A teacher notices that a child in her class - let’s call her Tracey - struggles to follow spoken instructions, becomes distressed during noisy activities and finds unexpected changes overwhelming.
The school meets with the family, and it turns out they have been raising concerns with their GP for years. Tracey says it is the noise at lunchtime and not knowing what is coming next that she finds hardest.
Everyone agrees that the child needs help, but the conversation ends, as so many do, with: “We need to wait for a diagnosis.”
If you work in a school or you have a child who has struggled at school, you may well recognise this scenario. But what, exactly, are we hoping the medical specialist will discover? That the child is struggling to follow instructions, cope with noise and manage transitions?
We already know this. A clinical assessment may be needed or helpful, but it answers a health question, not an educational one.
Moving to ‘needs-led’ SEND support
We were both privileged to serve as topic group members on the new Independent Review into Mental Health Conditions, ADHD and Autism, led by Professor Peter Fonagy. We are delighted that the review emphasises that diagnosis is not the same as need.
The review calls for a shift from a “diagnosis-dependent” system to a “needs-led plus diagnosis” one, where support is not “withheld while waiting for a diagnosis”.
This matters because, as the review makes clear, waiting does harm. More than 560,000 people were waiting for their ADHD assessment by the end of 2025, and more than 254,000 were waiting for an autism assessment.
The worry is that more than seven in 10 people waiting for over six months see their difficulties worsen.
We want to be clear that diagnosis matters. It can help people to make sense of their experiences, guide treatment and open the door to specialist support. For many families it brings a valued sense of identity and community.
Clinical expertise also matters in school. A child’s difficulty in concentrating might involve anxiety, disrupted sleep or a hearing problem, and a needs-led approach can never become an excuse for leaving a child’s health needs untreated.
What the teacher sees
But what a diagnostic label cannot do is tell a teacher how a child learns. Those of us who have taught in classrooms know that two autistic children may need very different support.
In the words of the review: “People with the same diagnosis may require very different kinds of help.” Equally, a child without a diagnosis may benefit from many of the same adjustments that help a neurodivergent child to learn.
Teachers are well placed to see these differences because they spend every day getting to know how children learn. However, the system often acts as if the view of the teacher doesn’t count until a medical clinician has signed it off. This makes little sense, and it isn’t fair.
Access to diagnosis is shaped by family income, ethnicity and where you live. This means that a system that waits for diagnosis helps those best able to navigate the clinical pathways.
None of this is an argument against health services. Health and education bring different, complementary expertise, and children need both skillsets.
Two frameworks to help
Two World Health Organisation frameworks can help us to understand this point.
The International Classification of Diseases (ICD) is the manual that clinicians use to diagnose health conditions.
The International Classification of Functioning, Disability and Health (ICF) helps us consider what a person can do in everyday life, and what in their surroundings helps or hinders them.
The ICF helps with the educational question because it looks at functioning in context. What can this child do? What are they finding difficult? And how does the classroom help or hinder them?
Imagine a child who struggles when several instructions are fired across a noisy classroom, but who understands a task when it is broken into steps in a quieter space. The child hasn’t changed. The classroom has.
Often the change is simple and inexpensive: a visual agenda for the day, a two-minute warning before transitions, instructions given both aloud and in writing, offered to the whole class.
Finding the right fit
This is the thinking behind our recent paper setting out an Educational Needs-Led Framework (ENLF), which describes educational need as relational and dynamic. Put simply, need arises from the fit between a child and their setting, and it changes as either one alters.
Think of a ramp: it transforms what a wheelchair user can do without changing their impairment. Good classroom adjustments work in much the same way.
So, what does this look like in practice? Our framework flips the usual order. Concern leads straight to action in the classroom rather than leading to referral, waiting, diagnosis, and only then support.
School staff sit down with the child and family to note what the difficulty is, when it happens, what the child is good at and what already helps.
Together they try some changes and check whether these adjustments are working. If there are health concerns, clinical assessment runs alongside the support being offered. Neither service waits for the other to finish before it begins its role.
Health and education working together
Working side by side does not mean doing each other’s jobs, and this is where the review’s recommendations for a shared needs assessment framework will need careful design. A child struggling in lessons does not tell us whether they are autistic or have ADHD.
Equally, how a child manages in a quiet clinic appointment cannot tell us what they need across a busy school day; for that, we need evidence from school and from the child and family.
Teachers’ observations are valuable to clinicians, but spotting a barrier to learning does not make a teacher solely responsible for diagnosing its cause.
What matters is that everyone knows their part. Health colleagues take the lead on clinical questions, education colleagues on teaching and provision, and children and families help set priorities and judge whether support is making a difference.
We are realistic. Some children will still need intensive, specialist provision. And when support works, it does not mean a child’s difficulty has disappeared. Removing support because a child is “coping” mistakes the benefit of support for the absence of need.
Nor can a needs-led system run on goodwill alone. Schools need time, training and resources.
Health services need enough capacity to respond. Families who have fought hard for a diagnosis will understandably be wary of anything that looks like support being taken away, and parental trust has to be earned.
What getting it right could look like
This means we need to get the order right: invest in diagnostic services to meet demand now and only loosen the link between diagnosis and support once schools have shown they can meet children’s needs without health practitioners acting as gatekeepers.
Let’s return to Tracey. In the system we are describing, the meeting between school and family ends differently.
The school and family co-produce a plan for quieter lunchtimes, warnings before classroom changes happen and written instructions. These changes start on Monday, while the GP referral carries on in parallel.
Diagnosis answers health questions. Understanding the child in their classroom answers educational questions. It is encouraging to see health and education beginning to speak a shared language.
The real test is whether we can now organise services around a shared understanding, so that teachers and clinicians can each get on with their jobs, and children can get the right help at the right time.
Karen Guldberg is professor of autism studies and head of the School of Education at the University of Birmingham. She chaired the Department for Education Neurodivergence Task and Finish Group and is a member of the DfE Expert Panel for National Inclusion Standards and Specialist Provision Packages. She writes here in a personal capacity
Mark Mon-Williams is chair in cognitive psychology at the University of Leeds and professor of psychology at the Bradford Institute for Health Research. He is the deputy chair of the Department for Education’s Science Advisory Council. He writes here in a personal capacity
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