlier in relation to what they actually need. Because surprisingly, diagnosis doesn't tell you what people need. So after you have a diagnosis, it still needs to be figured out what it is that they require. So that seemed to us illogical. That it's also I want to emphasize that diagnostic assessment for us and specialist services remain essential in this system. We are not trying to downgrade the service and indeed to be protected, and it needs to be strengthened.
But we called for a number of other changes, which is. Perhaps ambitious, but a stronger focus on prevention. A public health approach to well-being, and tackling the social and environmental drivers that we identified for the increasing. Prevalence of common mental disorders in particularly young people, particularly children, young people, but across all ages seem to us to be important. And also we identified that the current system was actually incompatible with delivering effective prevention.
So the system that we are proposing is far more aligned to a system that targeted prevention can be aligned with offering support at the point when people present with need. So we argued that we need to create conditions for people to stay well, rather than relying predominantly on specialist services. Thank you. Just a couple of other things, if I may, because it's really essential to our logic that A be recommended because of the co-occurrence, the very high level of co-occurrence of neurodevelopmental disorders and common mental disorders.
Which do you mean
09:36
09:37
09:37
Speaker 2
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Speaker 2
For a clinician, it is that a person who is diagnosed with a, say, a ADHD or autism is likely, in the majority of cases to also have common mental disorders of anxiety, depression, self-harm, or eating disorder. And that means that in order to deal effectively with both common mental disorders that carry with them traits of autism and neurodevelopment, other neurodevelopmental problems such as ADHD, it's essential that the assessments occur as part of a single system.
That doesn't mean it's the same assessment. It doesn't mean it's a single assessment, but it does mean it's an integrated assessment. At the moment, what happens is that people get put on one of three pathways, as I'm sure you know, and that is an inefficient system that requires people sometimes to be assessed on a number a number of times and wait on a number in a number of waitlists before they actually acquire a diagnosis. There are other things that we recommended that we perhaps come around to be able.
To
That doesn't mean it's the same assessment. It doesn't mean it's a single assessment, but it does mean it's an integrated assessment. At the moment, what happens is that people get put on one of three pathways, as I'm sure you know, and that is an inefficient system that requires people sometimes to be assessed on a number a number of times and wait on a number in a number of waitlists before they actually acquire a diagnosis. There are other things that we recommended that we perhaps come around to be able.
To
09:38
09:38
09:38
Speaker 5
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Speaker 5
Thank you. One of the the experiences we all have as as local MPs is exactly as, as Leyla describes there hearing from from families who are very distressed that their young people are not getting the support that they need. I think another thing that we will all be familiar with is others telling us that it's all down to the snowflake generation, that the mental health crisis we're seeing in our young people is because they just aren't resilient enough.
Your report rejects that. I Dia, could you perhaps just explain why you you reach that conclusion and the evidence that lies behind behind that.
Your report rejects that. I Dia, could you perhaps just explain why you you reach that conclusion and the evidence that lies behind behind that.
09:39
Speaker 2
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Speaker 2
Okay, I'd like that you asked actually two questions and I'll I'll answer the first, the second one and then maybe turn to. Professor Baird to answer the second. The snowflake generation is an insult to young people. I challenge all of you here to cope with the pressures that young people are under and sustain the quality of childhood and young adulthood that you all were privileged to experience.
You did not have. Two major categories of pressures. One is increased stress. Now I can go into detail in relation to this, but increased stress that's financial, that's well known of insecure work, unaffordable rents and so on, but also increased stress in terms of social media, in terms of social comparisons that are incessant, in terms of educational pressures. And we have evidence for that. And again, I can go into that, but it does seem that young people are less well protected, less well supported.
And that's the second category of issues that there have, and that's recorded a lower level of belonging to their schools. They don't feel that they belong. But it's not just schools. There has been a 73% reduction in youth services that are funded by local authorities since 2011. They don't have other young people to go to. And finally, in terms of the lack of protection, I want to mention what be found particularly important, which is the opportunity for recovery, which is unstructured play, which is not just youth clubs, but actually just being able to sleep.
And if you have social media that actually keeps you awake and it stops you from sleeping and also reduces face to face interactions, you will have less capacity to cope. Now, when you were young, when I was young, we had friends and we went to see friends and we're in trouble. If that's taken away and is replaced by mobile phones, you know they have greater stress and less support. So I would reject the idea that it's a snowflake generation.
Do you want to take the second question?
You did not have. Two major categories of pressures. One is increased stress. Now I can go into detail in relation to this, but increased stress that's financial, that's well known of insecure work, unaffordable rents and so on, but also increased stress in terms of social media, in terms of social comparisons that are incessant, in terms of educational pressures. And we have evidence for that. And again, I can go into that, but it does seem that young people are less well protected, less well supported.
And that's the second category of issues that there have, and that's recorded a lower level of belonging to their schools. They don't feel that they belong. But it's not just schools. There has been a 73% reduction in youth services that are funded by local authorities since 2011. They don't have other young people to go to. And finally, in terms of the lack of protection, I want to mention what be found particularly important, which is the opportunity for recovery, which is unstructured play, which is not just youth clubs, but actually just being able to sleep.
And if you have social media that actually keeps you awake and it stops you from sleeping and also reduces face to face interactions, you will have less capacity to cope. Now, when you were young, when I was young, we had friends and we went to see friends and we're in trouble. If that's taken away and is replaced by mobile phones, you know they have greater stress and less support. So I would reject the idea that it's a snowflake generation.
Do you want to take the second question?
09:42
09:42
Speaker 5
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Speaker 5
Actually that was more of a flavor to get into into the question. And I we will come back to that, but I don't want to I don't want to steal anyone else's thunder on that question, really. I just wanted to, to, to follow up on, I think, a very helpful answer there about this idea of a snowflake generation being an insulting narrative. Why do you think it has gained such traction despite the, the, the lack of evidence for it? And, and how do we combat it?
09:43
Speaker 2
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Speaker 2
Okay, this is I'm going outside the report slightly and now expressing my personal views. Not so much me because I'm the other side of this. But looking at you, most of you are of a generation that was brought up believing that you will have a future that's better than your parents. We are currently with a generation who are convinced, and rightly so, that they will not have the opportunities that their parents had.
That sense of hopelessness which has been demonstrated. That's this is not this is an empirical fact. That's part of their beliefs, but also part of our beliefs about them is an enormously powerful influence. But it also makes us feel somewhat guilty in relation to them. And therefore, it's much easier for us to say they're a snowflake generation than for us to say, actually, we really messed it up for them and it's our fault.
I mean, if you think back, Covid was the first time that I can remember when our generation or the adult generation brought, in a sense, a way of adjusting to a major health crisis that advantaged adults and disadvantaged children and young people, mostly the priority is given to the new generation. But for whatever reason, and I have not here to blame anyone, we decided that our priority, our health, was more important than theirs.
That sense of hopelessness which has been demonstrated. That's this is not this is an empirical fact. That's part of their beliefs, but also part of our beliefs about them is an enormously powerful influence. But it also makes us feel somewhat guilty in relation to them. And therefore, it's much easier for us to say they're a snowflake generation than for us to say, actually, we really messed it up for them and it's our fault.
I mean, if you think back, Covid was the first time that I can remember when our generation or the adult generation brought, in a sense, a way of adjusting to a major health crisis that advantaged adults and disadvantaged children and young people, mostly the priority is given to the new generation. But for whatever reason, and I have not here to blame anyone, we decided that our priority, our health, was more important than theirs.
09:45
Speaker 5
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Speaker 5
I think that's a profoundly challenging answer. I'm challenging to all of us here, and I just briefly reflect that with AI coming down the track as well, it's, you know, not at risk of getting easier. I think the other prevailing narrative that we hear a lot is that a rise in in need reflects better diagnostics, better diagnosis, and identification of mental ill health by practitioners. That's perhaps slightly less of a pernicious myth, but nevertheless one that you also rejected in your report.
Could you again, just say a little bit about how you came to that conclusion?
Could you again, just say a little bit about how you came to that conclusion?
09:46
Speaker 3
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Speaker 3
Well, the first thing to say is that there's no evidence of overdiagnosis. We didn't find evidence to some extent. The studies haven't been done. Nobody has taken a very large number of people with one diagnosis, and another group of people have then examined them to see whether or not they'd come to the same conclusion. That would be the obvious way to answer this question. But despite a huge amount of anecdote and report and opinion, there was no evidence.
And this is a highly evidence based review. What we did find was evidence of misdiagnosis, where somebody would be would have a diagnosis of one condition, where another condition was not recognised. That might better explain their difficulties. And this comes back to the co-occurrence, which is a central feature of the review and the obvious examples with eating disorders. Only more recently are people recognising that many have autism as well, which has an influence on the management of the condition.
You could be diagnosed with having autism, and actually, somebody else might think that your major problem was ADHD or anxiety or another mental health problem, but the way in which services are so often organised as single diagnosis pathways, this means that you go for an assessment where the answer is yes, you do, no, you don't have this. And then you may have to rejoin a completely different pathway for an integrated assessment of what the main problems might be.
The other thing is that when we looked at the number of people with a common mental disorder, anxiety or depression, we found that you might think the first thing would be, well, perhaps people have got much milder problems these days. That is not what the evidence found. The evidence found that the level of impairment was as high or sometimes higher. So the symptoms were causing greater impairment. So not a milder problem.
So and there are various other possible explanations for why the number of people with, let's say, a diagnosis of ADHD or autism might be rising. I'm happy to go into those, but there may be some other questions about those. So there have been a broader understanding of some of these difficulties. There have been diagnostic criteria changes. And of course, while the underlying traits, features, symptoms of neurodevelopmental conditions are heavily genetically influenced, the impairment that people experience is a result of the interaction of genetic predisposition with environment.
And this is a highly evidence based review. What we did find was evidence of misdiagnosis, where somebody would be would have a diagnosis of one condition, where another condition was not recognised. That might better explain their difficulties. And this comes back to the co-occurrence, which is a central feature of the review and the obvious examples with eating disorders. Only more recently are people recognising that many have autism as well, which has an influence on the management of the condition.
You could be diagnosed with having autism, and actually, somebody else might think that your major problem was ADHD or anxiety or another mental health problem, but the way in which services are so often organised as single diagnosis pathways, this means that you go for an assessment where the answer is yes, you do, no, you don't have this. And then you may have to rejoin a completely different pathway for an integrated assessment of what the main problems might be.
The other thing is that when we looked at the number of people with a common mental disorder, anxiety or depression, we found that you might think the first thing would be, well, perhaps people have got much milder problems these days. That is not what the evidence found. The evidence found that the level of impairment was as high or sometimes higher. So the symptoms were causing greater impairment. So not a milder problem.
So and there are various other possible explanations for why the number of people with, let's say, a diagnosis of ADHD or autism might be rising. I'm happy to go into those, but there may be some other questions about those. So there have been a broader understanding of some of these difficulties. There have been diagnostic criteria changes. And of course, while the underlying traits, features, symptoms of neurodevelopmental conditions are heavily genetically influenced, the impairment that people experience is a result of the interaction of genetic predisposition with environment.
