ADHD Report

Clinician Specialty: Child Psychiatrist REASON FOR REFERRAL AND PRESENTING CONCERNS Patient, a 9-year-old male, was referred by his paediatrician due to significant concerns regarding inattention, hyperactivity, and impulsivity impacting his academic performance and social interactions. His parents report increasing difficulties with completing homework, following multi-step instructions, and frequent interruptions during conversations. He also displays fidgeting and restlessness, especially in structured environments like school. PAST MEDICAL HISTORY Patient has a history of mild asthma, well-controlled with a daily inhaler. He experienced an ear infection at age 3 requiring antibiotics, with no other significant illnesses or hospitalisations reported. Immunisations are up to date. EARLY DEVELOPMENTAL HISTORY Early developmental milestones were met within typical ranges. He sat independently at 6 months, walked at 13 months, and spoke his first words around 15 months. Parents recall him being a highly energetic and curious child from a young age, often described as 'always on the go'. No significant delays or events were noted during infancy or early childhood beyond typical toddler explorations. FAMILY AND SOCIAL HISTORY Patient lives with both biological parents and a younger sister, aged 6. The family environment is reported as supportive and stable. There is a family history of ADHD on the paternal side; his father was diagnosed with ADHD in adulthood. The patient attends a local primary school and participates in a weekly football club. MENTAL HEALTH AND WELLBEING Patient reports feeling frustrated sometimes when he can't focus but generally describes himself as happy. He expresses occasional sadness when he gets into trouble at school for not listening. Coping mechanisms include playing video games and spending time outdoors. No past mental health concerns have been formally diagnosed, though his parents note persistent challenges with attention and behavioural regulation since starting school. CURRENT DEVELOPMENT AS REPORTED BY PARENT/GUARDIAN Social Communication & Interaction Patient is generally friendly but often interrupts others during conversations and struggles with turn-taking. He can maintain eye contact but sometimes appears to be 'tuning out' when spoken to directly. He expresses himself clearly but sometimes rushes his words. Friendships & Relationships Patient has a few close friends at school but often has minor conflicts due to his impulsivity, such as blurting out answers or not waiting his turn in games. His parents report that while he desires friendships, his behaviour sometimes makes it difficult to maintain them without intervention. Restricted & Repetitive Behaviours and Interests/Activities No significant restricted or repetitive behaviours were reported. He enjoys a variety of activities, including sports, building with LEGOs, and reading adventure books. He can hyperfocus on activities he enjoys, often for extended periods. Emotional & Behavioural Regulation Patient has a low frustration tolerance and can exhibit emotional outbursts when things don't go his way, particularly regarding homework or when asked to transition between activities. He can be moody if tired or overwhelmed, but these episodes are usually short-lived. He struggles with self-regulating his impulses, often acting before thinking. Attention Parents consistently report significant difficulties with sustained attention, particularly for non-preferred tasks like schoolwork. He is easily distracted by external stimuli and frequently loses focus during conversations or instructions. He often misplaces items and struggles to follow multi-step directions without constant reminders. Self-Care & Independence Patient is largely independent in self-care activities such as dressing, bathing, and eating. He requires frequent prompts for hygiene routines like brushing teeth and tidying his room. He can manage simple daily tasks but often forgets chores or needs reminders to complete them.