Example formulations

Example formulations

Example formulations

Autism formulation examples

ADHD formulation examples

Autism example formulations

Autism example formulations

Example 1

Example 3 - mixed evidence autism diagnosis.

Positive diagnosis examples

''Straightforward' autism diagnosis.

Example 4 - ACEs/trauma

Example 2

These summaries are presented for guidance and reference only.

Evidence of masking.

Example 5 - Additional learning needs.

Example 13

Example 7

Example 1

Non-diagnosis examples

Example 13

Example 8

Example 2

Example 9

Example 3

Unable to conclude examples

Example 10

Example 4

Example 1

Example 11

Example 5

Example 2

Example 12

Example 6

ADHD example formulations

Example 4

Example 1

Positive diagnosis examples

Hyperactive impulsice diagnosis, ACEs.

Inattentive diagnosis, older teen, low mood.

Example 5

Example 2

Inattentive diagnosis (masking).

Inattentive diagnosis, older teen, disengaging.

ADHD example formulations

Example 6

Example 3

Inattentive diagnosis, behavioural aspect.

Combined diagnosis, potential signs of autism.

These summaries are presented for guidance and reference only.

Example 1

Non-diagnosis examples

Non-diagnosis but close to threshold.

Example 2

Complex presentation, autism and ACEs.

Example 3

Non-diagnosis.

Example formulations

Example 1: straightforward Autism diagnosis

Joey is currently managing the school day well and is supported with any planned changes by his parents and school staff. It is anticipated that he will require support with this as he prepares for bigger life changes, for example his upcoming transition to secondary school. A number of sensory seeking and aversive behaviours were also noted. In summary, Joey’s strengths, difficulties and differences were noted in; the developmental history, during the observational assessment and reported by Joey himself. The evidence from these contexts fulfils all areas of DSM5 diagnostic criteria therefore a diagnosis of autism is appropriate. In addition, the team discussed the reported and observed information relating to concentration, impulsive and sensation seeking behaviours through his love of rollercoasters. It is therefore recommended that a further assessment of ADHD is explored.

Joey’s case was discussed during a multi disciplinary meeting with NAME ALL PROFESSIONALS AND ROLE. All of the evidence gathered was discussed to reach a diagnostic decision and the team were all in agreement there was a clear pattern of traits typically associated with autism in relation to Joey’s social and nonverbal communication and evidence of repetitive and firm behaviours and interests. From an early age, Joey experienced differences in his communication style when interacting with others. He has a preference for talking about his own interests which he is very knowledgeable about and some differences were noted in his non-verbal communication. Joey is able to express himself well, for example through using his advanced vocabulary and gestures however this often has a notable exaggerated or learnt quality to it. He has experienced difficulties with making friends in the past and while this is improving there is evidence of frequent breakdowns in communication with peers with Joey holding firm views on others behaviour.

Example formulations

Example 2: Autism diagnosis statement, evidence of masking

There was some mixed information reported relating to differences associated with autism in JL’s younger years. However, it was considered that some of these traits may not have been apparent until JL became older and social expectations increased. There is also some evidence relating to JL copying others' facial expressions, body gestures, tone of voice or phrases in her younger years which may have masked some of her difficulties. Furthermore, JL has described some current masking behaviours such as preparing herself and planning for social interactions. In summary, JL’s difficulties and differences were noted in; the developmental history, during the observational assessment and reported by JL herself. The evidence from these contexts fulfils all areas of DSM5 diagnostic criteria therefore a diagnosis of autism is appropriate.

A multi disciplinary meeting was held and JL's case was reviewed by assessing clinicians, AP (Speech and Language Therapist), TF (Occupational Therapist) and Neurodevelopmental Team Lead, CS (Speech and Language Therapist) where all assessment information was carefully considered. All of the evidence gathered was discussed as part of the assessment to reach a diagnostic decision. The team considered JL's early experiences and the impact these may have had on JL, such as her ability to express and describe emotions. Overall and in addition to this, the team were in agreement that there is a pattern of significant difficulties in the areas associated with autism; reciprocal social interaction, social communication and restrictive, repetitive patterns of behaviour, interests and activities.

Example formulations

Example 3: Autism diagnosis - mixed evidence

The team discussed how there was some mixed information from school however there was detail relating to anxiety and in some situations this is exacerbated by sensory aversions. The team considered that H's difficulties and differences may be more subtle at school and this could be heightened due to his involvement in football and him having very specific roles within this. As described the information provided regarding his development, current presentation at home and in the observation cannot otherwise be explained beyond a diagnosis of autism. The evidence gathered fulfils all areas of DSM5 diagnostic criteria and therefore a diagnosis of autism is appropriate.

A multi disciplinary meeting was held and H's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. All of the evidence gathered was discussed as part of the assessment to reach a diagnostic decision. The team were in agreement that there is a pattern of significant difficulties in the areas associated with autism; reciprocal social interaction, social communication and restrictive, repetitive patterns of behaviour, interests and activities. These difficulties and differences were very apparent in; the developmental history and during the observational assessment.

Example formulations

Example 4: Autism diagnosis and adverse childhood experiences/trauma

However, it is important to note that N demonstrates repetitive behaviours, and intense, all encompassing interests which are not typically associated with the specific chromosome deletion. All were in agreement that there is a pattern of significant differences in the areas of reciprocal social interaction, social communication and restrictive, repetitive patterns of behaviour, interests and activities. These differences are long-standing and clinically significant. It was concluded that N meets the Diagnostic Statistical Manual 5 (DSM-5) criteria and therefore, a diagnosis of autism is appropriate. N will remain open to Healios and NHS Healthcare Trust to engage with a diagnostic assessment for Attention Deficit Hyperactivity Disorder (ADHD).

A multi disciplinary meeting was held and N's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. N was referred to Healios for an autism assessment. The information gathered during the assessment revealed a pattern of significant differences, in the areas of reciprocal social interaction, social communication and restrictive, repetitive patterns of behaviour, interests or activities. During the MDT, N's adverse child events were considered. It was acknowledged that this is likely to have significantly influenced how N views himself, other people and the world. However, all clinicians were confident that this did not fully explain N's presentation and differences in isolation. N's chromosome deletion was also discussed. It was acknowledged that many features of the deletion would map across to the DSM-5 autism criteria.

