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Sussex CAMHS Neurodevelopmental Screening Form - Teachers and School Staff

The Sussex CAMHS Neurodevelopmental Pathway is a neurodivergent positive CAMHS specialist service offering assessment for Autistic Spectrum Condition (ASC) for young people aged 11+ and Attention Deficit Hyperactivity Disorder (ADHD) for young people aged 6 up to 18 years. We also provide medication treatment for young people diagnosed with ADHD. If the young person is outside of these age ranges, please ask to be referred to the local child development centre or adult health service.

Please note these are not referral forms. Only screening forms which are linked to an accepted referral will be reviewed. Please do not complete and submit the screening forms unless the young persons referral has been accepted by the local Neurodevelopmental team.

Due to the high demand for our neurodevelopmental assessments, unfortunately, we have long waiting lists. Consequently, if a young person is referred to us at the age of 17 years, it is unlikely they will be seen by children's services. However, we will ensure that their details are passed on to the local adult teams when they turn 18 years. We sincerely apologise for the extended waiting times for assessments and understand the frustration this may cause. We would like to reassure you that we are working hard to address the increased demand on the neurodevelopmental service.

We are very grateful for your help, support and time filling in this screening form properly, with lots of evidence and detail, in order for our Neurodevelopmental Specialist Practitioners to decide if further assessment of the young person for ASC, ADHD or both is indicated.
Our Neurodevelopmental Specialist Practitioners are screening only for ASC, ADHD or both. Should you have any concerns about your young person's general mental health and wellbeing please discuss with your GP or school nurse, who can then direct you to the most appropriate service.
The form contains around 50 questions: some are multiple choice but most will ask you for evidence and details.
For users who are logged in, you can save your progress and are not required to complete the form in a single session. However, for those who do not have an account or are not logged in, it's essential to complete the form in one go. The process may take anywhere between 20 minutes and two hours, so please allocate enough time accordingly.
Sometimes, neurodivergent young people expend considerable energy masking their differences, and become very good at trying to look like everything is OK when it isn't. The more evidence and detail you provide, the easier it will be for our Neurodevelopmental Specialist Practitioners to decide if this may be happening.
Click on the information button throughout the form to for prompts to help you understand more about the evidence and detail our Neurodevelopmental Specialist Practitioners are looking for.
Neurodevelopmental Specialist Practitioners do not need to see evidence and detail for every single question, as some are only relevant for ADHD or Autism on their own. Don't worry too much if you really cannot answer a question. You can put 'not applicable' or 'NA' if the form won't let you go to the next question without putting something.

If further assessment is indicated, the young person will be added to our waiting list by our Neurodevelopmental Specialist Practitioners and you will receive a confirmation letter with further details. If further assessment is not indicated we will send a letter to that effect.

We are experiencing a high demand for this service which is resulting in growing waiting lists. Please be assured that we are working hard to address this. All our local commissioners (the funders of our service) have recognised that the group of young people with neurodevelopmental conditions (including ADHD) is growing.

Neurodivergent positive means acknowledging that:

Neurodivergent young people have a different neurology or neurotype that is part of natural human variation, like sexuality, gender or race.
Neurodivergent young people are often disabled by barriers put in place by society, not as a consequence of their impairments or differences.
Diagnosis can be a gift to the young person, through which many can acknowledge their strengths as well as their differences and vulnerabilities
Diagnosis can help a young person find belonging and identity in membership of a worldwide community of neurodivergent people
Diagnosis can provide the language for young people to self-advocate
Diagnosis can provide the legal foundations for equality of access to education and future work through the Equalities Act (2010) and making reasonable adjustments
Diagnosis can validate educators and parents in growing a more effective and compassionate understanding of young people

Sussex CAMHS Neurodevelopmental Screening Form - Teachers and School Staff

This form offers the convenience of progress saving, allowing users to save their work and return to it at a later time. To take full advantage of this feature, users are required to log in to their accounts. By logging in, they can ensure that their data and inputs are securely stored, enabling a seamless and uninterrupted experience during their interactions with the form.

Caution: Logging in to your account to take advantage of the progress-saving feature will result in the loss of any unsaved data or inputs made so far on this form.

GP Details

What is the young person's NHS Number?

How to find their NHS number

The NHS number is a 10 digit number, like 485 777 3456.

You can use the NHS website to find their NHS number. Vist https://www.nhs.uk/find-nhs-number/what-is-your-name.

GP Surgery:

GP Name (if known):

Education Details

School/College/Organisation Name: *

School/College/Organisation Address: *

School/College/Organisation Postcode: *

Year Group: *

Best Contact Full Name: *

Best Contact Email Address: *

Any other information relating to the young persons education:

School Services

Please list below any school services that are involved with the young person

What are school services?

