ADHD Clinic Letter to GP

Letter to Dr. Sarah Evans, GP Visit Diagnosis/Symptom Complex: 1. Attention Deficit Hyperactivity Disorder (ADHD), Combined Presentation 2. Generalised Anxiety Disorder Problem List 1. Chronic difficulty with academic focus and completion of tasks 2. Impulsivity leading to social difficulties 3. Restless sleep patterns Current Medicines: 1. Methylphenidate 18mg, modified release, once daily in the morning 2. Sertraline 25mg, oral tablet, once daily in the evening Education: Patient is currently in Year 6 at Willow Creek Primary School. He receives additional support for literacy and numeracy twice a week in small group sessions. Examination Weight 32 kg Height 135 cm Blood Pressure 105/68 mmHg, within normal limits for age. Plan 1. Continue current medication regimen; review efficacy and side effects at next appointment. 2. Recommend school-based behavioural strategies, including preferential seating and visual timetables. 3. Refer for cognitive behavioural therapy (CBT) to address anxiety symptoms. 4. Follow-up appointment scheduled in 6 weeks to assess medication response and progress with interventions. Outcome Today's appointment confirmed the need for ongoing management of ADHD and co-occurring anxiety. The patient and his mother were engaged and understood the proposed plan. Further intervention and follow-up are arranged. Dear Colleagues I was pleased to review Michael Jones who was brought to my community clinic by his mother, Mrs. Emily Jones. Michael was referred by your practice due to ongoing concerns regarding his attention, hyperactivity, and impulsivity in both home and school environments, which have been present for approximately three years and have significantly impacted his academic progress and social interactions. Current Situation Mrs. Jones describes Michael as a bright and energetic 10-year-old boy who struggles significantly with staying focused on tasks, particularly homework and classroom activities. She reports frequent instances of Michael interrupting conversations, difficulty waiting his turn, and often losing belongings. He often fidgets and struggles to sit still, even during preferred activities. Socially, he finds it challenging to maintain friendships due to his impulsivity, which sometimes leads to him saying or doing things without thinking. Mrs. Jones also notes that Michael often appears anxious, worrying excessively about school performance and social acceptance, which sometimes manifests as stomach aches before school. In-Clinic Questionnaires Michael self-reported feeling frustrated by his inability to concentrate and often feels misunderstood by his peers and teachers. He expressed a desire to do well in school but finds it very hard to stop his mind from wandering. He sometimes feels overwhelmed by tasks and tries to avoid them. He copes by retreating to his room to play video games, which he finds calming. Mrs. Jones provided additional observations, clarifying that Michael's difficulties are pervasive across settings and have worsened over the last year, coinciding with the increased academic demands of Year 6. She noted that while he is intelligent, his output does not reflect his potential due to his struggles with organisation and sustained attention. She also highlighted his sensitivity to criticism. Relevant background information includes a paternal history of ADHD, which Mrs. Jones believes contributes to Michael's presentation. There is no reported history of significant trauma; however, Michael experienced a brief period of bullying in Year 4, which led to increased social anxiety at the time. Development Michael met all early motor and speech developmental milestones within expected ranges. He was an early walker and talker. His primary school teachers first raised concerns about his attention and hyperactivity in Year 2. Sleep Michael struggles with falling asleep, often taking over an hour to settle. He wakes frequently during the night and experiences restless sleep. No medications are currently used to support sleep. Past Medical History And Background Born at full term via spontaneous vaginal delivery with no complications. No significant past medical conditions or hospitalisations. Up to date with all routine childhood vaccinations. No known allergies. Family History Michael lives with both parents and a younger sister, aged 7. His father has a diagnosed history of ADHD. There is a maternal history of anxiety disorder. No other significant family medical or mental health history reported. ADHD Evaluation Information From Mrs. Jones In August 2024 Strengths Mrs. Jones reports Michael is creative, imaginative, and has a good sense of humour. He is very kind to animals and enjoys drawing and building Lego. He is very keen to please and responds well to positive reinforcement. Challenges Mrs. Jones