Example formulations

Example 5: Autism diagnosis plus learning needs

A multi disciplinary meeting was held and D's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. All evidence from the assessment was considered, including the screening questionnaires, direct observational assessment, parent interview with D’s mother regarding her early years, school information and the more recent information detailed in her educational psychology assessment report. This report highlighted a profile of cognitive and learning difficulties which the team took into consideration when making a diagnostic decision. On review of all the evidence, the team were in agreement that there is a pattern of significant differences in the areas associated with autism; reciprocal social interaction, verbal and non-verbal social communication and understanding relationships. The team considered the likely additional impact D’s learning needs/cognitive age has on her social interactions with others and ability to understand social relationships.

In addition there was also evidence for restrictive, repetitive patterns of behaviour, and activities typically seen in an autistic profile. These include, repetitive and idiosyncratic language, repetitive use of objects when D was younger, and repetitive hand and finger and complex mannerisms; a preference for planning and routine, and difficulties coping with change; a range of interest that appeared to be intense in quality; and sensory seeking behaviours and some aversions. D’s mother reported a range of differences in the development of D's social interaction and communication skills as well her patterns of behaviour as being present since her younger years, therefore these differences are long-standing. The team agreed that on the basis of all the information gathered D’s current pattern of skills, difficulties and behaviour, together with her developmental history, indicate that she does present with the core areas of difficulty and differences seen in autism and does meet the criteria for a diagnosis of autistic spectrum disorder as outlined in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM 5).

Example formulations

Example 1: non-diagnosis - mixed evidence, prior diagnosis of epilepsy

It was noted that L has experienced difficulties throughout his childhood with the management of his epilepsy. Exploration of his cognitive functioning would be beneficial in further understanding his strengths and needs. It was therefore agreed that a diagnosis of autism is not appropriate based on the information available at this time and that L’s presenting difficulties can be understood in the context of his epilepsy diagnosis and possible learning needs.

A multi disciplinary meeting was held and L's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. The team agreed that the evidence gathered throughout the assessment was mixed. Social communication difficulties were noted during the observation of L’s current behaviours (including reduced reciprocity and non-verbal communication and limited insight into social relationships), however, the parental report indicated strengths were apparent historically, in L's early childhood. Conversely, some evidence suggests that L appears to have had long-standing difficulties in maintaining social relationships. In relation to restricted, repetitive patterns of behaviour, L presents with some difficulties managing change and sensitivity to noise, however, the team were in agreement that L’s difficulties in managing change and coping with noise were not of the severity associated with autism.

Example formulations

Example 2: non-diagnosis, prior diagnosis of ADHD

While many of the difficulties that were identified could in isolation be misconstrued as autism, it is important to note that there are a significant number of overlapping features in each of these conditions. Overall, when taking A's presentation of strengths, difficulties and pre-existing neurodevelopmental diagnosis into account, the evidence indicated that A did not meet the criteria for a diagnosis of autism spectrum disorder (DSM-5).

A multi disciplinary meeting was held and A's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. Information gathered during the assessment was somewhat mixed with more difficulties reported by A's mother, fewer difficulties reported by his school setting, and fewer difficulties observed during the assessment with Healios. Whilst A presented with some clear difficulties with social interaction, emotional expression, and self-regulation, he was also observed to struggle consistently with information processing and verbal expression. This combination of features were felt to be best understood through A’s diagnosis of ADHD and potentially additional language and learning needs.

Example formulations

Example 3: non-Diagnosis, mixed evidence, recommendation for ADHD assessment

It is likely there are a number of interacting and exacerbating factors contributing to the difficulties she experiences. The team considered the reported difficulties in her understanding of spoken language and how this may contribute to some of the misunderstandings she experiences in her friendships and ability to follow instructions in class. In addition there is evidence of difficulties with sustaining concentration and the need for movement combined with sensory seeking behaviour. This was noted during the observation and reported within the developmental history. This is likely to have a further impact on her social interactions, for example missing social cues and her everyday experiences in the classroom. Concerns around ADHD were previously raised by her school prior to the referral for autism assessment and further investigation into this may be warranted following a period of implementing the strategies around supporting her concentration detailed in this report. As described the team acknowledges that O has a number of interacting difficulties which impact on her everyday functioning however she does not meet the DSM-5 criteria for autism and therefore does not receive a diagnosis.

A multi disciplinary meeting was held and O's case was reviewed by assessing clinicians, WG (Speech and Language Therapist), BR (Psychotherapist) and Neurodevelopmental Team Lead, MP (Speech and Language Therapist) where all of the assessment information was carefully considered. The team were in agreement that there is insufficient evidence to give O a diagnosis of autism. A number of strengths were noted in her social communication during the observational assessment which resulted in a reciprocal interaction and building of rapport with the clinician. There was also insufficient evidence of persistent difficulties with non-verbal communication, social interaction and reciprocity throughout her early development. O can also be flexible, for example, with changes to routine and there was also not sufficient evidence of any circumscribed or intense interests. O is a young person who experiences emotional dysregulation which has impacted on her interactions with others and her education for a number of years.

Example formulations

Example 4: non-diagnosis, mixed evidence recommendations for ADHD and cognitive assessment

The school information suggests that he does initiate with other children regularly and he is reported to have a group of friends. Throughout the developmental history there is also evidence of him seeking out and responding to interactions in a prosocial way. There are concerns around his vulnerability in certain situations and not being able to read social cues. Again this may be better explained by ADHD. It has also been suggested K has a cognitive assessment and a difficulty with learning may also be contributing to his difficulties with understanding of social situations and others intentions towards him. In addition, while there was a limited use of non-verbal communication noted during the observation, this is not consistent with the developmental history. The team considered whether the sensory seeking behaviour observed may have contributed to a reduced use of gestures. Minimal verbal language was also used during the assessment which again reduced the opportunity for K to use gestures alongside his spoken language.K does not receive a diagnosis of autism at this time. The team acknowledges that K is experiencing difficulties both at home and at school and supports the decision for further assessment for ADHD and a cognitive assessment.

