An independent provider in the Wiltshire area

7. Mrs E complains about failings in the ADHD assessment the Practice completed for her in February 2025. Specifically, Mrs E complains:

• the Practice applied the DSM-5 model too rigidly to Mrs E in her assessment, particularly the scoring of childhood symptoms and meeting the required threshold • the Practice did not recognise some of the traits Mrs E displayed due to overlapping autistic masking • the Practice did not reconcile contradictions between her autism and ADHD assessment reports.

8. As a result of these failings, Mrs E says she remains without a full accurate diagnostic picture which has delayed her access to appropriate treatment, support and workplace adjustments. She says she has been denied a fair opportunity to have her case considered.

9. Mrs E says she is concerned about the consequences for others who find themselves in a similar situation, specifically that her two daughters and husband are waiting for an assessment at the Practice.

10. Mrs E wants the Practice to acknowledge its failings and make service improvements.

11. Mrs E had an ADHD assessment completed at the Practice in February 2025. She did not receive a diagnosis for ADHD. Mrs E did not agree with this decision not to diagnose her and disputed the clinical reasoning given.

12. Mrs E also had an ASD assessment completed at the Practice in March 2025. She was diagnosed with ASD in April 2025.

13. The Practice said the decision not to diagnose Mrs E with ADHD was based on the subthreshold symptom presentation in childhood, the presence of alternative explanations and the lack of sufficient functional impairment attributable to ADHD.

The Practice’s application of the DSM-5 model

18. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

19. In her complaint to us Mrs E said she was under-scored for the presence of childhood symptoms in her ADHD assessment. She said the decision not to diagnose her, was made largely on the lack of reported childhood symptoms and she believes she presented more of the criteria than what the assessing clinician scored her for.

20. The Practice said Mrs E only scored three out of nine for childhood inattentiveness and one out of nine for hyperactivity in childhood, which is below the threshold needed to secure an ADHD diagnosis.

21. We have found the Practice did act in line with guidelines on this matter. The decision that Mrs E did not meet the necessary threshold to support an ADHD diagnosis was based on all of the available evidence at the time of the assessment and on the clinical judgment of the assessor.

22. ADHD is a neurodevelopment condition, where the brain works differently to most people.

23. Our psychiatrist referred us to section 1.3.3 of NICE Guideline 87. We saw this says ‘for an ADHD diagnosis of hyperactivity, impulsivity or inattention should:

• meet the diagnostic criteria for hyperkinetic disorder in DSM-5 or ICD-11 (but exclusion based on a pervasive developmental disorder or an uncertain time of onset is not recommended) and • symptoms present before 12 years age • cause at least moderate psychological, social, or educational or occupational impairment based on interview or direct observation in multiple settings and • be happening often, occurring in two or more important settings including social, familial, educational or occupational settings.’

24. Our psychiatrist also highlighted that the DSM-5 requires symptoms are not better explained by other disorders.

25. The Practice completed Mrs E’s ADHD assessment using specific diagnostic tools and combining information about her. The diagnostic interview for ADHD in adults (DIVA-5) is a structured, clinician-administered interview, designed to ensure a comprehensive and standardised assessment of ADHD symptoms. It requires clinical expertise and judgement for accurate use.

26. The assessment was conducted by evaluating Mrs E’s behaviours in relation to the diagnostic criteria set out by the DSM-5. The assessing clinician used this to assess core symptoms of inattention, hyperactivity, and impulsivity. This tool is designed to analyse the presence of these symptoms during both childhood and adulthood, as well as any associated impairments. It is essential that any impairments function across multiple settings.

27. Mrs E did not meet several of the DSM-5 diagnostic criteria. Our psychiatrist recognised, the assessing clinician identified six of the possible nine inattentive symptoms in adulthood, which could be deemed as significantly impairing. However, only three out of nine hyperactive symptoms were found to be present. This would have been sufficient for diagnosis as an adult of inattentive ADHD but not for a combined diagnosis of inattentive and hyperactive ADHD.

