Child ADHD Diagnostic Assessment Template

Introduction

I met with Oliver Barnaby (DOB: 14/06/2015, NHS Number: 485 920 1184) and his mother, Sarah Barnaby, for an in-person diagnostic assessment at the Neurodevelopmental Clinic within the Child and Adolescent Mental Health Services (CAMHS) on 12/05/2025 at 10:00.

Reason for Assessment

Oliver was referred by his General Practitioner and school Special Educational Needs Coordinator (SENCO) for a specialist diagnostic evaluation regarding suspected Attention Deficit Hyperactivity Disorder (ADHD), following persistent difficulties with sustained attention, impulse control, and motor restlessness across both home and school environments.

History of Presenting Complaint

Oliver's parents first noted marked motor activity and brief attention span at age three whilst he attended nursery. These features became significantly more impairing upon transitioning to Key Stage 2 at age seven, where increased academic demands and expectations for independent working highlighted his executive functioning deficits. Over the past two years, his symptoms have remained persistent and pervasive, leading to a widening gap between his cognitive potential and academic output.

Main Presenting Concerns

At school, teachers report that Oliver struggles to remain seated during carpet time and classroom instruction, frequently calls out without raising his hand, and leaves tasks incomplete due to easy distractibility. At home, his mother describes extreme difficulty executing morning and bedtime routines, requiring constant one-to-one verbal prompting to get dressed or brush his teeth. He exhibits rapid emotional dysregulation when transitioning away from preferred activities, though these episodes are brief and resolve quickly without lingering low mood.

Developmental History

Oliver was born at 39 weeks gestation via normal vaginal delivery following an uncomplicated pregnancy, with a birth weight of 3.4 kg. His mother did not smoke, consume alcohol, or take prescribed medications during pregnancy, and no neonatal Special Care Baby Unit admission was required.

As an infant, Oliver was described as alert and colicky, with fragmented sleep patterns and a high need for physical movement to settle. He was an active baby who disliked being restricted in a pram or highchair for prolonged periods.

He achieved all gross and fine motor milestones within normal limits, sitting unsupported at six months and walking independently at 11 months. Toilet training was completed by age three without subsequent enuresis or encopresis.

Oliver is socially motivated and keen to form friendships, having several playmates at school and in his local neighbourhood. However, his relationships can become strained as peers occasionally find his boisterous play style and tendency to dominate rule-making overwhelming.

His speech and language milestones were achieved on time, speaking single words at 12 months and combining phrases by age two. There is no history of speech therapy input, and his receptive and expressive vocabulary are age-appropriate.

Oliver demonstrates intact social reciprocity, making appropriate eye contact and using varied facial expressions during conversation. He understands humour and non-literal language well, showing no evidence of social communication deficits.

He exhibits no notable sensory aversions to noise, clothing textures, or food groups. He does display mild sensory-seeking behaviours, such as chewing on shirt collars and seeking rough-and-tumble play when under-stimulated.

During early childhood, Oliver engaged in varied imaginative and cooperative pretend play with peers. Presently, he prefers high-energy outdoor sports such as football or fast-paced video games, quickly abandoning board games or construction toys that require patience.

Past Psychiatric History

Oliver has no previous formal mental health diagnoses and has never been prescribed psychotropic medication. His parents completed a local authority behavioural parenting workshop last year, which provided helpful boundary-setting strategies but did not resolve his core attentional difficulties.

Relevant Medical History

Oliver has a diagnosis of mild seasonal allergic rhinitis and childhood eczema. He takes cetirizine 5 mg PO OD PRN and uses emollient creams topically. He has no history of head injuries, seizures, thyroid dysfunction, or cardiac abnormalities, and there are no known drug allergies.

Family History

Oliver's maternal uncle was diagnosed with ADHD in childhood, and his mother reports experiencing lifelong difficulties with organisation, though she has never sought formal assessment. There is no family history of autism spectrum disorder, psychosis, bipolar affective disorder, or suicide. On the paternal side, his grandfather had hypertension, and there is explicitly no family history of sudden cardiac death under the age of 40 or congenital arrhythmias.