09:49
09:49
09:49
Speaker 6
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Speaker 6
Thank you. I'd like to talk now a little bit about the drivers of mental distress, which you referred to in the report, and you talked about several things, including emotional pressures, social media, economic uncertainty and reduced social connectedness. And I notice that you've already talked about social media. You refer quite a lot to sleep in the report. And we know that sleep is really important to good health and social. Being on phones late at night is a real barrier to good sleep.
So is it possible for you to quantify the extent to which each of these pressures you think is driving demand, where you think the main focus should be? Where should the priority be in the government's response? Is.
So is it possible for you to quantify the extent to which each of these pressures you think is driving demand, where you think the main focus should be? Where should the priority be in the government's response? Is.
09:50
Speaker 2
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Speaker 2
That's a brilliant question. And as with all brilliant questions, I can't answer it. The the reason I can't answer it, there is an honest reason which is these are interacting. And if influence is interact, it's very hard to see, you know, which came first, the egg or the chicken because. There are three things that I can say with with confidence. One is that.
Which I've already said that they are not making it up, but the language has changed. Awareness of mental disorder has changed so that it has become a psychological language. So the same level of distress that a person might feel today is more likely to drive them towards a being a. In a getting mental health support than it used to. Now, that may seem like a negative, but actually it's a positive because we can help these people.
I think in terms of the drivers, social media actually doesn't. There is a lot of negative content in social media, and I don't want to minimize. I don't want to be an apologist for social media. But what it does is it displaces things that are protective rather than simply causing harm. So I'm mentioning that because of the second part of your question, what can the government do now by banning social media broadly? I don't think we can achieve quite as much, because the same distress that drives people towards social media and to seek answers from social media will still be there, even if we ban it, except with less support.
I think what's really important is that the good things that it displaces can be encouraged and can be supported. So, for example, physical exercise and greenspace, if social media displaces physical exercise, but we can encourage it. If social media displaces a face to face interactions, we can create situations where it's actually enhanced. If there is, it causes problems in sleep. We can actually have good ways of dealing with sleep problems.
You can't force people to go to sleep, but you can put on an alarm clock and make them wake up, which is a very simple measure of actually deepening, dealing with sleep disorder that we have used for a number of years. But one final thing, if I may, about that, that touches on the earlier point that I made. One thing that we could all do in relation to discouraging children to overuse social media is to use our own social media less.
You know, the number of people who are engaged rather than face to face interactions with their cellphones over meals is actually appalling. And of course, it sets a model for young people because they are there to learn from us. And that's how human beings learn, is looking at adults and see what they do. If we set an appalling model, can we be surprised that they do appalling things? Yeah.
Which I've already said that they are not making it up, but the language has changed. Awareness of mental disorder has changed so that it has become a psychological language. So the same level of distress that a person might feel today is more likely to drive them towards a being a. In a getting mental health support than it used to. Now, that may seem like a negative, but actually it's a positive because we can help these people.
I think in terms of the drivers, social media actually doesn't. There is a lot of negative content in social media, and I don't want to minimize. I don't want to be an apologist for social media. But what it does is it displaces things that are protective rather than simply causing harm. So I'm mentioning that because of the second part of your question, what can the government do now by banning social media broadly? I don't think we can achieve quite as much, because the same distress that drives people towards social media and to seek answers from social media will still be there, even if we ban it, except with less support.
I think what's really important is that the good things that it displaces can be encouraged and can be supported. So, for example, physical exercise and greenspace, if social media displaces physical exercise, but we can encourage it. If social media displaces a face to face interactions, we can create situations where it's actually enhanced. If there is, it causes problems in sleep. We can actually have good ways of dealing with sleep problems.
You can't force people to go to sleep, but you can put on an alarm clock and make them wake up, which is a very simple measure of actually deepening, dealing with sleep disorder that we have used for a number of years. But one final thing, if I may, about that, that touches on the earlier point that I made. One thing that we could all do in relation to discouraging children to overuse social media is to use our own social media less.
You know, the number of people who are engaged rather than face to face interactions with their cellphones over meals is actually appalling. And of course, it sets a model for young people because they are there to learn from us. And that's how human beings learn, is looking at adults and see what they do. If we set an appalling model, can we be surprised that they do appalling things? Yeah.
09:54
Speaker 6
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Speaker 6
So there's quite a movement now for delaying the purchase of smartphones for children, you know, going to secondary school, not having one at 11 but pushing it back. Do you think that actually just not having a device until young people are older, do you think that would make a difference, make them more resilient?
09:54
Speaker 2
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Speaker 2
Perhaps young people are resilient, very resilient, remarkably so. But at the same time, I would want to emphasize that they are also shrewd. And any attempt at some kind of government injunction to deprive them of something that they feel that they need is less likely to be successful than we hope. I think we can do a great deal to change social norms and expectations on them and emphasize, as I said, activities that are displaced by social media.
But you know, one thing that I do a lot of advising parents about how they should bring up their children, and there's one advice that I give that's above all advice , stop criticizing your child and notice when they do something that you want them to do and reinforce that, encourage that. I think we need to be less spiteful and less depriving in our approach to young people, and far more encouraging.
And that's a general shift that I you know, that I think your advice to government could actually probably take forward.
But you know, one thing that I do a lot of advising parents about how they should bring up their children, and there's one advice that I give that's above all advice , stop criticizing your child and notice when they do something that you want them to do and reinforce that, encourage that. I think we need to be less spiteful and less depriving in our approach to young people, and far more encouraging.
And that's a general shift that I you know, that I think your advice to government could actually probably take forward.
09:56
Speaker 6
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Speaker 6
Thank you. And just lastly, I've got a private member's bill about outdoor education, because I believe that getting children out. For. That is a very cheap way of improving children's mental health, sense of belonging, wellbeing, all of that. Could you tell us how important you think it is for children to to have to be outside more, to be in nature? The
09:56
Speaker 2
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Speaker 2
reduction of green space correlates positively with the increase in mental health issues for young people and the decrease in well-being. So I'm sure you're very familiar with those statistics. Obviously, being outside is an opportunity. I don't think that shoving people outside my father is irrelevant. But my father, in order to enhance my resilience, made me wear short trousers throughout winter. And that was in Hungary, which the continental climate, I don't think it made me more resilient.
So I don't think that being exposed, I think it's the opportunities that it brings with it, which is communication with other young people, which at from age eight through to age 1112, there's a shift in the interest of young people from their parents as the primary influence to other young people being the primary influence. If we deprive them of having that opportunity, we deprive them of the major way that they actually are.
Their genes have enabled them to integrate with modern culture. So I think what you're doing, God's work, if I may say. thank you.
So I don't think that being exposed, I think it's the opportunities that it brings with it, which is communication with other young people, which at from age eight through to age 1112, there's a shift in the interest of young people from their parents as the primary influence to other young people being the primary influence. If we deprive them of having that opportunity, we deprive them of the major way that they actually are.
Their genes have enabled them to integrate with modern culture. So I think what you're doing, God's work, if I may say. thank you.
09:58
09:58
Speaker 7
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Speaker 7
Thank you very much. And thank you so far for the evidence. It's been quite difficult for me because in one breath, I agree with everything you say, and then you say something else, which I fundamentally disagree with. So it's so it's been it's been interesting, but I totally agree with you on the Covid point. I think locking, you know, locking our children away is, was probably the worst thing we did. And we should never do that again.
I just before I get into my main question, I, I just want to clarify something you seem to be suggesting, which I haven't heard before, which you seem to be suggesting that a number of societal factors were having a significant impact on diagnoses of people's mental health, which then begs the question, if those societal factors are removed or improved, are you saying that diagnoses or people who have been diagnosed with ADHD could. I would say, for want of a better phrase, get better.
? As
I just before I get into my main question, I, I just want to clarify something you seem to be suggesting, which I haven't heard before, which you seem to be suggesting that a number of societal factors were having a significant impact on diagnoses of people's mental health, which then begs the question, if those societal factors are removed or improved, are you saying that diagnoses or people who have been diagnosed with ADHD could. I would say, for want of a better phrase, get better.
? As
09:59
09:59
Speaker 7
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Speaker 7
You see, if I can, if I can drill that down. So for example, I'm someone with red hair. Light skin used to be red light skin. I have a genetic predisposition, predisposition to skin cancer because of those factors. But if I don't go out in the sun or I put factor 50 on all the time, I'm less likely to get skin cancer. Is am I being very reductive in this? Is you're saying you might have a predisposition to ADHD, but.
But if the societal factors are vastly improved, but not in every case, but in some cases you wouldn't develop. I'm using non-medical language here. Develop ADHD or indeed, if you had developed it and those factors were to disappear, improve, you would not because it's not it's not a disease. It's a condition. It's a multifactorial condition. I'm trying to understand what you're saying here. Really.
But if the societal factors are vastly improved, but not in every case, but in some cases you wouldn't develop. I'm using non-medical language here. Develop ADHD or indeed, if you had developed it and those factors were to disappear, improve, you would not because it's not it's not a disease. It's a condition. It's a multifactorial condition. I'm trying to understand what you're saying here. Really.
10:00
Speaker 2
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Speaker 2
What I'm saying is that it's a continuum. It's not something that you either have or do not have. I will turn to the local expert here to actually answer the question, but let me just. Emphasize one thing, and maybe that you could give your one of your favorite examples on this, but attention deficit is actually a misnomer. It's attention regulation that is the problem. And hyperactivity is a way that young that people with ADHD cope with a problem of attention regulation by.
For example. The subjective inner restlessness they feel is reduced by hyperactivity. So. But it is a continuum between a. As indeed, most disorders are between environmental and situational demand, and . When the disadvantages in mental abilities become disabling, it's more difficult to cope with the demands of modern life, and you struggle more. And that moves you over to a threshold that's actually ultimately arbitrarily defined.
For example. The subjective inner restlessness they feel is reduced by hyperactivity. So. But it is a continuum between a. As indeed, most disorders are between environmental and situational demand, and . When the disadvantages in mental abilities become disabling, it's more difficult to cope with the demands of modern life, and you struggle more. And that moves you over to a threshold that's actually ultimately arbitrarily defined.
10:02
Speaker 7
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Speaker 7
And yes, and I'm not in any way trying to suggest that the condition doesn't exist. I fully accept that. It absolutely does. What I'm trying to do, as we would do with anything we would look, how do we prevent and how do we cure? We've talked a lot about how we diagnose and how we deal with that diagnosis, but we don't seem to talk in these areas about prevention and cure. But but maybe that's for another time.
10:02
10:02
Speaker 3
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Speaker 3
I'll certainly try and, and, and move that slightly forward because it is helpful to consider a dynamic interaction between genetic predisposition and environmental, environmental circumstances. And for ADHD, particularly the demands for attention and the demands on executive function will make more manifest. So just a figure, first of all, that if you have a common mental disorder, age 16 to 24, that's anxiety or depression, 60% will screen positive for autism traits and for inattention traits of ADHD.
