In this ‘RESHAPE Study’ series episode, Professor Tamsin Ford and Clara Faria explore the findings from the ‘National Study of Health and Wellbeing: Children and Young People’ as they relate to eating disorders, and why these findings are important.
The ‘RESHAPE Study’ series is a new mini-in conversation series that will explore the RESHAPE study and the impact of its findings for parents, teachers, policymakers, and mental health professionals.
Discussion points include:
- The National Survey Study design and the methods used to measure the number of children and young people with eating disorders.
- The correlation between an increase in population-level prevalence of eating disorders and help seeking.
- The increase in waiting times following the COVID-19 pandemic and the unmet needs of children and young people with eating disorders.
- Recommendations for commissioners and how we can ensure early identification of eating disorders.
- The importance of ensuring boys and men are not overlooked.
- Recommendations for future interventions and how to improve medical education around eating disorders.
RESHAPE or ‘REflecting on the impactS of covid-19 on cHildren And young People in England: exploring experiences of lockdown, service access and education’ is a large study looking at how life changed for children, young people, and parents during the lockdown and how this may have affected them. This is a follow-on study from the National Study of Health and Wellbeing: Children and Young people and is a joint effort between the University of Exeter, the University of Cambridge, King’s College London and the NHS.
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Tamsin Ford is Professor of Child and Adolescent Psychiatry at the University of Cambridge. She researches the organisation, delivery, and effectiveness of services and interventions for children and young people’s mental health. Her research covers the full range of psychopathology and agencies, practitioners and interventions that relate to the mental health of children and young people. Every interaction with a child presents an opportunity to intervene to improve their developmental trajectory. Her work has direct relevance to policy, commissioning and practice.
Tamsin completed her postgraduate training in psychiatry on the Royal London Hospital Training rotation and then the Bethlem and Maudsley Hospitals, after which, she completed her PhD at the Institute of Psychiatry, Kings College London. She moved to Exeter in 2007, where she established a group of researchers whose work focuses on the effectiveness of services and interventions to support mental health and well-being of children and young people. In October 2019 she moved to the University of Cambridge.
Tamsin has been a member of ACAMH since 1996. She was an Editor for ACAMH’s journal CAMH for six years, stepping down as lead editor in June 2014. She has been a board member for ACAMH since 2011, and vice-chair since September 2020.
Clara Faria is a junior doctor and aspiring child and adolescent psychiatrist. She serves as a Young Person Ambassador for ACAMH and is interested in eating disorders and in the epidemiology of mental health disorders in young people. She is currently a MPhil student at the University of Cambridge.
Other resources
- RESHAPE Study: Key Takeaways on Young Peoples’ Lockdown Experiences with Professor Tamsin Ford and Lauren Cross
Transcript
[00:16:13.139] Clara Faria: Hello, welcome to the RESHAPE Study series for the Association for Child and Adolescent Mental Health, or ACAMH for short. This is a new mini In Conversation series that will explore the REHAPE Study and the impact of its finding for parents, Teachers, policymakers and mental health professionals. I’m Clara Faria, an ACAMH Young Person Ambassador, and an MPhil student at the University of Cambridge. And today, I have the pleasure of talking with Professor Tamsin Ford, Professor of Child and Adolescent Psychiatry at the university.
RESHAPE, or ‘REflecting on the impactS of covid-19 on cHildren And young People in England’ is a large study looking at how life changed for children, young people and parents during the lockdown, and how this may have affected them. It’s a follow-on study from the National Survey of Mental Health and Wellbeing, MHCYP for short. You will hear us talking this term a lot today and is a joint effort between the University of Exeter, the University of Cambridge, King’s College London and the NHS. In this episode we will focus on a very important topic, the eating disorders findings in the National Survey and why they matter.
If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform, let us know how we did with a rating or review, and share with friends and colleagues.
Welcome back, Tamsin. Thank you so much for being here today with us. I was wondering, just for the first-time listeners of the podcast, can you give us a short introduction and an overview of what you do?
[00:17:39.070] Professor Tamsin Ford: Yes, hello, everyone. My name is Tamsin Ford, and I’m a Child and Adolescent Psychiatrist by clinical background, and a Psychiatric Epidemiologist by research background, which thanks to COVID, I don’t really have to explain as much as I used to. But broadly speaking, my research focuses around what can we do to optimise the mental health of children and young people as they grow up? And how can we arrange services and provide support for those who need it, to either prevent young people from struggling with their mental health or to quickly identify and treat those who are, so that their development is not out of course and they fulfil their potential in the longer term?