28. In addition to this, only four symptoms of childhood inattentiveness and one symptom of hyperactivity were found to be present. This meant because of the lack of childhood symptoms that were evidenced and confirmed by Mrs E during the assessment, ADHD could not be diagnosed. Our psychiatrist advised this was appropriate in the circumstances and they could not find further evidence of any symptoms being present before the age of 12.

29. Our psychiatrist explained that assessing clinicians are only able to make a clinical judgement based on the evidence presented to them at the time. They referred us to the RC Psych Guidelines, which specifically outline ‘clinical judgement is paramount in diagnosis’, which appears to have been appropriately applied in Mrs E’s ADHD assessment.

30. Our psychiatrist commented that whilst a more detailed or structured corroborative history may have been helpful, it would not have changed the outcome given that multiple DSM-5 criteria (outlined previously above) were not met.

31. Considering all this evidence and advice, we found the assessing clinician reached an evidence-based decision that was in line with guidelines. The guidelines directed them to apply the DSM-5 model. They applied it using the scores the evidence they gathered supported. As such, we saw no indication of a failing regarding this issue.

32. We recognise Mrs E found the outcome of her assessment disappointing. We hope we have assured Mrs E that the Practice correctly applied and explored the DSM-5 criteria in her assessment.

The Practice did not consider autistic masking

33. Mrs E told us the Practice did not recognise some of the symptoms she displayed in her ADHD assessment due to autistic masking. She said because of this, certain traits were deemed not impairing and were overlooked by the assessing clinician.

34. The Practice said the presence of alternative explanations such as adult-onset conditions which Mrs E had reported to be living with and an autistic-spectrum functioning profile, better explained the symptoms she presented during the assessment.

35. We have found the Practice recognises the need to be aware of autistic masking when carrying out assessments, and in Mrs E’s case, fully considered any potential masking she displayed during her assessment for ADHD.

36. Our psychiatrist explained there is currently no specific national guidance that sets out how a clinician should account for autistic masking within ADHD assessments. They told us that an awareness of it should be taken into account when assessing someone’s clinical presentation and it is the patient’s behaviour that will indicate whether masking is occurring or not.

37. Our psychiatrist highlighted the Practice provided significant detail regarding autistic masking in Mrs E’s ASD assessment report which suggested to them, the Practice had a firm understanding of the importance in identifying masking and the impact of such behaviours.

38. Our psychiatrist said, having reviewed the assessment reports, there was an indication of possible autistic masking by Mrs E although these were not significant enough to be determined as having a negative impact on the outcome of the assessment.

39. They said there was nothing to suggest Mrs E felt uncomfortable or anxious during the assessment. The thoroughness of the report suggests adequate time was taken by the assessing clinician to complete the assessment which is evidence of it not being rushed. They told us that a relaxed atmosphere and allowing ample time to complete the assessment, demonstrates a positive approach to achieving the most accurate assessment possible.

40. Having reviewed the advice and evidence, we consider the Practice recognised and accounted for autistic masking while taking the time it should have to explore Mrs E’s symptoms and behavioural traits. Staff considered these factors in deciding on the outcome of her assessment. This is what the guidelines we refer to and what our psychiatrist say should have happened. We note section 1.3.1 in NICE Guideline 87 says staff should assess for ADHD having considered a patient’s behaviours and symptoms.

41. We hope we have clearly explained how the Practice did recognise autistic masking in Mrs E’s ADHD assessment and how staff are equipped to do so. We hope we have reassured her that it did not negatively affect the outcome of her ADHD assessment.

The Practice did not reconcile contradictions between Mrs E’s ASD and ADHD assessment reports

42. In her complaint to us, Mrs E said, there were contradictions between her ASD and ADHD reports. She believes she displayed traits which were fully acknowledged in her ASD assessment but were under-scored in her ADHD assessment, despite there being a strong overlap.

43. The Practice said having reviewed Mrs E’s assessment reports, it concluded the reports were consistent with one another and did not recognise any contradictions between them and were reflective of current clinical guidelines.