highlighted significant challenges with task initiation and completion, organisation, and emotional regulation. She noted his forgetfulness and difficulty following multi-step instructions. Information From The School In July 2024 And September 2024 Strengths The school reported Michael's strong verbal reasoning skills and his eagerness to participate in class discussions when topics genuinely interest him. He is generally polite and well-mannered. Challenges The school's reports consistently highlight difficulties with sustained attention, particularly during independent work and group tasks. He struggles with completing assignments on time, often losing focus or becoming distracted by peers. His impulsivity sometimes leads to calling out answers without raising his hand or interrupting others. Academic performance is variable, with strong results in subjects he enjoys and struggles in those requiring sustained, rote learning. Information From School - Received October 2024 Strengths Recent reports indicate an improvement in Michael's participation in class discussions and a growing willingness to ask for help when he feels stuck. He continues to demonstrate creativity in art classes. Challenges Recent challenges include increased difficulty regulating emotions when frustrated, leading to occasional outbursts. Socially, he continues to struggle with turn-taking and listening to others, which affects his ability to maintain friendships. Academic challenges persist in subjects requiring meticulous attention to detail. Conners parent, teacher, and self-report questionnaires gather information regarding a range of behaviours and symptoms. The scores indicate whether the observed symptoms are disproportionate to those expected for a child of the same age. T-scores greater than 70 for attention and hyperactivity or impulsivity in all settings indicate that the symptoms are significant. Parents' Rating T Scores - October 2024 Inattention / Executive Dysfunction - 75 Hyperactivity - 72 Impulsivity - 70 Emotional Dysregulation - 68 School Work - 71 Peer Interactions - 65 Family Interactions - 60 Teachers' Rating T Scores - October 2024 Inattention / Executive Dysfunction - 78 Hyperactivity - 73 Impulsivity - 71 Emotional Dysregulation - 65 School Work - 74 Peer Interactions - 68 Self-Reported T Scores Inattention / Executive Dysfunction - 62 Hyperactivity - 58 Impulsivity - 59 Emotional Dysregulation - 63 School Work - 60 Peer Interactions - 55 Family Interactions - 52 QB Test - September 2024 Michael underwent a Quantified Behavioural Test (QbTest) to objectively measure core ADHD symptoms. This computer-based test assesses attention, impulsivity, and motor activity against age- and gender-matched normative data. The scores were as follows: Activity Level - 2.5 (significantly elevated, indicating high motor activity) Attention - 1.8 (below average, suggesting difficulty sustaining attention) Impulsivity - 2.1 (elevated, indicating a tendency to respond without inhibition) The overall QbTest findings are consistent with an ADHD profile, demonstrating objective difficulties in attention and impulse control, alongside increased motor activity, which aligns with both parental and teacher reports. On Examination During the consultation, Michael was observed to be restless, often fidgeting in his chair and tapping his feet. He frequently interrupted during discussions, particularly when excited about a topic. He had difficulty maintaining eye contact for extended periods but was otherwise cooperative and engaged when prompted. Affect was appropriate, and mood was euthymic but with underlying anxiety noted when discussing schoolwork. No gross neurological deficits were observed. Conclusion And Plan Based on the comprehensive assessment, including parent and teacher reports, self-report, and objective QbTest data, Michael continues to meet the diagnostic criteria for Attention Deficit Hyperactivity Disorder, Combined Presentation. His symptoms are pervasive, long-standing, and significantly impact his academic, social, and emotional functioning. Additionally, he presents with symptoms consistent with Generalised Anxiety Disorder, likely exacerbated by his ADHD challenges. The current plan involves continuing his prescribed stimulant medication, with a review in 6 weeks to optimise dosage and monitor for side effects. Referral for CBT is recommended to address his anxiety. We will also collaborate with the school to implement supportive strategies to aid his learning and behaviour. Psychoeducation regarding ADHD and anxiety management will continue for Michael and his family. This letter relates to today's clinic appointment and was created using voice recognition software. Please contact the clinic should you have any questions or identify any inaccuracies. This is not for medico-legal purposes.