[00:18:23.730] Clara Faria: And, Tamsin, can you explain to the public about the National Survey study design and what methods we used to measure the number of children and young people with eating disorders?
[00:18:34.740] Professor Tamsin Ford: Yes, thank you. This work was prompted by the increased number of presentations to services in England of children with eating disorders. The main survey, MHCYP, as Clara explained, was conducted in 2017, and it was the third in a series of these National Surveys, where a very carefully selected sample across England in 2017 – the previous surveys were in 1999 and 2004, and they had also involved a small number of children from Wales and from Scotland, but this latest one in 2017 was just England.
So, first of all, they selected postal codes, so these are small units of usually about 150 households, and they randomly selected these postal sectors by their size, to have a sample across the country, and then, within them, stratifying by the socioeconomic structure of the area, and also the age profile, they selected a handful of families to invite from interview. Now, the sample frame was the NHS Register, so the primary care, GP Register, and the idea being is that nearly every child in the population is on this register. There is a slight problem that if people have moved house within the area, they might not have told the GP, because they can phone them and turn up. So, it’s not perfect, but the idea was very carefully to get a representative sample.
So, the survey used multi-informant, standardised diagnostic measure called the Development and Well-Being Assessment, or DAWBA. And if I unpick that a bit, what that means is this is a series of questionnaires that ask very structured questions, with, kind of, forced choice responses about the kinds of difficulties that children and young people might have if they had any of a number of common mental health conditions. If there’s a problem area, then the young people or the parent or the Teacher, in the baseline survey, is asked to describe these problems in more detail, using some semi-structured prompts. So, if you have very structured questions, you have something that’s very reliable, you’ll get a similar answer if you use it with the same person repeated reasonably quickly, or if you have a number of people administer the interview, you’d get similar answers.
However, you can’t tell if somebody’s giving you responses that are not very good because they’ve misunderstood the question, and you have no option to explain. My favourite example of this was a little boy who in the very first survey, got a – the computer counting symptoms on these structured questions thought that he had obsessive compulsive disorder, because he had repeated behaviour that happened for a certain amount of time every day and it was getting in the way of family life. But in this more semi-structured data, his mother said he was playing football repeatedly in the house, and she’d misunderstood what compulsive behaviour was, and this little boy didn’t have OCD, at all. He really liked football, and he needed, you know, a park to play in or a garden to play in, or a football club.
So, the semi-structured data provides an opportunity to pick up that kind of misunderstanding, but also, to pick up children whose problems fall between different types of problems, and both are international classifications of mental health conditions. So, there are two, one called DSM, which is used in America, and one called ICD, or the International Classification of Disease, which is developed by the World Health Organization. They allow you, if you think a child is impaired by their difficulties, to give them a diagnosis, say, of anxiety not otherwise specified. So, it means it’s not a phobia, it’s not generalised anxiety, it’s not post-traumatic stress disorder, it’s not panic disorder, but actually, this child has features of some or all of those and is struggling to cope. And if you saw them in a clinic they would need treatment.
To add complexity to that, parents were interviewed if the child was up to the age of 16. So, this survey went down to age two and up to 19, so with the older teenagers, 17 to 19, they were the primary informant, their parents were also invited, provided the young person thought that was okay. And for those at school age, if the young person and the parent agreed, a Teacher was contacted by mail, so they filled in a questionnaire by mail and sent it back. And then, younger children, aged 11 to 16, were also interviewed.
So, we had a small number of clinical raters who reviewed all the data from whichever informants we had. So, for some children that would have been the parent, the child themselves, and a Teacher. And they looked at the answers to the very structured question, which a computer probably counts more accurately than a person does, but what the computer can’t do is understand the more qualitative data. And then we used DSM and ICD, and we worked with both classifications, to assign diagnoses. So, that’s what we did in 2017.
Now, in the follow-up surveys, it became evident very quickly that clinical presentations, particularly emergency and urgent presentations, had more than doubled to services who were really struggling to cope during the middle part of COVID, and it’s carried on afterwards. Now, that then begs the question, is this because families were locked down together, parents were more likely to be aware, young people were more likely to seek help, perhaps? Or is this a population level change that there was something around the restrictions of COVID, or the anxieties of COVID, that led more children and young people to develop an eating disorder? So, it seemed really important to go back to the population, as we were doing, with questions about mental health. We went back to the original sample in 2020, 2021, 22 and most recently, and with statistics published in 2023.