So that brings up the likelihood that the dynamic interaction with the environment will occur, that the problems will become more manifest, and you will probably come into a diagnostic category. The example that I was that Peter was referring to is sometimes a helpful way to think about this is with type two diabetes, type two diabetes, a well described medical condition, genetic predisposition that if a combination of genetic predisposition, lifestyle, particular features such as overweight all come together, your blood sugar is in difficulties because of the insulin resistance.
So the diagnosis of diabetes becomes manifest. If you reduce the lifestyle, the obesity, the diabetes can disappear. But if you have that combination of problems for long enough, you get secondary effects. So you get a cumulative impact, which then has secondary effects, which are much more difficult to diminish. Does that is.
So that brings up the likelihood that the dynamic interaction with the environment will occur, that the problems will become more manifest, and you will probably come into a diagnostic category. The example that I was that Peter was referring to is sometimes a helpful way to think about this is with type two diabetes, type two diabetes, a well described medical condition, genetic predisposition that if a combination of genetic predisposition, lifestyle, particular features such as overweight all come together, your blood sugar is in difficulties because of the insulin resistance.
So the diagnosis of diabetes becomes manifest. If you reduce the lifestyle, the obesity, the diabetes can disappear. But if you have that combination of problems for long enough, you get secondary effects. So you get a cumulative impact, which then has secondary effects, which are much more difficult to diminish. Does that is.
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Speaker 7
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Speaker 7
Thank you. So moving on to some of your recommendations. I think it was recommendation five. Essentially, you looked at essentially a complete overhaul of the commissioning, funding, oversight, etc. of the system. So what changes do you actually propose to improve the ADHD and autism diagnostic and treatment pathways, and specifically, which changes do you think would have the greatest impact on on improving the waiting times?
10:05
Speaker 3
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Speaker 3
The most important is to integrate the mental health and neurodevelopmental disorder assessment so that if you are having have have problems, you're coming for assessment, then you will be having an assessment of all the possible contributory factors. If you have one problem, you are so much more likely to have another and to miss to miss that then has a huge impact on the the level of support and appropriateness of support that you're likely to retrieve.
So that's going to be one of the most important things that we could do rather than these separate pathways. There's a huge amount of duplication which is currently going on, so that people will have an assessment in one place, then in another, a lot of duplication. So integration, both of assessment and then of services following that will be one of the most important recommendations which will help.
So that's going to be one of the most important things that we could do rather than these separate pathways. There's a huge amount of duplication which is currently going on, so that people will have an assessment in one place, then in another, a lot of duplication. So integration, both of assessment and then of services following that will be one of the most important recommendations which will help.
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Speaker 2
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Speaker 2
Okay. Well, I there are several. The first one that be emphasized is changing the sequence. Which is from a sequence that's. Wait, assess, diagnose support to something that's recognised need. Then understand need, then begin support, then establish diagnosis where it changes and then review and adapt as needed. So this is a completely this is a radical change that has been implemented actually in a number of places.
It's not as we cite in our review, this is, you know, we try and seem original, but actually we are not. This has been quite discovered. It only works though. And this is also documented in the review. It only works if it's sufficiently well supported to have a needs based system without adequate support, actually creates a problem rather than solving one. So what we ask for are two things.
One is for further resources to actually support that needs based system. And second, a reorganisation that's more efficient than anything that's in place now. And a combination of the two will, I think, and we can talk about that, will, I think, lead to ultimately a reduction in cost because of earlier intervention, because what we have at the moment is a system where you gatekeep in order not to be able to treat.
If children and young people, particularly if you wait long enough, the treatments that we have are not helpful. So it is setting thresholds at a level where you can no longer intervene effectively is a particularly mindless thing to do. And yet it's understandable. But moving support earlier, all the evidence is it makes treatments that we have far more effective. If you wait for two weeks, the likelihood of a condition getting worse is something like 20%.
Even for two weeks. If you wait for six months, it's 75%. So, you know, reducing waiting lists is really a key part of what you're recommending.
It's not as we cite in our review, this is, you know, we try and seem original, but actually we are not. This has been quite discovered. It only works though. And this is also documented in the review. It only works if it's sufficiently well supported to have a needs based system without adequate support, actually creates a problem rather than solving one. So what we ask for are two things.
One is for further resources to actually support that needs based system. And second, a reorganisation that's more efficient than anything that's in place now. And a combination of the two will, I think, and we can talk about that, will, I think, lead to ultimately a reduction in cost because of earlier intervention, because what we have at the moment is a system where you gatekeep in order not to be able to treat.
If children and young people, particularly if you wait long enough, the treatments that we have are not helpful. So it is setting thresholds at a level where you can no longer intervene effectively is a particularly mindless thing to do. And yet it's understandable. But moving support earlier, all the evidence is it makes treatments that we have far more effective. If you wait for two weeks, the likelihood of a condition getting worse is something like 20%.
Even for two weeks. If you wait for six months, it's 75%. So, you know, reducing waiting lists is really a key part of what you're recommending.
10:09
Speaker 7
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Speaker 7
Thank you. And in the one, not just one minute, I've got really sorry, really, really specific question on the CQC regulation recommendation. What's your reasoning behind the thought of banning public advertising for NHS funded assessment? Where's the evidence there? Sorry, I don't have a lot of time. So as pithy as possible.
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Speaker 8
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Speaker 8
in. Yeah. Okay. I'm going to before I pick up on that particular rabbit hole, I want to go back to a rabbit hole that you had at the start of your conversation with Greg, because actually it was quite interesting talking about how culture and education culture has probably led to a rise in diagnoses. And I thought it was back in an A-level psychology class. Talk about the social model of disability again. But actually , I wonder if there is a factor that in the last well, kind of .
Since Michael Gove, education has been more focused on a specific, strict type of education, whilst society has moved in a different direction in terms of the education economy and whether that that has led to more people being likely to to present with ADHD symptoms in an education environment.
Since Michael Gove, education has been more focused on a specific, strict type of education, whilst society has moved in a different direction in terms of the education economy and whether that that has led to more people being likely to to present with ADHD symptoms in an education environment.
10:12
Speaker 3
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Speaker 3
Yeah. Yes. Is the answer. The changes meant that it that people felt that the only way that they could get support was to through diagnosis. So the number of AHC, the education health plan just went up like that after after 2014. And also diagnoses changed as the other interesting feature. So we've, we've talked a little bit about the co-occurrence and the importance of not just thinking about things in terms of single diagnoses.
Well, in 2016, for example, the proportion of people with special educational need who had a learning disability, something like 15%, that that is halved by 2025, whereas the autism has gone like that. So not only the number going up, but the.
Well, in 2016, for example, the proportion of people with special educational need who had a learning disability, something like 15%, that that is halved by 2025, whereas the autism has gone like that. So not only the number going up, but the.
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Speaker 3
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Speaker 3
Just a learning disability, a general learning disability. So having across the board intellectual disability right across the board, intellectual disability that the number of pupils diagnosed with that has has gone down, whereas other diagnoses have gone up. But the main answer to your question is that after 2014, there was a change.
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Speaker 8
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Speaker 8
Yes, I mean, that it seems to be the case that people just don't feel they can get support another way. If I look at my local ICB at West Yorkshire, the cost of the neuro neurodiversity service has risen from 3,000,000 in 22 23 to 20 5,000,000 in 2526, which is clearly unsustainable. Do you think that the model that you suggest of having support before diagnosis would make a significant difference to that?
10:14
Speaker 2
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Speaker 2
I think we wouldn't have suggested if we didn't think it did. I think you people ask us sometimes, you know, are we optimistic about change that some of this is going to be implemented? Our response to that is , unless there is change, we are going to have such a catastrophic set of problems that change is inevitable. The question is, how can we change? What we are suggesting here is a feasible, practical pathway that has been tested and has been shown to work, which is early intervention linked to prevention .
And I think the costs are so high and the processes involved are so frequently bidirectional, that the solutions that we propose actually cause the problems later down the line , that I think we have to wait. And I don't know if you mentioned five years, you know, waiting on a list, you know, for five years. In fact, I can't mention the person, but one of the media encounters that we've had recently since the release, a person representing me said, I just had my child assessed, having waited, had it privately done.
It was a 20 minute assessment of the child, a one hour assessment of us as parents, and we got the diagnosis of autism and that was it. And now what do we do?
And I think the costs are so high and the processes involved are so frequently bidirectional, that the solutions that we propose actually cause the problems later down the line , that I think we have to wait. And I don't know if you mentioned five years, you know, waiting on a list, you know, for five years. In fact, I can't mention the person, but one of the media encounters that we've had recently since the release, a person representing me said, I just had my child assessed, having waited, had it privately done.
It was a 20 minute assessment of the child, a one hour assessment of us as parents, and we got the diagnosis of autism and that was it. And now what do we do?
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Speaker 8
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Speaker 8
And I think fundamentally that's what this comes down to because, I mean, I think about, you know, there's a lot of kind of problematizing lots of people going through these assessments as if they're the problem. Yeah. But actually at the centre of that is usually a parent who's worried that their kid isn't getting the support they need for education.
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Speaker 8
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Speaker 8
And I, you know, and, and so ultimately, that's where it's falling down. And I wonder if, if you think a rising tide would lift all boats in some of this. So if, if we assess need rather than disability, then that, would that not be better for all children going through an education system? Not simply not simply those children who happen to be like happen to cross the line to neurodivergence?
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Speaker 2
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Speaker 2
Yeah, absolutely. I mean, at the moment we are in a system that defines children and young people in terms of their limitations. We should be in a system that describes them in terms of their potential. And if that change was made systematically across the board, the problems would be instead of problems, they would be opportunities for enhancing an individual's capacity. That means focusing on their functioning, which is linked to need.
You meet them where the limitations of their function is, you support them and suddenly the problem changes.
You meet them where the limitations of their function is, you support them and suddenly the problem changes.
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Speaker 8
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Speaker 8
The . So the right to choose assessments is obviously something that everyone with an inbox who's a member of Parliament has come across. It is, you know, the idea that people have a right to choose to have a private assessment after a certain time. Now in West Yorkshire, there's a two year minimum wait for that. I use that just because it's my local ICB. So it's closer to me now. Obviously, that's that's that's over 10% of someone's educational experience.
Yeah. Is right to choose working as a model.
Yeah. Is right to choose working as a model.
10:18
Speaker 2
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Speaker 2
I think as to we did not be. I think it's important that we did not recommend abolishing right to choose, but we did recommend prioritisation. So I think at the moment, as professor said, there is a major issue in relation to the population changing for those who meet criteria. I think parents are not looking for a label. Parents are looking for helping their child to actually deal with the challenges that the children face.
Yeah. If we change the system that what it offers is support for the parents, right to choose becomes an irrelevance. Yeah, except for the cases where it isn't.
Yeah. If we change the system that what it offers is support for the parents, right to choose becomes an irrelevance. Yeah, except for the cases where it isn't.