Social services/Voluntary agencies/Charities/Justice system/youth emotional team.

Other Services

Please list below any other services that are involved with the young person

What are other services?

1:1 support, learning support, therapy input, Additional help/support/EHCP or Individual educational plans /professionals who support the young person in the education setting such as physiotherapist, Speech and language therapist, occupational therapist, play therapist etc

Young person's views

We would like to capture the views of the young person who you are making this referral for. Where possible please detail the young persons perception of the problem in their own words and how you have obtained this information:

Gaining the young persons views can be completed in a number of ways using mapping tools, drawings and writing. Or through conversation. If you have any attachments to provide please email to NDP.Screening.WestSussex@spft.nhs.uk.

Young Person's Voice: *

Current Concerns

What are your main concerns about the young person's behaviour? Could you describe these behaviours; are they triggered by people, situations, places or time? What can make the situation easier or less likely to occur and what makes the situation worse? Please give details: *

Do you have any current or previous concerns about the young person self-harming or expressing that they would like to seriously harm themselves or others?*

Yes

(Please consider: current or historic self-harm, suicidal thinking/intent, thoughts of harm to others, bereavement, substance misuse, criminal justice, exploitation, adverse childhood experiences, trauma, parental MH or substance misuse, domestic abuse)

Why are we asking this?

We ask this so our Neurodevelopmental Specialist Practitioners understand more about the risk that the young person presents to themselves before they ring you for the first time. In particular, we want to try to understand if there are any risks that you are struggling to manage, and understand exactly what the young person has done to themselves (if anything).

Reminder:

We are not a 24 hour emergency service, and our Neurodevelopmental Specialist Practitioners meet to screen referrals at various different times. If you feel the young person needs immediate support and are a danger to themselves, please use one of the links below:

Look at https://www.sussexcamhs.nhs.uk.
Contact the Sussex Mental Health line 0800 0309 500 (which is open 24/7) or NHS 111.
Attend A&E for emergencies and medical treatment. Before you attend A and E if the young person is feeling suicidal, please have a conversation with your young person about the thoughts they are having, and whether they actually intend to harm themselves, and whether they have any concrete plans to harm themselves. It's important that carers are sure that attending A and E is the right thing for the young person, as waiting for assessment there can often take several hours.
If the young person absconds, contact the police by dialling 999.

Are there any other factors that have caused you, or others, concern?*

Yes

Academic Profile

What is their work at school like? Is their academic performance as expected i.e. are they able to complete their class work? Do they complete their homework? Do they have any specific learning or literacy difficulties? Please give details: *

For each of the following three questions can you please indicate if the young person is behind their peer group in learning attainment e.g. are they a month behind or are they significantly behind e.g. a year, if they are significantly behind can you please describe what assessments or referrals the school have completed to understand their learning needs, e.g. Education Psychology.

How would you describe the child/young person in terms of age related expectations in reading? *

How would you describe the child/young person in terms of age related expectations in writing? *

How would you describe the child/young person in terms of age related expectations in maths? *

Classroom behaviour

How does the child/young person respond to classroom routines and expectations? *

How does the child/young person present when working in whole class or group situations? *

How does the child/young person manage in the playground or in unstructured times? *

Does the child/young person have difficulties focusing or paying attention? Is the child/young person distracted by classroom noise? *

Does the child/young person present with disruptive behaviour in the classroom? In which lessons is this most noticeable and when are we least likely to see this behaviour? *

Young Person's Strengths

Please comment on the young person's strengths? Please give details: *

Relationships

Please describe their friendships with other people e.g. friends, siblings, adults? Do they join in with conversations just to be friendly or just to give you information? Please give details: *

Do they meet up with friends? Can they participate/join in with group activities i.e. take turns, not dominate, know what to say and when? Please give details: *

What is the young person's response to other people's emotions? Is it what you expect? Do they show concern if someone is upset? Do they sometimes misinterpret peoples' emotions? Please give details: *

Does the young person seem overly worried, anxious or nervous? Please give details: *

How well do they cope with change? Please give details: *

What is the young person's response to adults setting boundaries or asking them to follow rules? Do they ever become aggressive, threaten to hurt others or actually hurt other people? Please give details: *

Does the young person have any unusual interests or obsessions compared to their age group? Please give details: *

Have you noticed any repetitive behaviours e.g. checking, hand-washing, vocal or motor tics. Please give details: *

Language and Communication

Do you have any general concerns about the young person's speech and language? Do they have a stammer? Do they speak too loud, too fast? Please give details: *

