The idea that common special educational needs such as ADHD and autism are “invented” will be unpalatable to some. But this is one of the key messages that Sami Timimi wants to convey.

In his book, Searching for Normal, the consultant child and adolescent psychiatrist questions the neurological basis for these conditions, as well as for various mental health disorders, and raises concerns about the increasing numbers of young people seeking diagnoses for them.

Diagnostic labels are being repackaged as “commercial brands”, he says, and, as a result, young people are being medicalised for behaviours that might once have been considered ordinary and understandable.

Timimi’s ideas have taken hold in policy circles and feed into wider debates around overdiagnosis and England’s spiralling crisis in its special educational needs and disabilities (SEND) system, which the Institute for Fiscal Studies has said is on track to cost the government more than £15 billion a year by 2029 if it is not reformed.

Critics worry that arguments such as Timimi’s will be used to justify cuts to much-needed support systems. Indeed, parents or teachers who have fought hard to obtain an education, health and care plan (EHCP) for a child are likely to recoil from the suggestion that the diagnoses underpinning such documents are not valid.

The British psychiatrist does not believe that his views place him in opposition to teachers or parents, though. Rather, he sees himself as being on their side.

“Most parents know and understand that their child doesn’t fit neatly in one box. They are just as dissatisfied with the current system. Labelling more and more people will not solve this problem,” he says.

“Supportive relationships,” Timimi adds, “do far more than abstract labels.”

So, what does Timimi believe is the driving force behind the current reliance on diagnoses of SEND? And what would an alternative approach look like?

We sat down with him to find out more about his ideas, and what they might mean for schools.

Can you sum up what you were aiming to do with your book Searching for Normal?

Timimi: In the book, I set out to question the basis on which we categorise and understand what we call “mental health”. Unlike most other branches of medicine, where you can see clear evidence of progress, in mental health the opposite seems to happen. We’ve had more and more people accessing treatments. But outcomes, if anything, have gotten worse.

The more treatment we have, the larger the number of people who are presenting with what have been categorised as mental or behavioural disorders - and I also see the whole neurodevelopmental trend as being very much within that.

I asked the question: what might be behind that? Is it just a correlation or is there something deeper going on?

And where did that question take you?

Because all definitions of mental health and behavioural difference are subjective, we literally don’t know what we’re talking about when it comes to mental health. This means that the concept can be expanded in all sorts of ways.

In our society, we are going through a cost-of-living crisis, with stress levels rising, and there’s also a crisis of legitimacy. People don’t trust that the politicians know how to improve the situation.

Within that vacuum, what I call the “mental health industrial complex” has been able to commodify emotional distress and behavioural difference for people who are struggling, and now offers a range of attractive consumables, in terms of labels.

‘We literally don’t know what we’re talking about when it comes to mental health’

What we call “diagnoses” are not diagnoses in the medical sense, because they don’t refer to any cause. They are descriptions (and often quite vague ones) that have been turned into commercial brands. Some have become more popular than others. Top of the list is ADHD, then autism. Bipolar disorder, anxiety and many others have also found a commercial niche.

When you consume a commercial brand, you open up a market for all sorts of things, from very expensive assessments to medications, therapies, coaching, books, self-help programmes and so on.

What’s happening is that these concepts of mental health and neurodevelopmental difference are expanding at a really quite phenomenal rate, particularly among young people.

Why is this so problematic, in your view?

People who are feeling that things are not right, feeling distressed, that they’re not fitting in - all things that are common within a society that feels broken - now have a variety of labels that come with the promise to help them to understand why they feel like that and offer some relief.

Turbocharged by social media, these invented concepts spread into our culture, into our society, and become in themselves an important cause of emotional distress, because even the more understandable and common ups and downs of life are being identified as potential mental disorders.

Particularly for teenagers, you can see how this is happening for many forms of stress, anxiety, worries, feeling left out, feeling insecure and so on.

The struggles of adolescence are a vital part of growing up; being able to just experience them, learn how to live with them and develop an understanding that things will change.

But once you enter into the framework of imagining these stresses and struggles as markers for potential mental disorders, you could inadvertently end up in a lifelong relationship with feeling that there’s a part of your identity that is dysfunctional or broken or dysregulated, which needs to be managed, controlled, treated or suppressed.

When you talk about diagnoses as ‘commercial brands’, do we need to be cautious about undermining any special educational needs that might have a genuine neurodevelopmental basis? Do you make any distinction between different types of conditions?

No, I don’t. They are invented. There is no evidence to support that there is something specific and characteristic that is neuro-based to differentiate people.

This is not an argument against people having needs; it’s an argument against the idea that the categories we use will help us to understand what those needs are.

The problem with these categories is that they create stereotypes that don’t match how people actually function in different contexts in their real life.

Furthermore, they promote an idea that in order to get particular types of support, you need a “ticket”. In doing so, they create an administrative system that excludes certain people who might benefit.

For example, I’ve worked for over 30 years in child and adolescent mental health, and during that time I have seen the label of “autism” spread. This has led to the idea that any anxiety that a child diagnosed with “autism” is struggling with is a result of their “autism”, and, therefore, the anxiety can’t be treated.

One area where we do have consistent evidence that there is a greater probability that you have some sort of neurological compromise, in very broad terms, is learning difficulties.

Can you explain what that evidence is?

There is a higher probability of finding specific genetic abnormalities (such as copy number variants or specific genetic deletions) and/or anatomical abnormalities associated with things like foetal alcohol syndrome, birth injury or head trauma, for example.

But it’s important to understand that learning difficulties is a very wide, generic category. It is not a specific category. It doesn’t say what specifically you might need help with.

Those who have difficulty processing information are more likely to be bullied, suffer abuse and be behind their peers in learning, meaning there is a considerable psychosocial element to their struggles, too.

