The place for diagnosis in the UK education system?

ABSTRACT

Currently, the number of students in the UK with diagnoses of mental health or psychiatric conditions is rising, as are the number of students categorised as having a special educational need or disability (SEND). To support these students’ objective evidence of deficit or difficulty is required, this usually takes the form of a legitimising diagnosis. However, in the case of mental health conditions, social, emotional and behavioural problems or even in some neurodevelopmental disorders, diagnosis is less useful as there are fundamental problems with the classification and understanding of mental health conditions. Despite this, the prevalence and importance of diagnosis remains in supporting students in education and those who are categorised as SEND. Therefore, this paper seeks to discuss the place that diagnosis has in education and the alternative models that exist in an effort to understand potential other avenues of supporting students and the benefits and limitations of these.

KEYWORDS:

• Diagnosis
• neurodiversity
• PTMF
• SEND

Introduction

Across the globe we are seeing increasing evidence of mental distress and special educational needs and disabilities (SEND). Indeed, in the UK, for example, diagnoses of depression, attention deficit hyperactivity disorder (ADHD) and anxiety has been increasing year-on-year in our children and adolescents (Cybulski et al. 2021; Deighton et al. 2019; Pitchforth et al. 2019). However, it is important to acknowledge that the increased prevalence of diagnoses of affective disorders such as depression and anxiety and even neurodevelopmental disorders such as Autism and ADHD in children and young people has a significant repercussion for many facets of society, such as education. Indeed, conditions such as these have been implicated in worse educational functioning, worse academic self-concept and lower educational achievement (Barkley et al. 1991; Bodfield and Culshaw 2023; Bodfield et al. 2022; Dijkhuis et al. 2020; Evans, Van der Oord, and Rogers 2020; Smith et al. 2020; Whitby and Mancil 2009) and the mere presence of these needs, or indeed the preoccupation with obtaining a diagnosis to accelerate additional funding raises questions around the prominence of diagnosis in education. In the past 10 years, local authorities (LA’s) have experienced drastic reductions to their budgets (Graby and Homayoun 2019), budgets in which both funding for SEND students and Education Health and Care Plans (EHCP’s) (Department for Education and Department of Health 2015) are sourced. Given the budget cuts LA’s have experienced, it is of little surprise that recent research has outlined that many schools and LA’s focus on what to do instead of an EHCP (Ahad, Thompson, and Hall 2022). This is despite the incidence of SEND categorisation and indeed wider diagnoses of mental health and psychiatric conditions increasing year on year (Marsh 2023; Marsh and Howatson 2020; Rabinowitz et al. 1994; Russell et al. 2022). However, it is of necessary discussion as to how important the use of diagnosis is in supporting students with SEND conditions. Indeed, research has demonstrated that diagnosis and SEND are loaded with conceptions such as incapability and weakness (Beilke and Yssel 1999; Bianco and Leech 2010; Friedrich et al. 2015). Furthermore, a diagnosis in and of itself is poorly linked to many mental health and neurodevelopmental disorders, inappropriately captured by a taxonomy with little or conflicting evidence (Johnstone and Boyle 2018; Johnstone et al. 2019). Therefore, it is necessary to discuss the current state of supporting students with additional needs in education and the usefulness or appropriateness of diagnosis in facilitating this system before exploring alternative avenues and approaches.

Supporting students with special educational needs and emotional and behavioural problems: the Current practice

The latest statistics for England state that there are over 1.5 million students categorised as having a special educational need and/or disability (SEND) (GOV.uk 2022). Furthermore, there are more than 250,000 students identified as having an emotional and/or behaviour problem. As stipulated in the SEND Code of Practice (Department for Education and Department of Health 2015), many of these students’ access education in mainstream schools. Indeed, in England, schools should operate from an inclusion framework where education should be accessible to both disabled and non-disabled individuals with adaptations and support in place to foster inclusivity, until such a point that it is not in the best interests of the person involved (Polat 2011; Qvortrup and Qvortrup 2018). For example, when the level of disability or difficulty is to such an extent that it is not possible to meet the individuals needs in mainstream education even with adjustments and support. Inclusive education is underpinned throughout teaching and educational legislation; teachers have an obligation to support students to succeed in class as mandated in the Teachers’ Standards (Department for Education 2013). The initial teacher training (ITT) core content framework (Department for Education 2019) lays out eight standards that must be met during teacher training to take forward into professional practice. These include setting high expectations, promote good progress and outcomes, demonstrate good subject and curriculum knowledge, plan and teach effectively, adaptive teaching, accurate and productive assessments, effective behaviour management and fulfil wider responsibilities. Of these eight standards, standard five which is adaptive teaching is explicitly defined as the appropriate differentiation in teaching, overcoming barriers to students learning and finally supporting students’ needs at different stages of development and ability.

