Young Adult Support Unit – ADHD Assessment (Parent Collateral Information Gathering)
Situation
Date: 01/11/2024
Time: 10:30 AM
Attendees: Patient (Liam Smith), Mother (Mrs. Sarah Smith), Father (Mr. David Smith)
Clinician: Dr. Eleanor Vance, Psychologist
Appointment type: In-person consultation, Clinic Room 3
Patient has arrived for the appointment and provided consent for the interview.
Background
Liam Smith, a 16-year-old male, presents with concerns regarding his attention, concentration, and organisation, as reported by his parents. He uses he/him pronouns. His parents are seeking an assessment for potential Attention-Deficit/Hyperactivity Disorder (ADHD) due to long-standing academic struggles and behavioural challenges at home.
Presentation:
- Well-groomed, age-appropriate casual attire.
- Maintained eye contact throughout the interview.
- Affect was generally calm and cooperative, though mother appeared somewhat distressed.
- Speech was clear, coherent, and at a normal pace.
- Thought content focused on Liam's difficulties and the impact on family life.
Early Development
- Pregnancy and birth history: Full-term pregnancy, no reported complications. Vaginal delivery, birth weight 3.5 kg. No prematurity.
- Early developmental milestones: Achieved motor milestones within typical range (walked at 12 months, first words at 15 months). Communication and social milestones were also met appropriately, though parents noted he was an unusually active toddler.
- Early temperament and behaviour: Described as a very active and curious child. Sleep was often irregular in infancy, and he was prone to frequent temper tantrums until around age 5, struggling with mood regulation when frustrated.
Childhood Behaviour and Functioning
- Attention and concentration: Parents report Liam was easily distracted from a young age, struggled to finish tasks like puzzles or drawing, and often seemed to be in his own world, frequently daydreaming in class.
- Activity level and impulsivity: Consistently high activity levels, often described as 'bouncing off the walls'. Would often blurt out answers in class and interrupt conversations. Engaged in some minor risk-taking behaviours, such as climbing tall trees, but nothing severe.
- Emotional regulation: Prone to significant tantrums and outbursts when things didn't go his way. Frustration tolerance was low, often giving up on tasks quickly if they became challenging.
- Organisation and routines: Consistently struggled with keeping track of belongings, often losing school items. Homework was a constant battle, and daily routines were difficult to establish and maintain.
- Social relationships: Had a fluctuating circle of friends. Sometimes struggled to maintain friendships due to impulsivity and difficulty understanding social cues, leading to occasional conflicts. Often preferred solitary play or group activities where structure was provided.
School and Learning (Primary and High School)
- Academic progress: Demonstrated early reading ability but struggled significantly with maths and written expression. Has had consistent learning difficulties, particularly with organisation and sustained effort. Parents believe he has high potential but underperforms.
- Teacher feedback: Frequent comments from teachers about inattention, difficulty staying seated, blurting out answers, and not following multi-step instructions. Often praised for creativity but criticised for effort and inconsistent performance.
- Reports of disruptive behaviour: Numerous reports of calling out in class, fidgeting constantly, not sitting still, and difficulties following instructions, leading to frequent detentions in primary school.
- School reports or interventions: Received some informal learning support in primary school. Currently has an Individual Education Plan (IEP) focused on organisation and time management strategies, and extended time for exams.
Adolescence
- Changes with increased demands: Significant increase in difficulties with organisation as academic demands increased. Struggles with managing multiple subjects, transitioning between classes, and maintaining independence in schoolwork. Often forgets deadlines.
- Risk-taking behaviour: Has experimented with vaping and occasional alcohol use with friends, but parents report no severe substance misuse. Has shown some unsafe driving habits (speeding) since getting his learner's permit.
- Motivation and engagement: A noticeable drop in grades since year 9. Shows struggles with sustained effort in subjects he finds less engaging, leading to a general lack of motivation towards schoolwork.
- Peer relationships and family dynamics: Experiences some conflict with peers due to impulsivity. Family dynamics are strained due to constant reminders about schoolwork and chores, leading to withdrawal and reliance on his mother for executive functioning tasks.
Medical and Mental Health History
History of other diagnoses: No formal diagnoses of learning disorders or autism. Has experienced periods of anxiety, particularly around academic performance, but no formal diagnosis of an anxiety disorder.
Medical issues: No relevant medical issues such as thyroid problems, seizures, or head injuries. Parents report chronic mild sleep problems, difficulty falling asleep and restless sleep.
