CYP ADHD Specialist Nurse Assessment Report

Specific Information for GP to Note Recent medication change: Patient has started taking Vitamin D supplements for low levels. No other medication changes requiring immediate GP action. Safeguarding concerns: None identified. Risk disclosures: None identified. Recommended referrals: Referral to local ADHD support group. Has Alex stopped taking any prescribed medications listed on SCR? No Does Alex have any diagnoses that they are querying? No Current Mental Health Diagnosis Anxiety (Generalised Anxiety Disorder) Current Psychotropic Medications Sertraline 50mg daily Current OTC/Herbal Remedies/Vitamins Vitamin D 1000 IU daily Magnesium Glycinate 200mg daily Any Known Drug Allergies/Sensitivities Penicillin (rash) Current Physical Health Diagnosis SCR and as discussed with Alex at the appointment. Eczema Mild Asthma Vitamin D Deficiency Specific Information for Education to Note Alex's school has been informed of the ongoing ADHD assessment. A psychoeducation session for teachers regarding ADHD in adolescents is recommended. Consent has been given to share relevant information with the school's SENDCO to facilitate appropriate classroom accommodations. No urgent follow-up or safety planning is currently required. Summary of Findings and Diagnosis I had the pleasure of assessing Alex on 01/11/2024. Alex meets DSM-5 criteria for ADHD (combined type). Diagnosis based on clinical assessment and pre-assessment rating scales. Following comprehensive assessment, other potential contributing factors to Alex's presentation, such as environmental stressors or other psychiatric conditions, have been carefully considered and largely excluded as primary causes for the pervasive and long-standing symptoms consistent with ADHD. Symptoms are not better explained by other conditions. ADHD can be made worse by co-morbid mental health disorders such as depression, anxiety, trauma, and substance misuse. For women, ADHD can also be affected by hormone levels during menstruation. If any of these are a concern, your assessor will signpost appropriate services for further support. Given Alex's current anxiety diagnosis, ongoing support from their GP and potentially a therapist for anxiety management is encouraged. Capacity and Consent Does Alex "have capacity and consent to treatment? Yes The patient has been assessed as competent with capacity in an age appropriate way alongside their parent or carer (Gillick competent). Alex demonstrated the ability to understand the information relevant to treatment and to make informed decisions about it alongside their parent or carer. They actively participated in the discussion, provided detailed responses to questions and consented to follow up actions. Alex has capacity and has consented to management plan voluntarily. Management Plan 1. GP to consider adjustment of Sertraline dosage in consultation with Alex and family if anxiety symptoms persist, as discussed with the assessor. 2. Alex to complete ADHD self-help workbook focusing on organisational skills (action: Alex and family). 3. School to implement recommended accommodations as per Appendix II (action: School SENDCO, with support from Alex's parents). 4. Referral to local ADHD support group for peer support and further resources (action: Assessor, with patient consent). 5. Follow-up appointment scheduled in 6 weeks to review progress and discuss potential pharmacological options (action: Assessor). Appendices Appendix I - Letter for education and professional settings Appendix II - Supportive accommodations Appendix III - Resource List Appendix IV - EHCP supporting Letter ADHD Assessment Introduction and Professional Credentials Sarah Williams is a Learning Disability Nurse with a special interest in neurodiversity, trained in conducting ADHD assessments. Our assessment process follows NICE guidelines and adheres to the Child and Young Person Assessment Quality Assurance Standards for the assessment and treatment of ADHD. Presenting Complaint Reason for Seeking ADHD Diagnosis Alex, aged 14, presented for an ADHD assessment at the suggestion of his parents and school. Symptoms of inattention and hyperactivity have been noted since early primary school, significantly impacting his academic performance, social interactions, and home life. Recently, these difficulties have become more pronounced with the increased academic demands of secondary school and a growing sense of frustration and low self-esteem in Alex. He describes struggling to focus in class, often losing his belongings, and finding it hard to complete homework assignments without constant prompting. His parents report a long history of difficulty with task initiation and completion, as well as frequent interrupting in conversations. Current ADHD Symptoms and Presentation At home, Alex often forgets chores, struggles to follow multi-step instructions, and leaves tasks unfinished. He frequently misplaces school items and personal belongings, leading to frustration for both him and his