10:19
Speaker 3
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Speaker 3
But I think also that the and you'll be familiar with this from your own icbs the proportion of their resource which is currently going to. Right to choose is the costs of that are far higher than perhaps the NHS costs would be. It then means that there's nothing available to support the families afterwards, so you can. And you cannot possibly blame parents. They're doing the right thing for their child. They want a diagnosis.
They think it will help. Of course they're going to do whatever they possibly can in order to get that, but it is not followed by anything. So you can find I've got I've got my diagnosis, my child has autism, may be non-verbal. What's going to follow? And they fall into a hole. That is not the way to manage these situations.
They think it will help. Of course they're going to do whatever they possibly can in order to get that, but it is not followed by anything. So you can find I've got I've got my diagnosis, my child has autism, may be non-verbal. What's going to follow? And they fall into a hole. That is not the way to manage these situations.
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Speaker 8
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Speaker 8
I can I can sense Leyla looking at me so I know that I'm on my last question. The final thing, obviously, a lot of the private providers have an incentive to find people have those issues. Do you think more needs to be done to regulate the private providers, to make sure that they're coming out with good results? I think it adds to this.
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Speaker 9
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Speaker 9
Thank you, chair, and just a very, very brief supplementary. I was fascinated to hear, and I declare an interest as the chair of the all party parliamentary group on learning disability, that learning disability diagnoses have halved. Do you think part of that could potentially play into the sort of misdiagnosis around, particularly autism, that maybe people are seeing that as the route to go through to get support for their child, and that's in fact obscuring perhaps an underlying learning disability.
10:21
Speaker 3
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Speaker 3
I think. Yes, I do, and I think it's also probably obscuring underlying difficulties of a variety of sorts. Speech and language impairments, other specific learning difficulties, dyslexia. So there are a number of conditions which co-exist, which, if you don't look for them, can be overlooked. And of course, particularly what our report was about was the combination of common mental disorders, severe anxiety, and the neurodevelopmental disorders all interlinked.
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Speaker 1
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Speaker 1
you. That sets me up very well for the questions I want to ask my staff. I might give you a slight break, professor, and direct them at Professor Baird, because they're about data and the underlying data, about misdiagnosis, overdiagnosis and so on. You touched on it, on it earlier. Your report says, and you talk about the balance of risks of under-diagnosis misdiagnosis and overdiagnosis may be changing. You then say that you need more evidence to be able to determine whether or not how this is changing over time.
I mean, from your perspective, what should we be recommending to government that they do now as a matter of course, to make sure that that evidence base exists for where we are now and what needs to happen moving forwards so that we can check whether these interventions are or any others are working. Could I ask you to answer that?
I mean, from your perspective, what should we be recommending to government that they do now as a matter of course, to make sure that that evidence base exists for where we are now and what needs to happen moving forwards so that we can check whether these interventions are or any others are working. Could I ask you to answer that?
10:23
Speaker 3
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Speaker 3
First of all, we were we have some good evidence, which the report refers to in the Adult Psychiatric Morbidity Survey, which was done relatively recently, 2024. But when it came to conditions like autism and ADHD, there is no recent population survey in England, which was the focus of our report. That geographic area since 2017. So we are relying therefore on information for population prevalence on rather old data. Can I
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Speaker 1
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Speaker 1
I think you've answered most of this, but I just want to make sure we haven't missed any points. You say that diagnoses, particularly misdiagnoses, can do harm, perhaps, Professor Fonagy, because you nodded most emphatically. But can you describe what harm is it that we are potentially doing with misdiagnoses? And what would stop misdiagnoses from happening?
10:24
Speaker 2
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Speaker 2
You know, imagine a person. Imagine a young person who doesn't want to go to school. Wakes up in the morning already exhausted, complains about attention problems, but also complains that, you know, the overwhelming experience in they have in kind of social context in school, parents obviously are out of their mind with anxiety. They go and the child gets referred to because of complaining of attention problems, gets referred to the ADHD pathway for assessment.
Now that child beating on the pathway to get more anxious and you know, the problems will get worse if we actually intervened in terms of addressing the attention problems by getting their child to sit closer to the teacher, to get written instructions, to have the available simple anxiety reduction that mental health support teams can deliver. It may well be that the attention problems will quieten, and that you will not have that.
Difficulty. The harm that it does is that the problems that are most likely to be resolvable are not addressed in a timely manner, and they get worse as a consequence of waiting. And that's very simple. It's a misdiagnosis is not simply making a mistake. It's missing an opportunity for effective intervention.
Now that child beating on the pathway to get more anxious and you know, the problems will get worse if we actually intervened in terms of addressing the attention problems by getting their child to sit closer to the teacher, to get written instructions, to have the available simple anxiety reduction that mental health support teams can deliver. It may well be that the attention problems will quieten, and that you will not have that.
Difficulty. The harm that it does is that the problems that are most likely to be resolvable are not addressed in a timely manner, and they get worse as a consequence of waiting. And that's very simple. It's a misdiagnosis is not simply making a mistake. It's missing an opportunity for effective intervention.
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Speaker 2
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Speaker 2
Primarily because of the delay. And, you know, the child, you know, if the child gets put on, say, stimulant medication, because the anxiety reduction, the anxiety treatment didn't deal with it, you are still in a situation where you've put many of the. Ways of addressing their child's problem already in place. So you're more likely to be successful. Missing the diagnosis of anxiety in, in that case is a major problem.
And, and that probably happens quite a bit, as the professor had explained, because of the way that mental health problems can drive. The.
And, and that probably happens quite a bit, as the professor had explained, because of the way that mental health problems can drive. The.
10:27
Speaker 1
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Speaker 1
In that example, is that not underdiagnosis because there's a condition that has not been diagnosed as part of it? Or is that a misdiagnosis? Because in fact, that child doesn't have ADHD? I'm trying to understand. I mean, you say they're concurrent and but I'm trying to just pin it down for the sake of the parents watching, who are now worried that their child who's on a medication, for example, may not need to be I mean, can you just try and unpick it for their sake?
10:28
Speaker 2
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Speaker 2
Yes. I'm not saying if they were put on medication. I'm not saying that that's unlikely, that all the evidence that we have suggests that people put on medication diagnosed now have problems as profound as they ever did. As professor mentioned, what I'm saying is that there may be others for whom, as described, we are missing the opportunity to intervene in a dynamic interaction between environmental pressures and genetic predisposition in a way that may be able to afford the possibility of dealing with the problem before medication and diagnosis.
What do
What do
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Speaker 1
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Speaker 1
you say to parents who want to diagnosis to better understand how to help their children? You know, and I've had many in my own surgery who say, I don't know if my child is or isn't, but I kind of want the diagnosis because that will give me a toolkit to better help them. Is that a good thing to do or a bad thing to do? I'm that too.
10:29
Speaker 2
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Speaker 2
Yeah, that's a wonderful thing to do. But there are two things, and possibly I can tell is dying to come in here. But but if I can just say one thing, the toolkit shouldn't be sitting behind the diagnosis. The toolkit should be there delivered by the NHS. And that's one of our recommendations that a not just an awareness toolkit, but an action oriented toolkit that you can do should be there.
10:29
Speaker 1
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Speaker 1
And just on that very briefly, and I And just on that very briefly, and I will come to you very briefly. You mentioned twice, particularly recommendations two and three about AI enabled shared need assessments and priority frameworks. And then again, recommendation three digitally enabled mental health and neurodevelopment assessments and . We are, as a committee, very interested in that digital strand of the NHS. It's something that we're taking a particular interest in.
I just wondered if you could point us at good practice where this is happening. I suppose my concern was you said this because it's, you know, AI will solve all problems and I'm your evidence base. So I'm confident that that's not what happened. But could you point us to the best practice so that we can help the NHS to, to do this further, faster?
I just wondered if you could point us at good practice where this is happening. I suppose my concern was you said this because it's, you know, AI will solve all problems and I'm your evidence base. So I'm confident that that's not what happened. But could you point us to the best practice so that we can help the NHS to, to do this further, faster?
10:30
Speaker 2
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Speaker 2
You want me to? Okay. So there are three quite different jobs that digital more broadly could do. The first is, as we were touching on it, information and support that's more specifically to parents do this already. I mean, you know, they go to chat GTP and say, how do I deal with and sometimes GP answers in a sensible way, sometimes not. The NHS could do a lot better job to give better advice in that in that way.
Second, digital tools are very helpful in assessing people's needs more efficiently and. We are very clear about it. AI describes. The clinician decides. So there is a clinician sitting behind that because particularly because the increased suicide.
Second, digital tools are very helpful in assessing people's needs more efficiently and. We are very clear about it. AI describes. The clinician decides. So there is a clinician sitting behind that because particularly because the increased suicide.
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Speaker 3
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Speaker 3
Yes, there's some some examples, particularly in different places. What's required is a far more integrated system. I mean, a lot of places are using in some areas that in the UK, in the UK. Oh I see. So there are some in South London, for example, we've had fantastic from around the Maudsley Hospital, the. I believe the Scottish Government are looking to for exactly this. And of course, they have the possibility of then extending it across the whole of Scotland.
So there are a number of different places where it is in bits, but insufficiently. And we are suggesting that the information section should be a nationwide system. Thank you
So there are a number of different places where it is in bits, but insufficiently. And we are suggesting that the information section should be a nationwide system. Thank you
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Speaker 10
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Speaker 10
Professor Fonagy, you say that there is no evidence of a substantial overdiagnosis in conditions like ADHD and autism, yet your own report identifies a population prevalence of autism in young people of about 1.2%, but a diagnosis that has increased to over 4%. How? And that doesn't include waiting lists. How is that anything other than evidence of overdiagnosis based just on your figures?
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Speaker 10
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Speaker 10
But you identify the population prevalence of autism in young people as 1.2%, but the diagnosis rate as over 44%, and that is increasing further with a big waiting list. That seems to me evidence of overdiagnosis, when nearly four times the amount of young people are being diagnosed as the population prevalence.
10:33
Speaker 2
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Speaker 2
I think it's important. I think this is a really important point, and I'm really grateful for you raising it , because overdiagnosis implies that there is nothing wrong with that person, that the diagnosis is applied and there's nothing wrong with them. We find absolutely no evidence of that. We find that there may be that some of those 4% are misdiagnosed, as Professor Baird has already pointed out. We find no evidence that they that there is a group of people who are just presenting and there is nothing wrong with them.
Overdiagnosis has a pejorative, a very unfortunate pejorative term that indicates that people are presenting with problems that they do not have. All the evidence that we have is that the risk of misdiagnosis is increased, which, for example, covers, but that there is a, at the moment, new evidence for overdiagnosis. What we do point out is that there is a warning sign in the figures that we present that unless the system is changed, it is almost inevitable that over the problem of overdiagnosis will arise because, for example, with young people in adolescent age group, the prevalence of ADHD has reached the level at which.
All the figures that we have available suggest the population prevalence should be. At which point the administrative prevalence, the number of diagnoses should have leveled off. There should.