The SEND Code of Practice (Department for Education and Department for Health 2015) states that a child or young person have a special educational need ‘if they have a learning difficulty or disability which calls for special educational provision to be made … ’ (15) and stipulates that for the purposes of conceptualisation of a special educational need a learning difficulty or disability is ‘a significantly greater difficulty in learning than the majority of others of the same age’ (16) or ‘a disability which prevents or hinders him or her from making use of facilities of a kind generally provided for others of the same age in mainstream schools’ (16). Given the policy directive that students must remain within mainstream education wherever possible (Department for Education and Department for Health 2015) and subsequently a close relation between adaptive teaching and inclusive education principles, there appears to be a strong (although not exclusive) focus on adapting learning for students with SEND. Thereby insinuating that adaptive teaching is only needed for those who are classed as SEND despite adaptive teaching being potentially beneficial to all students regardless of disability or need. Indeed, the ITT core content framework (Department for Education 2019) explicitly states that adaptive teaching can be done through collaborative working with Special Educational Needs Coordinators (SENCOs) in schools and consultation of the SEND Code of Practice (Department for Education and Department for Health 2015). Reference to collaborative working with SENCOs seems to implicitly suggest that if adaptive teaching is required it is because the child has some form of SEND consideration.

Adjustments made by teachers adapting teaching can be formal or informal in nature, with informal adjustments being routine changes a teacher might make to delivery of a lesson, for example, reducing activity times to maintain focus. Formal adjustments in provision are usually documented in either an individualised educational plan (IEP) or an EHCP. Formal adjustments made in an IEP or EHCP may include dedicated time to develop language skills or specific times with learning support assistants during the day. The EHCP is organised by the local authority and is much more comprehensive than an IEP, with an EHCP involving elements of health and social care and, if appropriate, a personal budget (Department for Education and Department for Health 2015). An IEP is created and managed by school staff, namely the school SENCO and is focused purely on academic functioning, therefore an IEP does not usually come with a budget for student support unless the school explicitly sets aside funding for the plan. Anyone experiencing difficulties in education may receive an IEP, whereas an EHCP usually requires objective evidence of disability such as a diagnosis of a recognised SEN. The use of IEPs and ECHPs are an attempt to support students learning and development within education. However, past research has presented conflicting findings supporting and rejecting both IEPs and ECHPs in supporting students. For example, research by Barnard-Brak and Lechtenberger (2010) found that disabled student participation in IEPs was positively associated with increased positive academic achievement in reading and maths. Furthermore, a review of research on IEPs by Blackwell and Rossetti (2014) complimented the findings of Barnard-Brak and Lechtenberger’s (Barnard-Brak and Lechtenberger 2010) research finding that participation of students in the IEP process was an effective strategy for improving self-determination skills such as increased engagement in academia and the development of their own IEPs. Therefore, IEPs, in this instance, seem to be useful methods of supporting students with disabilities. However, EHCPs have been critiqued and evaluated much more recently due to their more recent introduction into the education system in the 2015 SEND Code of Practice (Department for Education and Department for Health 2015) in which ‘Statements of Special Educational Need (SEN)’ were changed to EHCPs.

