ADHD Diagnostic Assessment Letter for GP

I am contacting you about my patient, Oliver Sterling (DOB: 14/05/1996, NHS Number: 485 772 9104), who attended my clinic on 18/05/2024.

Mr Sterling attended for a formal diagnostic assessment for Attention Deficit Hyperactivity Disorder (ADHD). We discussed his lifelong difficulties with executive functioning, sustained attention, motor restlessness, and the resulting impact on his occupational and domestic functioning.

His difficulties with concentration and restlessness were first noted in primary school, where teachers frequently commented on his daydreaming and inability to remain seated. While structured environments and parental oversight allowed him to manage during early adolescence, the transition to university and subsequent full-time employment exposed significant deficits in self-organisation, time management, and task completion, prompting this referral.

Mr Sterling experiences marked emotional lability, characterised by low frustration tolerance, rapid irritability when overwhelmed by competing demands, and a longstanding sensitivity to perceived rejection or criticism.

He has no history of psychiatric admissions, self-harm, or suicidal ideation, though he previously accessed primary care talking therapies for work-related stress in 2021.

He has no forensic history, arrests, or convictions, though he has accumulated several fixed penalty notices for speeding and late payment of vehicle tax due to forgetfulness.

Medical History

Current health: Mr Sterling is generally fit and well, with a baseline blood pressure of 118/74 mmHg, pulse of 68 bpm, height of 178 cm, and weight of 74 kg. Chronic medical conditions: He has mild seasonal allergic rhinitis and childhood-onset mild asthma, which is well controlled. Neurological issues: He has no history of head injury, seizures, tics, or syncope. Medications:

• Prescribed: He uses a salbutamol (Ventolin®) 100 mcg/dose inhaler PRN.
• Over-the-counter: He takes cetirizine 10 mg PO OD during spring.
• Supplements: He takes colecalciferol (vitamin D3) 1,000 IU PO OD and omega-3 fatty acids 1,000 mg PO OD. Allergies: He has no known drug allergies (NKDA).

Mental Health

Current mental state and mental-state history: On mental state examination, he was well-kempt, cooperative, and maintained appropriate eye contact, though he fidgeted continuously with a pen and tapped his right foot throughout the interview. His speech was mildly pressured in rate but normal in volume, his mood was euthymic with reactive affect, and there was no evidence of formal thought disorder, delusions, or perceptual abnormalities. Previous mental health diagnoses: He was diagnosed with mild generalised anxiety by his GP in 2021, which he attributes to secondary stress from unmanageable workloads. Psychiatric treatments and their outcomes: He completed 6 sessions of low-intensity Cognitive Behavioural Therapy (CBT) in 2021, which improved his cognitive reframing but failed to resolve his core organisational and attentional deficits.

Developmental History

Pregnancy and birth complications: He was born at full term via normal vaginal delivery with no antenatal, perinatal, or neonatal complications. Early developmental milestones: He met all motor, speech, and language milestones within normal developmental timeframes. School experiences: Primary and secondary school reports consistently described him as a bright pupil who underachieved due to careless mistakes, forgotten homework, and constant chatter in class. Social and peer relationships: He formed friendships easily through shared sporting activities in childhood, though he occasionally alienated peers by interrupting games and struggling to take turns.

Family History

Mental health conditions: His mother has a history of recurrent depressive episodes managed in primary care. Neurodevelopmental conditions: His younger brother was diagnosed with ADHD at age 10, and his maternal cousin has a diagnosis of Autism Spectrum Disorder (ASD). Family dynamics: He was raised in a supportive, stable household, though his parents frequently had to implement strict routines to manage his disorganisation.

Educational and Occupational History

Highest educational level: He holds a Bachelor of Science (BSc) in Marketing, achieving a 2:2 classification after submitting several assignments late and relying on last-minute cramming. Employment history: Since graduating, he has held four different junior marketing roles in five years, leaving two positions prematurely due to performance improvement plans triggered by missed deadlines and administrative errors. Current employment status: He currently works full-time as a Digital Account Executive, where he is struggling to manage multiple client accounts simultaneously.

Psychosocial History

Living arrangements: He lives in a privately rented two-bedroom flat with his long-term partner. Support network: He reports a strong support network comprising his partner, parents, and a small group of close friends. Relationship history: He has been with his current partner for three years; while the relationship is supportive, his partner expresses frequent frustration regarding his failure to complete household chores and his forgetfulness with shared financial admin.

Substance Misuse History

Alcohol use: He consumes approximately 6 to 8 units of alcohol per week, primarily socially at weekends, with no history of dependence. Recreational drug use: He tried cannabis briefly at university but denies any current or regular illicit substance use. Tobacco use: He has never smoked tobacco or used nicotine vapes.

