ADHD Assessment & Management Note

Date of Assessment or Review: 1 November 2024, Initial Assessment. Referral Reason and Informant Context: Referred by the child's general practitioner following concerns raised by Mrs. Zandile Ndlovu (mother) and teachers at KwaMashu Primary School regarding persistent difficulties with attention, impulsivity, and disruptive behaviour in the classroom. Concerns include frequent daydreaming, difficulty completing tasks, blurting out answers, and fidgeting, impacting academic progress and peer interactions. The family resides in a peri-urban area, and Mrs. Ndlovu expressed challenges in accessing consistent support. Developmental and Behavioural History: Antenatal care was regular, and birth was full-term with no complications. Early developmental milestones were within normal limits, though Mrs. Ndlovu noted that Sipho (patient) was always a "busy" child. He adapted reasonably well to crèche but started exhibiting more pronounced behavioural patterns in Foundation Phase (Grade R and 1), particularly with sitting still and following instructions. Family structure includes his mother, Mrs. Ndlovu, and his grandmother, who provides significant caregiving support. His father works in another province and visits quarterly. Current Symptom Profile (Inattention/Hyperactivity): Sipho demonstrates significant inattention, frequently losing focus during classroom activities, struggling to follow multi-step instructions, and often failing to complete homework assignments. He is highly impulsive, often interrupting others, blurting out answers, and has difficulty waiting his turn. Teachers report frequent fidgeting, getting out of his seat during lessons, and excessive talking. Socially, he struggles with peer interactions due to impulsivity, sometimes leading to arguments or exclusion from games. Functional Impacts: Academic performance is significantly impacted, particularly in subjects requiring sustained attention and organisation, such as Mathematics and English, where he consistently performs below CAPS expectations. Executive functioning challenges are evident in poor organisation of school materials and difficulty planning tasks. Interpersonal relationships with peers are strained due to his impulsivity, and he often receives negative feedback from educators. Emotionally, he appears frustrated by his difficulties, occasionally exhibiting outbursts. The family faces socioeconomic stressors, impacting access to resources and additional support. Screening/Rating Tools Used: SNAP-IV completed by both mother and teacher indicated elevated scores in both inattention and hyperactivity/impulsivity domains, consistent with ADHD. Educator reports from KwaMashu Primary School detailing classroom observations were reviewed. SBST feedback highlighted previous interventions focused on classroom management that yielded limited success. Diagnosis and Rationale: Diagnosis: Attention-Deficit/Hyperactivity Disorder, Combined Presentation. Rationale is based on a comprehensive assessment including developmental history, current symptom profile reported by multiple informants (mother, teacher), and objective screening tools (SNAP-IV) demonstrating pervasive and impairing symptoms of inattention and hyperactivity/impulsivity across multiple settings (home, school) for longer than 6 months. Differential diagnoses considered included anxiety and learning barriers; however, the primary pattern of symptoms aligns most closely with ADHD. Trauma exposure was screened for and deemed unlikely to be the primary cause of symptoms, though community stressors are acknowledged. Management Plan: 1. Medication: Initiate Methylphenidate (short-acting), titrate carefully based on response and side effects. Provide detailed psychoeducation to Mrs. Ndlovu regarding medication purpose, administration, potential side effects, and expected benefits. 2. Psychoeducation for Caregivers: Ongoing psychoeducation for Mrs. Ndlovu and grandmother on ADHD, behavioural management strategies, and creating a structured home environment. Refer to a local NGO-run parenting programme focusing on ADHD management. 3. School Liaison: Collaborate closely with the school (ILST/SBST) to implement classroom accommodations (e.g., preferential seating, reduced distractions, frequent breaks, visual aids) and support strategies for academic tasks. Schedule a meeting with the teacher and SBST coordinator. 4. Follow-up: Schedule review in 4 weeks to assess medication efficacy and side effects, and to monitor behavioural and academic progress. Subsequent follow-ups every 3 months in the private sector setting.