Now, if we want to make a direct comparison with the data we got in 2017, then we needed to use comparable questions, and the DAWBA has screening items. So, what we did form 2021 on is we used the screening items about eating, and those showed really worrying increases in the number of children who were screening positive. But the problem is this screening item was developed to scoop everybody who might have a problem into further questions. So, whilst we can be really sure that the children who screened negative, and we tested it out in our most recent data and showed it was almost entirely always the case, less than half a percent of those who screen negative on further questioning turned out to have an eating disorder, actually, the proportion of those who screened positive who had an eating disorder was likely to be very low, because you didn’t want to miss anybody for the further questions.
So, we persuaded the Government to let us add on not the whole diagnostic module, and of course, we couldn’t go and interview people face-to-face, as happened in 2017, but we invited all those who screened positive and a random pre-selected sample of about 500 people who screened negative, to test how well the screen worked, to complete the eating disorders module online. So, we did have some free text, but it was typed, rather than spoken, and then a small group of Researchers, of which you and I were both contributing, tried as hard as we could to replicate what happened in 2017. Although, of course, we only had that one eating disorders module.
[00:26:41.850] Clara Faria: Thank you, Tamsin. That was a very comprehensive explanation, and as you mentioned, I think one of the points very important to highlight is the difference between eating problems, or disordered eating, and eating disorders. I think sometimes that may cause some confusion to the public, depending on who is reading the report. The DAWBA, which is this diagnostic interview Tamsin mentioned, and that was used to assess the children and young people in all the versions of the survey, has the screening part which is made of five questions for eating disorders.
And when we say a child is screening positive, this means that they answered “yes” to one of the questions, if they were self-reporting. If we are using a parent or carer interview, the young person is considered as screening positive if they answered “yes” to two or more out of the five questions, and then, they are going to be tried to answer the full eating disorders diagnostic assessment, and then, this assessment would be rated by us, this small group of trained clinical raters, who are trained by Tamsin and by other epidemiology experts. And we would meet regularly, and all of our rating decisions were also reviewed by Senior Consultants in eating disorders. That’s, basically, how we reached the decision if that child or young person had an eating disorder or not.
And the report of the official statistics, which Tamsin mentioned, that just came out in November, showed really concerning figures. For example, the prevalence of any eating disorder in 17 to 19-year-olds was 12.5%, if we consider only girls in that category. So, 17 to 19-year-old girls, that figure was 20%, which means one in every five girls who is 17 to 19-year-old in England in 2023 had an eating disorder. And we are talking about population level prevalence, so those data are from a community sample, not a clinical sample, which makes it especially concerning. And, naturally, the report that came out in November raised many concerns. Many people were concerned with the prevalence of eating disorders reported.
And then, I wanted to ask you, do you think this increase in the population level prevalence reflects increased help-seeking, or actually reflects an increased need?
[00:29:00.419] Professor Tamsin Ford: That’s a really good and really important question, and really was the driving force to address that question of, you know, why we pushed very hard for this work to be done. I think there can be little doubt that this is a population level increase. I think we have to be cognisant of the methodological differences that we couldn’t get round between 2017 and 2023. However, this is the same measure in the same sample, and we’ve waited for non-response and dropout. We know a lot about those who were invited and who didn’t come.
So, I worry, there is a level of imprecision around what are still not massively common disorders. So, you get a point estimate, but there’s a range where that estimate is likely to lie in, and just by chance, we could fall towards the higher end, or even outside that range. I think these data convinced me that there has been an increase, that it is substantial, that it has affected all age groups, and we only have binary gender, but the group that seemed to be doing particularly badly are young women in their older teens, who were more vulnerable anyway. But I think we need to not forget the young boys, who are also not doing terribly well, and their increase has been quite marked, from almost unmeasurable to, kind of, one in 20 in their late teens.
