ADHD Child Assessment Report

Psychiatrist: ADHD Child Assessment Report Introduction: I met with patient, Master Alex Turner, a 7-year-old male, for an ADHD assessment on 1 November 2024, via video call, through the 'MindWell Paediatric Psychiatry' service. The assessment was conducted with his mother, Mrs. Sarah Turner, present. Reason for Assessment Master Turner was referred for assessment due to concerns from his primary school regarding difficulties with attention, hyperactivity, and impulsivity in the classroom, impacting his learning and social interactions. His mother also reported similar behaviours at home, noting challenges with completing tasks and following instructions. History of Presenting Complaint Symptoms of inattention and hyperactivity were first noticed by Mrs. Turner when Alex was approximately 3 years old, primarily manifesting as extreme difficulty staying seated during mealtimes and an inability to focus on age-appropriate tasks like story time for more than a few minutes. These behaviours became more pronounced upon starting school, with teachers reporting issues with his concentration during lessons and frequent disruptions due to excessive movement. Over the past year, the difficulties have escalated, leading to academic struggles and peer conflicts. Main Presenting Concerns At home, Mrs. Turner reports that Alex frequently forgets instructions, struggles to complete chores, and has difficulty focusing on homework. He often misplaces personal items such as school books and toys. In the educational environment, teachers report that he is easily distracted, fidgets constantly, and struggles to remain seated during lessons. He often calls out answers without waiting for his turn and interrupts other children during activities. Socially, he finds it challenging to maintain friendships due to his impulsivity and occasional aggressive outbursts when frustrated. Emotionally, he can become easily frustrated and has low tolerance for boredom. Developmental History Mrs. Turner reported a full-term pregnancy with no reported complications. Delivery was vaginal and uncomplicated. Alex met all major developmental milestones within the typical range. He walked at 13 months, spoke his first words at 15 months, and was forming sentences by 2.5 years. No significant delays in motor or speech development were noted. As an infant, he was described as a 'busy baby' who required constant stimulation and had a shorter sleep duration compared to his peers. Peer relationships have always been challenging, with Alex often dominating play and struggling with turn-taking, leading to frequent arguments with other children. His language development was initially normal, but he often speaks rapidly and sometimes struggles to articulate his thoughts clearly when excited. He tends to prefer solitary play or directing others in play, struggling with reciprocal social engagement. He exhibits mild sensory-seeking behaviours, particularly enjoying loud noises and rough-and-tumble play. His play behaviours are often imaginative but can be short-lived, with him flitting between activities rapidly. Past Psychiatric History There is no documented past psychiatric history or previous mental health diagnoses for Master Turner. He has not received any mental health treatments previously. Relevant Medical History Master Turner is not currently on any medication and has no diagnosed medical conditions. He has no known allergies. Family History There is a family history of ADHD on the paternal side, with his father, Mr. David Turner, having been diagnosed with ADHD in adulthood. His maternal uncle has a history of anxiety. There are no other significant family histories of psychiatric conditions. On his mother's side, there is a history of type 2 diabetes and hypertension, but no significant physical health conditions on his father's side. Living Situation Master Turner lives with both his parents, Mrs. Sarah Turner and Mr. David Turner, and his younger sister, Lily (aged 4), in a detached house in a suburban area. Family Information Alex grew up with both his biological parents. Mrs. Turner describes their relationship as generally stable, though she notes that his father's ADHD can sometimes lead to disorganisation within the household. He has a generally positive relationship with his younger sister, though sibling rivalry and occasional squabbles are present. Childhood Experiences Mrs. Turner denies any traumatic childhood experiences, difficult relationships with family, mistreatment, or abuse. Alex had a stable and supportive upbringing. School Experiences Alex attends St. Peter's Primary School. His teachers report that he is a bright child but struggles significantly with focus and organisation. He frequently gets out of his seat, calls out in class, and often loses track of what he is supposed to be doing. He has been involved in several minor altercations with peers due to his impulsivity but has not been a victim of bullying. His behaviour in the classroom is often disruptive, despite interventions such as preferential seating. Academic Achievement Alex's academic achievement is inconsistent. He performs well in subjects he finds engaging, such as art and physical education, but struggles in subjects requiring sustained attention and organisation, such as literacy and numeracy. His examination results are variable, often reflecting a lack of focus rather than a lack of understanding. He is currently working below age-expected levels in reading and writing. Mental State Examination During the video call, Alex presented as a well-nourished, appropriately dressed boy for his age. He appeared restless, frequently shifting in his seat and fiddling with objects on the desk. His speech was rapid and sometimes difficult to follow due to its speed. His affect was generally cheerful but occasionally irritable when asked to remain still. Thought process appeared tangential at times, with frequent digressions. No perceptual disturbances were noted. He was oriented to person, place, and time. His concentration was poor, often looking away from the screen and requiring redirection. His memory appeared intact. No suicidal ideation or self-harm thoughts were expressed or observed. Risk Assessment No immediate risks of harm to self or others were identified during the assessment. There are no current concerns regarding self-harm, suicidal ideation, or aggressive behaviour that poses a significant risk. The main risks identified relate to academic underachievement and potential social difficulties due to his presenting symptoms. Forensic History There is no documented forensic history. Drug and Alcohol Use There is no reported drug or alcohol use. Presentation When Seen Master Turner presented as an energetic and lively child who struggled