Overdiagnosis has a pejorative, a very unfortunate pejorative term that indicates that people are presenting with problems that they do not have. All the evidence that we have is that the risk of misdiagnosis is increased, which, for example, covers, but that there is a, at the moment, new evidence for overdiagnosis. What we do point out is that there is a warning sign in the figures that we present that unless the system is changed, it is almost inevitable that over the problem of overdiagnosis will arise because, for example, with young people in adolescent age group, the prevalence of ADHD has reached the level at which.
All the figures that we have available suggest the population prevalence should be. At which point the administrative prevalence, the number of diagnoses should have leveled off. There should.
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Speaker 10
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Speaker 10
But it hasn't levelled off. And it seems to me a problem. If it can't be asserted, it can be disputed. But it can't be asserted that if population prevalence of autism in young people is 1.2% and diagnosis rates have climbed above 4%, it seems a problem if it can't be asserted that that is an overdiagnosis. Now it could be explained as a misdiagnosis, but for autism itself, those are the figures and I cannot see how that can be anything other than overdiagnosis.
What support is then required for people who are being overdiagnosed is a separate and very valid conversation, but you seem to be asserting a lack of overdiagnosis when your figures say something different.
What support is then required for people who are being overdiagnosed is a separate and very valid conversation, but you seem to be asserting a lack of overdiagnosis when your figures say something different.
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Speaker 3
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Speaker 3
Quoted was the last one. So we don't know whether the population prevalence has changed. You may have thought that it would be impossible if it was a substantially genetically predisposed position, that it would rise, but that's not the case. You could have a rise for the reasons that I outlined earlier. So we don't know what the population prevalence is. So we're making a comparison between now in 2020 526 with figures that were available probably just before 2017.
So that that is one thing. The second thing is, and I'll turn perhaps to ADHD, because we do have rather better figures about that. So the exactly the same situation pertains to ADHD, but that the population prevalence we has again was 2017. We've projected forwards from the previous figures to a possible population prevalence of 3.8%, but diagnosis in some groups of children and adolescents is already at that and a little bit higher than that.
We know that when the DSM five, the diagnostic and statistical manuals, the classification systems that we all rely on for diagnosis when they were rewritten and published in 2013, there were changes in the conceptualization of ADHD. There are specific changes for ADHD, which raised the possible population prevalence by 2% in adults and 3% in children. So the changes in the way in which people are understanding these conditions has changed.
So you're using a population prevalence in this country of 2017 on a slightly changing base. Now in autism, we don't have quite the same detailed figure to give you of what happened when the changes were made in the DSM five. But there has been far greater recognition in girls and women, and the numbers of diagnoses have then increased. Is that.
So that that is one thing. The second thing is, and I'll turn perhaps to ADHD, because we do have rather better figures about that. So the exactly the same situation pertains to ADHD, but that the population prevalence we has again was 2017. We've projected forwards from the previous figures to a possible population prevalence of 3.8%, but diagnosis in some groups of children and adolescents is already at that and a little bit higher than that.
We know that when the DSM five, the diagnostic and statistical manuals, the classification systems that we all rely on for diagnosis when they were rewritten and published in 2013, there were changes in the conceptualization of ADHD. There are specific changes for ADHD, which raised the possible population prevalence by 2% in adults and 3% in children. So the changes in the way in which people are understanding these conditions has changed.
So you're using a population prevalence in this country of 2017 on a slightly changing base. Now in autism, we don't have quite the same detailed figure to give you of what happened when the changes were made in the DSM five. But there has been far greater recognition in girls and women, and the numbers of diagnoses have then increased. Is that.
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Speaker 10
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Speaker 10
Thank you. Yes, it does help, although I notice the data up until 2017 allows you to conclude that there has been no substantial change in the prevalence. Perfectly correct up until 2017. Can I just ask on support for those with these sorts of conditions? Obviously, support is given through education, through health, through welfare. And a proposition I'll put to you is that there's been an oversupply of money to deal with an issue, particularly in welfare, rather than the therapeutic, health, educational support.
Would you agree that there is either that is your view, or at least it needs to be explored whether the right support is being given and there may be an or have been an overemphasis on money to families, rather than health and educational support in community environments.
Would you agree that there is either that is your view, or at least it needs to be explored whether the right support is being given and there may be an or have been an overemphasis on money to families, rather than health and educational support in community environments.
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Speaker 3
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Speaker 3
Right. So so the there are varying levels of support that are actually required at different stages of a child's life. And I guess the most important thing we would want to emphasize that there's a developmental accumulation of problems if you don't deal with something early enough. So putting money in for early support is, is absolutely vital. And yes, we also need more focused support for the particular therapeutic approaches which we have outlined in the report and which for which there's a good evidence base that they're there.
They're happening. I mean, with regard to your later question about Pip and and so on and so forth, I that is not what our study was, was about at all. We were looking at prevalence. What evidence we had for interventions and so on. And, and what works and what doesn't work.
They're happening. I mean, with regard to your later question about Pip and and so on and so forth, I that is not what our study was, was about at all. We were looking at prevalence. What evidence we had for interventions and so on. And, and what works and what doesn't work.
10:41
10:41
Speaker 11
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Speaker 11
Thank you. If, as you suggest, and as you know, a lot of the reviews around said system in education are proposing we should be moving to much earlier intervention. And instead of a diagnosis first system having a support first system, what do you think some of that support should look like? Is it the same kinds of interventions that typically currently have to wait until after diagnosis? Is it different lower level interventions? Because lots of parents I've spoken to fear that if they are going to get support first, it's going to be going on a course or it's going to be online or it's going to be sporadic.
Rather than feeling that if they get diagnosis, they will get a robust package of interventions. So what do you see as being the difference if we make that shift?
Rather than feeling that if they get diagnosis, they will get a robust package of interventions. So what do you see as being the difference if we make that shift?
10:42
Speaker 2
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Speaker 2
That is a that was a concern that was expressed to us by lived experience partners. And it's a concern that we share. The important qualification is that we know what works, that in this country we have a remarkably good system for identifying what are the best health interventions that can be applied. And that's defined by. Nice. I know of no other country in the Western world where actually that's available, where we are very clear that there is a real gap at the moment between what Nice recommends and what's offered even after a diagnosis, and that the gap can be eye watering.
What we are suggesting is, yes, probably you could reduce the intensity of the intervention if it's applied earlier, but this cannot be something that is not tested and recommended by Nice. However, we also recommend that it's a much broader set of interventions that than health that we have to contemplate here, that it's partly education, partly welfare, partly youth justice and partly Home Office, that this needs to be a cross-governmental initiative that has early intervention and prevention of increased problems at heart.
So if I can plead for one thing for your wonderful cross-departmental. Select committee, to recommend is to broaden it even further, not just education and health, but also welfare, and that these systems need to work integrated and aligned in order to achieve the objectives that we know need to be achieved, much of which is actually really not rocket science and education, I'm really pleased to say, is moving towards that. But unless we can align health with education and the recommendations that education is coming up with in terms of sound reforms and health has a education comes up with one set of understanding about what need is and one language, what need is health comes up with another set of definitions of what need is.
We are back in the same catastrophic position. If you can persuade these government departments to work together to arrive at a single definition of need, you will have done something useful. And if that's aligned with welfare, which already works in in principle, not in terms of diagnosis, but in terms of need, that would be a the ideal which I hope you all select committee, your joint Select committee can achieve.
What we are suggesting is, yes, probably you could reduce the intensity of the intervention if it's applied earlier, but this cannot be something that is not tested and recommended by Nice. However, we also recommend that it's a much broader set of interventions that than health that we have to contemplate here, that it's partly education, partly welfare, partly youth justice and partly Home Office, that this needs to be a cross-governmental initiative that has early intervention and prevention of increased problems at heart.
So if I can plead for one thing for your wonderful cross-departmental. Select committee, to recommend is to broaden it even further, not just education and health, but also welfare, and that these systems need to work integrated and aligned in order to achieve the objectives that we know need to be achieved, much of which is actually really not rocket science and education, I'm really pleased to say, is moving towards that. But unless we can align health with education and the recommendations that education is coming up with in terms of sound reforms and health has a education comes up with one set of understanding about what need is and one language, what need is health comes up with another set of definitions of what need is.
We are back in the same catastrophic position. If you can persuade these government departments to work together to arrive at a single definition of need, you will have done something useful. And if that's aligned with welfare, which already works in in principle, not in terms of diagnosis, but in terms of need, that would be a the ideal which I hope you all select committee, your joint Select committee can achieve.
10:45
Speaker 11
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Speaker 11
So I think I'm hearing you right. Your suggestion is that nice has to stay in control of what the interventions are and where we have a process at the moment where schools are going to be reimagined as much more inclusive. So that need can be met in mainstream . For many, preserving then specialist for the most complex needs that actually nice and health need to be involved in designing what those educational environments and interventions are. Is that right? Yeah.
10:46
Speaker 2
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Speaker 2
The way we put it is that health is the steward of the like you are steward of anything you don't define for, but you oversee and ensure that good practice is implemented. I do hope that that's possible. And nice ADHD guidelines already make many recommendations that are to do with education, except education feels that that need not be followed because that's made by nice. And that's all to do with health.
10:46
10:46
Speaker 9
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Speaker 9
Thank you. So we've talked a lot about the harm that's being done on current waiting lists. And the fact that I think you described as a mindless thing to do, making people wait for that threshold while complexity increases and the chance of reversible issues increases. But what safeguards are needed to ensure that any move to a needs based support does not weaken access to specialist support, to reasonable adjustments, and to statutory entitlements.
10:47
Speaker 3
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Speaker 3
The it's certainly a concern and one that's been very well articulated, as Peter says, to to us, I think that there are there are several levels of that. And I think that for. But the way in which it's organised will also make a very big difference. So, for example, if you're. We've been talking about integrating services. If you can integrate support services as close to home as possible, and to a large extent that fits with the devolution agenda of the present government , that if you have them there and people can see that they're actually working for them, then that dissipates a great deal of the concern.
I do think there's a job of work to be done about enhancing parental trust in how the education system is going to manage that, and they're very well aware of that, because at the moment, there is generally a feeling that you've articulated that parents feel they're not going to get anywhere without the diagnosis. But I think equally, parents understand that diagnosis alone is not actually working for them. It's not getting them the support that they require.
I mean, one example is with ADHD that the opportunity for moving from a diagnosis of ADHD to actually implementing a very specific treatment, first of all, a psychosocial intervention, which is number one, treatment. And secondly, medication intervention has halved since Covid. But there is there is no follow through at the moment. So I think it's going to be in the doing of it and how the doing is organised that that's going to work best.
I do think there's a job of work to be done about enhancing parental trust in how the education system is going to manage that, and they're very well aware of that, because at the moment, there is generally a feeling that you've articulated that parents feel they're not going to get anywhere without the diagnosis. But I think equally, parents understand that diagnosis alone is not actually working for them. It's not getting them the support that they require.
