YASU ADHD Structured Interview - Patient

**Young Adult Support Unit – ADHD Assessment** **<u>Situation</u>** **Date:** [date of appointment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in format DD/MM/YYYY.) **Time:** [time of appointment](Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **Attendees:** [list of attendees including patient and other family members] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **Clinician:** [clinician name and role](Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **Appointment type:** [document type of appointment such as mode, setting and location](Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **<u>Background</u>** [mention patient's name, pronouns, age, medical condition and presenting issue] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences.) **<u>Assessment</u>** **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." **<u>Presentation:</u>** [document mental state and presentation observations such as dressing, appearance, affect, speech, and thought content] (Only include observations explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as a bullet point list, with each item on a new line.) (If the appointment was a phone session, write the following. Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit entirely.) "- Pt's appearance was unable to be assessed due to phone appt" **GATHERED INFORMATION** Presenting Concerns and Symptom Review - Current ADHD concerns (who raised them and why):[document who raised ADHD concerns and their reasons] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Presence of core ADHD symptoms (inattention, hyperactivity, impulsivity):[document core ADHD symptoms reported such as inattention, hyperactivity and impulsivity] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Associated difficulties:[document associated difficulties reported such as emotional dysregulation, sleep, organisation difficulties] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Onset (and if prior to 12), duration, and severity of symptoms: [document onset, duration and severity of symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Contexts where symptoms occur: [document contexts in which symptoms occur such as home, school, work or relationships] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Adaptive coping strategies:[document adaptive coping strategies reported] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Functional Impact - Primary school education impact: [document primary school functional impact on aspects such as attention, organisation, academic progress, classroom behaviour, and peer relationships] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - High school education impact: [document high school functional impact on aspects such as attention, organisation, academic progress, classroom behaviour, and peer relationships] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - University education impact: [document university functional impact on aspects such as attention, organisation, academic progress, classroom behaviour, and peer relationships] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Workplace: [document workplace functional impact on aspects such as productivity, task completion, time management, and performance reviews] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Home/personal life: [document home and personal life functional impact on aspects such as routines, relationships, responsibilities, daily living skills] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Emotional and social functioning:[document emotional and social functional impact on aspects such as friendships, self-esteem, and regulation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Developmental and Medical History - Developmental history: [document developmental history such as pregnancy, birth, milestones, and early behaviour if known] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Medical history: [document medical history such as chronic conditions, medications, neurological concerns, and sensory issues] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - History of developmental assessment: [document history of developmental assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Family history of ADHD:[document family history of ADHD] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **ADDITIONAL INFORMATION** - "Provided explanation further psychometric testing, specifically the CAARS. Provided explanation of how to complete." (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - "Obtained consent to send CAARS to an observer. Observer name and email address -"[observer name and email](Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - "Obtained consent to speak with parent to gather developmental information. Parent name and email address –" [parent name and email] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - "Asked for patient to collate and provide primary and high school reports. Explained rationale for this information." (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **<u>Plan</u>** [document plan such as next review date, ongoing assessments, feedback to be provided, resources to be provided to patient and patient reminders] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as a numbered list, with each item on a new line.)