ASD/ADHD Assessment Report

**Family History** Parents: Both parents are alive and well, no significant medical history. Siblings: One older sister, no known issues. Family history of ADHD or other psychiatric conditions - Mother diagnosed with anxiety. **Developmental History** Pregnancy: Uncomplicated pregnancy. Birth: Vaginal delivery at term, no complications. Developmental Milestones: Met all milestones within expected ranges. **Educational History** Primary Education: Attended mainstream school, achieved average grades. Secondary Education: Attended mainstream school, struggled with organisation and time management. **Employment History** [Patient's Name] currently works as a software engineer. **Social History** Relationships: Good relationships with family and friends. **Medical History** Conditions: No significant medical conditions. **Psychiatric History** Anxiety: Reports occasional anxiety, particularly in social situations. **Alcohol & substance use/addictions** Caffeine Use: Drinks coffee daily. **Risk** To self: No current suicidal ideation. **Mental state** Appearance & Behaviour: Appears well-groomed and appropriately dressed. Calm and cooperative during the interview. Speech: Clear and coherent speech. Mood: Reported mood is generally stable. Affect: Affect is congruent with reported mood. **Assessment of ADHD Symptoms** **ADHD Diagnostic Criteria: Inattention** Fails to pay close attention to details, makes careless mistakes: Frequently makes careless mistakes at work. Has trouble sustaining attention on tasks or play: Struggles to focus on tasks that are not of interest. issues following instructions - Difficulty following multi-step instructions. **ADHD Diagnostic Criteria: Hyperactivity/Impulsivity** Fidgets with hands/ objects; moves feet or squirms in chair: Taps fingers when thinking. **Assessment of Autistic Symptoms** **Observations of [Name]'s strengths and difficulties on the ADOS were as follows:** Language and communication – including verbal skills (frequency and type of communication, quality of language, echolalia, jargon, intonation and pitch, stereotyped and idiosyncratic use) and non-verbal skills (pointing, gestures, use of others' body to communicate). - Observations related to language and communication skills, including verbal and non-verbal communication: Good verbal skills, but struggles with non-verbal cues. Reciprocal Social Interaction – including eye contact, social smile, facial expression, gaze interaction, shared enjoyment, response to name, requesting, giving and showing, joint attention (response and initiation), quality of social overtures - Observations related to reciprocal social interaction, including eye contact, facial expressions, shared enjoyment, and quality of social interactions: Avoids eye contact. Imagination - including imagination and creativity - Observations related to imagination and creativity during play and storytelling: Limited imagination during play. Stereotyped behaviours and restricted interests – including complex mannerisms, unusual sensory interests, self-injurious behaviour, repetitive interests & stereotyped behaviours - Observations related to stereotyped behaviours and restricted interests, including sensory seeking behaviour, mannerisms, and unusual or highly specific interests: Intense interest in computer programming. **SOCIAL COMMUNICATION DIFFERENCES** A1: Social Approach and Interaction [Describe the social approach, play behaviour at home, at social gatherings, and specific interests.] (Include observations on social engagement and interaction styles.) A2: Nonverbal Communication [Outline understanding and use of eye contact, gestures, facial expressions, and body language.] (Include specifics on how these nonverbal cues are used in communication.) A3: Play Style and Friendships [Describe play style, and the ability to make and maintain friendships.] (Include any relevant details on peer interactions.) RESTRICTED AND REPETITIVE BEHAVIOURS B1: Repetitive Behaviours [Describe repetitive speech, body movements, and use of items.] (Include observed repetitive actions or speech patterns.) B2: Routines and Transitions [Detail routines, rituals, and how the patient manages transitions.] (Include any noted difficulties with changes in routine or unexpected transitions.) B3: Special Interests and Collections [Outline specific interests, collections, and any obsessions with particular topics or items.] (Include only if these are significant in daily activities.) B4: Sensory Processing Differences [Describe sensory processing differences, including hypersensitivities or hyposensitivities across various senses.] (Include only if relevant sensory patterns are observed.) AUTISM QUOTIENT SCORING [Include the results of Autism Quotient (AQ) scoring, with details on each domain scored, such as Social Skills, Attention Switching, Attention to Detail, Communication, and Imagination. Provide the total score and interpret the result based on standard scoring thresholds.] (Include only if the Autism Quotient scoring was completed and provide clear, interpretable results for the reader.)