Statements for SEN were established in the Education Act 1981, where it stipulated that it was a statutory requirement for the education system to provide support for children and young people with SEND. Statements for SEN were first recommended in the Warnock Report (1978), a seminal report highlighting the need to address SEND needs in a more tailored and inclusive manner (Robinson, Moore, and Hooley 2018). The report advised the creation of a statement where a child or young person’s needs were addressed in relation to their time in education and preparation for their eventual transition to life beyond school. The Statement was reviewed annually and terminated when the individual left school. The change from Statements to EHCPs was designed to address criticisms of the Statement process which included age limitations, lack of emphasis on multi-agency working and lack of consistency in legislation interpretation across local authorities leading to inconsistent care (Sales and Vincent 2018). However, research has shown that EHCPs have not successfully addressed all these limitations, namely issues regarding consistency of care and accessibility of support for students, particularly when the student does not have a formal SEN diagnosis. Indeed, interviews conducted by Sales and Vincent (2018) on families and education professionals have identified that in their experiences the outcomes of the EHCP referral process did not necessarily reflect the needs of the child but were also influenced by other factors such as the funding of provision and the capacity of the parent/carer to advocate for the child. Further research has also highlighted the lack of funding and resources as a clear barrier to the implementation of EHCPs to support children in school. Indeed, in interviews of SENCOs carried out by Boesley and Crane (2018), a major theme identified was that of decreased funding for SEN which led to local authorities reducing the number of applications for EHCPs with an emphasis on alternative support stipulated by interviewees.

Nevertheless, although there still appears to be issues with provision for students with additional needs even with movement from Statements, it is important to also emphasise the positives of EHCPs. In the interviews conducted by Sales and Vincent (2018) all the interviewees found the specified outcomes in the EHCPs made for better documents and the involvement of parental and child opinion and views were extremely valuable. The research by Boesley and Crane (2018) concurred with this, with the interviewed SENCOs expressing support for the principals behind the system and noting that the EHCP system had potential. Thus, the introduction of EHCPs as an alternative to Statements of SEN seem to have addressed some of the criticisms of the former Statement process. Overall, the IEP and EHCP system appear to be positive strategies for supporting students with additional considerations in education, though these are not without their criticisms.

Although the EHCP and IEP processes seem to present suitable ways of supporting students in education, these elements of adaptive teaching are not always easily implemented or systemically supported. In research by Woodcock and Woolfson (2019) using data from multiple countries, they found that the consistent key barriers to appropriately supporting students in the classroom were budget limitations and the constraints of attempting to support many students at once. These findings echo similar results shown in research across the commonwealth with the work of Round et al. (2016) demonstrating that Australian teachers believed that schools were inappropriately and inadequately resourced to allow inclusion. This perception was also echoed in the work of Boesley and Crane (2018) in the UK education system where themes found in interviews of SENCOs were of decreased funding for SEN to support children in education. Furthermore, the difficulties of catering for all students in the class is not a new concept, where it has also been previously referenced in research by Anderson, Klassen and Georgiou (2007) where it was suggested that teachers are essentially balancing spinning plates, trying to cater for the needs of many diverse individuals and support inclusion, while also spending the appropriate amount of time with all children to meet the requirements of the curriculum.

The problem with diagnosis and/or categorical models of understanding behaviour and distress

As highlighted through discussion of the use of IEP’s and EHCP’s in education, for a formal arrangement to be put in place to understand and support the needs of students, evidence of clear deficit and difficulty is required, usually taking the form of a diagnosis from a medical professional. A further concern with the use IEP’s and EHCP’s is the interpretive authority that other professionals, in particular medical professionals, have even in the case of educational matters. Although a key purpose of EHCP’s was to increase a multi-agency approach to address the child or young person’s needs (Sales and Vincent 2018), there remains a hierarchical structure where certain professionals have more authority in stipulating the needs and requirements of the individual. This is evidenced in a study conducted by Gore (2016) which found that SENCOs reported a lack of clarity of their role in the EHCP process. Budget constraints and an inconsistency in ring-fencing funding results in LA’s having a variable readiness to effectively implement plans once they were finalised, essentially creating postcode lottery of support (Cochrane and Soni 2020). This is where the juxtaposition between medical practice and education arises; the complex symptomatology of specific needs such as social, emotional and mental health needs create a difficulty in its diagnoses and the ability to label becomes complex. Conceptualising disability and impairment enable professionals to classify people with additional needs using what Algraigray and Boyle (2017) term as ‘normalising judgements of diagnosis and identification’ (3). Although the requirement of diagnosis for support in education is indicative of the hegemony of the medical model in understanding distress and atypicality, this is not a model without its criticism, problems or perhaps even questions regarding its usefulness and necessity. Indeed, particularly amongst psychiatric and neurodevelopmental conditions, the medical model is often found to be lacking. This is due to a problem of nosology (that is, the science of disease classification) as psychiatric and neurodevelopmental disorders unlike physiological conditions are not usually easily identified by biomarkers (such as insulin abnormalities in diabetes or blood pressure abnormalities in cardiovascular issues) and often demonstrate substantial diagnostic overlap (Kotov et al. 2017).

