Behavior Template

Problem List: 1. Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Presentation; Generalised Anxiety Disorder. Medications: 1. Methylphenidate ER 20mg once daily in the morning; Sertraline 50mg once daily in the evening. Discontinued Medications: - Atomoxetine 40mg due to insufficient therapeutic effect and gastrointestinal side effects. Support Team: - Parents (Mr. and Mrs. Smith), School counsellor (Ms. Davies). School: St. Augustine's Primary School Grade: Year 5 Presenting Complaints: Concerns regarding ongoing inattention and impulsivity at school, difficulty with homework completion, and increased anxiety symptoms. I had the pleasure of reviewing the patient who is now 10 years and 3 months on 1 November 2024. The patient attended with Mrs. Smith, who is the patient's mother. School Progress: The patient's mother, Mrs. Smith, reported that the patient continues to struggle with staying focused during lessons, particularly in subjects requiring sustained attention such as English and Maths. The stimulant medication, Methylphenidate ER, appears to be effective for the first few hours of the school day, with the patient showing improved concentration during morning classes. However, by the afternoon, the caregiver observes a noticeable decline in the patient's ability to focus and complete tasks, suggesting the medication's efficacy wanes. The patient has also exhibited some behavioural challenges, including occasional fidgeting and talking out of turn, leading to minor disruptions in class. There have been no formal suspensions, aggression, or significant anxiety noted at school recently. The patient receives learning support from a teacher's aide for two hours a week, focusing on organisational skills and breaking down larger assignments. Home Progress: At home, the caregiver reports that the patient's difficulty with attention extends to homework completion, often taking an excessive amount of time and requiring constant prompting. The patient becomes easily frustrated and anxious when faced with complex tasks. While there are no overt signs of aggression, the patient does display increased irritability and emotional dysregulation when overtired or overstimulated. The caregiver also notes a reluctance to participate in extracurricular activities, preferring solitary play, which has been a recent change. The caregiver expressed significant stress regarding the patient's academic struggles and their impact on family dynamics, often leading to evening conflicts over homework. Allied therapies and External supports: The patient is currently engaged in weekly psychology sessions to address anxiety and develop coping strategies, focusing on cognitive behavioural therapy techniques. The goal of these sessions is to help the patient identify triggers for anxiety and implement calming techniques. The patient also attends fortnightly occupational therapy sessions, which aim to improve fine motor skills and sensory regulation, both of which are considered foundational to improved focus and academic performance. There are no other ongoing allied health or external supports at this time. Mood and Mental Health: The caregiver reports that the patient has been experiencing increased symptoms of anxiety, including worries about school performance and social interactions. The patient often verbalises fears about making mistakes and is reluctant to try new activities due to fear of failure. The patient denies any thoughts of self-harm or suicidal ideation. The patient's mood is generally reported as anxious, but occasionally cheerful when engaged in preferred activities. Confidential Adolescent Psychosocial History: Home: The patient lives with both parents and a younger sibling. The patient reports feeling safe and supported at home, though acknowledges tension sometimes arises due to homework struggles. Education: The patient is in Year 5 and continues to experience difficulties with academic performance, particularly in subjects requiring sustained attention. The patient denies being bullied but admits to occasional arguments with classmates. Academic performance is satisfactory in some subjects but below average in others, particularly those requiring strong executive function. Activities: The patient enjoys reading fantasy novels and playing video games in their spare time. There is no current involvement in organised sports or volunteering activities. Drugs: There has been no discussion of smoking, vaping, drug use, or alcohol use with the patient. Sexuality and Gender: Not applicable for a 10-year-old patient. Mental Health: The patient experiences anxiety related to school and social situations. Denies thoughts of suicide or self-harm. The patient reports difficulty falling asleep due to worrying. Sleep and Diet: The caregiver reports that the patient struggles with sleep onset, often taking 30-60 minutes to fall asleep due to racing thoughts and worries. The patient typically sleeps for around 8-9 hours per night but often wakes feeling unrefreshed. The patient's diet is generally balanced, though there is a preference for sugary snacks, which the caregiver is trying to limit. Side Effects of Medications: The caregiver reports that the patient occasionally experiences a decreased appetite in the mornings after taking Methylphenidate ER, but this usually resolves by lunchtime. There are no other reported side effects from either medication. Examination: Weight – 32 kg Height – 138 cm BMI – 16.8 kg/m2 BP - 105/65 mmHg The patient presented as a well-groomed, cooperative child. Speech was of normal rate and rhythm. Mood was anxious, and affect was congruent. Thought process was linear, and thought content was appropriate for age. Cognition appeared within normal limits. Insight into difficulties was fair, and judgment was appropriate. Developmental screening using the Conners 3rd Edition Parent Form showed elevated scores in Inattention and Hyperactivity/Impulsivity scales, consistent with the diagnosis of ADHD. The Vanderbilt ADHD Diagnostic Teacher Rating Scale also indicated significant inattentive and hyperactive-impulsive symptoms. The SCARED (Screen for Child Anxiety Related Emotional Disorders) questionnaire indicated elevated scores for Generalised Anxiety Disorder. Summary: This 10-year-old male patient with diagnosed ADHD (Combined Presentation) and Generalised Anxiety Disorder presents for review. Concerns relate to ongoing inattention and impulsivity impacting school performance and home life, alongside persistent anxiety symptoms. The current medication regimen provides some benefit, but challenges remain, particularly in the afternoon and with managing anxiety. Plan: - Continue Methylphenidate ER 20mg daily; consider trial of dose escalation or afternoon booster if inattention continues to be problematic in the afternoon. Discuss with caregiver at next review. - Continue Sertraline 50mg daily; monitor for therapeutic effect and side effects. - Continue weekly psychology sessions for anxiety management and coping strategies. - Continue fortnightly occupational therapy for fine motor skills and sensory regulation. - Liaise with the school counsellor to discuss classroom strategies for supporting attention and reducing anxiety. - Follow-up appointment in 3 months to review medication efficacy, side effects, and overall progress with school and home difficulties.