Skip to main content

Table 3 Supplementary information: clinical assessment report content

From: Guidance for identification and treatment of individuals with attention deficit/hyperactivity disorder and autism spectrum disorder based upon expert consensus

• Diagnostic and aetiological formulation.

• Current presenting problems (e.g. physical health (including presence/absence of patient/family contraindicating use of ADHD medication, known genetic anomalies, GI/immune problems, sleep, allergies), comorbid psychiatric conditions and associated problems) and current treatment (psychological/pharmacological).

• Specific findings from a clinical interview (incorporating information from the individual and informants, if present) applied to either DSM or ICD diagnostic criteria.

• If administered, findings from observational assessments (qualitative and semi-structured) and/or standardised test results (e.g. rating scales, cognitive and language assessments, neuropsychological tests) that support the clinical decision made.

• Outcome of risk assessment and consideration of future challenges (e.g. personal, clinical, educational and social transitions).

• Factors that may lead to the masking or moderation of behaviour in different settings, e.g. compensatory strategies or accommodations at home or school (both functional and dysfunctional), realistic expectations of behaviour and achievement.

• Consideration of strengths as well as weaknesses (both in terms of personal, family and external networks).

• Level of support required across settings and how this might be provided or improved.

• Appropriate interventions (e.g. psychoeducation for the individual, parents/carers, teachers; environmental accommodations that can be made at home, educational and/or other settings; parent-mediated interventions; individual work using a cognitive behavioural paradigm to improve coping strategies and develop skills and determine whether this needs to focus more on behavioural interventions). The appropriate mode of intervention should also be specified, e.g. whether the person can manage individual and/or group interventions or whether these must be applied indirectly via parents/carers and environmental changes (ideally a mixture of both).

• Further assessment needs, if required (e.g. observation or Functional Behavioural Analysis in specific settings, development coordination disorder)

• Recommendations for local carer’s assessments for parent/partners, or vulnerable adult assessments for patients, as appropriate.