It’s also worth mentioning that learning difficulties, or its modern incarnation “intellectual difficulties”, increase your chances of experiencing a variety of psychiatric difficulties - such as anxiety, unhappiness, obsessions, distractibility and so on - but don’t point specifically to which of these you might experience.

So, even with demonstrable neurodevelopmental problems, this should be taken out of defining what special needs support is needed, because there’s no shortcut to looking at each individual person and doing an individualised assessment.

How do you see all of this playing out in schools?

One of the problems is that there has been a rapid growth in young people who are, for example, getting the label of autism. There are plenty of online questionnaires and private services that will give you a diagnosis, which you then present at school to show that the child needs extra time in exams or extra support in the classroom.

Education, meanwhile, is underfunded. Class sizes are too big, and the pressure on teachers to do all sorts of things is enormous and growing. So we’ve got these systemic problems, which these diagnoses aren’t going to help. In fact, they may actually draw resources away from tackling problems at the whole-school level.

We have increasing numbers of children identified as having some sort of neurodevelopmental condition, and that might not be good for them, because sociologists have shown how people internalise the labels attached to them (as do their carers) and start to think of themselves in that way, too.

So, with these labels, I would argue you are probably unnecessarily “disabling” a whole group of young people, whilst drawing resources away from tackling structural problems.

You talk quite a lot in Searching for Normal about the rise in ADHD diagnoses. Why do you think the numbers of children presenting with this condition, in particular, have increased so much?

The behaviours associated with ADHD are all behaviours that the majority of children show to a greater or lesser extent. We’re not talking about something that’s qualitatively different, like delusions. We’re talking about degrees of behaviour, and how you think of these different behaviours, and the meanings they are communicating.

ADHD started its life as a concept, at least in this country, as “hyperkinetic disorder”, which was considered very rare and also developmental (meaning that most kids will grow out of it). It focused particularly on high levels of activity.

In the mid to late 1990s the label of “ADHD” entered the picture. It was estimated that about 0.5 per cent of children had the condition and might require treatment. That treatment was medication (stimulants that are chemically similar to or are actual amphetamines), which made it feel more “medical” because a pill was being given. This opened up new markets.

‘I’ve gone through all the genetic evidence; the cupboard is empty on that’

Between 2000 and 2010, about 3 per cent, maybe even up to 5 per cent of children were thought to potentially have ADHD. As time went on, the belief that the condition was “developmental” started to fade, as the idea of adult ADHD came into the discussion.

At this point, ADHD was being diagnosed mainly in males, but then a new concept came in: masking (or camouflaging). This says that you don’t even have to display ADHD behaviours; you just have to believe you have them. Feeling that sense of impulsivity, that sense that you can’t concentrate is enough.

The concept of masking opened the condition up to more people, including more women and girls (and in adulthood, the main psychiatric market is women - for all sorts of sociological reasons).

Thus ADHD has gone through a mutation of constructs to finally include people who feel that they don’t “fit in” in some way. That’s such a wide group in a society that feels broken.

At no point along this journey of expansion has there been any specific and repeated scientific evidence. It’s not come along with a discovery of any genetic factors. I’ve gone through all the genetic evidence; the cupboard is empty on that. There are also no significant neurological differences that can be demonstrated, which is why, when we talk about a test for ADHD (or a test for autism or most psychiatric conditions) we’re mainly talking about questionnaires.

For me, that’s no different to the kind of pop psychology quizzes you can get about what sort of person you are. It’s really no more sophisticated than that.

Do you have any fears about your ideas being misinterpreted and then used, by politicians perhaps, to dismiss the struggles that some young people might be experiencing or to cut the support they currently have access to?

At the moment I think we’ve got the opposite problem. We’re identifying children as having a condition that requires professional expertise - that’s beyond the realm of the “liveable through” without extra help - and isn’t something that parents and teachers can figure out together.

Of course, there’s always a potential for ideas to be misunderstood, particularly at a time where we have one government after another looking to where they can make cuts. But there is undoubtedly an issue that is not going to be sustainable in terms of this growth of the proportion of young people who are now categorised as having special educational needs, primarily due to a mental health problem or neurodiversity.

What do you think needs to happen to help schools offer pupils more individualised support that isn’t so reliant on labels?

Ultimately, for me, the thing that would make the biggest difference would be some sort of government legislation that takes “neurodiversity” and psychiatric diagnosis out of the picture as having a role in understanding the particular needs of any child.

We need to introduce a different way of using psychological and psychotherapeutic knowledge within the school system. There are already projects in Scotland and in England where therapists and other practitioners are working with teachers to develop an inclusive, holistic and relational-based whole-school philosophy.

The other thing that needs to be taken out of schools is universal approaches to mental health awareness, including teaching about it and the use of cognitive behavioural and mindfulness methods.

Study after study, including a big one that was published by the Department for Education earlier this year, have found that pupils undergoing teaching about mental health have worse outcomes. They’re more likely to experience depressive and anxiety symptoms.

Taking diagnoses out of the picture would remove at least some of the incentives for a diagnosis and make teachers and others less likely to make stereotyped assumptions about what a child can and can’t do.

We’re losing sight of creating a culture within the school that is inclusive, that’s welcoming, that looks at the pupils from a strengths point of view, rather than focusing on their perceived deficits. You shouldn’t need labels with no empirical validity to enable acceptance of a child as they are.

Furthermore, we should not be fixing a child in their imagination, and in the imaginations of those around them, with an idea that they have a “lifelong” condition. The one constant about growing up is change.

I think we could do with something similar to the Cass review (which looked at the outcomes from children attending gender identity services, and suspended services as a result). We could do with a similar national review of the whole neurodiversity and mental health awareness discourse for kids.

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