parents. Socially, he reports difficulty maintaining conversations, often interrupting others, and struggling to wait his turn in games. This has occasionally led to misunderstandings with friends. In school, his teachers have noted consistent difficulty with sustained attention during lessons, often daydreaming or becoming easily distracted by external stimuli. He frequently misses deadlines and struggles with organisation, despite interventions. During the assessment, Alex exhibited some fidgeting and occasionally struggled to maintain eye contact for extended periods, but was generally cooperative. Impact on Patient's Life Alex's ADHD symptoms have significantly influenced his emotional wellbeing, leading to feelings of inadequacy and frustration, particularly regarding his academic performance. He has expressed sadness about not being able to keep up with his peers academically, despite feeling capable. Relationships with his parents are strained at times due to constant reminders and perceived lack of effort. Friendships have been challenging, with some peers finding his impulsivity and interruptions difficult to navigate, although he has a small, supportive group of close friends who understand him. Positive Aspects of ADHD Alex demonstrates remarkable creativity and innovative thinking, often coming up with unique solutions to problems in his favourite subjects like art and design technology. He is highly energetic and passionate when engaged in topics of interest, able to hyperfocus for extended periods on his hobbies, such as building intricate Lego models. His quick thinking also allows him to be very responsive in dynamic situations, such as during football matches where he excels as a goalkeeper. Alex has developed several strategies to manage his challenges. He uses a visual timetable at home for daily routines, which is somewhat effective. He also tries to sit at the front of the class to reduce distractions, and his parents help him break down large tasks into smaller, more manageable steps. However, despite these efforts, consistency remains a significant challenge, and many approaches have proven unsuccessful in the long term, particularly with self-organisation. Goals for Diagnosis Alex and his family hope that an ADHD diagnosis will provide a better understanding of his difficulties and validate his experiences. They are seeking strategies and support to manage his symptoms more effectively, particularly in academic and social settings. Both Alex and his parents are open to exploring both non-pharmacological interventions and, if deemed appropriate, pharmacological management to improve his quality of life and academic potential. History and Context Family History Neurodevelopmental Disorders Alex's maternal uncle has a confirmed diagnosis of ADHD, and his paternal grandmother has reported lifelong struggles with organisation and concentration, consistent with undiagnosed ADHD traits. There are no reported cultural factors acting as barriers to understanding or accepting neurodiversity within the family. Family History of Mental Health Concerns Alex's mother has a history of anxiety, managed with medication, and his father experienced a period of depression during his late twenties. Physical Health and Past Medical History Acute or Chronic Illnesses Alex has a history of mild eczema, which is well-controlled with topical creams, and mild asthma, managed with a reliever inhaler as needed. There are no current acute illnesses. No red flags requiring immediate GP discussion were identified, beyond the need for consideration regarding future ADHD medication if pursued. Medications and Healthcare Input Alex currently takes Sertraline 50mg daily for anxiety, which was started 6 months ago. He also takes a Vitamin D supplement daily due to previously identified low levels. He sees his GP for regular reviews of his asthma and eczema. No other significant input from healthcare professionals. Cardiovascular History No personal or family history of significant cardiovascular issues that would contraindicate ADHD medication. ECG performed 3 months ago as part of anxiety medication initiation was normal. Other Medical Conditions No history of other chronic or significant health conditions relevant to the assessment. Surgeries and Absorption Considerations Alex had an appendectomy two years ago. No other recent surgeries that would affect medication absorption. Female Health Considerations Not applicable as patient is male. Sleep History and Issues Sleep Difficulties Alex reports significant difficulty with falling asleep, often describing his mind racing with thoughts and ideas, making it hard to switch off. He often lies awake for an hour or more before sleep, and frequently wakes during the night. Use of Sleep Aids Alex occasionally uses melatonin (over-the-counter) to assist with sleep, taking 3mg on nights when he anticipates particular difficulty. He does not use any prescribed sleep aids. Impact on Daily Life Lack of consistent, quality sleep often