Clinic Letter Learning Disability (Youth)

Clinician Specialty: Physician **Name:** Thomas Smith **Date of Birth:** 15/03/2010 **NHS Number:** 123 456 7890 **Date of appointment:** 01/11/2024 **Attendees:** * Sarah Smith (Mother) * David Smith (Father) * Dr. Eleanor Vance (Consultant Psychiatrist) **Diagnoses:** * **6A00.Z** Intellectual developmental disorder, global developmental delay, unspecified * **6A06.0** Attention deficit hyperactivity disorder, predominantly inattentive presentation * **6A02.2** Autism spectrum disorder with intellectual developmental disorder and with mild or no impairment of functional language **Current medication:** * Methylphenidate 10mg modified-release capsule, once daily in the morning. * Melatonin 2mg modified-release tablet, 30 minutes before bedtime. **Measurements:** Height: 145 cm Weight: 42 kg Heart Rate: 82 bpm BP: 110/70 mmHg Age-adjusted BMI: 19.9 (75th percentile) **Reason for appointment:** Thomas, a 14-year-old male with a diagnosis of global developmental delay, autism spectrum disorder, and ADHD, was brought in by his parents for a review of his current psychotropic medication and persistent difficulties with focus, impulsivity, and sleep. His parents also expressed concerns about escalating anxiety symptoms observed over the past three months, particularly in social settings and when facing unexpected changes to routine. **Developmental History:** Thomas had significant developmental delays, with independent walking achieved at 2 years and first words appearing around 3 years of age. He received early intervention services, including speech and language therapy and occupational therapy, from a young age. He was formally diagnosed with a moderate learning disability at 6 years old following a comprehensive cognitive assessment. Social reciprocity and communication difficulties have been evident since early childhood, consistent with his autism diagnosis. He has a history of sensory sensitivities, particularly to loud noises and certain textures. **Education History and Current Setting:** Thomas attends Willow Creek Special School, where he is in year 9. He receives significant one-to-one support in the classroom and follows a modified curriculum. He particularly struggles with literacy and numeracy but shows strong skills in visual arts and practical tasks. His teachers report difficulties with staying on task and occasional disruptive behaviours related to his ADHD. There are no vocational plans in place yet, but his parents hope for him to explore supported employment opportunities in the future. **Family and Social Context:** Thomas lives at home with both his parents, Sarah and David, and his younger sister, Emily (10 years old). The family dynamic is generally supportive, though parents report feeling overwhelmed at times by Thomas's needs. He has limited peer relationships outside of school and prefers solitary activities. His main social interactions occur within structured school settings or during family outings. There is no known family history of significant psychiatric illness. **Strengths and Difficulties:** Thomas's strengths include a keen interest in drawing and painting, a good sense of humour, and a generally compliant nature when routines are predictable. He enjoys spending time outdoors. Difficulties reported by parents include significant impulsivity, short attention span, and difficulty regulating emotions, often leading to meltdowns when frustrated or overstimulated. His anxiety manifests as repetitive questioning, avoidance of new situations, and increased irritability. **Mental State Examination (MSE):** Thomas presented as a pleasant young person, accompanied by both parents. He made limited eye contact, preferring to look at the floor or objects in the room. His speech was quiet, concrete, and sometimes fragmented, requiring prompts from his parents to elaborate. His mood appeared anxious, with occasional fidgeting and restless movements in his chair. He was able to attend to questions for short periods but easily distracted. No overt psychotic phenomena were observed. His thought content revolved around his school activities and concerns about upcoming changes to his school timetable. Insight into his difficulties was limited, consistent with his developmental stage and learning disability. **Physical Health:** Thomas's general physical health is good. He has no known chronic physical conditions. Sleep has been disrupted, with difficulty initiating sleep and occasional night-time awakenings, attributed to both his ADHD and anxiety. Appetite is generally good, though he can be particular about food textures. He maintains a regular bowel and bladder routine. There are no current physical health concerns requiring urgent attention. **Risk Assessment:** There is no evidence of active suicidal ideation or intent. Thomas has no history of self-harm. He does not pose a direct risk to others, although occasional outbursts of frustration can occur. Due to his learning disability and autism, he remains vulnerable to exploitation and bullying, particularly in less structured environments. His parents are vigilant in monitoring his safety and social interactions. **Impression:** Thomas is a 14-year-old male with a moderate learning disability, autism spectrum disorder, and ADHD. He presents with ongoing difficulties related to his neurodevelopmental conditions, exacerbated by emergent anxiety symptoms. His current challenges include attention and impulsivity difficulties, social communication impairments, and significant anxiety regarding routine changes and social interactions. These difficulties impact his functioning in both educational and home environments. **Plan:** 1. Continue current medication regimen (Methylphenidate 10mg MR daily, Melatonin 2mg MR nocte). 2. Increase Methylphenidate to 18mg MR daily for 2 weeks, then review its impact on focus and impulsivity. 3. Refer for an initial assessment with the Child and Adolescent Mental Health Services (CAMHS) for a comprehensive anxiety management programme, adapted for young people with learning disabilities. 4. Liaise with Willow Creek Special School to implement anxiety reduction strategies within the classroom setting and ensure consistent routines. 5. Advise parents on strategies to manage Thomas's anxiety at home, including visual schedules and social stories. 6. Schedule a follow-up appointment in 6 weeks to review medication efficacy and anxiety management progress. Yours sincerely, Dr. Thomas Kelly, Consultant Paediatrician Cc: Sarah Smith (Mother) for Thomas's school Ms. Eleanor Green, Social Worker, Local Authority Social Care Team