The concept and indeed value of diagnosis resonates with Beckers labelling theory (1963) where the rationale and indeed impact of such an approach requires further examination. In the context of SEN, the requirement for diagnosis, and indeed labels, continues to remain a key factor in both educational practice and policy (Holland, Pell, and Kids 2018). The intended benefits being perceived as being conducive to provision of learning opportunities, awareness, support and understanding of need (Department for Education and Department for Health 2015). However, there too lies concern, where Boyle (2014) warns of possible negatives associated with labelling, such as personal and family impact, and future education and employment opportunities in addition to entire perceptions of incapability and deficit (T. Armstrong 2012). Algraigray and Boyle (2017) also note stigmatisation, discrimination, and exclusion as potential prerequisites of labelling. Demetriou (2022) posits that conservative societies are more likely to view disability through a medical model which views disability as deficit or an unfortunate circumstance and places less influence on how the constructs of society inhibit individuals with SEN needs.

It is important here to note that the intent of this paper is not to blame SEN labels or diagnosis for marginalisation but to question and discuss their role and value in supporting educational progress. The debate on the value of labels in SEN in education is not a new one. From a pedagogical perspective, teachers report that teaching is often subdivided between students with and without SEN. Given the current issues with recruitment and retention within education, it can be construed that such added pressure may contribute to feelings of accountability and stress (Perryman and Calvert 2020). A counter argument may be that no two students are the same and that teachers will naturally adapt teaching to meet the needs of their learners, suggesting that labels are not always necessary. Indeed, the presence of labels and subsequently individual learning plans, may provide information on specific needs, which teachers can use to adapt planning and teaching immediately, rather than first observing need themselves (Lauchlan and Boyle 2020). Draper (2018) highlights the benefits of this but also warns that preconceived labels can subjugate the student into ‘expected norms’ of the diagnosis, limiting opportunity to address unique needs. A subjugation that permeates across to teaching practice as Bodfield and Culshaw (2023) demonstrate, teachers in the UK often conflate the atypicality of behaviours students present as SEND or specific, despite no reference made to SEND or conditions. This is a crucial insight into the ways in which teachers categorise and think about behaviours as atypical even when they are not necessarily indicative of SEND. This both reduces individuation in education and also limits opportunity to look beyond atypical behaviour and the reason for it, which may have its roots in adverse or traumatic experiences for the child or young person (Bethell et al. 2017). A further point is a potential preconceived notion of ability based on a medical model understanding of diagnosis, where it has been evidenced that teachers tend to have a lower expectation of students with a SEND label (Lauchlan and Boyle 2020). Therefore, this suggests that the education system is too rigid in its categorisation of behaviours which are suitable and unsuitable for the classroom, with little deviation allowed from the norm and typical.

Whilst the debate of whether to seek out diagnosis or not remains unresolved, an issue appears to lie with how individuals with a label of SEN are perceived within education. Armstrong (2017) explores complex issues in special and inclusive education and lists neoliberalism, curriculum, pedagogy and attitudes as ‘wicked problems’ (229) that persist. Qu (2022) examines Armstrong’s wicked problems further and posits that the medical or social lens can also impact on how the rights of children and reasonable adjustments can be perceived. Needs that align to the SEND Code of Practice (Department for Education and Department for Health and Social Care 2015) category of social, emotional and mental health needs are, due to their extensive variation in manifestation and loose link to a medical taxonomy are more complex to diagnose (Bodfield and Culshaw 2023; Kotov et al. 2017). Lozupone et al (2019) note that the lack of concrete biomarkers for psychiatric conditions as a key factor to this complexity. Lewis-Fernández and Kirmayer (2019) also note that symptoms that fall under the social, emotional and mental health category are often self-reported. Also, when considering diagnostic markers such as those listed by the American Psychiatric Association (2013) the impact of the social and environmental context of a person is often not considered. Such points highlight how they may have clear implications for educational practice. A typical example is a student with a diagnosis of depression, it can be assumed that they would be supported through the SEND Code of Practice (Department for Education and Department for Health 2015). However, a wider consideration of the needs surrounding depression and the student beyond the diagnostic label might indicate that the students home environment is aversive, and their depression is an appropriate response to their circumstances, rather than a neurological abnormality. Algraigray and Boyle (2017) advocate for the need to consider the ecological world of students (Bronfenbrenner 2005) as a way to consider the whole world of the child to promote an inclusive education, and to ensure support offered to children is cognisant with their needs, beyond the label.