ADHD-Related Symptoms

Inattention: Mr Sterling exhibits pervasive difficulties with sustained attention, particularly during mundane or administrative tasks such as data entry or reading lengthy client briefs. He frequently makes careless errors in spreadsheets, loses his train of thought mid-conversation, and leaves projects 80% complete once the initial novelty wears off. His workspace is chaotic, and he relies heavily on multiple digital alarms to remember daily appointments, yet still misplaces his keys, wallet, and work pass on a near-daily basis. Hyperactivity and impulsivity: While overt childhood motor hyperactivity has largely internalised into a persistent sense of inner restlessness and an inability to relax in the evenings, he continues to fidget constantly during meetings. Impulsivity manifests primarily in verbal interactions, where he habitually finishes colleagues' sentences, blurts(out) unvetted ideas during client pitches, and experiences intense irritability when waiting in queues or slow-moving traffic. He also engages in impulsive online spending on short-lived hobbies.

Effects of ADHD on Daily Life

Education: His academic trajectory was marked by chronic procrastination, missed coursework extensions, and significant disparity between his strong verbal contributions in seminars and his disorganised written examinations. Employment: His career progression has stalled due to inconsistent output, errors in attention to detail, and high levels of occupational burnout from working late to compensate for daytime distractibility. Emotional health: Chronic underperformance relative to his peers has resulted in low self-esteem, persistent impostor syndrome, and secondary anxiety regarding job security. Finances: He incurs regular financial penalties from forgotten bill payments, unused subscription services, and impulsive purchases of equipment for hobbies he quickly abandons. Friendships: While warm and engaging in person, he struggles to maintain long-distance friendships due to forgetting to reply to text messages for weeks at a time. Leisure time/relaxation/sleep: He finds it nearly impossible to watch a full-length film without scrolling on his phone, and he suffers from delayed sleep phase onset (~01:30) due to racing, unstructured thoughts at night.

Part 2: Diagnosis And Formulation

DIVA-5 Outcome Summary

A. A continuing pattern of inattention and/or hyperactive-impulsive behaviour that disrupts functioning or development – marked by difficulties in social communication and social interaction in more than one context, demonstrated by all of the following, currently or historically:

A1: Inattention Symptoms

• A1(a): Do you frequently overlook details or make careless errors at work or in other activities? What was this like in childhood (for schoolwork or other activities)? Adult: present, Child: present

• A1(b): Do you frequently struggle to maintain attention during tasks? What was this like in childhood (including during play)? Adult: present, Child: present

• A1(c): Do you often appear not to hear someone who is speaking directly to you? What was this like in childhood? Adult: present, Child: present

• A1(d): Do you often fail to carry out instructions or complete chores and workplace duties? What was this like in childhood (including schoolwork)? Adult: present, Child: present

• A1(e): Do you frequently struggle to plan and organise tasks or activities? What was this like in childhood? Adult: present, Child: present

• A1(f): Do you frequently avoid, dislike or hesitate to undertake activities requiring prolonged mental effort? What was this like in childhood? Adult: present, Child: present

• A1(g): Do you frequently misplace items needed for activities or tasks? What was this like in childhood? Adult: present, Child: present

• A1(h): Are you frequently diverted by unrelated sights, sounds or other stimuli? What was this like in childhood? Adult: present, Child: present

• A1(i): Are you frequently forgetful in everyday activities? What was this like in childhood? Adult: present, Child: present

Total criteria met for Attention Deficit: Adult: 9/9, Child: 9/9

A2: Hyperactivity And Impulsivity Symptoms

• A2(a): Do you frequently move or tap your hands or feet, or shift about in your chair? What was this like in childhood? Adult: present, Child: present

• A2(b): Do you frequently get up from your seat when you are expected to remain seated? What was this like in childhood? Adult: not present, Child: present

• A2(c): Do you frequently experience inner restlessness? What was this like in childhood? Adult: present, Child: present

• A2(d): Do you frequently find it hard to take part in leisure activities quietly? What was this like in childhood (including during play)? Adult: not present, Child: not present

• A2(e): Are you frequently active as though constantly driven, or “on the go”? What was this like in childhood? Adult: present, Child: present

• A2(f): Do you frequently speak more than is appropriate? What was this like in childhood? Adult: present, Child: present

• A2(g): Do you frequently answer before the question has been completed? What was this like in childhood? Adult: present, Child: present

• A2(h): Do you frequently struggle to wait for your turn? What was this like in childhood? Adult: present, Child: present

• A2(i): Do you frequently interrupt or intrude into other people’s activities or conversations? What was this like in childhood? Adult: present, Child: present

Total criteria met for Hyperactivity/Impulsivity: Adult: 7/9, Child: 8/9

B. Multiple inattentive or hyperactive-impulsive symptoms occurred before 12 years of age: Yes

C. Multiple inattentive or hyperactive-impulsive symptoms occur in at least two settings: Yes

• Work/Education: Chronic difficulties with time estimation, prioritising multi-step client projects, completing expense reports, and sustaining focus during lengthy team briefings.