Living Situation

Oliver resides in a privately owned three-bedroom house with his mother, father, and older sister, where he has his own bedroom.

Family Information

His mother, aged 38, works part-time as a graphic designer, and his father, aged 40, is a civil engineer. His sister, Emily, is 12 years old and is neurotypical with no health or educational concerns. The family dynamic is warm and supportive, though parents acknowledge feeling exhausted by the constant supervision Oliver requires.

Childhood Experiences

Oliver has grown up in a stable, nurturing household with no history of domestic violence, neglect, physical or emotional abuse, or involvement from children's social care services. He has experienced no significant bereavements or traumatic life events.

School Experiences

Oliver attends Year 5 at a mainstream primary school where he is on the Special Educational Needs (SEN) register and receives classroom adaptations, including a wobble cushion and movement breaks. There is no history of bullying. Conners rating scales returned by his class teacher indicate elevated scores (T-score > 70) for both inattention and hyperactivity/impulsivity. His teacher notes that he constantly taps his pencils, swings on his chair, and loses track of multi-step instructions, although he is polite and remorseful when redirected.

Academic Achievement

Despite demonstrating strong verbal reasoning during class discussions, Oliver is currently working below age-related expectations in written literacy and mathematics because he fails to complete worksheets and makes frequent careless errors in calculation signs.

Mental State Examination

Oliver presented as a neatly dressed nine-year-old boy who appeared his stated age. He was cooperative and friendly but demonstrated marked psychomotor restlessness throughout the session, repeatedly spinning on the swivel chair, tapping his feet, and fiddling with items on the desk. His speech was spontaneous, rapid, and elevated in volume, though coherent and normal in tone. His mood was euthymic with a bright, reactive affect. His thought form was tangential when excited, requiring redirection to the question asked, and there were no abnormalities of thought content or perceptual disturbances. He was oriented to time, place, and person, though his attention was poorly sustained during direct questioning, with limited insight into the impact of his behaviours.

Risk Assessment

Oliver presents no deliberate self-harm behaviours or suicidal ideation. His primary risk relates to accidental physical injury secondary to impulsivity, such as running across roads without checking for oncoming traffic or climbing to unsafe heights.

There is no forensic history or police involvement.

There is no history of alcohol, tobacco, or illicit substance use.

Presentation When Seen

Oliver separated easily from his mother for the individual portion of the assessment and engaged warmly with the clinician. His attentional fatigue became increasingly pronounced after 15 minutes, at which point he began lying across the chairs and asking repeatedly when the appointment would finish.

Child Interview

During his individual interview, Oliver stated that he enjoys school primarily for playtime and physical education, describing classroom lessons as boring and too long. He acknowledged that his brain feels busy and that he often forgets what the teacher has asked him to write before he picks up his pencil. He expressed frustration that he frequently loses his golden time privileges for talking in class despite trying hard to stay quiet.

Related Observations

Throughout the 90-minute clinical interview, Oliver required frequent verbal prompts from his mother to lower his voice and stop climbing on the clinic room furniture. Baseline physical observations were obtained and were within normal limits: height 138 cm (50th centile), weight 32 kg (50th centile), blood pressure 104/66 mmHg, and pulse 82 bpm with normal cardiovascular auscultation.

Young Diva Questionnaire

A1 This symptom was endorsed as present. At school, Oliver frequently misses calculation symbols in maths tests and skips whole questions on the back of worksheets because he rushes through the work without checking it.

A2 This symptom was endorsed as present. His mother noted that he cannot watch a full-length family film without getting up multiple times, and at school he loses focus within five minutes of independent reading.

A3 This symptom was endorsed as present. Parents have had his hearing tested in early childhood—which was normal—because he frequently appeared not to hear when called from a short distance, requiring physical touch on the shoulder to gain his attention.

