Prof. Fonagy and Prof. Baird are Chair and Vice-Chair of the Independent Review into Mental Health Conditions, ADHD and Autism. The session focused on proposals to move towards a needs-led approach, improve support before diagnosis, and better integrate mental health, ADHD and autism services.
A summary is below, the page covering the evidence session is here and the full transcript here.
What was said about GPs and primary care
GPs were not a major focus of questioning, but several themes were relevant to primary care:
- Earlier identification of need.
- Better coordination between health, education and wider support services.
- Development of integrated local services and neighbourhood hubs.
- Providing support to children and young people while they await specialist assessment.
Neither of the London MPs on the Health and Social Care Committee attended the session.
Summary of evidence from witnesses
- Support should come before diagnosis
The review was highly critical of the current pathway, which it outlined as:
- Wait.
- Assessment.
- Diagnosis.
- Support.
The report authors proposed a new pathway of:
- Identify need.
- Assess need.
- Start support.
- Diagnose where necessary.
- Review and adapt support.
Prof. Fonagy argued that children and young people should receive support when they present with need, rather than waiting for a diagnosis. He stated that diagnosis alone does not determine what support an individual requires.
- ADHD, autism and mental health should be assessed together
A central recommendation was to move away from separate ADHD, autism and CAMHS pathways, highlighting high levels of co-occurrence between:
- ADHD.
- Autism.
- Anxiety.
- Depression.
- Self-harm.
- Eating disorders.
The witnesses argued that children are often assessed multiple times across different services because of fragmented pathways. They recommended integrated assessments that consider all relevant factors rather than focusing on a single diagnosis.
- Long waits are causing harm
Prof. Fonagy and Prof. Baird repeatedly stated that waiting lists are not neutral, it is their view was that:
- Conditions often worsen while children wait.
- Opportunities for early intervention are missed.
- Treatment becomes less effective when support is delayed.
The review argued that support should be offered much earlier before children reach the threshold for specialist services.
- No evidence of widespread ADHD or autism overdiagnosis
This was one of the most debated parts of the session, with Prof. Fonagy say:
- The review found no evidence of large-scale overdiagnosis.
- There was evidence of misdiagnosis and incomplete assessment.
- Many children have multiple overlapping conditions.
He argued that concerns about overdiagnosis should be distinguished from problems caused by fragmented pathways and failure to identify co-occurring conditions.
- Concerns about the current diagnostic system
The review raised concerns that:
- Some assessments may be very brief.
- Families can receive a diagnosis without receiving meaningful support afterwards.
- Greater consistency and quality assurance are needed across providers.
- Diagnosis was being seen as the endpoint of care.
- Mental Health Support Teams (MHSTs)
The witnesses argued strongly for expanding the role of MHSTs as a way of addressing:
- MHSTs are often focused on mild-to-moderate conditions only.
- There is a large “missing middle” group whose needs exceed current MHST support but do not meet CAMHS thresholds.
Suggested changes included:
- Expand MHST skills and capability.
- Provide support for more complex presentations.
- Deliver evidence-based interventions earlier.
- Schools and SEND reform
A recurring theme was that health and education often operate using different systems and language. The review warned that SEND reform will struggle unless:
- Health and education adopt a common understanding of need.
- Joint working and commissioning improve.
- Families can access support without needing a diagnosis first.
The witnesses repeatedly stated that parents are usually seeking help and support rather than simply seeking a label.
- Social determinants and prevention
Professor Fonagy strongly rejected the idea that current levels of mental ill health reflect a “snowflake generation”.
Factors identified as contributing to rising levels of distress included:
- Housing insecurity.
- Financial pressures.
- Educational pressures.
- Reduced youth services.
- Reduced social connectedness and belonging.
- Social media.
- Poor sleep.
The review emphasised prevention and addressing wider social and environmental factors affecting young people’s mental health.
- Right to Choose
The review does not recommend abolishing Right to Choose, instead arguing:
- Families often pursue Right to Choose because local services are unable to meet demand.
- Better support before diagnosis could reduce reliance on alternative assessment routes.
- The current system places considerable emphasis on assessment and diagnosis.