ADHD Assessment

MSE: - Behaviour: The patient appeared restless and frequently shifted in their seat during the session. They also interrupted the psychologist multiple times. - Mood: The patient reported feeling frustrated and overwhelmed. The psychologist observed signs of irritability. - Thoughts: The patient's thoughts were coherent and oriented to time and place. - Cognition: No concerns reported or observed. Observations: - The patient frequently tapped their foot and seemed distracted by noises outside the room. Reason for assessment: - The patient was referred for an ADHD assessment due to ongoing difficulties with attention and impulsivity impacting their academic performance. Background: - Family members: Lives with both parents and a younger sibling. - Family history: The patient's father has a history of ADHD. - School and Year level: Attends Greenfield High School, currently in Year 9. - Pregnancy and Birth History: No significant concerns reported. - Childhood History: Experienced frequent ear infections as a child. A) Inattention 1) Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities - The patient often makes careless mistakes in math assignments. 2) Often has difficulty sustaining attention in tasks or play activities - The patient struggles to maintain focus during class lectures. 3) Often does not seem to listen when spoken to directly - The patient frequently needs instructions repeated. 4) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace - The patient often leaves homework incomplete. 5) Often has difficulty organizing tasks and activities - The patient struggles with organizing their school backpack. 6) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort - The patient avoids reading assignments. 7) Often loses things necessary for tasks or activities - The patient frequently misplaces school supplies. 8) Is often easily distracted by extraneous stimuli - The patient is easily distracted by classroom noises. 9) Is often forgetful in daily activities - The patient often forgets to bring necessary materials to class. B) Hyperactivity and Impulsivity 1) Often fidgets with or taps hands or feet or squirms in seat - The patient frequently taps their foot during class. 2) Often leaves seat in situations when remaining seated is expected - The patient often gets up during class without permission. 3) Often runs about or climbs in situations where it is inappropriate - Not observed. 4) Often unable to play or engage in leisure activities quietly - The patient is loud during group activities. 5) Is often “on the go,” acting as if “driven by a motor” - The patient is described as always being on the move by teachers. 6) Often talks excessively - The patient talks excessively during class. 7) Often blurts out an answer before a question has been completed - The patient frequently interrupts the teacher with answers. 8) Often has difficulty waiting his or her turn - The patient struggles to wait their turn in games. 9) Often interrupts or intrudes on others - The patient often interrupts peers during conversations. Symptoms interfere with or reduce the quality of: - Social Functioning: The patient has difficulty maintaining friendships due to impulsive behavior. - Academic Functioning: The patient's grades are affected by inattention and incomplete assignments. - Occupational Functioning: Not applicable. - Home Functioning: The patient often argues with family members due to impulsivity.