I mean, one example is with ADHD that the opportunity for moving from a diagnosis of ADHD to actually implementing a very specific treatment, first of all, a psychosocial intervention, which is number one, treatment. And secondly, medication intervention has halved since Covid. But there is there is no follow through at the moment. So I think it's going to be in the doing of it and how the doing is organised that that's going to work best.
10:49
10:49
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10:49
Speaker 3
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Speaker 3
The vast majority have more than one condition. Half of the people with a common mental disorder are going to have two or more conditions. It's it's the rule rather than the exception. It's a question of finding what what the co-occurring condition is and treating it appropriately. And I mean, to go back to one of the points over here in the discussion about how the dynamic environmental interaction is making things more obvious.
I definitely do not want to ever suggest that people do not have very significant problems with each of these individual diagnoses as well. People have very significant autism, very significant learning difficulties, but it's the combination when they come together. So about 4% of young people will have combined difficulties with life long impact. Whatever you do, it will go on affecting them. They and their families need a very particular form of support in general that has been less available to them because of the huge waiting lists, and they just have to join a waiting list like everybody else.
It's one of the reasons why we have proposed a very careful prioritisation based on complexity and risk.
I definitely do not want to ever suggest that people do not have very significant problems with each of these individual diagnoses as well. People have very significant autism, very significant learning difficulties, but it's the combination when they come together. So about 4% of young people will have combined difficulties with life long impact. Whatever you do, it will go on affecting them. They and their families need a very particular form of support in general that has been less available to them because of the huge waiting lists, and they just have to join a waiting list like everybody else.
It's one of the reasons why we have proposed a very careful prioritisation based on complexity and risk.
10:51
10:51
Speaker 2
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Speaker 2
Okay. One of the difficulties with the current system, and indeed be nice, which I very strongly support as a an arm of the health service. One of the problems is that it's based on single diagnosis, and that needs to be changed. That needs to change because of what Professor Baird said about the co-occurrence, the prevalence of co-occurrence. So single diagnostic pathways are probably unhelpful. In general, I would say that that doesn't mean that single problems can't be or shouldn't be dealt with in turn, but it needs to be a multidisciplinary team.
And the the team around the child represents the appropriate addressing of the problem of co-occurrence. And I would very much hope that in those new neighborhood services that I was talking about, we will have a mental health, physical health represented because of the co-occurrence of physical health problems in many of the children, which at the moment is completely separate.
And the the team around the child represents the appropriate addressing of the problem of co-occurrence. And I would very much hope that in those new neighborhood services that I was talking about, we will have a mental health, physical health represented because of the co-occurrence of physical health problems in many of the children, which at the moment is completely separate.
10:52
Speaker 9
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Speaker 9
And excuse me, and you've touched on the the breadth of the experience and the services that need to be offered, but who should be responsible for coordinating that support for individuals with complex and overlapping needs and moving past school into employment? What does that look like for employers?
10:53
Speaker 2
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Speaker 2
Okay. Who should be in charge matters less than somebody should be in charge. So where we have problems is when there is dissipation of responsibility. I don't think it's a problem if the system is organized in a way that's can be specific to a local system. I don't think it needs to be a national model that's implemented. It can be fitting that local system and the prevalence that occurs within that system, which widely vary because of a whole range of social factors.
So it's appropriate to a locality, but at the same time it's integrated and coherently organised. So one of the things that we recommend is that all the parts are there in the current system. What we're recommending is coordinating those in a more efficient way. The coordination should come locally, but that means leadership. And if there's no leadership, the service will fail.
So it's appropriate to a locality, but at the same time it's integrated and coherently organised. So one of the things that we recommend is that all the parts are there in the current system. What we're recommending is coordinating those in a more efficient way. The coordination should come locally, but that means leadership. And if there's no leadership, the service will fail.
10:54
10:54
Speaker 2
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Speaker 2
Well, I think the same principles apply. At the moment. We have a system which you're well familiar with that in a way, incentivizes disability. We need to have a system where employers are supported in enabling and supporting, rather than simply signing off that the same thing needs to apply. At the moment, doctors do not give advice to employers about what can be done with this person that might help them.
They give advice that they are unfit to work. That is the that is a limited way of dealing with it. I think the principle that we are recommending for education applies equally to employment. That is, it's it's focused on need and supporting that need, and that employers are supported in supporting needs.
They give advice that they are unfit to work. That is the that is a limited way of dealing with it. I think the principle that we are recommending for education applies equally to employment. That is, it's it's focused on need and supporting that need, and that employers are supported in supporting needs.
10:55
Speaker 3
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Speaker 3
And that means understanding the barriers to perhaps being able to participate. And that's we're coming back to your original question about single diagnosis or understanding how a particular diagnosis can have an impact. So, for example, if somebody with autism may have a very marked reaction to the sensory environment that is different from, although anxiety may be mixed with it, it's different from simply feeling anxious and thus avoidant, so that you might need for the sensory environment.
It's an effortful to manage that. You might need longer periods of recovery rather than the avoidance, which might come with an anxiety. So, so there are there are subtleties which need need to be borne in mind. And in school, it's very helpful to understand the particular profiles that people present and understand how how that they therefore, their particular difficulties impact. So examples. Again, in autism you might have learning difficulties.
You might have extreme anxiety associated with it. You may have a demand avoidance profile. There are a variety of different ways in which children interact with the environment that need to be understood, and then can be helped individually. Thank you.
It's an effortful to manage that. You might need longer periods of recovery rather than the avoidance, which might come with an anxiety. So, so there are there are subtleties which need need to be borne in mind. And in school, it's very helpful to understand the particular profiles that people present and understand how how that they therefore, their particular difficulties impact. So examples. Again, in autism you might have learning difficulties.
You might have extreme anxiety associated with it. You may have a demand avoidance profile. There are a variety of different ways in which children interact with the environment that need to be understood, and then can be helped individually. Thank you.
10:57
Speaker 1
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Speaker 1
I just quickly pick up on, if I may demand avoidance profile. So we've had a a question from a clinician who I think had written to you, Professor Baird, about in the report itself, there's a comment that this is are we talking about the same thing? PD A is that the same thing? Yeah. That the evidence for that is clinically contested. I believe that's that's what the report says.
And what this professional said to us is that at the same time, the 2021 Nice guidance, which she believes you were in fact involved in drafting, specifically says that PD A is a subset of of autism. Her concern was that this is a mixed message to clinicians who were looking at the report and trying to do the best they can for their the families who are coming to their door. But it's slightly, it feels to her, slightly at odds with the fact that nice, say, PD A does exist and is not clinically contested.
Could you just clear that up for the clinician who wrote to us, please?
And what this professional said to us is that at the same time, the 2021 Nice guidance, which she believes you were in fact involved in drafting, specifically says that PD A is a subset of of autism. Her concern was that this is a mixed message to clinicians who were looking at the report and trying to do the best they can for their the families who are coming to their door. But it's slightly, it feels to her, slightly at odds with the fact that nice, say, PD A does exist and is not clinically contested.
Could you just clear that up for the clinician who wrote to us, please?
10:58
Speaker 3
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Speaker 3
Yes. The way in which most clinicians work is to follow the international classification systems, particularly the Diagnostic Statistical Manual called the DSM, or the ICD International Classifications by the W.H.O.. They have particular diagnoses and the. So the. When we were compiling the this particular report, we were using the standard classification systems for different diagnoses, and that's in chapter nine. There are a number of situations which are clinically very important, but which do not necessarily come into the DSM or the ICD.
Challenging behaviour. Is one of them a common problem in young people who have a combination of severe learning difficulties, often autism as well, and challenging behavior. Challenging behavior is not a diagnosis in itself. So we separated. Therefore a list of conditions which are important but which are not in the classification systems. And that's where PDA comes into our report. But as a recognised way of behaving.
Yes, clinicians will be familiar with it and nice guidelines can be followed. So I hope that's a.
Challenging behaviour. Is one of them a common problem in young people who have a combination of severe learning difficulties, often autism as well, and challenging behavior. Challenging behavior is not a diagnosis in itself. So we separated. Therefore a list of conditions which are important but which are not in the classification systems. And that's where PDA comes into our report. But as a recognised way of behaving.
Yes, clinicians will be familiar with it and nice guidelines can be followed. So I hope that's a.
10:59
10:59
Speaker 12
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Speaker 12
Thank you. So my questions will be around schools and family support. So we've heard time and again. And it's come through clearly in the report that it very much needs to be a needs led system rather than young people with their parents facing excruciating waits and feeling like they're in a, in an abyss of a void of actually getting the support that they need. So my question is, what's the role of a school in terms of ensuring that the needs are identified as early as possible, so the needs are addressed appropriately before waiting for that rubber stamped label diagnosis?
11:00
Speaker 2
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Speaker 2
I think that's excellent. And I'm really pleased to be able to say that current sand reforms are very much in line with developing those strategies. So many of the things that we know work for neurodevelopmental conditions are not clinical, but are best implemented in the context of education. And if there is a very well known study, the Oxford Study Survey of Young People that actually asks young people, what is helpful in your mental health need, they prioritize family and friends, but immediately afterwards they say the school way down the line comes child, adolescent mental health services.
And I think that's really underscoring the importance of how much schools can do. Importantly, there are limitations, and I just want to underscore those. So. Special educational needs actually , particularly CPS, in terms of looking at the evidence, haven't quite delivered in the way that people had hoped. So the outcomes, even despite greater investment, has not improved. Hard to assess, but but we know that major, major influence of mental health prevalence are things like school climate.
So you have vast differences between two schools in the same demographic area in terms of mental health prevalence. That's actually understandable in terms of the climate of that school. We know, for example, the teacher distress generates pupil distress. You know, it's it's important that we we address that. I think children also mask their discomfort at school. Often they, I many children that I've worked with who are regarded by their teachers, they're doing fine.
They're just doing fine at home. They're really difficult. And I think what we need to do is to integrate a sensitivity to a child's problems with education, far better mental health support teams that I had something to do with establishing is a step in that direction. Yeah.
And I think that's really underscoring the importance of how much schools can do. Importantly, there are limitations, and I just want to underscore those. So. Special educational needs actually , particularly CPS, in terms of looking at the evidence, haven't quite delivered in the way that people had hoped. So the outcomes, even despite greater investment, has not improved. Hard to assess, but but we know that major, major influence of mental health prevalence are things like school climate.
So you have vast differences between two schools in the same demographic area in terms of mental health prevalence. That's actually understandable in terms of the climate of that school. We know, for example, the teacher distress generates pupil distress. You know, it's it's important that we we address that. I think children also mask their discomfort at school. Often they, I many children that I've worked with who are regarded by their teachers, they're doing fine.
They're just doing fine at home. They're really difficult. And I think what we need to do is to integrate a sensitivity to a child's problems with education, far better mental health support teams that I had something to do with establishing is a step in that direction. Yeah.
11:03
Speaker 12
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Speaker 12
So I certainly recognize as a former school leader, I recognize a lot of what you have just shared, but what more do you see mental health support teams being able to do? Because dedicated and caring teachers and wider school staff, the whole pastoral team, etc., they cannot replace and should not replace the specialist health teams that are there. So what more can mental health support teams do in schools?