A multi disciplinary meeting was held and K's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. The team were in agreement that there is insufficient evidence to give K a diagnosis of autism. Some traits associated with autism were identified such as; intense interests, repetitive and rigid behaviours, sensory interests and aversions.These behaviours may be better explained by a potential diagnosis of ADHD which K is currently awaiting further assessment for. The team acknowledged there are difficulties with his social interaction which was particularly noted in the observational assessment. It is recognised that this may not be representative of K’s typical interactions with others. The team considered that low mood and/or a general uncomfortableness may have contributed to his presentation on the day of the assessment.

Example formulations

Example 5: non diagnosis - mixed evidence, possible anxiety/obsessive compulsive behaviours/ADHD present

A multi disciplinary meeting was held and E's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. The team were in agreement that there is insufficient evidence to give E a diagnosis of autism. Some difficulties associated with autism were identified, including historic difficulties with friendships and rigid and repetitive behaviours. However, E presented with strengths in her social and non-verbal communication during the observational assessment building good rapport and sense of reciprocity with the clinician. There was also insufficient evidence of autism from the developmental history such as the ability to respond to and recognise other emotional reactions between the ages of 4-5 and reported engagement in reciprocal play and storytelling during her early years and childhood. There was also insufficient evidence to suggest a diagnosis in the information provided by the school.

It was reported throughout the assessment that E experiences difficulties with anxiety, overactive behaviours as well as obsessions and compulsions. This was reflected on E’s scores on the RCADs where E scored within the ‘high’ range for obsessive compulsive disorder and generalised anxiety. The reported overactive behaviours, anxiety and obsessions and compulsions were taken into consideration which may account for some of the difficulties she is currently presenting with. It was discussed that further exploration of E’s experiences of anxiety and obsessive behaviours should be prioritised after which an assessment for ADHD could be considered if the overactive behaviours and difficulties with focus and distractibility persist following exploration and strategies to support her more anxious behaviours persist.

Example formulations

Example 6: non-diagnosis, mixed evidence, ADHD assessment in progress

A multi disciplinary meeting was held and F's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. The team were in agreement that there is insufficient evidence to give F a diagnosis of autism. A number of strengths were noted in F’s interaction during the observation with him building a sense of reciprocity and rapport with the clinician. Some strengths were also noted in his use of non-verbal communication. It is also noted that throughout his development, F has demonstrated shared enjoyment with others including engagement in pretend play. There are also no difficulties reported with coping with changes to routines.

It is acknowledged that F has some difficulties with friendships and how others perceive him. It is considered these difficulties may in part be due to difficulties associated with ADHD which F is currently being assessed for. The behaviours around somewhat intense interests and also his sensory needs may also be associated with ADHD. F does not meet the DSM5 criteria for autism and therefore does not receive a diagnosis.

Example formulations

Example 7: non-diagnosis, mixed evidence, complex trauma

A multi disciplinary meeting was held and R's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. R presented with strengths in her social and non-verbal communication building a sense of reciprocity and enjoyment with the examiner during the observational assessment. Some difficulties with attention and concentration were noted which impacted on the interaction with R, following her own train of thought which could be difficult to follow at times. The school information provided was also not indicative of autism but does describe difficulties with concentration, some anxious behaviours and difficulties with emotional regulation which can at times impact on her friendships and understanding of others.

R showed some insight into this during the observational assessment. R's mother acknowledged that the early years of R's development were challenging with her working hard to overcome these. These challenges may in part explain some of the anxious behaviours and concerns R has over separating from her mother which R also described during the observation. Recommendations have been made in this report to support this. R does not meet the DSM-5 criteria for autism and therefore does not receive a diagnosis.

Example formulations

Example 8: nondiagnosis, mixed evidence, language and learning difficulties/low mood

A multi disciplinary meeting was held and C's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. The team were in agreement that there is insufficient evidence to give C a diagnosis of autism. Although difficulties in C’s interaction skills were observed during the observation, the team considered the impact of other factors that are likely to impact on her social communication skills for example her language and learning needs and reported low mood. C’s reduced use of non-verbal communication, particularly, gestures were noted during the observation and reported in the school information however this was considered to be typical throughout her early development. It is likely that she found some tasks draining, challenging and lost focus which may explain the decrease in her social communication skills as the assessment progressed.

C has also had historic and ongoing difficulties with friendships. Again this could be explained by the identified difficulties in her learning and understanding, for example, interpreting social situations and understanding boundaries. Her difficulties with bullying have impacted on C’s mood and likely her confidence in making and developing friendships. It was noted in her younger years that C demonstrated lots of pro-social intent towards peers. In addition, there was no evidence of circumscribed interests, repetitive behaviours, difficulties coping with change or sensory needs. The outcome of this assessment is that C does not meet the DSM-5 criteria for autism and therefore does not receive a diagnosis.

Example formulations

Example 9: non diagnosis - mixed evidence, learning needs/potential OCD behaviours

A multi disciplinary meeting was held and G's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. The team were in agreement that while some traits associated with autism were identified there is insufficient evidence to give G diagnosis of autism. While G was responsive to the examiner during their interaction, he also presented with difficulties with reciprocal conversation, frequently interrupting the examiner during the observation. This has also been noted in the school information provided however may be better explained by overactivity which was also observed.

The team took into account G’s learning needs and the impact these may have on his overall behaviour and communication, for example, she is reported to find learning new routines or ways of doing things challenging which may account for some of the rigidity in performing certain tasks. In addition, G has developed some OCD repetitive type behaviours, such as hoarding paper, which may warrant further investigation. G presents as an engaging young person with a complex profile of strengths and needs. He does not however meet the DSM -5 criteria for autism and therefore does not receive a diagnosis of autism.

Example formulations

Example 10: non-diagnosis, mixed evidence, low mood/OCD

A multi disciplinary meeting was held and J's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. Some difficulties associated with autism were identified, such as historic circumscribed interests. However, J presented with strengths in his social communication building a good rapport and sense of reciprocity with the clinician during the observational assessment.

