In many cases, clients will tell you themselves that they think they have autism or ADHD. They will often have lots of evidence to back this up. This is a rough guide to making a decision about whether to refer someone for assessment and what information you will need.

More details about accessing the Neurodevelopmental Specialist Service, and how to make a referral, can be found on our webpage: Neurodevelopmental Specialist Service (NeSS) | Nottinghamshire Healthcare NHS Foundation Trust

What to consider before making a referral

If the client requests autism / ADHD assessment, it is important to consider whether there is sufficient evidence to warrant the referral AND whether the client will benefit from a diagnosis. Reasons for assessment vary from person to person, but usually fall into these categories:

Internal benefits: Self-understanding, acceptance and reframing of difficulties

  • Often adults with neurodevelopmental conditions grow up feeling different to others. As a result, they may experience rejection, social isolation, poor academic / employment outcomes, and mental health problems. People who have always struggled often benefit significantly from reframing these difficulties as neurodevelopmental. The words they have grown up with instead ( lazy , stupid , weird etc.) do far more harm than a neurodevelopmental diagnosis would have done, and we often see people's self-esteem improve after diagnosis. 

External benefits: Accessing support, reasonable adjustments, and improved understanding from others

  • Diagnosis can increase friends' and family's understanding and can help other agencies understand the person's difficulties and needs. People are entitled to reasonable adjustments under the Equality Act (2010) if they are diagnosed with autism or ADHD. This might include support at university or at work, and also includes healthcare settings. Examples include having extensions on coursework, additional time in exams, exam breaks, getting notes and lectures in advance, using accessible rooms e.g., having a quiet space, being allowed to use sensory strategies (headphones, screen filters etc.), having predictable shift patterns, flexible hours, extra time in GP appointments, adapted therapies and many other adjustments.

Things to look for when screening for autism and / or ADHD

As autism and ADHD are neurodevelopmental conditions, evidence of difficulties should be present in both childhood and adulthood. Individuals also experience difficulties with executive functioning.

Autism

Social communication and relationship difficulties

  • Lacking interest in or difficulty forming relationships.
  • Interpreting communication literally, such as jokes and sarcasm.
  • Difficulty making conversation ('small talk').
  • Difficulty using and understanding social cues (such as eye contact, gesture, turn taking, vocal intonation, personal space).
  • Difficulty with taking another person's perspective or appearing to lack empathy.

Restricted, repetitive patterns of behaviour, interests, or activities

  • Difficulty coping with change or new situations.
  • Difficulty responding to changes in a conversation.
  • Preferring routine.
  • Finding it difficult to plan ahead or predict what might happen next.
  • Engaging in repetitive behaviours.
  • Having very strong interests.

Sensory differences

For autistic people, the senses may be over (hyper) or under (hypo) stimulated. Difficulty understanding sensory information can make people react in extreme ways or create unusual ways of coping and can significantly impact on their functioning and wellbeing. Below are examples of sensory differences that autistic people may experience.

  • Vision: May find eye contact uncomfortable, prefer to view things sideways, prefer to look at small details.
  • Hearing: Can be very sensitive to different sounds and find it difficult to ignore sounds, may like some repetitive sounds, may like loud music.
  • Taste: Finds some food flavours too strong, or seeks out strong flavours like spices, dislikes some food textures.
  • Touch: Doesn't like to be touched or dislike light touch, like heavy things, sensitive to clothing textures.
  • Smell: May seem to have no sense of smell or be very sensitive to certain smells, dislike certain perfumes or shampoos.
  • Balance (vestibular): Like to rock or spin, difficulty with activity requiring controlled movement such as catching a ball.
  • Body Awareness (proprioception): May bump into people or furniture because it is difficult to measure distance, may grip things too hard without realising.
  • Interoception: Sense of internal bodily states and emotions.