Can the young person have a two-way conversation with adults and/or other young people? Do they show interest in what the other person is saying, rather than the conversation being one-sided? Please give details: *

Do they use rather formal language, unusual or repetitive phrases, or repeat themselves? Please give details: *

Are they literal in their understanding? Do they give excessive attention to detail and/or go off on a tangent? Are they able to follow instructions or do they need instructions to be repeated or rephrased? Please give details: *

How well can/did the young person play imaginatively now/ when they were younger? Can/did they develop their own stories and 'pretend' play by themselves? Could they join in with pretend play with other children? Please give details: *

Sensory

Do they have any unusual sensory interests or responses to smells, lights, loud noises, being in crowded places? Do they have any sensory difficulties with clothing? Please give details: *

SNAP-IV

Adapted from the SNAP-IV parent and teacher rating scale, originally created by James M Swanson PHD, University of California, Irvine, CA 92715.

For each item, select the box that best describes this child / young person

What is this?

This is a validated screening questionnaire. Our Neurodevelopmental Specialist Practitioners want you to rate your young person, selecting the option that best describes the young person, from 0='Not at all', 1='Just a little' 2='Quite a bit' and 3='Very much'.

If you think about the child/young person's behavior, are you completing this screening questionnaire based upon the*

Past week

Past month

Past year

Other - Please specify

Attention Levels

Question	Not at All (0)	Just a Little (1)	Quite a Bit (2)	Very Much (3)
Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities	0 - Not at All - Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities	1 - Just a Little - Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities	2 - Quite a Bit - Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities	3 - Very Much - Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

Often has difficulty sustaining attention in tasks or play activities	0 - Not at All - Often has difficulty sustaining attention in tasks or play activities	1 - Just a Little - Often has difficulty sustaining attention in tasks or play activities	2 - Quite a Bit - Often has difficulty sustaining attention in tasks or play activities	3 - Very Much - Often has difficulty sustaining attention in tasks or play activities

Often does not seem to listen when spoken to directly	0 - Not at All - Often does not seem to listen when spoken to directly	1 - Just a Little - Often does not seem to listen when spoken to directly	2 - Quite a Bit - Often does not seem to listen when spoken to directly	3 - Very Much - Often does not seem to listen when spoken to directly

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties	0 - Not at All - Often does not follow through on instructions and fails to finish schoolwork, chores, or duties	1 - Just a Little - Often does not follow through on instructions and fails to finish schoolwork, chores, or duties	2 - Quite a Bit - Often does not follow through on instructions and fails to finish schoolwork, chores, or duties	3 - Very Much - Often does not follow through on instructions and fails to finish schoolwork, chores, or duties

Often has difficulty organizing tasks and activities	0 - Not at All - Often has difficulty organizing tasks and activities	1 - Just a Little - Often has difficulty organizing tasks and activities	2 - Quite a Bit - Often has difficulty organizing tasks and activities	3 - Very Much - Often has difficulty organizing tasks and activities

Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework)	0 - Not at All - Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework)	1 - Just a Little - Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework)	2 - Quite a Bit - Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework)	3 - Very Much - Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework)

Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)	0 - Not at All - Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)	1 - Just a Little - Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)	2 - Quite a Bit - Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)	3 - Very Much - Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

Often distracted by irrelevant noises or events nearby	0 - Not at All - Often distracted by irrelevant noises or events nearby	1 - Just a Little - Often distracted by irrelevant noises or events nearby	2 - Quite a Bit - Often distracted by irrelevant noises or events nearby	3 - Very Much - Often distracted by irrelevant noises or events nearby

Often is forgetful in daily activities	0 - Not at All - Often is forgetful in daily activities	1 - Just a Little - Often is forgetful in daily activities	2 - Quite a Bit - Often is forgetful in daily activities	3 - Very Much - Often is forgetful in daily activities

Activity

Question	Not at All (0)	Just a Little (1)	Quite a Bit (2)	Very Much (3)
Often fidgets with hands or feet or squirms in seat	0 - Not at All - Often fidgets with hands or feet or squirms in seat	1 - Just a Little - Often fidgets with hands or feet or squirms in seat	2 - Quite a Bit - Often fidgets with hands or feet or squirms in seat	3 - Very Much - Often fidgets with hands or feet or squirms in seat

Often leaves seat in classroom or in other situations in which remaining seated is expected	0 - Not at All - Often leaves seat in classroom or in other situations in which remaining seated is expected	1 - Just a Little - Often leaves seat in classroom or in other situations in which remaining seated is expected	2 - Quite a Bit - Often leaves seat in classroom or in other situations in which remaining seated is expected	3 - Very Much - Often leaves seat in classroom or in other situations in which remaining seated is expected