J’s low mood and the impact this may have on his interaction with others was also taken into consideration, however, his interaction skills were noted to improve as he became more relaxed during the assessment. J’s difficulties with rigid and repetitive behaviours were also discussed however considered to be better explained by his diagnosis of OCD. There was also insufficient evidence of social interaction difficulties associated with autism in the developmental history and in the school information provided. J presents as an engaging young person with a complex profile of strengths and needs. He does not however meet the DSM -5 criteria for autism and therefore does not receive a diagnosis of autism.

Example formulations

Example 11: non-diagnosis, mixed evidence - speech and language difficulties

There were some indicators of difficulties with understanding and spoken use of language observed during the assessment, for example, some word finding difficulties and therefore it has been recommended that T seek further advice and assessment from Speech and Language Therapy Services in order to establish if some underlying difficulties with language may be contributing to his current difficulties. In addition, the team considered T’ reported low mood in the RCADS questionnaire and it was felt he presented with low-self esteem during the assessment. Again this may be having an impact on his social communication skills, presentation and confidence in engaging with others. In terms of friendships, T has had historic difficulties in this area, however he also showed some thoughtful and appropriate insights into his understanding of friendships and his role within these. Despite some of the difficulties observed, it was felt that T was responsive and able to build a reciprocal rapport with the examiner. Finally there were no reported difficulties with repetitive or restrictive interests or behaviours throughout the developmental history or noted during the observational assessment. T does not meet the DSM-5 criteria for autism and therefore does not receive a diagnosis.

A multi disciplinary meeting was held and T's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. The team were in agreement that there is insufficient evidence to give T a diagnosis of autism. While some difficulties associated with autism were identified such as difficulties with non-verbal communication and historic difficulties with friendships, the team considered there are potential other reasons for these which are not consistent with a diagnosis of autism. T has identified difficulties with processing and memory and it is likely these difficulties have an impact on his social interactions with others. This was noted during the observational assessment and T was also able to comment on how his difficulties with using language in response to others has been part of the challenging experiences he has had with peers in the past.

Example formulations

Example 12: non-diagnosis, mixed evidence, complex trauma and attachment difficulties

A multi disciplinary meeting was held and Y's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. The evidence gathered from Y's observation, the care-giver interview, interview with Y's social worker, and the school report were carefully considered against the DSM-5 criteria for autism. All were in agreement that there is a pattern of significant differences in the areas of reciprocal social interaction and social communication. However, there was little evidence to indicate significant differences with restrictive, repetitive patterns of behaviour, interests and activities.

All clinicians involved in the MDT acknowledge that there are differences with Y's presentation, and that he finds certain aspects of daily life difficult. Upon considering Y's adverse childhood life events, and the difficult situations that he continues to experience, all clinicians were in agreement that early childhood trauma and attachment difficulties are likely to have significantly contributed to Y's presentation and differences. It is important to note that often, symptoms of childhood trauma can present in a very similar way to autism. However, clinicians were confident that, based on the available information, Y did not demonstrate key features of autism (stereotyped or repetitive speech or motor movements, highly restricted or fixated interests, and significant sensory processing differences). All were in agreement that Y's presentation was not consistent and indicative of autism (DSM-5). Therefore, a diagnosis of autism is not appropriate.

Example formulations

Example 13: non-diagnosis, mixed evidence - ADHD assessment recommended

A multi disciplinary meeting was held and R's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) All evidence from the assessment was carefully considered, including the screening questionnaires, direct observational assessment, parent interview with Reico’s mother regarding his early years and school information. On review, there is evidence of differences in R's social communication skills, non-verbal communication, reciprocity and relationships. There are also long-standing difficulties managing change and sensory difficulties, as well as reports of circumscribed interests, repetitive ritualistic play and need for routine. However, there was also considerable evidence of hyperactivity and difficulties with attention, noted in the referral and school information, and observed during the assessment. R’s case was therefore additionally reviewed by SC, Clinical Lead, in order to establish whether the differences observed could be better explained by a potential diagnosis of ADHD, autism or both.

Potential differential diagnosis (ADHD and autism) was discussed and it was agreed that an autism diagnosis for R is supported by multiple examples of repetitive behaviour not typically seen in ADHD, such as a high level of repetitive use of objects in his play and a tendency to line items up from an early age. He also demonstrated significant differences with regard to non-verbal communication that is more in keeping with a diagnosis of autism. However, there were also significant differences and behaviours noted that could, additionally, be attributed to ADHD, as detailed above. Therefore, it is recommended that R is assessed for ADHD by the local service in due course to establish if this additional diagnosis has a further impact on his social interaction. A full understanding of R’s strengths and needs will also help support R to reach his academic potential and establish the appropriate support required.

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Example formulations

Continued example 13: non-diagnosis, mixed evidence - ADHD assessment recommended

Additionally, it was discussed that school information reported few concerns with regard to R’s social interaction and communication skills at school. Taking this into consideration, the clinical team noted a history of difficulties regarding school attendance, as well as concerns raised by his nursery regarding sensory differences and difficulties with peer interaction. R’s mother also reported that she feels that he ‘masks’ at school, and has learnt to suppress certain behaviours whilst there, resulting in dysregulation at home, which likely accounts for his difficulties being less apparent during the time that he attends. The difficulties and differences identified are long-standing and pervasive; the team were therefore in agreement that there was sufficient evidence to confirm an autism spectrum diagnosis (DSM-5).

Example formulations

Example 14: non-diagnosis, mixed evidence, possible medical/genetic investigations required

A multi disciplinary meeting was held and M's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. All of the evidence gathered was discussed as part of the assessment to reach a diagnostic decision. The team were in agreement that there is a pattern of significant difficulties in the areas associated with autism; reciprocal social interaction, social communication and restrictive, repetitive patterns of behaviour, interests and activities. These difficulties and differences were noted in; the developmental history, the school information provided and during the observational assessment.The evidence from these different contexts fulfils all areas of DSM5 diagnostic criteria.

