ADD Risk Strategy

Progress Note: ASD Assessment Discussion Date: 1 November 2024 Reason for Assessment: The assessment was conducted to evaluate the presence of Autism Spectrum Disorder (ASD) traits and to develop a comprehensive management plan. Mental Health: The patient, a 12-year-old male, presents with anxiety and social withdrawal. Past mental health issues include mild depression diagnosed at age 10. There is no history of self-harm or harm to others, and no psychiatric hospitalisations. Current medications include fluoxetine 10mg daily. Social History: The patient lives with both parents and a younger sibling. He has limited social interactions outside of family and prefers solitary activities. He is currently in school but struggles with group work and prefers individual tasks. ASD-related Observations: The patient exhibits challenges in social interactions, often avoiding eye contact and struggling with understanding social cues. He has sensory sensitivities, particularly to loud noises. Cognitive processing appears to be detail-oriented, and he has a strong interest in trains. He adheres to a strict daily routine and becomes distressed with changes. Family History: There is a family history of anxiety disorders on the maternal side. No known history of ASD in the family. Risk Assessment: Currently, there is no significant risk to self or others. The patient is well-supported at home. Plan: The treatment plan includes continued cognitive behavioural therapy sessions to address anxiety and social skills training. A follow-up appointment is scheduled in three months to monitor progress and adjust the management plan as needed.