11:04
Speaker 2
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Speaker 2
You would again do us an enormous favor if you recommend you agreed with us that increasing the competence and increasing the complexity of problems that mental health support teams can deal with is a major way of dealing that with that group of children who do not meet criteria for specialist intervention, but exceed the capacity currently of mental health support teams. The missing middle, it's sometimes called, and if you can get mental health support teams empowered, but you could do to have to deliver the interventions, which we know work in a timely way.
In the context of schools, I think you would improve the outcome of schools quite, you know, quite broadly at the moment, even though mental health support teams are being rolled out, but they are somewhat underpowered, they don't deal with the missing middle. And
In the context of schools, I think you would improve the outcome of schools quite, you know, quite broadly at the moment, even though mental health support teams are being rolled out, but they are somewhat underpowered, they don't deal with the missing middle. And
11:05
11:05
Speaker 3
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Speaker 3
No, I totally agree. And you've got it absolutely right. And there are there are a number of interventions where at small scale, they're shown to be very effective and they could be increased. But specific treatments for anxiety in school, noticing earlier instituting that make a huge difference in the avoidance of school. People not wanting to go to school. We're also concerned, and no doubt the Education Department is to about the 1.5% of children who are not attending school for a whole variety of reasons.
So much to be done. But it's one reason why we've been very supportive of neighbourhood hubs, which bring together the people who could further support in school. So the expert at hand, as the education reforms have it. But these could be mental health professionals who could help run behaviour programmes for parents, help with the anxiety inputs and so on, and also would have specialisms in autism just as well as they have specialisms in being deaf, the visually impaired and so on, but all co-located, which would enhance very considerably in neighbourhood sections.
This integration that we think is absolutely vital.
So much to be done. But it's one reason why we've been very supportive of neighbourhood hubs, which bring together the people who could further support in school. So the expert at hand, as the education reforms have it. But these could be mental health professionals who could help run behaviour programmes for parents, help with the anxiety inputs and so on, and also would have specialisms in autism just as well as they have specialisms in being deaf, the visually impaired and so on, but all co-located, which would enhance very considerably in neighbourhood sections.
This integration that we think is absolutely vital.
11:06
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11:07
Speaker 13
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Speaker 13
And I'm going to now turn to look at the sort of send proposed send reforms a little more widely. I noted with interest your your recommendations seem to focus quite a lot on taking a more holistic approach to, to these sort of common conditions and perhaps not seeing things in silos. For example, I noticed that you warned that the reforms will fail if health and education services don't develop a shared approach, and particularly around language to assessing needs.
Would you be okay to speak a little bit further on that? And where you think particularly health services might be able to see their role as not just in terms of medical interventions?
Would you be okay to speak a little bit further on that? And where you think particularly health services might be able to see their role as not just in terms of medical interventions?
11:08
Speaker 2
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Speaker 2
Indeed, I think there are four , four issues about four conditions that are required in order for reforms to succeed. One is shared language investment is another one. And that touches on what you are raising. We need to have specialist advice and we need to have parental confidence in the system. But what is required, I think most of us would agree, is a model where parents can be confident that their child is not being deprived of the support that they need in order to thrive in that school.
11:09
11:09
Speaker 2
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Speaker 2
Well, one of the things that we are very hopeful would be adopted is for a common metric for understanding benefit from services that at the moment, health has measured symptoms at the same time as education measures, educational attainment and. Believe it or not, there are some people who do very well in education are quite unhappy. And unless you have an alignment of objectives based around what we call participation, that is, people feel that they belong.
They belong to the school, which is as much a wellbeing issue as it is an issue. What in education? Sadly, young people less and less feel that they belong. But that's not a. That's not an issue that schools are assessed on.
They belong to the school, which is as much a wellbeing issue as it is an issue. What in education? Sadly, young people less and less feel that they belong. But that's not a. That's not an issue that schools are assessed on.
11:10
Speaker 13
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Speaker 13
I noticed this in your review and you said that education itself can contribute to distress through factors such as the lack of belonging. And we've been talking a little bit around social model of disability as well. Do you think that in their current guise, schools can actually be a risk factor for people who are predisposed to ADHD and autism?
11:10
Speaker 2
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Speaker 2
I can I just be very clear about this. Although children are linked, their unhappiness to school, that is not necessarily a development that has occurred recently, that there have been children who have linked their unhappiness to school time immemorial. So I, I think it's really an easy mistake, in my view, to make to blame schools. As professor mentioned, there have been some changes in schools, but the focus has.
The focus has moved to performance in a particular modality . That may indeed create pressures on a particular population of children. And that that should be broadened is, to me, a no brainer. But I would really I think schools are trying to do their best, and I would be very unhappy if any part of our report was read as trying to blame schools for. The problems. There are problems that could be changed that the.
There are aspects of schools that could be changed that would reduce the problems. But that is in relation to broadening the parameters that are used to evaluate education in this country.
The focus has moved to performance in a particular modality . That may indeed create pressures on a particular population of children. And that that should be broadened is, to me, a no brainer. But I would really I think schools are trying to do their best, and I would be very unhappy if any part of our report was read as trying to blame schools for. The problems. There are problems that could be changed that the.
There are aspects of schools that could be changed that would reduce the problems. But that is in relation to broadening the parameters that are used to evaluate education in this country.
11:12
Speaker 13
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Speaker 13
And perhaps. Professor Baird, I can kind of turn to you on a similar sort of vein. Not necessarily that schools are to blame as such, but the way that the education system is set up. And you said there were changes previously that have led to a kind of focus. So for people, to use your analogy earlier, that are predisposed to autism or ADHD is, is the way that schools kind of focus on particular things such as, you know, certain types of educational attainment or attendance metrics, for example, could that be something that is exacerbating some of these issues?
11:12
Speaker 3
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Speaker 3
Well, there's no doubt that when we looked at the evidence that around exam time, people's anxiety rises, but then generally it comes down again. So the certainly the specific aspects, I think the important thing is that people need to feel they're succeeding, don't they? They need to feel that they, they, there's something in which they're being successful. And, and schools have a really difficult job, but it's, it's the range of what people are able to experience and engage in having something at which people are good at and can do.
And the Positivities, I think are extremely helpful and necessary. And so there are certain people do comment on various aspects of school, which some of them have struggled with. But I totally concur with exactly what Peter has said, that the overall people have always found some things very difficult about school and, and people get. Adolescence is a time when people are really trying to discover themselves. That sense of belonging and the opportunities for the rest and recovery that Peter has emphasised throughout the report are really the most important factors.
And learning how to manage social relationships and the interactions with the outside world. That's really some of the job that I think needs to be enhanced.
And the Positivities, I think are extremely helpful and necessary. And so there are certain people do comment on various aspects of school, which some of them have struggled with. But I totally concur with exactly what Peter has said, that the overall people have always found some things very difficult about school and, and people get. Adolescence is a time when people are really trying to discover themselves. That sense of belonging and the opportunities for the rest and recovery that Peter has emphasised throughout the report are really the most important factors.
And learning how to manage social relationships and the interactions with the outside world. That's really some of the job that I think needs to be enhanced.
11:14
Speaker 13
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Speaker 13
Thank you. And I don't envy anyone being a teenage girl, I hated it. So, you know, if we move on to the wider send reviews and proposals, because I we touched on this a little bit, one of the key things that we've taken quite a lot of evidence about is the lack of health being around the table when it comes to either planning, individual educational, health and care plans, or when it comes to commissioning send services.
We time and again have taken evidence that they're just not there. They don't play their part, and it's a systemic issue rather than any particular regional area or variation, how should we ensure that that change is how do we make sure that health see their role as being more than just okay, we need to improve our diagnostic time frame. And I know this is very interesting. My local area, their focus seems to be on improving the delay in diagnostics rather than actually maybe holistically looking at how they support the wider system.
How do we get them to do that?
We time and again have taken evidence that they're just not there. They don't play their part, and it's a systemic issue rather than any particular regional area or variation, how should we ensure that that change is how do we make sure that health see their role as being more than just okay, we need to improve our diagnostic time frame. And I know this is very interesting. My local area, their focus seems to be on improving the delay in diagnostics rather than actually maybe holistically looking at how they support the wider system.
How do we get them to do that?
11:15
Speaker 3
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Speaker 3
Well, I think the model that we proposed of the local neighborhoods, using examples where it's already happening, I would suggest, would be really very helpful indeed. The next is is commissioning and having integrated commissioning so that that's what people are organised and they're, that's, that's their job again, as close to home as possible. So those, I would say would be the main two drivers that you that you have for actually going forward.
11:15
Speaker 2
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Speaker 2
Can I have two others to it on either end commissioning for outcomes rather than commissioning for the. Performance of actions that may be successful or not. So commissioning for outcome and better outcomes is defined as actually participation. And the other is which touches on what what Gillian mentioned is understanding increasing in education, that health is responsible for improving understanding. I can't think of a better example than understanding behavioural problems .
That health has a better understanding of why behavioural problems emerge in children than education does, which has to deal with it much more in terms of the whole class, whereas health, if it was at the table, could provide better ways of managing problem behaviors in children, either via help supporting parents, which I personally believe is the most effective mode, but also, as we know, supporting teachers and assistant teaching assistants in managing behaviour better. I mean, one example that I.
We've developed. And we developed a model of a family school , pears, family school, Anna Freud, where actually what we do is we bring parents into the school to observe how to manage their child's behaviour better from teachers and from assistant teachers. And but the embedded in that are supporters of the teachers to manage the child's behaviour. And this is children with diagnosis of autism, children with diagnosed severe OCD.
These are children. This is a children who have been excluded from other schools. But integrating the wisdom is the answer.
That health has a better understanding of why behavioural problems emerge in children than education does, which has to deal with it much more in terms of the whole class, whereas health, if it was at the table, could provide better ways of managing problem behaviors in children, either via help supporting parents, which I personally believe is the most effective mode, but also, as we know, supporting teachers and assistant teaching assistants in managing behaviour better. I mean, one example that I.
We've developed. And we developed a model of a family school , pears, family school, Anna Freud, where actually what we do is we bring parents into the school to observe how to manage their child's behaviour better from teachers and from assistant teachers. And but the embedded in that are supporters of the teachers to manage the child's behaviour. And this is children with diagnosis of autism, children with diagnosed severe OCD.
These are children. This is a children who have been excluded from other schools. But integrating the wisdom is the answer.
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11:18
Speaker 13
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Speaker 13
There is a there is definitely a move. Well, it seems that you're saying there's definitely something that could be done centrally in terms of maybe articulating that health does have this role in prevention, in increasing knowledge, in increasing that kind of education for both teachers and parents. Currently, you'll be aware that the delivery of education, health and care plans, the statutory responsibility , falls solely on local authorities. And we've taken some evidence that actually putting a similar duty on health bodies, and indeed, I tabled an amendment that was supported by both of our committees to the recent health bill to place a kind of equivalent duty on icbs or health trusts to deliver that health plan, to give them that real onus , that owning of the issue.