[00:30:35.789] Clara Faria: Yes, I totally agree, and some Researchers were concerned that such high estimate could represent an overestimation in prevalence, but as you just said, and even with the methodological differences from 2023, when comparing to 2017, I would say that we were much more conservative when rating. Whenever we had a borderline case, we would tend to make the decision to not classify as an eating disorder, as to classify it as one. So, definitely, I would say the chances of overestimation are…
[00:31:10.410] Professor Tamsin Ford: I think you’re absolutely right, we minimised them. And as with 2017, we looked for definite evidence that there was an eating disorder. Tentative evidence that there might be would not be sufficient. So, we held the bar quite high, because the question we were being asked by Government to solve in both surveys are, how many children out there need treatment? So, that was in the back of my mind when we were having all those rating discussions. And when we had our eating disorder specialists come in to review the tricky cases with us, that was what I charged them with, “Tell me, if you saw this person, do you think they’d belong on your caseload in a clinic, getting treatment?”
[00:31:55.360] Clara Faria: Yes, and I think the discussions with the specialists helped greatly, because they have a clinical perspective that we don’t have. Also, in the aftermath of the COVID lockdowns, there was a sharp increase in waiting list times in response to escalating referrals and there was widespread concern about how services would cope. Now, the situation seems to be a bit more under control, but there is still an unmet need. We have official statistics to back that claim. The NHS released official statistics for the fourth quarter of 2023, and 78.7% of patients started urgent treatment within one week, and 82.5% of patients started routine treatment within four weeks. That is an improvement if we compare to the rates for pandemic times. It’s still below the eating disorder referral treatment standards, which is 95%, but things definitely have improved.
Do you have any recommendations for Commissioners and how we can ensure early identification of eating disorders in children and young people, especially considering this rise in the population level prevalence?
[00:33:03.070] Professor Tamsin Ford: Well, I think, first of all, Commissioners and practitioners need to congratulate Child and Adolescent Mental Health Services and specialist eating disorder services for rising to this challenge. Because the increase in prevalence in the population is four/five times what we saw in 2017, and the level of referrals have gone up over 100%. So, yes, they struggled and, yes, you know, the timeline slipped, but they’ve responded and things are improving again. So, I think we need to congratulate people on the really hard work that they’re doing in order to deliver those statistics.
I think the data that we’ve just collected suggests that this pressure on access to treatment for eating disorders is not going to go away. It’s evident in the population at an order of magnitude bigger than those currently seeking help. And we haven’t got access to the data yet to be able to see how many of those children and young people diagnosed with an eating disorder are in contact with mental health services. But I think Commissioners need to be aware that this – let’s hope it’s a bulge that then drops back down again, but this level of demand is going to persist for a little while longer.
We, therefore, need to upskill people working with children to be alert to eating disorders. So, there are organisations like Beat, which is a third sector organisation, a charity, that’s devoted to trying to help people with eating disorders to recover. They’ve got lots of really good information for non-specialists, say, people working in schools and colleges who might come into contact with children and young people, and might be very worried about this.
People in education are often the first adults to become aware, because either a young people discloses to a Teacher, or their friends do. And it can often be quite subtle things, like not wanting to eat lunch, or to go to situations where, you know, there is a shared meal. A young person may talk about someone in their friendship group giving away their lunch. So, just to be alert to those signals that there is something wrong with eating behaviours, and to engineer a situation where perhaps you could have a sensitive discussion and make it clear to the young person if they wanted help, there was help that they could go to.
And then, I think those working within children’s mental health services absolutely need to have a weather eye to children presenting with other problems, that there might also be an eating disorder there. Comorbidity is the rule in clinical services, and to make sure that they’re – if there is an eating disorder, that that is also actively treated. We have really good evidence-based treatments for eating disorders. We just need to make sure that those children and young people who need them get access to them.
[00:36:08.619] Clara Faria: Yes, I think another point to make is that eating disorders can affect all genders, but some groups are disproportionately affected, and we saw that very clearly in the 2023 report. Were there any findings in the report that surprised you or any group you think we should pay particular attention to?
[00:36:26.740] Professor Tamsin Ford: We’re alert to the fact that eating disorders are common in girls, and I think most people’s picture of someone with an eating disorder is a painfully thin teenage girl with anorexia. And, in fact, our data shows that, yes, that diagnosis has increased, but actually, it’s the more mixed presentations, sometimes with elements of bulimia, elements of restriction, elements of purging, but not straightforward anorexia or bulimia on its own, that have really increased. So, we need to be a bit wary of our preconceptions.