• Relationships and Family: Frequent domestic friction caused by leaving household chores half-finished, forgetting shared calendar commitments, and relying on his partner to manage household administration.

• Social Contacts: Social fatigue following group events due to the effort required to filter out background noise and restrain himself from interrupting others.

• Free Time/Hobbies: Inability to engage in passive relaxation without dual-tasking, alongside a history of starting and rapidly abandoning numerous expensive hobbies.

• Self-Confidence and Self-Image: Persistent feelings of inadequacy and frustration since childhood, stemming from repeated criticisms regarding his perceived lack of effort despite high intellectual capability.

D. There is definite evidence that the symptoms impair or diminish social, educational or occupational functioning: Yes

E. The symptoms are not limited to schizophrenia or another psychotic disorder and are not better accounted for by another mental disorder (for example, a mood, anxiety, dissociative or personality disorder, or substance intoxication or withdrawal): Yes

A) Inattention

1) Frequently overlooks details or makes careless errors in schoolwork, employment or other activities

• Submits client budget spreadsheets containing transposition errors and typographical mistakes despite attempting to proofread his work.

2) Frequently struggles to sustain attention during tasks or play

• Loses focus within 10 minutes of reading campaign briefs, requiring him to re-read the same paragraph multiple times to absorb the content.

3) Frequently appears not to listen when spoken to directly

• Frequently asked by his partner and line manager to repeat back verbal instructions because he appears zoned out during direct one-to-one conversations.

4) Frequently fails to carry out instructions or complete schoolwork, chores or workplace duties

• Routinely starts domestic tasks, such as unloading the dishwasher, but wanders off to address an unrelated task before completion.

5) Frequently struggles to organise tasks and activities

• Unable to sequence subtasks logically for major marketing launches, resulting in missed interim milestones and chaotic desk spaces.

6) Frequently avoids, dislikes or hesitates to undertake tasks requiring sustained mental effort

• Procrastinates heavily on quarterly tax and expense returns, delaying them until threatened with disciplinary action or financial penalties.

7) Frequently misplaces items needed for tasks or activities

• Misplaces his work security pass, house keys, and mobile phone several times a week, requiring AirTags on all essential items.

8) Is frequently distracted by unrelated stimuli

• Easily derailed from his workflow by background office chatter, passing traffic outside the window, or incoming email notifications.

9) Is frequently forgetful in everyday activities

• Regularly forgets to attend scheduled dental appointments, fails to pick up prescribed items from the pharmacy, and leaves wet laundry in the washing machine for days.

B) Hyperactivity And Impulsivity

1) Frequently fidgets, taps the hands or feet, or shifts in the seat

• Continuously clicks pens, taps his heels against chair legs, and shifts posture throughout clinical assessment and workplace meetings.

2) Frequently gets up when remaining seated is expected

• In childhood, he was repeatedly reprimanded for wandering around the classroom; in adulthood, he manufactures excuses to make tea or visit the restroom to escape long meetings.

3) Frequently runs about or climbs in situations where this is unsuitable

• Experiences a constant internal sense of agitation and mental restlessness when forced to sit still in waiting rooms or on public transport.

5) Is frequently active as though “on the go” or “driven by a motor”

• Describes feeling internally "wired" and unable to switch off in the evenings, pacing the flat while speaking on the telephone.

6) Frequently speaks excessively

• Dominates casual conversations and struggles to keep his verbal updates concise during daily stand-up meetings at work.

7) Frequently gives an answer before the question is finished

• Pre-empts questions during assessment and workplace discussions, answering based on assumptions before the speaker has finished their sentence.

8) Frequently struggles to wait for a turn

• Experiences intense impatience and irritability when queueing in supermarkets or waiting for slow-loading software.

9) Frequently interrupts or intrudes on others

• Cuts across colleagues during brainstorming sessions because he fears he will immediately forget his thought if he waits for a pause.

Symptoms impair or diminish the quality of

• Social Functioning: Frequent interruptions and failure to respond to messages have strained several friendships and caused him to withdraw from large group socialising due to self-consciousness.

• Academic Functioning: Underperformed in his university degree (achieving a 2:2 despite high baseline ability) due to severe procrastination, disorganised revision, and penalties for late coursework submission.

• Occupational Functioning: Placed on two performance improvement plans across his career due to missed deadlines and administrative oversights, resulting in frequent job changes and stalled career progression.

• Home Functioning: Causes significant strain in his cohabiting relationship due to an unequal distribution of mental load, forgotten household bills, and chronically unfinished domestic chores.