Towards a new model: neurodiversity, Power, threat and meaning

Given the problems with diagnosis and the alignment with the medical model in understanding both psychological distress and deficit in education, there is a clear need to move towards a new model and explore other avenues. Of interest are two frameworks, namely the Power, Threat, Meaning Framework (PTMF) (Johnstone and Boyle 2018) and the neurodiverse model of understanding and supporting SEND behaviour. The PTMF (Johnstone and Boyle 2018) is a model of understanding emotional and psychological distress, an appropriate response to aversive situations/negative power operations whereby individuals ascribe meaning to their experiences and explores the context around their distress (M. Boyle and Johnstone 2020; Johnstone et al. 2019). The origins of the PTMF (Johnstone and Boyle 2018) are found in clinical psychology practice but its appropriateness to apply to the education system is highlighted in a previous paper by the authors (Bodfield and Culshaw 2023).

Consideration of the manifestation and origin of distress and difficulty an individual is experiencing outside of a clinical and psychiatric model has clear implications for educational practice. This is because it encourages a wider consideration of areas in which to intervene and support the student. Indeed, if we are to take a wider look at many students who have a mental health condition/active diagnosis or are recognised as SEND due to a mental health or social, emotional and behavioural issue than we would likely see contributing contextual factors. A few factors that could be relevant to the aetiology of social, emotional, behavioural and mental health problems in the educational context are poverty, trauma and bullying (Schilling, Aseltine, and Gore 2007; Sheffler, Stanley, and Sachs-Ericsson 2020).

The PTMF (Johnstone and Boyle 2018) is perhaps most readily applied to the SEND system in the UK. As already discussed, the current SEND process in the UK education system focuses heavily on the medical model of disability and objective evidence of deficit, usually through the form of a legitimising diagnosis from a medical professional. The work of Foucault resonates with this context as much of his work surrounds the examination of societal constructs of madness, the patient and the criminal (Foucault 1977). Allan (1996) argues that children with SEND can be constructed in similar ways in education where due to diagnostics, certain needs take precedent over others. By adhering to a framework that categorises need and as a result ‘normalises judgement’ where it is permitted that certain individuals can be subjugated due to their perceived ability or inability; “the whole indefinite domain of the non-conforming is punishable’ (Foucault 1977, 178)., Indeed, as already noted, the SEND Code of Practice (Department for Education and Department for Health 2015) states that a child or young person has a special educational need if they require special provisions to be made to support learning and accessibility, where the need is identified as greater than the majority of their peers. The medical model of disability is heavily informed by physical illness and physiology, it is therefore less useful for mental health conditions and psychological distress where there is often a lack of a concrete biomarker and large deviations in categories of conditions such as in the case of mental health conditions (Hogan 2019; Kotov et al. 2017). The PTMF (Johnstone and Boyle 2018) would allow in this instance for a conceptualisation of problems based on their manifestation rather than an attempt to ascribe them to an arbitrary categorical model such as found in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-V; American Psychiatric Association 2013) and the International Classification of Diseases (ICD-XI; World Health Organisation 2019). The PTMF (Johnstone and Boyle 2018) has already begun to be considered in the context of supporting students with SEND. The PTMF has its origins in psychology where the focus shifts from traditional diagnostic labels to understanding the impact of power, threats, and meanings in a person’s life (M. Boyle and Johnstone 2020; Johnstone et al. 2019). Although its application in education remains limited (Bodfield and Culshaw 2023) the framework permits a wider consideration of how societal and individual factors contribute to distress, which can exacerbate social, emotional and mental health needs. In an educational context, the PTMF explores how societal and individual factors contribute to distress and aims to provide a more holistic understanding of mental health issues. The framework encourages a narrative approach to understanding need and can contribute to educational settings and complement formal diagnosis criteria by widening consideration of the role of power in life, the threat that power may pose to children and young people, and the sense or meaning they make of this threat. Milligan (2022) has clearly highlighted that educational psychologists find a benefit in using the PTMF (Johnstone and Boyle 2018) in their own practice of assessing and supporting students. However, there is still the need for further inclusion of the PTMF (Johnstone and Boyle 2018) in educational practice and work on integration into schools although there is some progress being made in this direction as demonstrated in the work of O’Toole (2019).