Family history: Maternal uncle has a diagnosis of ADHD. Paternal grandmother has a history of anxiety and depression.
Protective Factors and Strengths
- Areas of talent or special interest: Highly talented in digital art and coding, spending many hours on these hobbies. Enjoys playing team sports (football) where structure is provided.
- Supports used successfully in the past: Responded well to one-on-one tutoring for specific subjects in primary school. Benefited from a structured reward system at home for chores and homework completion.
- Resilience factors/adaptive strategies: Displays persistence in his areas of interest. Shows creativity in problem-solving within his hobbies. Is generally a kind and empathetic individual.
Plans:
- Provide psychoeducation about ADHD to parents.
- Recommend further assessment for Liam, including cognitive and academic testing.
- Refer to a paediatrician for medical assessment and consideration of pharmacological intervention.
- Schedule a follow-up appointment with parents in 4 weeks to discuss assessment findings and develop a comprehensive management plan.
- Provide resources on ADHD parenting strategies and local support groups.
**Young Adult Support Unit – ADHD Assessment (Parent Collateral Information Gathering)**
**<u>Situation</u>**
**Date:** [date of appointment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in format DD/MM/YYYY.)
**Time:** [time of appointment](Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
**Attendees:** [list of attendees including patient and other family members] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
**Clinician:** [clinician name and role](Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
**Appointment type:** [document type of appointment such as mode, setting and location](Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
**[document that patient has arrived for appointment and provided consent]**(Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
**<u>Background</u>**
[mention patient's name, pronouns, age, medical condition and presenting issue] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences.)
**<u>Presentation:</u>**
[document mental state and presentation observations such as dressing, appearance, affect, speech, and thought content] (Only include observations explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as a bullet point list, with each item on a new line.)
(If the appointment was a phone session, write the following. Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit entirely.)
"- Pt's appearance was unable to be assessed due to phone appt"
Early Development
- Pregnancy and birth history:[document pregnancy and birth history including complications, prematurity and birth weight if known] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- Early developmental milestones: [document early developmental milestones such as motor, communication and social milestones] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- Early temperament and behaviour:[document early temperament and behaviour including aspects such as activity levels, sleep, feed and mood regulation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
Childhood Behaviour and Functioning
- Attention and concentration:[document attention and concentration history including if patient was easily distracted, struggled to finish tasks and daydreaming] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- Activity level and impulsivity: [document activity level and impulsivity history including risk taking] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- Emotional regulation:[document emotional regulation history including tantrums and frustration tolerance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- Organisation and routines:[document organisation and routines history including keeping track of belongings, homework, and daily structure](Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- Social relationships:[document social relationships history including making and keeping friends, conflict, and social understanding] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
School and Learning (Primary and High School)
- Academic progress:[document academic progress including any learning difficulties, strengths, and giftedness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- Teacher feedback: [document teacher feedback including comments about inattention, behaviour, effort, and potential vs performance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- Reports of disruptive behaviour: [document reports of disruptive behaviour including calling out, not sitting still and difficulties following instructions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- School reports or interventions: [document school reports or interventions including tutoring, IEPs, and learning support] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
Adolescence
- Changes with increased demands:[document changes during adolescence with increased demands such as organisation, independence and transitions between classes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- Risk-taking behaviour: [document risk-taking behaviour in adolescence such as substance use, unsafe driving, and sexual risk-taking] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- Motivation and engagement:[document motivation and engagement during adolescence including drop in grades, and struggles with sustained effort] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- Peer relationships and family dynamics:[document peer relationships and family dynamics during adolescence including conflict, withdrawal, and reliance on supports] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
Medical and Mental Health History
History of other diagnoses:[document history of other diagnoses including learning disorders, autism, and mood/anxiety disorders] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
Medical issues:[document relevant medical issues such as thyroid, seizures, head injuries, and sleep problems] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
Family history:[document family history such as ADHD, autism, learning difficulties, and mental health conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
Protective Factors and Strengths
- Areas of talent or special interest:[document areas of talent or special interest such as sports, arts and hobbies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- Supports used successfully in the past:[document supports used successfully in the past such as mentoring, coaching and tutoring] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
- Resilience factors/adaptive strategies:[document resilience factors and adaptive strategies such as persistence, creativity, and problem-solving] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)
**Plans:**
[document plan such as next review date, referrals, follow-up booked, feedback and resources to be provided to patient and patient reminders] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as a bullet point list, with each item on a new line.)