ADHD

Inattention and poor concentration

  • Difficulty giving close attention to detail or making careless mistakes
  • Difficulty concentrating for very long or finishing tasks
  • Difficulty following through on instructions
  • Disorganised
  • Easily distracted
  • Difficulty switching from one task to another
  • Forgetful
  • Difficulty listening when people are talking
  • Avoids, dislikes, or is reluctant to do tasks that require sustained mental effort
  • Loses things necessary for tasks or activities - phone, diaries, letters, keys

Hyperactivity

  • Fidgety e.g., picking skin, tapping hands, shaking knees, changing position.
  • Unable to sit still.
  • Talking excessively.
  • Always on the go.
  • Feeling of inner restlessness.

Impulsivity

  • Acting quickly without thinking about the consequences e.g., saying what comes to mind without considering timing or social appropriateness
  • Difficulty waiting for others to finish tasks (without jumping in to do it themselves)
  • Feeling irritated when waiting in line
  • Interrupting other people
  • Difficulty waiting turn
  • Blurting things out, often before a question has been completed

Whilst most people can have these sorts of difficulties, individuals with ADHD, experience these symptoms to be severe, persistent, and pervasive, and they can seriously impact their life. This includes their relationships and social life, work, education, finances, and ability to complete day to day tasks.

Conditions that can co-occur with autism and ADHD

It is possible that adults may present with difficulties which look like ADHD or autism in adulthood but are caused by something else. It is important to consider differential diagnosis such as attachment difficulties, adverse childhood experiences, social anxiety, and other neurodevelopmental conditions.

Adults with autism and ADHD also often have comorbid conditions. Symptoms of these conditions may overlap significantly with characteristics of autism and / or ADHD. These include:

  • Emotional difficulties e.g., anger, anxiety, depression, aggression etc.
  • Significant mental health problems e.g., eating disorders, bipolar disorder, OCD, psychosis
  • Behavioural issues
  • Self-injury / suicidality

These difficulties can all occur alongside neurodevelopmental conditions, as they can with anyone. However, they are not part of the diagnostic criteria and may or may not be related to neurodiversity.

Sometimes we have to decline a referral because it contains a lot of information about these other difficulties (anxiety etc) and not enough description of the symptoms of ADHD or autism. When making a referral for autism and / or ADHD assessment, it is important to focus on providing evidence of meeting the diagnostic criteria. This will mean that the referral is more likely to be accepted.

Screening tools

There are a number of screening tools which clients can complete in relation to autism and ADHD, in order to inform whether further assessment is indicated. The following tools are contained in our referral form:

  • Autism Spectrum Quotient (AQ-10)
  • Adult ADHD Self-Report Scale (ASRS)
  • Barkley Functional Impairment Scale (BFIS)

It is important to note that no screening tool is 100% accurate and there are many reasons that a person might score highly on one of these measures. These are used simply as an indicator of whether further assessment might be warranted. 

If you suspect the client has autism / ADHD but they have not mentioned this to you

This is a more complex situation, and it is important to say that we do not assess or diagnose neurodevelopmental conditions in people who do not want a diagnosis for themselves. Neurodevelopmental conditions are lifelong and are related to the person's identity. It can therefore be harmful to diagnose a person with this unless they see some value in that label.

However, there may be times when it is appropriate to discuss the possibility of autism / ADHD with a client who has not raised the idea themselves. In these circumstances it is necessary to spend time ensuring the client understands what is being suggested (explain the signs and symptoms of autism / ADHD, explain why you think it might be relevant for them, and explain what the pros and cons of diagnosis might be).

If the client is enthusiastic, they can be referred to the service by their GP or another Nottinghamshire Healthcare NHS Foundation Trust professional. At this point, it would be helpful to support the client's understanding around the process of a diagnostic assessment. Due to high demand, the service has long waiting times. Signposting to appropriate support should be considered in the meantime, if this is indicated e.g., to LMHT if the individual is experiencing mental health problems. Assessment will include several components which could consist of screening questionnaires, a developmental interview, an interview with a partner or parent where possible, psychological assessment and observation. Diagnostic assessment will also include assessment of other difficulties that may better explain the client's difficulties, such as mental health problems or other developmental conditions.

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