In addition, the team discussed the current difficulties M is experiencing at home and the impact they are having on her family and considered that some of these behavioural challenges can not only be explained by her diagnosis of autism alone and it is recommended the family seek support through a Positive Behavioural Support agency in order to gain a better understanding of the triggers to M's behaviours, how to anticipate/identify these and therefore respond. Furthermore, the team considered M's physical health needs; the difficulties with toileting associated with this as well as her overeating and felt that a review by a paediatrician could be considered for potential investigation of any (additional) underlying medical or genetic explanations for her behavioural and developmental difficulties. M would also likely benefit from a cognitive assessment in order to understand her full learning profile. In summary, while M meets the criteria for a diagnosis of autism, further assessments and investigations of both her medical and cognitive profiles is recommended in order to have a clear picture of her overall developmental needs.

Example formulations

Example 1: diagnostic decision not reached, challenges with engagement in tasks

A multi disciplinary meeting was held and M's case was reviewed by assessing clinicians, WJ (Occupational Therapist), LBO (Speech and Language Therapist) and Neurodevelopmental Team Lead, BL (Speech and Language Therapist) where all of the assessment information was carefully considered. K was referred to Healios for an autism assessment. During this process some contrasting views of his presentation across different contexts were reported. For example, the parental interview indicated a number of traits associated with autism whereas the extensive school information gathered felt his needs were more in line with anxiety and his subsequent reduced attendance as opposed to a neurodiverse profile. Furthermore, K found it very difficult to participate in the observation session which was attempted on two occasions. During these sessions, K was unable to complete the tasks required beyond informal ‘warm up’ activities.

As a result, the team did not have sufficient information or evidence in order to make a confident or robust decision against the DSM5 diagnostic criteria. The team were in agreement that K is a young person who presents with a complex profile of strengths and needs. It is therefore recommended that his autism assessment is continued through his local team who will review the current information gathered and be in touch in due course regarding potential next steps. K will now be discharged from Healios.

Example formulations

Example 2: diagnostic decision not reached, complex assessment involving local ND team, presence of motor tics and tourettes

A number of MDT meetings have taken place from September 2021 and February 2022 attended by; the Healios assessing clinicians, PL (Occupational Therapist), LC (Speech and Language Therapist), Neurodevelopmental Team Lead, SC (Speech and Language Therapist) and Cardiff and Vale ND team clinician, MB. As described throughout this report difficulties were met in terms of concluding the DSM5 criteria for autism due to some inconsistencies in the evidence gathered throughout the assessment process. A number of communication differences, difficulties and patterns of behaviour associated with autism have been described by E's mother including difficulties with; reciprocal interaction, non-verbal communication and peer interaction. In addition, repetitive behaviours were described along with intense interests, difficulties coping with change as well as sensory needs.

This was somewhat consistent with the observation session carried out by Healios clinician, PL which identified difficulties with; fully maintaining a reciprocal interaction, limited insight into friendships and his own emotions. Furthermore, E's intense interest in fish was also a feature of his observation which at times impacted on the overall quality of the interaction. Definite signs of overactivity were noted alongside some possible sensory seeking behaviours. The school information provided at the time mainly highlighted strengths in his social interaction and the only concerns highlighted were around difficulties at home and some mild disagreements with peers.

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Example formulations

Continued example 2: diagnostic decision not reached, complex assessment involving local ND team, presence of motor tics and tourettes

Given the contrasting information provided, the team felt it necessary to carry out further assessment through an observation at school. This highlighted various strengths including; appropriate interaction with peers and non-verbal communication. At this time, some tic behaviours had been observed by school staff on at least one occasion as well as anxious behaviours, nail-biting and rocking on his seat. The BOSA assessment again highlighted strengths in the areas of; non-verbal communication and reciprocal interaction. Where areas of need were seen these were described as; some mild anxiety particularly at the beginning of the session, some reticence and limitations in terms of elaborating on verbal responses. The team also observed some definite complex motor and vocal tics. Overall the Cardiff and Vale Team concluded that from their assessments, there was insufficient evidence to support a diagnosis of autism.

This was further discussed in a follow up MDT with both teams and it was agreed that due to the inconsistencies of evidence, based on the high scores from the ADIr interview and observations made during E's online observation, the DSM5 could not be completed. Following this, E's mother confirmed that he has received a diagnosis of Tourette's Syndrome and it was discussed that this diagnosis is likely to explain in part some of the difficulties he experiences around anxiety and emotional regulation. General recommendations have been made in this report to support with this and further advice has been given in E's report from the Consultant Paediatrician.

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Example formulations

Continued example 2: diagnostic decision not reached, complex assessment involving local ND team, presence of motor tics and tourettes

Please note that the DSM5 although it appears on this report, has NOT been concluded or finalised by the assessing teams.E does not receive a diagnosis of autism however, the Cardiff and Vale team have agreed that E can be referred back to his local CAMHS team for support around his anxiety. The team have also suggested that the family can contact the Cardiff and Vale ND service in 12 month time if their concerns remain and can request to be reviewed under the second opinion pathway. During this time it would be prudent that the recommendations to support with his Tourette's syndrome are implemented consistently and further support sought to help E with his anxiety and his transition to Secondary School.

Example formulations

ADHD example 1: inattentive diagnosis, older teen, symptoms are contributing to a low mood and anxious presentation

xxxxxx has experienced some difficulties with his mental health since migrating to the UK to reside with his father and the blended family which have led to negative coping strategies resulting in CAMHS involvement. During the assessment process clinicians carefully listened to and gathered information from xxxxxx and his father to support formulation and decision making whilst holding mental health in mind as a possible differential explanation for his symptoms. It would appear that xxxxxx puts a lot of pressure on himself to try to adhere to the rules, boundaries and expectations set out for him by education and also within the family unit. Despite his best efforts he is unable to keep up, which has resulted in burnout, extreme fatigue, and subsequent withdrawal from social situations, perhaps in a bid to no longer have to mask his difficulties due to the effort it takes. Assessing clinicians agreed that xxxxxx's troubles with his mental health were most likely secondary to an underlying neurodevelopmental condition.