And I worry particularly about boys and young men being overlooked, because sometimes the picture with boys and young men is more about body shape than body size, and, sort of, compulsive exercise and undereating. And the level of distress and impairment, and potential physical impacts, are no less for the boys. So, as with girls with neurodevelopmental conditions who tend to get overlooked, we need to make sure that we don’t have the same but reversed gender disparity, and that we recognise that those boys who are struggling need our support too.
[00:37:41.240] Clara Faria: Absolutely, and as you said, and I think it’s a really important point to make here to the public, we saw that in the survey, the most common type of eating disorder that we saw, actually wasn’t anorexia or bulimia, but a category classified as “other type of eating disorder,” or “EDNOS,” as some Specialists would call it. And I think that for many people, that can be a bit confusing, because as you said, the stereotype of eating disorder people are used to is perhaps that overtly thin girl, but that’s not actually what we see in reality. And I was wondering if you could explain to the public what that “other” category means?
[00:38:19.559] Professor Tamsin Ford: Well, I think the problem we have is psychiatric diagnoses are descriptive, and they’ve descriptive of the cases that got to services when the condition was first recognised. And actually, you know, the history of eating disorders is really interesting, goes back to the Middle Ages. Again, mostly young women, mostly fasting, and sadly some of them dying, but with a religious overtone. So, there is a cultural element. The refusal to eat was usually around fasting and being impure, rather than feeling that you were overweight. But because of the fact that we have these diagnostic criteria that come from experts who see lots of cases, our classification system does not carve nature at the joints very neatly.
You know, both you and I will have rated cases in the survey who did neatly fall into the anorexic picture of having certain amount of weight loss, often with hormonal disruption, often with severe restriction in how much they would eat, and sometimes with binging and purging, but not always. And then we saw some people who fitted the classical bulimic picture of weight often in the normal range, but the alternating restriction and then binging regularly, and then behaviours to try and correct the binge that are often very, potentially damaging.
However, there are much more mixed pictures, and in fact, the government report uses the International Classification for Diseases from the World Health Organization, because it always has. But DSM-5, which is the American classification, actually has more options for different kinds of eating disorders which haven’t made it into ICD-10. Some of them are – will be in ICD-11, which is now beginning to be used around the country, but wasn’t what we used, because we wanted to compare with 2017, when it was ICD-10.
And so, you get these mixed pictures of young people whose eating behaviour is very disordered. They are often, but not always, restricting what they eat. They are often – have a very disordered perception of their body shape. So, there are questions in the diagnostic module which talk about how they see their body and how other people see their body, and similar questions are asked to their parents. And of course, for 11 to 16-year-old, we had parent and young person often. So, what you’re looking for is someone who thinks that they are fat and who is terrified of gaining weight, and who struggles almost, sort of – the bulimic picture is almost like an addiction to food, that they can’t stop thinking about food all the time.
Often binges, by which we mean eating a very large amount of food at one particular time, happens sometimes multiple times a day, more commonly several times a week, and that then feeds into – you can imagine somebody’s eating behaviour is very dysregulated. And they oscillate between starving themselves, not being able to, because the innate drive to nourish yourself, kind of, kicks in, so they lose control. They eat often not very nutritious foods and in huge volume, and then they feel dreadful. And so, they do various things, that could be about fasting, it could be about making themselves sick, it could be about using laxatives or other medication, to try and counteract the binges they’re having.
And you get these people who have elements of all of those to a level which is impairing their ability to function, so their peer relationships, their family relationships, their ability to learn and study and their leisure activities. And we needed to have that impairment very clearly evidenced in the responses the young person and/or their parent gave in order to say that, “Yes, this young person has a diagnosis.”
[00:42:21.500] Clara Faria: Absolutely. I think often diagnostic manuals, they don’t capture the nuances that reality has, and as you said, we saw so many diverse cases where the young person wouldn’t fit clearly into the diagnostic criteria for anorexia or for bulimia, but would sometimes oscillate between binge eating behaviours, and then would restrict a lot. And I think that’s what we mean when we end up classifying the person as “other.” It means that they are displaying disordered eating behaviours at a clinically impairing level, but they do not fit those diagnostic categories, but that does not mean that there is not suffering and impairment.
And to our last question, when looking at the current prevalence of eating disorders in children and young people, what do you think the main implications are for meeting their needs in the present and in the future? Do you have any recommendations for future interventions, or key take-away messages for our audience?