44. We found there to be no contradictions between the reports.

45. The Practice’s NHS Contract and Policy, list the assessment standards for ADHD that must be evidenced by the provider as being in place. These are as follows:

• a comprehensive clinical and psychiatric history • a detailed developmental history • an up-to-date physical health history • verbal and/or collateral history, including school or educational reports, references • a diagnostic framework (currently ICD-11, DSM-5) should be referred to • evidence of a diagnostic interview, either by using an established diagnostic tool such as the DIVA or detailing systematic exploration of current and childhood symptoms • reference to pervasiveness of symptoms across at least two important settings • impact of ADHD symptoms on psychological, social, educational/occupational aspects of the person’s life (the use of a questionnaire such as the WEISS functional impairment scale can be useful) • consideration of co-morbidities and their impact of ADHD symptoms presented by a patient and overall impairment • reference to limitations with the assessment due to inaccessible information, restrictive environments etc.

46. ‘The assessment must also be written into a comprehensive report and in addition to the above, should include, information about the professional/s who completed the assessment, their role title, professional registration, and that those involved in the assessment are consistent with adopting NICE guidance. A diagnosis of ADHD can be made by a single clinician with appropriate training and experience in ADHD assessment such as a psychiatrist, psychologist or another appropriately qualified professional.’

47. We have found Mrs E’s ADHD assessment is consistent with these standards. Our psychiatrist acknowledged that these also broadly aligned with sections 1.3.1 to 1.3.4 in NICE Guideline 87.

48. Our psychiatrist did not identify any specific contradictions between the ASD and ADHD reports. They said the reports were mainly consistent with each other, each report examined similar themes, and this is to be expected in these types of assessments. They noted that it would not be uncommon for the assessments to show an overlap given the use of comparable diagnostic criteria to establish the presentation of certain symptoms and so reported any similar symptom presentation correctly.

49. Our psychiatrist told us whilst there is an overlap of symptoms, the symptom groups are different and therefore the focus of interview is different. They found, that other than the possible display of hyperfocus, there is nothing within the ASD report that suggests ADHD. Our psychiatrist could not definitively say particular symptoms were present at the time of the ADHD assessment. They explained that assessments are largely based on clinical judgement, which are not usually changed. This is because it would undermine the objectivity of the process as well as the experience of the clinician involved.

50. Our psychiatrist also added that the known common co-occurrence of ASD and ADHD, would have made it difficult to know how much this may have influenced the ADHD assessment.

51. Having considered the available evidence and advice, we cannot see there were contradictions between Mrs E’s ASD and ADHD reports we would expect the Practice to reconcile. This means we see no indications staff failed to reconcile contradictions. In the absence of contradictions, the Practice composed a report containing the elements we described above from the guidelines we referred to.

52. We hope we have clearly explained our findings. We hope we have assured Mrs E that her ASD and ADHD reports do not contradict one another.

53. We are sorry to hear of Mrs E’s experience and want to thank her for bringing her concerns to our attention. We hope the explanations we have provided in setting out our decisions, help her in finding closure on these issues.

1. We have carefully considered Mrs E’s complaint about the Practice. We are very sorry to hear of Mrs E’s experience and recognise the challenges she has faced. We appreciate the importance of having her concerns regarding her ADHD (attention deficit hyperactivity disorder) assessment addressed. We have carefully considered her concerns.

2. We have seen no indication that anything went seriously wrong.

3. We have found the Practice did act in line with guidelines when deciding Mrs E did not meet the necessary threshold for presentation of childhood symptoms to diagnose ADHD.

4. We have found the Practice fully considered any potential autistic masking Mrs E displayed during her assessment for ADHD and staff recognised the need to be aware of it when carrying out assessments.

5. We found there to be no contradictions between Mrs E’s ASD (autism spectrum disorder) and ADHD reports.

6. For these reasons, we do not see any indications the Practice did something wrong and we have decided not to consider Mrs E’s complaint further. We have explained our decision in detail below.