A4 This symptom was endorsed as present. If sent upstairs to put on his shoes and fetch his coat, Oliver will reliably get distracted by a toy in his bedroom and return empty-handed, leaving chores half-finished.

A5 This symptom was endorsed as present. Since starting primary school, his tray and schoolbag have been disorganised and filled with crumpled worksheets, and he struggles to sequence his thoughts into paragraphs when writing stories.

A6 This symptom was endorsed as present. Oliver actively avoids homework and spelling practice, complaining of stomach aches or becoming tearful when asked to complete tasks that require more than ten minutes of concentrated effort.

A7 This symptom was endorsed as present. His mother reported replacing three school jumpers, four water bottles, and numerous stationery items over the current academic term alone due to him leaving them on the playground.

A8 This symptom was endorsed as present. In the classroom, he sits away from the window because any movement outside or a classmate dropping a pencil immediately pulls him off task.

A9 This symptom was endorsed as present. Despite having a consistent weekly schedule since Year 3, Oliver forgets to hand in permission slips, forgets his swimming kit on Tuesdays, and forgets daily lunchbox routines without parental checks.

H/I 1 This symptom was endorsed as present. At the dinner table and in class, Oliver constantly kicks his legs under the table, twists his hair, or taps cutlery rhythmically.

H/I 2 This symptom was endorsed as present. During family meals and school assemblies, he stands up repeatedly to wander around the room or finds excuses to visit the toilet or sharpen his pencil.

H/I 4 This symptom was endorsed as present. Oliver struggles to play quietly in his room or in libraries, typically narrating his actions loudly, making sound effects, or humming continuously.

H/I 5 This symptom was endorsed as present. His parents describe him as being constantly on the go from waking at 06:00 until bedtime, running rather than walking in corridors and exhausting adults who supervise him.

H/I 6 This symptom was endorsed as present. Both home and school report that Oliver talks incessantly, dominating dinner-table conversations and continuing to chatter during designated silent reading periods.

H/I 7 This symptom was endorsed as present. In class, he blurts out answers before the teacher has finished phrasing the question, and at home he guesses what his parents are going to ask before they finish speaking.

H/I 8 This symptom was endorsed as present. Oliver becomes visibly agitated in queues at theme parks or when waiting his turn during board games and school sports drills, occasionally pushing ahead of peers.

H/I 9 This symptom was endorsed as present. He frequently interrupts his parents when they are speaking on the telephone and walks into his older sister's bedroom to join her friends' games uninvited.

Discussion

I discussed the comprehensive assessment findings with Oliver and his mother, confirming that he meets the DSM-5 and ICD-11 diagnostic criteria for Attention Deficit Hyperactivity Disorder, Combined Presentation, given that he exhibits 9/9 inattentive symptoms and 8/9 hyperactive-impulsive symptoms that commenced prior to age 12 and cause significant functional impairment across both home and school settings. We discussed the multimodal management of ADHD, including environmental modifications, behavioural strategies, and pharmacological treatment options. I provided psychoeducation regarding first-line stimulant therapy with methylphenidate, explaining its mechanism of action, expected efficacy, and potential side effects including appetite suppression, initial insomnia, headaches, and mild elevations in heart rate and blood pressure.

Care Plan

A copy of this diagnostic report will be shared with Oliver's GP and, with parental consent, his school SENCO to inform his Individual Education Plan and classroom accommodations, such as chunked instructions and preferential seating. His mother was signposted to local ADHD support groups and recommended reading materials. Following informed consent and satisfactory baseline physical observations, we agreed to initiate a trial of modified-release methylphenidate (Equasym XL®) 10 mg PO OD in the morning after breakfast. I will review Oliver in the CAMHS medication titration clinic in four weeks to monitor clinical response, side effects, height, weight, pulse, and blood pressure, with teacher and parent Conners rating scales to be repeated prior to the review. His mother was advised to contact the clinic earlier should any adverse effects emerge.