The evidence gathered from the initial referral, xxxxxx’s interview, the interview with his father, school information, screening tools and excerpts from both the autism and ADHD clinical observations were carefully considered against the DSM-5 criteria for ADHD and age appropriate developmental stages. Qualitative examples of differences in the core areas of ADHD were expressed by all sources. xxxxxx is experiencing some significant challenges with his executive functioning that are having a high degree of impact academically and socially. These symptoms are also contributing to difficulties with emotional regulation and mental health. The information gathered supported the clinician's observations from the clinical session. The differences in xxxxxx's attention and focus are considered to be across the criterion domains for ADHD.

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Example formulations

Continued ADHD example 1: inattentive diagnosis, older teen, symptoms are contributing to a low mood and anxious presentation

Whilst debating the evidence, the clinical observations and objective information from school it is considered that overall, the information gathered during the assessment revealed ongoing significant difficulties in the areas associated with ADHD, with clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, and occupational functioning. All were in agreement that this was consistent, and indicative of an attention deficit hyperactivity disorder (ADHD) predominantly inattentive presentation (Diagnostic Statistical Manual 5th Edition; DSM-5). Therefore, a diagnosis of ADHD is appropriate. Recommendations should be used in collaboration with those provided on any other medical or professional reports.

Despite his challenges it is equally important to hold in mind xxxxxx's strengths. xxxxxx speaks many languages. He picks up languages very quickly, and he recently taught himself Norwegian. He likes music and enjoys going to concerts. Furthermore, he enjoys wearing fancy clothing such as themed costumes and oversized dungarees. His father described him as a walking encyclopaedia. He was reported to be very able academically.

Example formulations

ADHD example 2: inattentive diagnosis, older teen, symptoms are contributing to a low mood and anxious presentation, no longer engaged in education or employment

Having considered whether the level of his anxiety can best explain his symptomatology, it would appear that his ongoing difficulties with concentration/focus, struggles to complete theory/writing tasks that require mental effort, distractibility, and difficulties with working memory, could be considered a better explanation in terms of the main trigger to his anxiety. Overall consideration of the evidence provided to the clinician’s would indicate xxxxxx experiences differences with the triad of symptoms associated with ADHD. Qualitative examples of differences in the core areas of ADHD were expressed both by xxxxxx, his family and past education, and supported the clinician's observations from the clinical session. Differences in his attention are considered to be across the criterion domains for ADHD.

The evidence gathered from the initial referral, xxxxxx's interview, the parental interview, school information, screening tools, and excerpts from all the clinical observations were carefully considered against the DSM-5 criteria for ADHD and age appropriate developmental stages. xxxxxx is a young man who has fallen out of education, and training, and is currently occupationally deprived. His ongoing difficulties with sleep, and lack of routine in his daily activities of living are both a concern for xxxxxx and his mother. Historically within the educational setting xxxxxx has experienced significant levels of anxiety, which have impacted on his school attendance, his ability to engage, his attainment, and subsequently GCSE’s. Which has led to xxxxxx not being able to fulfil his true potential. Despite a lack of evidence from college, xxxxxx himself offered great insight into his differences with attention / concentration, which led to his choice of disengaging from further education.

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Example formulations

ADHD Continued example 2: inattentive diagnosis, older teen, symptoms are contributing to a low mood and anxious presentation

Although areas of difficulties have been identified for xxxxxx, it is equally important to recognise his many strengths; xxxxxx has enjoyed the practical elements of this course however, and he would like to get a job in either construction or building. He hopes that he can work as a builder or carpenter, and would like a woodwork studio/shed in the garden. He enjoys spending time with his friends, he likes to keep himself physically fit, he tends to use weights and plays football or basketball. xxxxxx also enjoys gaming. xxxxxx's mother shared that he is very placid, caring and quiet.

Whilst debating the evidence, the clinical observations and objective information from school it is considered that overall, the information gathered during the assessment revealed ongoing significant difficulties in the areas associated with ADHD, with clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, and occupational functioning. All were in agreement that this was consistent, and indicative of an attention deficit hyperactivity disorder (ADHD) inattentive presentation (Diagnostic Statistical Manual 5th Edition; DSM-5). Therefore, a diagnosis of ADHD is appropriate.

Example formulations

ADHD example 3: combined diagnosis, also needs asd assessment.

The evidence gathered from the initial referral, xxxxxx's interview, the interview with his mother, school information, screening tools and excerpts from the clinical observations were carefully considered against the DSM-5 criteria for ADHD and age appropriate developmental stages. Throughout the assessment xxxxxx and his parents provided many qualitative examples of ADHD symptomatology impacting on family life, xxxxxx's daily functioning and academic attainment as well as on his emotional well-being. This was supported by the school feedback, clinician’s observations and outcome measures. There have been long-standing concerns regarding impulsivity, motor restlessness, concentration, and with overall executive function. These differences are pervasive.

It would appear that xxxxxx's confidence and self-esteem is impacted to a degree by his sense of difference, with him actively avoiding challenging tasks and becoming emotionally aroused when he is unable to succeed at things easily. He is beginning to notice that other children can manage some things much more easily than he can. It will be incredibly important that all those interacting with xxxxxx are mindful of and supportive of his strengths, of which he has many, to support him to continue to build a secure sense of self. xxxxxx is reported to have an amazing imagination. He enjoys sports and is now playing cricket which he enjoys. He likes animals, with pandas being his favourites. xxxxxx also has strengths in maths, history and geography.

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Example formulations

Continued ADHD example 3: inattentive diagnosis, older teen, symptoms are contributing to a low mood and anxious presentation

The information gathered during the assessment revealed ongoing significant difficulties in the areas associated with ADHD, with clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, and occupational functioning. All were in agreement that this was consistent, and indicative of an attention deficit hyperactivity disorder (ADHD) combined presentation (Diagnostic Statistical Manual 5th Edition; DSM-5). Therefore, a diagnosis of ADHD is appropriate.

Further assessment considerations: Differences with social communication / interaction skills, sensory sensitivities were highlighted in the information gathered. These symptoms may be indicative of a social and communication difference therefore he would benefit from further assessment in this regard.

Example formulations

ADHD example 4: Hyperactive impulsive diagnosis, ACES.