The implementation of the PTMF (Johnstone and Boyle 2018) to educational practice, therefore, presents the opportunity to initiate change in the current SEND system by identifying negative operations of power in the aetiology and manifestation of certain needs. This consideration of operations of power and threat to understand need (meaning) is more reflective of a social model of disability which is where disability is defined by the prism of historical production where societal barriers impact on disability or need, and where the person is not their deficit (Piccolo 2022). Beresford (2002) and Mulvany (2000) liken the social model of disability to the social model of mental health where the focus is inordinately rerouted from focus on the person to focus on the complexity and multiplicity of societal restrictions.

The neurodiverse model of understanding behaviour has its origins in the Autism movement as a potentially alternative paradigm where language is reframed from deficit-focused to strengths-focused (Pellicano 2022) and has been more readily and frequently applied to education than the PTMF (Johnstone and Boyle 2018). The neurodiverse model refers specifically to the concept of neurodiversity, which has been defined in multiple ways, but the unanimously agreed general definition is that there are natural deviations in the neurology and neurological functioning of all humans, just the same as differences in ethnicity and that these differences should be celebrated as examples of typical human variation (Jaarsma and Wellin 2011). Indeed, Armstrong (2017) has suggested that there is a need to move towards a neurodiverse model and adopt this language due to the deficit focus of the SEND model. The deficit focus assumes that an inability to perform is associated with a problem (a presumed disability/lack of capability or need), with the SEND system working to remediate the said problem. This remediation response can be seen in the current UK education system, which works on the assessment of students’ abilities and the application of diagnostic labels as referred to in the SEND Code of Practice (Department for Education and Department for Health 2015). Indeed, a criticism of the current SEND system is its reliance on categories, such as speech and language problems or emotional and behavioural conditions. This is despite significant variation within these categories (Griffiths 2020) and the tendency for difficulties to co-occur. The emphasis on the remediation of weakness and categorical model of difficulty is a feature of past research (see Griffin and Pollak 2009).

The SEND system is fundamentally focused of deficit, diagnosis and the remediation of weakness (T. Armstrong 2017). The neurodiverse model is the counter to this, focusing on areas of strength within individuals who would be considered to have SEND and ways in which these strengths can be capitalised to remediate weakness, therefore focusing specifically on what these students can do, not what they can’t do. In addition to this focus on strength rather than deficit, the neurodiverse model of understanding and supporting student behaviour is aligned to, or at the very least, adopts a form of the social lens of disability (Kapp et al. 2013), in which social contexts are considered to be the predominant force behind individuals being disabled rather than any deviation in ‘typicality’ of functioning. In addition to the movement away from a focus on deficits within the individual as found in the medical model and the need to remediate perceived weakness within these, there is less of an emphasis upon ‘diagnosis’ within the individual as all individuals are neurodiverse with all the typical strengths and limitations that come with this. This would mean, according to Griffiths (2020) that students that do not fit the criteria for a diagnosis of certain conditions would still be supported, unlike as is the usual case in the current SEND model which requires clear and objective evidence of difficulty and deficit.

