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Wes Streeting is a politician whose keen interest in the zeitgeist is only matched by his seeming drive to be as close to the heart of it as possible. It is, therefore, not much of a surprise that the secretary of state for health and social care should end the year by announcing what the official blurb calls an “independent review into mental health conditions, ADHD and autism”. Many of the resulting headlines put it more pithily: in keeping with an increasingly deafening media din, this will seemingly be an investigation into “overdiagnosis”.
Candidates for 2025’s word of the year have so far included “rage bait” and “parasocial”, but overdiagnosis is surely the term that perfectly captures the intellectual and political fashions of the past 12 months. The mess of ideas it crystallises now has a set text, published back in March: The Age Of Diagnosis by the neurologist and epilepsy expert Dr Suzanne O’Sullivan. Having been pronounced on, with his usual belligerent ignorance, by Nigel Farage, overdiagnosis has become an obsession of the Reform UK deputy leader Richard Tice, who now holds forth about why some children with special educational needs shouldn’t be entitled to dedicated school transport, and claims that the sight of kids with sensory issues wearing ear defenders at school is “insane”.
News of an official review first broke in October, and its terms of reference seem comparatively reasonable. In the Guardian, Streeting wrote last week about a focus on “support for mental health conditions, autism and ADHD”, and “how the NHS can meet the needs of all”. The review’s launch document makes mention of “prevalence, drivers, early intervention and treatment”.
But clearly, its work has been commissioned partly for political reasons. There is a queasy whiff about its basic remit that – with strong echoes of what we hear from “overdiagnosis” merchants – clumsily mixes questions about mental illness (anxiety, depression) with autism and ADHD, which are neurodevelopmental. As mentions of “economic inactivity” prove, there is a clear sense of pitch-rolling for the return of so-called welfare reform. There are also telling uses of the word “medicalisation”, a term usually favoured by people who think that many conditions do not need any diagnosis at all.
And as is becoming its habit, the government has decided to speak to different audiences in contrasting tones of voice. In the front-page splash that first announced the review, the Times said the health secretary was “concerned” about rising rates of diagnosis of both mental illness and what we now understand as neurodivergence, and there was also mention of ordinary feelings and stresses being “overpathologised”. All this sounds worryingly like a polite manifestation of a very familiar kind of thinking, reflective of a country in which questioning other people’s needs is almost becoming a national sport.
Answers to questions the new inquiry asks might be less complicated than they seem. There are more people being diagnosed with anxiety and depression because of an education system and model of work that are so harshly competitive and inherently precarious, and the still-overlooked effects of the pandemic. ADHD – which, just to reiterate a very important point, is not a mental illness, but a matter of neural wiring – is something we are only just starting to understand, but it is worth recalling official reports that put the number of children and adults in England who are affected at 2.5 million, though only 800,000 currently have a formal diagnosis. Those numbers, moreover, are evidence of something that is not going to go away: our ever-growing understanding of the sheer complexity of our minds and brains, and how much our institutions still lag behind.
That is also true of rising autism diagnoses. We live in the long aftermath of diagnostic changes that happened in the 1980s and 1990s, when the definition of autism was widened to include people without an intellectual or learning disability, reflecting the basic – and incontestably correct – idea of a spectrum. The next stage of those shifts arrived only a relatively short time ago, when the different and often complex ways autism presents among women and girls finally began to be discussed. A new level of autism awareness fostered by the internet, meanwhile, had alerted people to the fact that they need not put up with constant misunderstanding and bullying; these days, they can find out who they – or their children – really are, what help they may need, and how to thereby live a life that is more settled and fulfilling,
That prospect ought to be exciting and liberating. Unfortunately, our economy is flatlining, and public spending is constantly squeezed. So, amid lengthening waiting lists, how do we deal with all that increased need? Overdiagnosis offers a simple answer: you tell people – not least those who can be classified as “mild” or “moderate” cases – to be more resilient, and wave them away.
There is one very convenient article of faith that seems to be increasingly fashionable in Westminster: the idea that diagnoses can do more harm than good, which is the key contention that defines O’Sullivan’s book. “The stigma of autism has been associated with low self-esteem among children,” she writes, while blithely feeding those same negative perceptions by referring to autism as a “brain disorder” and an “illness”. An autism diagnosis, she claims, runs the risk of being “a self-fulfilling prophecy, as some will take the diagnosis to mean they can’t do certain things, so won’t even try”. But unless we can specify who people are and what broad psychological category they fit into, how do we know how to help them: what educational methodologies to use, how to adjust their learning environment and what aptitudes and talents can be developed?
Over the past eight months, I have had hundreds of conversations about all this, at events put on to promote Maybe I’m Amazed, the memoir I’ve written about my autistic son James, and how, ever since he was a toddler, music has been a massive part of how we connect. From Jersey to the Yorkshire Dales, one insight has come up countless times: the fact that the autistic spectrum is not nearly as linear as some people think, and that the relevant traits occur with such wildly different intensities that crudely labelling people as “mild”, “moderate” and “severe” is sometimes all but impossible. That blurs into another regularly voiced point: how the plain fact that human beings’ brains work in completely varied ways rather makes a mockery of a basic method of education – standing in front of 30 kids and shouting at them for an hour – that is now decades out of date.
There is another thing that people always talk about. Autism often reflects traits that run through people’s family trees – something they tend to become aware of in retrospect. Past flickers and flashes of eccentricity, obsessiveness or social awkwardness will suddenly take on new meanings. More painfully, people suddenly become aware of relatives who had frustrating and broken lives, because so little was known about things that many of us now take as a given – not least the fact that autistic minds are as complex and sophisticated as any other kind, and in most cases, they need careful support and nurturing. And in that context, theories and pronouncements about overdiagnosis sound to many people like a nightmarish turning-back of the clock.
They are not wrong. Human psychology is complicated. Politics and power, by contrast, tend to be crass, cruel and prone to coming up with completely the wrong questions. Which brings me to one question I’d like to ask the health secretary: however much he prettifies it, why is he picking over the number of diagnoses, when he could be focusing on why our systems of work, education and care are still so closed off to the people who get them?
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John Harris is a Guardian columnist. His book Maybe I’m Amazed: A Story of Love and Connection in Ten Songs is available from the Guardian bookshop