The evidence gathered from the initial referral, xxxxxx's interview, the parental and foster carer interviews, screening tools and education was carefully considered against the DSM-5 criteria for ADHD and age appropriate developmental stages. There was extensive qualitative information provided by all sources which indicate that the symptoms that this young lady presents with are creating a barrier to her achieving her full academic potential. Furthermore, her presenting behaviour, which is described as highly impulsive, is having a lasting impact on social and family relationships. xxxxxx is a vulnerable young lady who has experienced a number of placement breakdowns throughout her life span. It would appear that her presenting differences likely impact her capacity for decision-making in the moment, contributing to a picture of escalating emotional dysregulation, which in turn increases her vulnerabilities further. Whilst there is evidence of some difficulty with attention and concentration, symptoms in this regard were below the diagnostic threshold.

The information gathered during the assessment revealed ongoing significant difficulties in the areas associated with ADHD, with clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, and occupational functioning. All were in agreement that this was consistent and indicative of an Attention Deficit Hyperactivity Disorder (ADHD), hyperactive/impulsive presentation (Diagnostic Statistical Manual 5th Edition; DSM-5). Therefore, a diagnosis of ADHD is appropriate. Of note, whilst there have been a number of difficulties raised regarding xxxxxx, it is equally important to recognise her strengths. xxxxxx is an articulate and forthright young lady who is not afraid to stand her ground and be heard. She can get very interested in things and when interested puts her all into the task at hand. xxxxxx did a wonderful job of helping clinicians understand her lived experience. Recommendations should be used in collaboration alongside those in other medical or professional reports.

Example formulations

ADHD example 5: inattentive (masking).

Assessment information collated by xxxxxx, Specialist Neurodevelopmental Practitioner (xxxxxx) and xxx, Specialist Neurodevelopmental Practitioner (Registered Learning Disability Nurse) has been reviewed with xxxxxxx, in a complex multi-disciplinary formulation meeting. The evidence gathered from the initial referral, xxxxxx's interview, the interview with her mother, educational information, and the ADHD clinical observation were carefully considered against the DSM-5 criteria for ADHD and age appropriate developmental stages. xxxxxx is a lovely young woman who, has managed well academically to date, although the move into secondary education has evidenced some clear difficulties with her executive functioning skills, in relation to attention skills and organisation. The information gathered from education does not highlight a high degree of impact nor does it appear that the symptoms described are regularly seen within that environment (although were evident at primary school).

That being said, the lived experience provided by xxxxxx indicates that she is having to work extremely hard to keep up with peers and also to maintain her own targets. Over the years it would appear that xxxxxx has become extremely aware of the things that she finds challenging and this has contributed to the development of compensatory behaviour largely driven by anxiety. Essentially, it seems that xxxxxx has become a master at masking her differences to ensure that she appears on the surface to "fit in". This takes its toll on her emotionally with xxxxxx explaining that she will become exhausted after a day at school and require some down time to refuel. Once she has achieved this, she feels able to relax and be herself at home. Furthermore, xxxxxx is extremely well scaffolded at home which again is likely to in some ways mask the things that she finds hard to do herself.

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Example formulations

Continued ADHD example 5: Hyperactive impulsive diagnosis, ACES.

Qualitative examples of differences in the core areas of ADHD were expressed by both xxxxxx and her family and supported the clinician's observations from the clinical session. Whilst there was some evidence of motor restlessness, there was insufficient evidence of symptoms to support a combined presentation. Whilst debating the evidence, the clinical observations and objective information from school it is considered that overall, the information gathered during the assessment revealed ongoing significant difficulties in the areas associated with ADHD, with clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, and occupational functioning. All were in agreement that this was consistent, and indicative of an attention deficit hyperactivity disorder (ADHD) predominantly inattentive presentation (Diagnostic Statistical Manual 5th Edition; DSM-5). Therefore, a diagnosis of ADHD is appropriate.

Example formulations

ADHD example 6: inattentive limited examples from school (behavioural aspect of adhd)

The evidence gathered from the initial referral, xxxxxx's interview, the interview with his mother, educational information, his recent autism assessment and report and the ADHD/autism clinical observations were carefully considered against the DSM-5 criteria for ADHD and age appropriate developmental stages. The outcome of xxxxxx's autism assessment will be shared separately further to conclusion. The potential cross-over of symptomatology was held in mind during diagnostic formulation discussions, alongside the possible influence of some key life experiences. XXXX is a lovely young man who is experiencing difficulties with his executive functioning skills, in relation to attention skills and organisation, and presents with an increased level of activity and impulsivity. He is currently awaiting the outcome of an assessment for autism (Healios; November 2023) and the potential crossover of symptomatology of this condition was considered and excluded as a differential diagnosis.

There are long-standing reports from education and home raising concerns with XXXX’s ability to offer sustained attention / concentration. Current school feedback is mixed indicating behavioural choices and motivation but also citing difficulties with sustaining attention, implying XXXX is underperforming due to behaviour rather than inattention. However, overall consideration of the evidence provided to the team would indicate XXXX experiences differences with the triad of symptoms associated with ADHD. Qualitative examples of differences in the core areas of ADHD were expressed both by family and past and current education, and supported the clinician's observations from the clinical session. Differences in his attention / focus and hyperactivity / impulsivity are considered to be across the criterion domains for ADHD. Although areas of difficulties have been identified for XXXX, it is equally important to recognise his many strengths;

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Example formulations

Continued ADHD example 6: inattentive limited examples from school (behavioural aspect of adhd)

Or: As XXXX is academically able and achieving to a high level, her differences with inattention are less noticeable, however XXXX is completing a large percentage of her work at home as she is unable to complete in the required time in class. Despite a lack of evidence from education, XXXX herself offered great insight into her differences with attention / concentration. Discussing that her academic performance / achievements are coming at great personal cost as she is having to work at a greater depth than her peers to support her inattention and lack of organisation, offering lots of qualitative examples. In relation to hyperactivity / impulsivity XXXX is a self confessed “adrenaline junkie”, challenging her overactivity into various intense and stimulating activities to fulfil her need to expel energy. Over the years XXXX’s parents have subtly adapted their parenting style and removed any demand cause and effect response with XXXX to support her emotionally and academically. This needs to be recognised as a hugely supportive measure that has minimised any overly noted difficulties within education.