Discussion and summary

The rising number of students with a SEND classification or identified mental health/emotional and behavioural difficulties (Cybulski et al. 2021; Deighton et al. 2019; Pitchforth et al. 2019) requires careful consideration of the best way to support these students. As outlined previously, the current model ties heavily into the medical model and the legitimising role of diagnosis in unlocking additional support. While there is a place for diagnosis in categorising and understanding areas of difficulty in students, this becomes less useful for students with mental health conditions or emotional and behavioural difficulties that have a psychological origin. Indeed, as previously referenced many of the psychiatric foundations for understanding mental health conditions have been questioned and lack definite evidence (Johnstone and Boyle 2018; Johnstone et al. 2019). In addition to the questionable theoretical underpinnings for some psychiatric diagnoses, there is wider criticism available of the diagnostic/medical model due to the deficit focus and the implications this has for students (Pellicano 2022). Therefore, given the abundant criticisms evident within the underpinnings of the current model of supporting students there is a need to explore alternative avenues. The PTMF (Johnstone and Boyle 2018) and neurodiverse model (T. Armstrong 2017) are two potential approaches that are complimentary in nature and may be beneficial in supporting students. Indeed, the PTMF (Johnstone and Boyle 2018) provides a framework for understanding distress and psychological problems in students including emotional and behavioural problems that focus on the students’ wider life experiences and narrative. This steps away from the medical model to acknowledge the role of transient and external factors in distress, but as acknowledged by Johnstone and Boyle (2018) can also be used in conjunction with diagnoses. Therefore, the PTMF (Johnstone and Boyle 2018) will provide further information to teachers in understanding students experiences and wider contextual factors that contribute. Although teachers may not be able to intervene to support predisposing factors such as poverty which may contribute to a child’s problems, it provides an explanation for the difficulties faced by the child and could therefore influence the teacher’s perception of the student and any subsequent interactions with them. Indeed, research has demonstrated that teachers may have negative preconceptions of students who experience adversity or trauma and has been suggested to lead to the Teacher Expectancy effect whereby lower expectations and the unconscious bias of teachers negatively impact academic achievement and functioning in students due to these perceptions feeding into interaction with the student that informed their own self-perception and thus their future behaviour (Friedrich et al. 2015). Therefore, any routes that can circumnavigate this adverse relationship has potential benefits for improving teacher interactions and subsequent student functioning and achievement, indeed, positive expectations lead to positive outcomes (Rubie-Davies and Rosenthal 2016).

The neurodiverse model although perhaps less of a beneficial model to apply to student mental health widely, captures the neurodiverse conditions such as Autism and ADHD that are currently agreed to originate from neurodevelopmental factors as opposed to societal stressors and are subsequently less easily applied to the PTMF (Johnstone and Boyle 2018). While the PTMF (Johnstone and Boyle 2018) encourages teachers to think about the narratives underpinning the distress of students and the origins of their behaviour, the neurodiverse model encourages a reframing of difficulty where emphasis is placed on strengths and the utilisation of strengths to overcome weakness (T. Armstrong 2017). Like with the PTMF (Johnstone and Boyle 2018) the focus on strength and ability can work to overcome a teacher’s own perception of perceived weakness within an individual and the remediation of deficit through an intervention acted upon the student to enable success. Although these have been demonstrated to initially work (Bernard et al. 2019), they are damaging for a student’s self-perception and reinforce a reductive narrative of incapability (Griffin and Pollak 2009).

Although the PTMF (Johnstone and Boyle 2018) and neurodiverse model (T. Armstrong 2017) are devised for understanding different phenomena, and there are some areas in which the application of the model universally to the education system is difficult, there are fundamental tenets which can be taken from both and applied. Namely, the consideration of aetiology of behaviours and difficulties that are fundamental to the PTMF (Johnstone and Boyle 2018) in addition to the orientation from deficit to strength and disability to ability within the neurodiverse model. As these two principles rely solely on teachers changing their pedagogic practice, the onus solely lies on educational practitioners to implement these changes with support from legislation, school policies and the educational context. These suggestions are not new and have been suggested before, indeed, in 2017 Rentenbach et al. suggested that teachers should manage their expectations on their ability to control neurodiverse behaviours and integrate strategies into the classroom that allow neurodiversity to manifest in healthy and positive ways. However, the integration of these strategies would be much easier if teachers understanding, perceptions and knowledge were adjusted away from the current SEND Code of Practice (Department for Education and Department for Health 2015) and other guidance, therefore highlighting the positive role that the PTMF (Johnstone and Boyle 2018) and neurodiverse models (T. Armstrong 2017) may have in supporting this.