significantly with sustained attention and impulse control throughout the assessment. He frequently interrupted his mother, spoke over her, and found it challenging to sit still for more than a few minutes. He was engaging when interested but quickly became distracted by other stimuli in the room. He often required prompting to stay on topic when responding to questions. Child Interview During the child interview, Alex was able to articulate some of his difficulties. He reported finding school 'boring' and said it was hard to 'stop wiggling'. He mentioned that he often forgets his homework and that his teacher sometimes gets cross with him for talking. He expressed a desire to have more friends but acknowledged that he sometimes gets into trouble for 'being too loud'. Related Observations During the assessment, Alex frequently stood up, walked off-screen, and returned. He played with a toy car throughout much of the interview, often revving it loudly. He made frequent eye contact when engaged but quickly lost focus and looked around the room. His mother often had to gently remind him to answer questions directly. Young Diva Questionnaire A1 Mrs. Turner reported that Alex often makes careless mistakes in schoolwork, such as missing parts of words or calculation errors, because he rushes through tasks. At home, he often spills things because he is not paying attention to what he is doing. A2 Mrs. Turner confirmed that Alex struggles significantly with sustaining attention in tasks. He cannot focus on a single activity for more than 10-15 minutes, even highly preferred ones like video games. During story time, he is often fidgeting or looking elsewhere, missing key parts of the story. A3 Mrs. Turner stated that Alex frequently appears not to listen when spoken to directly. She often has to repeat instructions multiple times. This was evident even in early childhood; for example, she would often have to call his name several times before he responded. A4 Mrs. Turner reported that Alex has significant difficulty following through on instructions and completing chores. He will often start a task, like tidying his room, but get sidetracked or simply forget to finish it. This has been a long-standing issue since he was old enough to be given simple responsibilities. A5 Mrs. Turner noted that Alex struggles immensely with organising tasks and activities. His school bag is often a mess, and he cannot plan his homework schedule. As a young child, he struggled to organise his toys into categories or follow a sequence of steps in games. A6 Mrs. Turner stated that Alex actively avoids or dislikes tasks requiring sustained mental effort, particularly homework. He will often procrastinate, complain of boredom, or find excuses to do something else when faced with such tasks, for instance, reading a book for school. A7 Mrs. Turner reported that Alex frequently loses things necessary for tasks or activities, such as his school jumper, pencils, or even his packed lunch. This has been a persistent problem since primary school, leading to frustration for both him and his parents. A8 Mrs. Turner confirmed that Alex is extremely easily distracted by extraneous stimuli. A slight noise from outside or a sibling walking into the room will immediately divert his attention from the task at hand, whether it's homework or a conversation. A9 Mrs. Turner reported that Alex is often forgetful in daily activities. He frequently forgets to bring home school notices, where he put his shoes, or what he was asked to do moments before. This has been a consistent pattern since early childhood. H/I 1 Mrs. Turner stated that Alex constantly fidgets with his hands and feet, tapping his foot or drumming his fingers. He also squirms in his seat during mealtimes and at school, making it difficult for him to remain still for extended periods. This behaviour has been present since he was a toddler. H/I 2 Mrs. Turner reported that Alex frequently leaves his seat in situations where he is expected to remain seated, such as during school lessons or family dinners. He will often wander around the room or stand up and look out the window. H/I 4 Mrs. Turner confirmed that Alex has difficulty engaging in leisure activities quietly. He tends to be loud and boisterous, even when playing independently. He will often hum loudly, sing, or make sound effects during quiet activities. H/I 5 Mrs. Turner described Alex as being 'always on the go' or acting 'as if driven by a motor'. He rarely sits still and is constantly moving, running, or climbing, even indoors. This has been a consistent trait since his early years. H/I 6 Mrs. Turner stated that Alex talks excessively, often speaking very quickly and jumping between topics without pausing. He can dominate conversations and struggles to allow others to speak. H/I 7 Mrs. Turner reported that Alex often blurts out answers in school before the question has been completed, or interrupts conversations at home. He struggles to wait for his turn to speak. H/I 8 Mrs. Turner confirmed that Alex has significant difficulty waiting his turn in games, queues, or conversations. He will often become impatient, frustrated, or try to go ahead of others. H/I 9 Mrs. Turner stated that Alex frequently interrupts and intrudes on others' conversations or activities. He will often jump into a game without being invited or take over someone else's task. Discussion Master Turner presents with significant difficulties consistent with symptoms of inattention, hyperactivity, and impulsivity. These symptoms are pervasive, impacting his functioning across home and school environments. His mother's reports and the information gathered from the assessment strongly suggest a chronic pattern of these behaviours since early childhood. The family history of ADHD in his father further supports a potential neurodevelopmental basis for his presentation. The Young Diva Questionnaire responses indicate a high number of criteria met for both inattentive and hyperactive-impulsive presentations. The impact on his academic achievement, social relationships, and daily functioning warrants further consideration for a diagnosis of ADHD. Care Plan The proposed care plan includes a comprehensive diagnostic formulation based on all gathered information. Recommendations will involve psychoeducation for Master Turner's parents and school regarding ADHD and its management strategies. Consideration will be given to a trial of medication in conjunction with behavioural interventions. A referral to the school's Special Educational Needs Coordinator (SENCo) will be made to explore classroom accommodations and support strategies. Regular follow-up appointments will be scheduled to monitor his progress, assess the effectiveness of interventions, and provide ongoing support to the family.