Is that something that you think would be helpful, or would it obscure the issue? It
Is that something that you think would be helpful, or would it obscure the issue? It
11:19
11:19
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11:19
Speaker 9
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Speaker 9
To push you a little bit on some of the practicalities of delivery, building on the questions that Jen has asked that I asked already. So I think the conversation that we've had today will be enormously frustrating for many of the stakeholders that my committee works with within education. So I think some of the things that you have said imply that schools can just do things. I think if you're working in the education sector as it is at the moment, that they are under a whole range of pressures, that that stem from their own accountabilities and what they're tasked with doing that that that would make it very difficult for, for them to do things.
And I think the it is hard to overstate the extent to which both the education sector and local authorities are tearing their hair out with the health system. And so this comes down to so we can all look at and we do on our committees at examples of good practice at who is doing things well at, you know, how things should be and, and what we can learn from. But this will boil down to accountability.
It boils down to what people are measured against and what they are required to do. And we don't have that for health at the moment in relation to the delivery of support for neurodivergent children and children with mental health difficulties in in schools. And we have been talking about this agenda for 25 years. We've been talking about Co-commissioning. We have Icbs, which are supposed to have local authorities at the table, that their voice is extremely weak.
They are supposed to do joint commissioning. These things are supposed to happen and yet they don't. So I would just make a plea that we move the conversation on from how things should be and hypothetically can be, and indeed are in some circumstances where things are done well to how we arrange the system in its fundamental accountabilities to deliver the things that we know children need in education, because that is the thing that's not happening at the moment.
And I think the it is hard to overstate the extent to which both the education sector and local authorities are tearing their hair out with the health system. And so this comes down to so we can all look at and we do on our committees at examples of good practice at who is doing things well at, you know, how things should be and, and what we can learn from. But this will boil down to accountability.
It boils down to what people are measured against and what they are required to do. And we don't have that for health at the moment in relation to the delivery of support for neurodivergent children and children with mental health difficulties in in schools. And we have been talking about this agenda for 25 years. We've been talking about Co-commissioning. We have Icbs, which are supposed to have local authorities at the table, that their voice is extremely weak.
They are supposed to do joint commissioning. These things are supposed to happen and yet they don't. So I would just make a plea that we move the conversation on from how things should be and hypothetically can be, and indeed are in some circumstances where things are done well to how we arrange the system in its fundamental accountabilities to deliver the things that we know children need in education, because that is the thing that's not happening at the moment.
11:21
Speaker 2
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Speaker 2
Do you believe that that's beyond our remit? I believe that's government that's responsible for doing that. We can recommend and we do recommend a commissioning system that actually is mindful of exactly the kind of things that. And it. An integrated system is the only system that could possibly work and meet the mental health crisis that we see in young people at the moment. We couldn't agree with you more.
Now, I would not want to in any way under estimate the pressures that schools are under. And I hope that I haven't tried to shift the blame, but I wouldn't want to underestimate the system that the health that those working in child and adolescent mental health care are, are under either. And it's very easy when you have two bodies that talk poorly to each other, to blame the other for not doing their job properly.
I think the conversation needs to change and it needs to start by a common language being around the needs of families, needs of children and needs of young people, and shared responsibility for those needs being met. I don't think that unless you do that, and unless you invest sufficient resources for that to be delivered in a timely way when it's needed, as soon as the problems present, you will deal with the problem.
Now, I would not want to in any way under estimate the pressures that schools are under. And I hope that I haven't tried to shift the blame, but I wouldn't want to underestimate the system that the health that those working in child and adolescent mental health care are, are under either. And it's very easy when you have two bodies that talk poorly to each other, to blame the other for not doing their job properly.
I think the conversation needs to change and it needs to start by a common language being around the needs of families, needs of children and needs of young people, and shared responsibility for those needs being met. I don't think that unless you do that, and unless you invest sufficient resources for that to be delivered in a timely way when it's needed, as soon as the problems present, you will deal with the problem.
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11:23
Speaker 9
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Speaker 9
Thank you. And my second practicality is around expertise. So I think we would agree with you. And this inquiry has heard a significant amount of evidence about the missing middle who are in education and whose mental health needs are not currently met through mental health support teams. But that requires a change in the expertise within mental health support teams, and it because they are not currently tasked with, you know, their current remit is mild to moderate mental health needs.
The children who we describe as being within the missing middle have a more severe need stopping short of requiring Camhs interventions. Can you say what you think is needed in terms of the level of expertise in mental health support teams, and also perhaps what that might look like in terms of a sort of change in the workforce required?
The children who we describe as being within the missing middle have a more severe need stopping short of requiring Camhs interventions. Can you say what you think is needed in terms of the level of expertise in mental health support teams, and also perhaps what that might look like in terms of a sort of change in the workforce required?
11:24
Speaker 2
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Speaker 2
I mean, we are quite explicit about that in the review. But let me just set the record straight. Although they are supposed to do mild to moderate mental health support teams, the reality, the objective reality is that actually they do moderate to severe. And they deal with co-occurrence. So most of the children referred have a diagnosis of neurodevelopmental conditions in addition to mental health conditions, which is all the other data that we have supports that.
So mental health support teams at the moment do more than what they were originally designed to do. It. The system needs to change for there being better training in cognitive behavior therapy, eating disorder, post-traumatic stress disorder, a whole range of systems. This is something that personally the different head I recommended 3 or 4 years ago. It hasn't been possible so far. If you can add your voice to this, maybe jointly will be successful.
At the moment, the initiative has been to spread the. All the schools include all the schools and we have been successful at that . And I would want to say that. In the case of anxiety, mental health support teams are remarkably successful, so they may not be dealing with everything that you want, but those who meet clinical levels of anxiety over 50% of the time are successfully dealt with. This is a trial.
This is a study that we. Recently published on 23,000 children, if I remember correctly. So it does deliver, but it could do a hell of a lot better . Then.
So mental health support teams at the moment do more than what they were originally designed to do. It. The system needs to change for there being better training in cognitive behavior therapy, eating disorder, post-traumatic stress disorder, a whole range of systems. This is something that personally the different head I recommended 3 or 4 years ago. It hasn't been possible so far. If you can add your voice to this, maybe jointly will be successful.
At the moment, the initiative has been to spread the. All the schools include all the schools and we have been successful at that . And I would want to say that. In the case of anxiety, mental health support teams are remarkably successful, so they may not be dealing with everything that you want, but those who meet clinical levels of anxiety over 50% of the time are successfully dealt with. This is a trial.
This is a study that we. Recently published on 23,000 children, if I remember correctly. So it does deliver, but it could do a hell of a lot better . Then.
11:27
Speaker 9
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Speaker 9
Final question is, so my committee has had a lot to say about how. So we think that prevalence in the classroom at the moment is about 20%. We think there are about 4 or 5 children in every classroom, in every school, right across the country, who have some type of neurodivergence or special educational need or disability. And yet our education system is fundamentally not designed for those children. And we know the government wants to shift towards inclusive, mainstream schools that can better meet the needs of all of the children who are in the classroom.
We want all children to thrive in education. There shouldn't be any conflict between high standards and meeting the needs of children who have a who have neurodivergence in the classroom, because those children are a part of our population, of peoples whose needs we are seeking to serve. What does an inclusive mainstream system look like from the perspective of your expertise, and what should. How should the government be defining that as it seeks to implement its own reforms?
We want all children to thrive in education. There shouldn't be any conflict between high standards and meeting the needs of children who have a who have neurodivergence in the classroom, because those children are a part of our population, of peoples whose needs we are seeking to serve. What does an inclusive mainstream system look like from the perspective of your expertise, and what should. How should the government be defining that as it seeks to implement its own reforms?
11:28
Speaker 3
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Speaker 3
Does slightly depend on what age you're talking about and the age group of the children. So let us start with the preschool and the way in which it is possible to integrate and have inclusion at that stage, while also defining the kind of problems that the children are going to experience as they move on. Now, it's not that any system has shown that you can accurately screen everybody and expect to get 100% sensitivity and specificity.
You don't, but you can have a very good idea by the time children are starting at five, six and so on, what some of the biggest problems they're going to get, and you should already be in a system of parental support. And you will know, of course, the success of Surestart and how one really wants needs to get back into that kind of, again, early support hubs, bringing families with, with you. And then by the time you get into primary school, then different problems may become manifest.
And that's the time when again, inclusion should be possible. But making the the modifications that again, an understanding of the individual pupil will bring. And I totally support your aim of trying to insist that the hubs, the local hubs have expertise which is able from health as well as education to investigate such children support school with an understanding of what they need.
You don't, but you can have a very good idea by the time children are starting at five, six and so on, what some of the biggest problems they're going to get, and you should already be in a system of parental support. And you will know, of course, the success of Surestart and how one really wants needs to get back into that kind of, again, early support hubs, bringing families with, with you. And then by the time you get into primary school, then different problems may become manifest.
And that's the time when again, inclusion should be possible. But making the the modifications that again, an understanding of the individual pupil will bring. And I totally support your aim of trying to insist that the hubs, the local hubs have expertise which is able from health as well as education to investigate such children support school with an understanding of what they need.
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11:30
Speaker 3
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Speaker 3
What they need or don't need. I hope I hadn't pressed something and and and the the next cliff edge tends to be entering into secondary school. And again, what we don't have are really good, properly integrated systems of planning for individual children who are likely to need additional support as they move from that stage to secondary and then onto further education. Peter, I'm sure, has other visions I.
11:30
Speaker 2
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Speaker 2
But I just want to put in a word for higher education, universities and universities are also facing pressure in accommodating people who now increasingly come with neurodivergent neurodiverse conditions. And the sad fact is, as far as we can tell, that the kind of accommodations that universities offer are totally without value.
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11:31
Speaker 7
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Speaker 7
A proper exploration of university provision, and there is no input of the kind that Gilliam was talking about from health into universities. Universities try to manage as best they can. Now, you know, you wouldn't expect the university to deal with brain scans that install a scanner so that they can deal with possible brain damage, but they are expected to deal with neurodiversity, and I don't think they are equipped to do so.
So if you could point to that, I think that would be helpful.
So if you could point to that, I think that would be helpful.
11:32
Speaker 1
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Speaker 1
Thank you. We're about to lose quorum, but I have one extremely fast. Final question. What is this is this is asking you to pick among your children. I appreciate this, this review comes as a whole, but if there was a one single most impactful recommendation that we could make, these two committees coming together to try and help to implement your review, what would it be? Professor Fonagy.
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Speaker 7
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Speaker 7
So family hubs come into that neighborhood integrated models, but really it's. Something that enables us to overcome the fragmentation that has stopped us from delivering what actually ensures mental health, which are three simple things people, place, purpose, people being relationships that support places, meaning places where you can benefit from that social support and purpose in your life. Education is a major purpose. Let's hope that we can do better for children and young people than we have been able to do over the past 20 years.
That's a good
That's a good
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