leaves Alex feeling tired and irritable during the day, further exacerbating his concentration difficulties at school and his emotional regulation. Diet, Appetite and Lifestyle Current Diet and Caffeine Intake Alex generally follows a balanced diet, although he has a tendency to snack on sugary foods when feeling stressed. He consumes one energy drink daily, usually in the late afternoon, which he reports helps him to feel more alert, but also contributes to sleep difficulties. Eating Patterns and Possible Disordered Eating No history of disordered eating behaviours or addictive tendencies around food was reported. His snacking habits are primarily linked to mood regulation rather than a broader eating disorder. Potential Impact of Medication on Eating Habits "It is important to note that, if you are confirmed to have a diagnosis of ADHD, eating and drinking habits may change if you decide to start pharmacological treatment for ADHD." Leisure Time Alex is actively involved in local football, training twice a week and playing matches on weekends. He finds physical activity helps significantly with his mental health, providing an outlet for his energy and improving his mood. He also enjoys playing video games, which can sometimes lead to prolonged screen time, but also provides a focused activity. Developmental History (Pregnancy, Birth and Early Childhood) Pregnancy Maternal Pregnancy History Alex's mother reported an uncomplicated pregnancy with no significant health issues or complications. Regular antenatal care was received. Birth History Alex was born at full term via spontaneous vaginal delivery, with a normal birth weight of 7 lbs 2 oz. There were no complications during delivery. Maternal Lifestyle Factors Alex's mother reported abstaining from alcohol and smoking throughout the pregnancy. No other maternal lifestyle factors that may be relevant to neurodevelopmental presentation were identified. Early Childhood Early Childhood Milestones Alex achieved most key developmental milestones within the expected ranges, although his parents recall him being slightly later in developing fine motor skills. Speech development was normal, but he was always described as a highly active and restless child from a very young age. Early Signs of ADHD Symptoms From nursery age, Alex's parents recall him having a very short attention span, constantly moving, and struggling to sit still during story time. Teachers often commented on his boundless energy and difficulty following instructions, even when he seemed to understand them. He frequently got into minor accidents due to impulsivity. Home Life and Living Skills Home Environment Alex lives with both parents and a younger sister in a semi-detached house. The home environment is generally supportive, although there are frequent frustrations related to Alex's ADHD symptoms, particularly around organisation and task completion, impacting family harmony. His parents have tried various strategies to support him, but consistency remains a challenge. Current Living Situation Alex requires significant parental support with organisation, time management, and remembering schoolwork due to his ADHD-related difficulties. While he can perform basic activities of daily living independently, initiating and completing multi-step tasks without prompting is challenging. He relies on his parents for reminders about appointments and deadlines. Educational History Preschool/Nursery During preschool, staff frequently commented on Alex's high energy levels, difficulty concentrating on structured activities, and tendency to disrupt group play. Concerns were raised about his readiness for primary school due to these behaviours. Primary Education Alex's primary school experience was marked by attendance issues due to frequent minor illnesses and occasional refusal to attend school. He struggled with learning, particularly in subjects requiring sustained attention. Teacher feedback consistently highlighted difficulties with focus, following instructions, and completing tasks. He often used humour as a coping strategy to deflect from academic struggles. Secondary and Tertiary Education Currently in secondary school, Alex's ADHD symptoms significantly impact his academic performance. He struggles to manage multiple subjects, deadlines, and the increased organisational demands. His grades are inconsistent, often reflecting incomplete work rather than lack of ability. His daily routines are chaotic, and he frequently arrives late to lessons or forgets necessary equipment. Parental Involvement and Support Alex's parents have been highly involved in his education, attending numerous meetings with teachers and trying various home-based interventions. Their consistent support has helped to minimise some of the impact of his ADHD-related difficulties, particularly by providing a structured home environment and assisting with homework completion, but the daily effort is significant. Friendships and Relationships Alex has experienced some social difficulties, particularly