From the very start when SPENCER was conceived the absolute intention was to offer parents, teachers and young people access to a bespoke primary level assessment and intervention.  It was based on the absolutes of psychological formulation and whilst not remotely ‘anti-diagnostic’, we wanted to focus on explaining and understanding young people and providing meaningful support.

Psychological formulation is a holistic approach that aims to bring together an understanding of the individual. In my experience as a clinical psychologist working with young people, I have always seen psychological formulation as trying to make sense of a child’s experiences, who they are, where they are in their development, their personality, their temperament, their background, and their relationships, turning to psychological theory to make sense of their needs and make informed decisions about how to bring about change if required.

I have often thought that psychologists have for the last 25 years at least contributed to what we might call the professionalisation of diagnostic labels as a way of describing day-to-day emotional, behavioural, and developmental ‘problems.’  I recall visiting a South London primary school to see a little girl for an assessment.  As I stood in the corridor waiting for the SENDCo I read poems about autumn pinned to the notice board, beautifully written, illustrated and presented by 10 year old pupils. Describing a visit to Dulwich Park a  girl had written how ‘depressed’ she was at the changing colours and the end of summer.  It was beautiful and observant, but ‘depressed’?  

From the late 1990s, when clinicians had to battle to get anyone to understand neurodiversity with any seriousness, it was typical for parents and teachers to describe simply what they saw in front of them. For example, a teacher might have said ‘he is such an odd little boy, he finds it hard to know the difference between children and adults and he can’t stand being in the assembly.’  A parent might say ‘I’m exhausted, she won’t sit still, climbs all over the furniture and takes hours to go to sleep.’  Today the phone rings or the email dings and an order comes up - ‘will you diagnose this pupil with autism’ or ‘my child has ADHD and I need a diagnosis.’  

So we were in one sense successful. Not only have the developmental difficulties in children become much better understood but we have an industry that can describe and diagnose. What inspired the creation of SPENCER was a reflection that clients were calling upon my services at what seemed to be the end of the journey rather than the beginning.

This was no better illustrated for me than in a recent conversation with Ben the mechanic who puts up with me and my car. The car had been feeling sluggish and, having had a similar problem before, I proudly informed Ben upon arrival that the car needed the air filter changing.  Armed with his laptop and screens he very kindly informed me that the problem was actually in the fuel supply to the engine. After the pain in my wallet had subsided, I realised that  rather than simply describing the symptoms presented, I had gone straight to the end of what I saw as the problem. I recognised in this what so often I see as a clinician.

This has also become apparent in the tendency to have a very binary construction of neurodiversity - is it ADHD or ASD?   The palette of causes is wide, intertwined, and complex, just as it is for Ben with the car, the SENDCo with a student, or the social worker with a child at risk. This is clear when you meet a child that has been abused and neglected. Their relationships are stressful, they can be very odd, they can be overactive and inattentive. Working with developmental trauma, you obviously can not ignore development, but we also have to think about the impact of trauma on a child and how that might help us to understand the things we see in their behaviours. 

I’d question if you go for ADHD/ASD too soon you miss the emotional turmoil and you miss the signs of the child being at risk of harm. I remember meeting a child I will refer to as Mary, who lived in a rural community in central England. Her teachers had become concerned about her social development and worried that they were missing a ‘diagnosis’ and were trying to determine if what they saw was symptomatic more of ADHD or Autism. As I got to know Mary, and understood her anxiety, low mood, her hypervigilance, and avoidance of people, I was prompted to look more into her background and home life. Suffice to say, upon lifting that rock, safeguarding concerns took over as the cause for greatest concern. 

Reflecting on that experience, I was worried that heading for neurodiversity, sometimes under pressure from her family, was taking us away from the real issue which was safeguarding. That is to say nothing of how trauma and other environmental factors can interact with, exacerbate, or otherwise mediate neurodiversity symptoms over time; impacting the brain long into the future. Nevertheless, seeing the whole picture then, and not just going straight to neurodiversity, is vital.