Recommendations, practical problems and limitations

Movement towards a new model of understanding psychological distress and difficulty is no easy feat, despite the limitations of diagnosis and the prominence of medical model thinking and practice within the educational world. Indeed, it is important to refrain from naively contesting the current process of prioritising diagnosis within education and its value in supporting our most vulnerable learners. The current process, stipulated by the SEND Code of Practice (Department for Education and Department for Health 2015) offers some practical steps to supporting need, and for many, this process is effective and enables them to thrive. Armstrong (2017) discusses potential barriers and note that educators and parents may be hesitant to move towards a change in conceptualisation of SEND from deficit to strength as it may naturally raise questions about the need for support if SEND students have areas of strength, thereby locking students out of additional support. Furthermore, Armstrong (2017) elaborated that some parents and teachers may be concerned that without the extra support and adjustments, struggling students may not be able to meet academic demands alone and only by using their strengths. However, viewing need and SEND differently does not imply that the use of labels will be abandoned, but it may suggest a movement towards labels, which highlight strength and promote inclusivity, rather than students being defined solely by their specific need (Demetriou 2022).

Viewing SEND differently and with a wider consideration of need both including and beyond the student allows for a more holistic view of not just individual deficits, but indication of support required in general (Demetriou 2022). Alternative ways of framing social, emotional and mental health needs are presented when seeking to understand neurodiversity and through applying the PTMF to these areas, and as Johnstone and Boyle (2018) state, ‘the potential to take us beyond medicalisation and diagnostic assumptions’, (5). Indeed, in an educational context, the PTMF may create forethought on how we understand and approach social, emotional and mental wellbeing in schools in general. Previous research has indicated the value of the application of PTMF (Johnstone and Boyle 2018) for Educational Psychologists (Milligan 2022), however a recommendation is for an increase in professional personnel within schools, such as SEND co-ordinators, pastoral staff, class teachers and senior leadership to allow for a seismic shift on how additional needs are viewed.

Despite these recommendations and potential avenues for future changes to understanding SEND, need and the role of diagnosis it is important to note the limitations of the neurodiverse model of understanding and supporting students and the role of the PTMF (Johnstone and Boyle 2018) in understanding and supporting students. The first major limitation of these is the lack of scope to implement them, and the relatively meaningless role they would play if implemented. Currently, the entire system of supporting and understanding students and their behaviours is built around diagnosis and SEND. Indeed, as outlined the guidance and legislation from the government is entirely phrased around this model as demonstrated in the SEND Code of Practice (Department for Education and Department for Health 2015) and the ITT Core Content Framework (Department for Education 2019). Therefore, the movement to other models would be difficult and would not amount to anything meaningful without a systemic or legislative change occurring to legitimise this movement. In addition to this, the movement away from the current model to alternative ones have significant repercussions for staff training and knowledge which will require time and effort from teachers, parents, students and a wider variety of allied professionals, this is time which large amounts of research have demonstrated they do not have (Bodfield et al. 2022).

Conclusion

To conclude, it is evident that the needs of students in the UK education system are rising due to elevated levels of psychological distress, the diagnosis of psychiatric and neurodevelopmental disorders and the increased prevalence of SEND classifications of students. The needs of these students are legitimised through diagnosis which forms the basis of understanding their difficulties and supporting the students. However, this in itself is loaded with conceptions of deficit or difficulty (Algraigray and Boyle 2017; T. Armstrong 2012; C. Boyle 2014; Demetriou 2022), which is an unhelpful message. Furthermore, the theoretical basis of diagnosis and the classification of mental health conditions and understanding social, emotional and behavioural distress/problems is fraught with problems (Kotov et al. 2017). Therefore, there is a need to consider other, alternative models to supporting students such as the neurodiverse model or the application of the PTMF (Johnstone and Boyle 2018) to education. These models present entire paradigm shifts to supporting students with less of an emphasis on diagnosis and deficit, focusing on contexts and strength. However, they are not without their own criticisms including the need for systemic shifts in practice and increased knowledge and training across staff, students, parents and stakeholders.

Disclosure statement

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Additional information

Notes on contributors

Kalum S. Bodfield

Dr. Kalum S. Bodfield is a senior lecturer and psychologist at Liverpool John Moores University. He has published in areas including neurodiversity, mental health and attachment. His areas of interest including self-perception, trauma, mental health and neurodiversity.

Aisling Culshaw

Aisling Culshaw is a lecturer at Liverpool John Moores University. She has published in areas including pedagogic and mental health. Her areas of interest include trauma-informed practice, mental health and alternative pedagogies.