in primary school where he was occasionally teased for his impulsivity. While he has a core group of friends now, he reports that his tendency to interrupt or dominate conversations can sometimes strain relationships. He has learned to be more aware of these behaviours with close friends. Romantic Relationships Alex is not currently in a romantic relationship. He reports some anxiety about how his ADHD symptoms might affect future relationships, particularly his organisational struggles and tendency to forget things. Occupational History Job History and Employment Challenges Not applicable as patient is a minor. Work Performance and Symptoms Not applicable as patient is a minor. Workplace Feedback and HR Issues Not applicable as patient is a minor. Past Psychiatric History and Psychological Treatments Current Mental Health Status Alex describes his current mental health as challenging due to ongoing anxiety and frustration regarding his academic performance and perceived difficulties fitting in. He was diagnosed with Generalised Anxiety Disorder 6 months ago and is currently taking Sertraline. He has not had any previous psychiatric diagnoses, but reports always feeling 'different' and 'on edge'. Hospital Admissions and Psychiatric Treatments No psychiatric hospital admissions or mental health-related hospital admissions. He has not received any other psychiatric treatments apart from current medication for anxiety. Psychotherapy and Counselling Alex attended 8 sessions of CBT for anxiety 4 months ago, which he found moderately helpful. There are no reported adverse childhood experiences that have significantly impacted his mental health. Specific Psychiatric History Alex reports symptoms consistent with Generalised Anxiety Disorder, including excessive worry, restlessness, and difficulty controlling anxious thoughts. There are no reported symptoms of tics, bipolar affective disorder, psychosis, or obsessive-compulsive disorder. Exclusion of Other Mental Health Conditions There is currently evidence of Generalised Anxiety Disorder based on Alex's history. However, symptoms of ADHD persist between episodes of anxiety, and have been present throughout their life span. Substance Use Drugs and Alcohol Alex reports occasional experimentation with alcohol (binge drinking on 2 occasions at parties in the last 6 months) and has tried cannabis once. He states that he uses energy drinks daily, and occasionally uses cannabis to 'calm his thoughts', linking this to self-medication for his restless mind. He is aware of the potential negative impacts but struggles with cessation. Openness to Substance Misuse Services Alex expressed some openness to seeking help from substance misuse services, acknowledging that his energy drink and cannabis use is becoming problematic. He is aware of the impact of substance use on his mental health and potential ADHD management. Forensic History Alex had one minor interaction with the police for shoplifting small items with friends last year. He attributed this to impulsivity and a desire to fit in with peers. No further legal matters. Driving Not applicable as patient is a minor. Mental State Examination (MSE) Appearance Dressed appropriately for the weather, well kempt, and no noticeable signs of neglect observed. Behaviour Was fully engaged in assessment, appropriate eye contact and was able to establish a good rapport. Some mild fidgeting noted throughout the assessment, consistent with reported hyperactivity. Speech Speech was normal for rate, rhythm, tone and volume. Mood and Affect Objectively Alex presented with a somewhat anxious affect, but subjectively reported his mood as 6/10 (0 being worst, 10 being best), stating he felt hopeful about the assessment outcome. Thought Thoughts were coherent and appropriate. No formal thought disorder noted. Perception No perceptual abnormalities noted. Cognition Orientated to time, person, and place. Noted some difficulty with sustained concentration during complex questions, requiring occasional re-direction. Insight and Judgement Patient demonstrated insight into their difficulties, particularly regarding the impact of his ADHD symptoms on his life and the need for support. Risk Alex denied current suicidal thoughts, self-harm intentions, or violence and showed a positive outlook for the future. Session Summary This assessment aimed to determine if Alex meets the diagnostic criteria for ADHD. Key challenges highlighted were significant inattention, hyperactivity, and impulsivity impacting academic, social, and home life since early childhood. While some anxiety is present, ADHD symptoms appear primary and pervasive. No acute mental health risks or safeguarding concerns were identified. Prescribing responsibilities will be with the GP should pharmacological treatment be pursued. Key agreed actions include school accommodations, self-help strategies, and referral to a support group. There are no features suggestive of autism based on Alex's developmental history and current presentation.