YASU ADHD Structured Interview - Patient

Young Adult Support Unit – ADHD Assessment Situation Date: 01/11/2024 Time: 10:30 AM Attendees:** Patient (Sarah Jenkins), Clinician (Dr. Emily White) Clinician: Dr. Emily White, Clinical Psychologist Appointment type:In-person consultation, YASU Clinic, Room 3 Background Sarah Jenkins, a 22-year-old female, presents for an ADHD assessment. She uses she/her pronouns and reports a long-standing history of difficulties with concentration and organisation, which she suspects may be related to ADHD. She is currently pursuing a degree in Graphic Design and finds herself struggling to meet deadlines and maintain focus during lectures. Assessment INTRODUCTIONS TO ASSESSMENT - Purpose of assessment: Build a full picture of strengths, challenges, and history, and to determine whether ADHD is the best explanation for the difficulties experienced. - Comprehensive approach: Assessment is not just about "ticking boxes"—it's about understanding the whole person and their context. - Approach: various forms of assessment including information gathering (which will be completed today), completion of questionnaires, structured clinical interview assessment, observer observations and reviewed historical school reports. - Multiple assessments and perspectives: Helps ensure accuracy, as symptoms can vary across settings and over time. - Importance of medical review: After psychology assessment, AYA med or psychiatry will conduct a medical review to rule out medical or neurological explanations (e.g., thyroid, seizures, medication effects). - At medical review: The outcome may be ADHD, another explanation, or a combination. Either way, the process should help clarify supports and strategies to improve daily functioning and wellbeing. - ADHD is not the only possibility: Many other conditions (e.g., anxiety, depression, trauma, sleep difficulties, autism, learning differences) can look similar or overlap with ADHD. Presentation: - Patient was neatly dressed in casual attire and appeared well-groomed. - Affect was generally subdued but cooperative, with some signs of anxiety noted through fidgeting hands. - Speech was clear and articulate, with a moderate pace and appropriate volume. - Thought content was logical and coherent, primarily focused on her struggles with academic performance and personal organisation. GATHERED INFORMATION Presenting Concerns and Symptom Review - Current ADHD concerns (who raised them and why): Sarah herself initiated the assessment, prompted by increasing academic difficulties and feedback from university tutors regarding missed deadlines and inconsistent work quality. Her parents had also previously raised concerns during her high school years. - Presence of core ADHD symptoms (inattention, hyperactivity, impulsivity): Sarah reports significant inattention, including difficulty sustaining focus during lectures and while reading, easily being distracted by internal thoughts, and frequently misplacing items. She denies overt hyperactivity but describes an internal restlessness and difficulty relaxing. Impulsivity is reported in the form of interrupting others and making spontaneous purchases she later regrets. - Associated difficulties: She experiences significant emotional dysregulation, particularly frustration and irritability when tasks are challenging. Sleep onset insomnia is a consistent issue, and she struggles with organisation, often feeling overwhelmed by daily tasks and long-term planning. - Onset (and if prior to 12), duration, and severity of symptoms: Symptoms of inattention and disorganisation were present since primary school, with teachers frequently commenting on her 'daydreaming'. Hyperactivity was more subtle, observed as fidgeting. Symptoms intensified significantly in high school and university, leading to current severe functional impairment. - Contexts where symptoms occur: Symptoms are pervasive, affecting her at home (difficulty maintaining routines, managing household chores), university (struggling with lectures, assignments, and studying), and in social relationships (forgetting plans, interrupting conversations). - Adaptive coping strategies: She has attempted using planners and digital reminders, but struggles with consistency. She also tries to break down large tasks into smaller ones, which sometimes helps. Functional Impact - Primary school education impact: Frequent comments on daydreaming and not paying attention. Required extra support from teachers to complete tasks. Often lost school supplies. - High school education impact: Struggled with organisation of assignments and studying for exams. Grades were inconsistent, often performing well in subjects she enjoyed but poorly in others due to lack of focus. Had difficulty completing homework on time. - University education impact: Currently on academic probation due to missed deadlines and poor performance. Finds it challenging to attend all lectures, stay focused during them, and manage multiple projects simultaneously. Often starts assignments last minute. - Workplace: Has held several part-time jobs (retail, hospitality) and reported difficulty with routine tasks, time management, and maintaining focus during shifts. Received feedback about needing to be more organised. - Home/personal life: Struggles with maintaining a consistent routine, leading to disorganised living spaces. Often forgets appointments or social engagements. Experiences tension in relationships due to perceived disorganisation and forgetfulness. Difficulties with budgeting and managing finances. - Emotional and social functioning: Reports low self-esteem due to academic and organisational struggles. Experiences significant anxiety and frustration. Has a few close friends but sometimes struggles to maintain these relationships due to disorganisation or forgetting commitments. Reports feeling misunderstood by others. Developmental and Medical History - Developmental history: Uncomplicated pregnancy and birth. Met developmental milestones within typical range. Early behaviour included being a 'fidgety' child and prone to 'zoning out'. - Medical history: No significant chronic medical conditions. Currently takes no regular medications. No history of neurological concerns or sensory issues reported. - History of developmental assessment: No prior formal developmental assessments have been conducted. - Family history of ADHD: Patient's maternal uncle was diagnosed with ADHD in adulthood. ADDITIONAL INFORMATION - Provided explanation further psychometric testing, specifically the CAARS. Provided explanation of how to complete. - Obtained consent to send CAARS to an observer. Observer name and email address - Liam Davies, liam.davies@example.com - Obtained consent to speak with parent to gather developmental information. Parent name and email address – Susan Jenkins, susan.jenkins@example.com - Asked for patient to collate and provide primary and high school reports. Explained rationale for this information. Plan 1. Patient to complete CAARS self-report and send observer CAARS to Liam Davies. 2. Patient to collate and provide primary and high school reports for review at the next session. 3. Clinician to contact Susan Jenkins (patient's mother) for additional developmental history. 4. Schedule follow-up appointment in two weeks to review CAARS results and collected historical information. 5. Provide patient with resources on ADHD, including websites and support groups, to read prior to the next session.