Access to the expertise that can unpick diagnosis and need is difficult. As we all grapple to meet need or, at least, give a diagnosis, colleagues across the UK and further away have been trying to find ways of increasing access, simplifying processes and spreading limited resources more efficiently.  There are tools being developed to support this, one such being The Portsmouth Neurodiversity (ND) profiling tool. The authors describe it as ‘a visual document that assesses nine developmental strands of a child or young person aged 0-19. This includes speech and language, energy levels, attention skills, emotion regulation, sensory levels, flexibility and adaptability, and empathy.’ 

It is a very strong and useful tool. However, I find myself drawn back to my conversation with Ben: what if we end up at the neurodiversity question too early and miss so much more about the child before ending up there. What happens to the child impacted by alcohol poisoning or one who is at risk of harm, trauma, anxiety, depression, language delay or sensory seeking behaviour. This also raises questions about ‘diagnosis’. Has it become a political potato that has created a world where a child cannot get ‘help or resources’ because they do have the ‘right label.’ I generalise somewhat, but such an observation would not go amiss in many clinical conversations I had over the last five years or so.

SPENCER was designed to be the tool that can go to the front of the problem. To help non-clinicians begin to develop their own formulation of a child’s needs and the supports required when they do not have access to specialists and clinicians. To allow them to intervene earlier, to get effective support in place for young people that need it. To take the expertise that parents and professionals have about that child and their history, their background, their personality, their behaviours, their hopes and dreams, and turn it into support strategies that work. 

SPENCER is designed to look across five domains of need including but beyond neurodiversity: the physical, emotional, neurodevelopmental, cognitive, environmental, and relationships domains by asking the people that know that child about the behaviours they see day-to-day. SPENCER also identifies strengths, things that professionals and parents can build on with young people as well. It then uses what it learns to suggest support strategies to allow intervention at the earliest possible stage. It can’t diagnose and it doesn’t replace clinicians and specialists, but the only expertise required is knowing and caring about a young person so it can be used by a much wider range of people. It gives greater access to primary assessment, it prompts thinking about the whole child, it promotes holistic understanding, and disseminates expertise and knowledge. The only barrier to entry is knowing and being able to answer questions about a child. It’s a tool designed to work at the front end of a problem to understand the needs of a young person.

At Spencer3D we have observed health and education services being interested in our products not only because we go beyond diagnosis to ‘need’, but because we ask about the whole child as they are rather than through the prism of diagnostic labels.  Our work attempts at all times to be driven by good evidence and we are very mindful of the work of the outcomes from the research at the Centre for Attention, Memory and Learning often referred to as CALM (MRC Cognition and Brain Sciences Unit University of Cambridge).

At Spencer3D we are mindful of their position that ‘we look beyond diagnostic labels and instead use a transdiagnostic approach to understand the cognitive and neural features that define children’s strengths and difficulties. Exploring the relationships between these different features has so far revealed that often behavioural problems, patterns of cognitive difficulties and neural profiles do not align with specific diagnoses. Our findings support the importance of child-centred, rather than diagnosis-centred, approaches to assessment and intervention.’

Hence, as we are thinking about how to meet the needs of so many more children and young people, with SPENCER we want to promote a wider conversation, a real child-centred approach that makes no assumptions as the starting point.  A methodology not driven by diagnosis but one that seeks to understand and meet need through psychological formulation.  

Arriving at the ND after this initial approach may be entirely appropriate, but so might introducing social skills, attachment-based education or improving the sensory environment.  Managing suicidality and self-harm or understanding the difference between obsessive compulsive behaviours and thoughts as opposed to ASD. At all times being driven by the core goal of understanding young people’s needs and finding the best support possible to help every child thrive.  Where we have been most excited is that Spencer helps people reframe challenging behaviour into a more sensitive, effective and compassionate understanding of why.  

Dr. Bryn Williams, Consultant Clinical Psychologist

BSc.(Hons) Psychology; MSc. Pead Clin. Neuro; PhD (UCL, London); D.Clin.Psychol. (UCCCantab)

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