[00:43:19.809] Professor Tamsin Ford: Well, that’s a really good question. I think, firstly, everyone who works with children and young people needs to be alert to the fact that many more young people than previously are struggling with either eating difficulties, or, frankly, eating disorders. Eating disorders can be very nasty and persistent. So, my advice to practitioners who are at all concerned is to encourage the young person to seek help via their GP, who can then at least monitor their weight and their pulse and their blood pressure and all the important physical parameters, and to seek referral to a child mental health service.
The other resource that may be really useful for young people, or parents who are worried about a child that they know is called Beat, as in beating eating disorders. This is a charity that’s devoted to supporting children and young people, and adults with eating disorders, and there is a wealth of useful information. You can also find a summary on the Association of Child and Adolescent Mental Health website, which will summarise sources of support.
And then, finally, I would say for those who work and commission child mental health services, this is something we need to get to grips with, and actually, we’re doing a reasonable job. So, when the presentations were absolutely at their peak, the services started to really struggle to meet their targets in terms of seeing urgent and emergency cases within a week and routine referrals within a month. That’s improving, so services are working really hard, but we need to keep an eye on this, because we don’t want staff to get burnt out. And those who aren’t working within specialist eating disorder teams or services need to keep their eye out for a young person who maybe is not responding to treatment as well as they should and, actually, actively ask whether there are difficulties with eating. Because young people will not always volunteer, and their parents may not be aware, so it’s worth actively seeking whether someone might be struggling with these problems.
And then, of course, I would say as an Academic, we need more research, but that’s maybe a discussion for another day.
[00:45:41.859] Clara Faria: And Tamsin, you mentioned a point that really appealed to me as a junior trainee. You mentioned that outside of specialist eating disorder services, often the first point of contact of the young person is going to be their GP, or maybe a Junior Doctor in an Emergency Department. And one point that people with lived experience of eating disorders have constantly been raising, and, also, I’ve noticed the Royal College of Psychiatrists has done lots of work trying to improve that, is the lack of knowledge among medical and healthcare professional in general about eating disorders in young people. As also someone that’s responsible for medical education, what’s your view on this, and how do you think we can improve medical education to empower health professionals to take better care of young people struggling with eating disorders?
[00:46:30.910] Professor Tamsin Ford: Well, that’s a really, really important point, actually, and it’s a training issue. These were once seen as, certainly in children and young people, but also in adults, as not terribly common disorders, but they are now increasingly common. They can persist, they can be fatal. We need to make sure that, in every level that – you know, during medical student training, and during postgraduate training for General Practitioners, who will often be the first port of call, but also Emergency Doctors, Paediatricians, Physicians, Dentists, as well, often pick this up if somebody’s repeatedly vomiting, because of the impact on their teeth.
So, making training available, making information available, and perhaps local networks where people can seek advice from Specialists. You know, one of the remits of a specialist eating disorder service is not only seeing the patients, it’s supporting and consulting and training colleagues to be able to respond. And I think we shouldn’t forget education. The other professionals who quite often are the first people to realise there’s a problem are Teachers. Quite often, it’ll be either the young person themselves discloses to a Teacher, or, perhaps more often, their friends report a worry about somebody not eating, or somebody giving away their lunch.
And I think we need to make it clear that we don’t expect Teachers to be mental health practitioners. It’s not their role to do the assessment or the treatment, but actually, knowing where to go for help, and encouraging young people to seek help, because, actually, we have treatments that work. And they’re not going to work if the young person doesn’t get treatment. So, we shouldn’t forget Practitioners working in other settings, other than health, but particularly education, who are often the first people to spot that there’s a problem, and it’s really crucial that they know what to do.
[00:48:33.940] Clara Faria: Thank you so much for your time, Tamsin. That was a really interesting conversation, and I hope we shed some light on the National Survey data. And for more details on Professor Tamsin Ford, please visit the ChARM and ACAMH websites. Our ACAMH website is www.acamh.org. Also, check our Twitter @ACAMH. ACAMH is spelt A-C-A-M-H. If you would like more information about the National Survey report, the report is publicly available at digital.nhs.uk/data-and-information. Do keep an eye out for other podcasts in the RESHAPE Study series, including episodes on special education needs and disabilities. And don’t forget to follow us on your preferred streaming platform, let us know if you enjoyed the podcast, with a rating or a review, and do share with friends and colleagues. Thank you so much for listening.
