Clinical assessment

clinical assessment

Clinical assessment

A clinical assessment can be helpful to inform the way an individual is supported, or to establish the meaning and context of behaviours that cause concern to others. It can also be a way of confirming a diagnosis of intellectual or learning disability for the person.

Here is what different clinical assessments might involve:

  • Spending time with the person, at home or in others places where they receive support from others
  • Talking to the person where possible, and those who know them best – usually parents or carers and support staff – using structured interviews and questionnaires to gather information about the behaviour of concern as well as how the person is supported now
  • Reviewing the person’s history and reading professional reports about the person
  • Writing a report which summarises all the information gathered during the assessment and makes recommendations about what might help to improve quality of life both for the person and for those around them

Case Study

An assessment to see if an individual has an intellectual or learning disability
It is important that the individual has consent to this assessment before a referral is made, or if they lack capacity to consent to the assessment, that the referral is made in their best interests.

The assessment usually takes around 3 days and involves:

  • Spending time with the person to complete an assessment of cognitive functioning. This is a series of puzzles and tasks that explore skills such as memory, reasoning and processing.
  • Completing a structured interview with the person and those who know them best – usually parents or carers, or staff who support them regularly.
  • Finding out information about the individual’s early years and experience of education, through interview and reading any available documents that describe this early history.
  • Writing a report which summarises the findings from the assessment and draws conclusions about the person’s strengths and areas for development.

A psychological assessment

This might be helpful as part of assessing an individual’s support needs and might cover a range of areas such as capacity, adaptive skills, risk and risk management and emotional well-being.

Psychological assessments vary in length depending on the number of issues or areas of interest. They will always involve meeting the individual and spending time with them, and are also likely to include interviews and meetings with people who now the person best.

All psychological assessments will result in a report which will summarise findings from the assessment and make recommendations for providing effective and appropriate support.

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Case Study – Clinical assessment

A functional behavioural assessment was carried out with a young man with learning disabilities and autism and his family as requested by the local authority funding his support. There were concerns about the level of distress he was showing and his parents were becoming increasingly upset at the lack of progress in understanding what was behind the episodes of agitation and aggression.

Through careful observation and completion of standardised questionnaires as part of a thorough assessment it was established that changes in the individual’s support network and inconsistencies of approach were contributing to feelings of uncertainty and anxiety.

A workshop was developed around the assessment findings, attended by the individual’s parents and the clinical staff providing support. This led to collaboration in drawing up a Positive Behaviour Support plan to enhance quality of life informed by a fresh understanding of the individual’s distress. Feedback suggested a renewed sense of partnership in working together to improve consistency and communication between network members, all of which led to reductions in episodes of agitation and improvements in well-being for everyone.