Often runs about or climbs excessively in situations in which it is inappropriate	0 - Not at All - Often runs about or climbs excessively in situations in which it is inappropriate	1 - Just a Little - Often runs about or climbs excessively in situations in which it is inappropriate	2 - Quite a Bit - Often runs about or climbs excessively in situations in which it is inappropriate	3 - Very Much - Often runs about or climbs excessively in situations in which it is inappropriate

Often has difficulty playing or engaging in leisure activities quietly	0 - Not at All - Often has difficulty playing or engaging in leisure activities quietly	1 - Just a Little - Often has difficulty playing or engaging in leisure activities quietly	2 - Quite a Bit - Often has difficulty playing or engaging in leisure activities quietly	3 - Very Much - Often has difficulty playing or engaging in leisure activities quietly

Often is "on the go" or often acts as if "driven by a motor"	0 - Not at All - Often is "on the go" or often acts as if "driven by a motor"	1 - Just a Little - Often is "on the go" or often acts as if "driven by a motor"	2 - Quite a Bit - Often is "on the go" or often acts as if "driven by a motor"	3 - Very Much - Often is "on the go" or often acts as if "driven by a motor"

Often talks excessively	0 - Not at All - Often talks excessively	1 - Just a Little - Often talks excessively	2 - Quite a Bit - Often talks excessively	3 - Very Much - Often talks excessively

Impulsivity

Question	Not at All (0)	Just a Little (1)	Quite a Bit (2)	Very Much (3)
Often blurts out answers before questions have been completed	0 - Not at All - Often blurts out answers before questions have been completed	1 - Just a Little - Often blurts out answers before questions have been completed	2 - Quite a Bit - Often blurts out answers before questions have been completed	3 - Very Much - Often blurts out answers before questions have been completed

Often has difficulty awaiting turn	0 - Not at All - Often has difficulty awaiting turn	1 - Just a Little - Often has difficulty awaiting turn	2 - Quite a Bit - Often has difficulty awaiting turn	3 - Very Much - Often has difficulty awaiting turn

Often interrupts or intrudes on others (e.g., butts into conversations/games)	0 - Not at All - Often interrupts or intrudes on others (e.g., butts into conversations/games)	1 - Just a Little - Often interrupts or intrudes on others (e.g., butts into conversations/games)	2 - Quite a Bit - Often interrupts or intrudes on others (e.g., butts into conversations/games)	3 - Very Much - Often interrupts or intrudes on others (e.g., butts into conversations/games)

Additional Information

Please give any additional information you would like to share:

Please also send copies of any reports you may already have for this young person, such as an EHCP or Speech and Language reports to NDP.Screening.WestSussex@spft.nhs.uk

Terms and Conditions

On receipt of the screening form, we will consider whether or not the neurodevelopmental pathway is the most, or only, appropriate CAMHS service for the young person. Our service is not 24 hours and it may take several weeks for the information to be screened. The information you have provided will be used primarily for the purpose of undertaking a neurodevelopmental assessment, and contacting you, the young person's parents/carers or the young person directly should we require more information, but there may be instances (particularly around risk) where contacting other Sussex Partnership NHS Foundation Trust services about the young person is deemed appropriate. This information will not be shared with anyone else without your consent. Information will be held as a part of the service user's record in line with the NHS Records Management Code of Practice. For more information on how we use your information, please see our privacy policy.

I have read and agree with the above terms and conditions.*

Sussex CAMHS Neurodevelopmental Screening Form - Teachers and School Staff

What do I need to know before filling in this screening form?

What will happen to this referral form once it has been screened?

What does neurodivergent positivity mean at Sussex CAMHS Neurodevelopmental Pathway?

Sussex CAMHS Neurodevelopmental Screening Form - Teachers and School Staff

Referral confirmation

Parents Consent

Completer Details

Young Person's Details

Young Person's Consent

Young Person's Contact Details

Parent/Carer Details

Academic Information

Other Information

GP Details

Education Details

School Services

School Services 1

School Services 2

School Services 3

School Services 4

School Services 5

School Services 6

School Services 7

School Services 8

School Services 9

School Services 10

Other Services

Other Service 1

Other Service 2

Other Service 3

Other Service 4

Other Service 5

Other Service 6

Other Service 7

Other Service 8

Other Service 9

Other Service 10

Young person's views

Current Concerns

Academic Profile

Classroom behaviour

Young Person's Strengths

Relationships

Language and Communication

Sensory

SNAP-IV

Attention Levels

Activity

Impulsivity

Additional Information

Terms and Conditions