Example formulations

ADHD example 1: non-diagnosis but close to threshold

Assessment information collated by xxxxxx, Specialist Neurodevelopmental Practitioner (xxxxxx) and xxx, Specialist Neurodevelopmental Practitioner (Registered Learning Disability Nurse) has been reviewed with xxxxxxx, The evidence gathered from the referral information, xxxxxx's interview, the interview with his parents, the school report, screening tools, and excerpts from the autism and ADHD clinical observations were carefully considered against the DSM-5 criteria for ADHD and age appropriate developmental stages. Whilst it is acknowledged that xxxxxx can present with aspects of inattention and motor restlessness at times, the evidence gathered from all sources was somewhat mixed, detailing a mixed profile of strengths and differences. The information gathered during the assessment did not reveal ongoing significant difficulties in the core areas associated with ADHD consistent across time and different contexts.

xxxxxx has a diagnosis of autism (Healios; December 2023) and consideration was given to the cross-over of symptomatology. A number of his challenges were considered by the clinical team to be linked to this diagnosis and identified needs. Therefore, it was agreed that even though xxxxxx presents with some signs of inattention and restlessness he does not meet criteria for an ADHD diagnosis. That being said, should it be the case that as the demands placed upon xxxxxx increase over time, he begins to demonstrate more difficulties that are not felt fully explained by his autism, further assessment could be considered in the future if felt appropriate. Recommendations provided within this report should be used in conjunction with other professionals’ reports.

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Example formulations

Continued ADHD example 1: non-diagnosis but close to threshold

ADD ON IF THERE ARE ALSO ACES CONTRIBUTING TO THE FULL PICTURE xxxxxx has experienced a degree of adversity over the years, which appears to have had a lasting impact on his emotional wellbeing, and in how he responds to certain situations. There may be times when xxxxxxxxx seeks an emotional connection with both peers and the adults around him by way of behaviour that is at times challenging to manage and understand. The experiences that xxxx has been exposed to are considered likely contributing factors to this overall complex presentation.

Example formulations

ADHD example 2: non-diagnosis, complex presentation / autism / aces / learning

Assessment information collated by xxxxxxxxxxxx, Specialist Neurodevelopmental Practitioner (xxxxx) and xxxxxxxxx, Specialist Neurodevelopmental Practitioner (xxxxxxxxxx) has been reviewed by , Neurodevelopmental Team Manager (xxxxxxxxx). Information gathered as part of the assessment has been reviewed and carefully considered alongside the DSM 5 diagnostic criteria for ADHD. This included review of video excerpts from the observational elements of the assessment and careful consideration of XXXX's existing diagnosis of autism, her cognitive profile (as assessed by the Educational Psychologist), the early adversity she has faced and the impact of these on her current presentation and functioning.

It was concluded that although there were difficulties reported that may be indicative of ADHD, there was an inconsistent picture with difficulties more evident in the home setting than school or in the observational element of the assessment.The multidisciplinary team were of the opinion that there was insufficient evidence of XXXX demonstrating ADHD symptoms across different settings and that her presentation and reported difficulties could be best understood in terms of the impact of her autism, learning needs and the impact of early adverse experiences on her development. These included exposure to domestic violence and possible substance use by her mother in utero and her needs not being consistently and adequately met in her early weeks by her mother. The multidisciplinary team were of the opinion that the family would benefit from appropriate support at home in order to help them understand XXXX's needs and how best to meet these and efforts will be made to signpost the family to appropriate local services.

Example formulations

ADHD example 3: non-diagnosis

Assessment information collated by xxxxxxxxxxxx, Specialist Neurodevelopmental Practitioner (xxxxx) and xxxxxxxxx, Specialist Neurodevelopmental Practitioner (xxxxxxxxxx) has been reviewed and formulated. The evidence gathered from the initial referral, the interviews with xxxxxx and his mother, education information past and present, and all clinical observations were carefully considered against the DSM-5 criteria for ADHD and age appropriate developmental stages. The qualitative information gathered from the referral, identifies clear long-standing concerns regarding xxxxxx's emotional well-being and presenting behaviour at home and at school. Whilst it is acknowledged that xxxxxx presents with distractibility, and with a degree of motor restlessness, and behaviours that challenge, the overall evidence relating to possible ADHD was limited, with many of xxxxxxs behaviours appearing to have an element of control not commonly associated with ADHD.

Many of the challenges faced by xxxxxx which led to him leaving mainstream school appeared to be steered by a degree of choice and with an underlying purposeful meaning. During the observation xxxxxx presented as angry but controlled. He did not behave impulsively instead presenting as extremely guarded. There has been an improvement in his presentation since moving to a SEMH provision and whilst it could be argued that the reason for this is that his needs are being better met, both xxxxxx and professionals describe a narrative that suggests the improvement in behaviour is motivated by a desire to recommence mainstream education. Historical information indicates that whilst difficulties did arise, xxxxxx was able to demonstrate control and regulate in situations that those with ADHD may find overstimulating.

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Example formulations

Continued ADHD example 3: non-diagnosis, complex presentation / autism / aces / learning

Overall, the clinical team concluded that there was insufficient evidence to support a diagnosis of ADHD at this time. The information gathered during the assessment did not reveal ongoing significant difficulties in the areas associated with ADHD. xxxxxx did not meet the diagnostic threshold for a diagnosis of ADHD. Further considerations The team wish to highlight that xxxxxx presents as a vulnerable young man. Despite not receiving a diagnosis of ADHD he continues to experience difficulties that impact him socially, and academically. Family relationships are also fractured. Clinicians are aware that xxxxxx and his family are being supported locally and would advocate for this to continue.

Caveat

• The following document has been created for the purpose of providing example formulations of both straightforward and more complex decision making following an MDT for both ND and ND Plus assessments.
• These summaries are presented for guidance and reference only.
• If further decision making support or guidance on a particular formulation is required please seek support from your Team Manager or follow the escalation process.