adhd
Doctor Information
Justin Greaves, age 10
PMH
chest infection 2011
nocturnal enuresis resolved age 7
No regular medication or known allergies
PMH
chest infection 2011
nocturnal enuresis resolved age 7
No regular medication or known allergies
Patient Information
Justin Greaves age 10
You are Kate Greaves, Justin's mother
History. you are worried about Justin. He has been suspended from school again because he threw a chair at the wall and it smashed. He is always doing things like this - running around breaking things, you are just so fed up.
It started when he was a toddler, he had so much energy he would never sit still. He has never slept through the night, he just gets up and wanders around, or plays on his nintendo. Even that he cant play for more than about twenty minutes, then he gets bored and does something else. He has never sat down to do his homework and you have had to bribe him, punish him, scold him. It seems he cant concentrate for long periods. School is a nightmare, his teachers say he is way below average because he is always distracted. He stands up during lessons, talks all the time, sometimes he even walks out of the classroom. He was suspended three months ago for swearing at his teacher and running out of the school in the morning. They called you in and told you to get help. He already has extra sessions one to one at school through his SEN (statement of educational needs) that was put in place last year. He doesn't really have any friends at school but equally he doesn't seem bothered by this.
Justin has two younger brothers age 7 and 2, both of whom are fine, but the little one Archie is starting to copy Justin in his ways. Your partner Ian now lives at home again, but the social worker Margaret still has to come once a week. Ian used to hit you in front of the kids so for a while he wasnt allowed to see them, then he had supervised visits, but now things are back to normal. He treats you much better and you are much happier with your relationship. He works as a builder and you as a cleaner.
Justin was a normal delivery at full term. He has not really had any problems except for one bad chest infection and the fact that he wet the bed at night until he was 7. He does not take any tablets and has no allergies. He is fully immunised.
Ideas: you are pretty sure he has ADHD, as he is just like your friend's daughter who has that
Concerns: you have just got your family back in the same house and the last thing you want is for Justin to be taken away if people think you are just a bad mother.
Expectations: cant you give him a sedative to make him calm down?
If you are offered tablets of any sort you will take them. If you are offered a referral, again you will be quite happy to see a specialist, although you have seen someone from CAMHS last year and they weren't very nice to you.
You are Kate Greaves, Justin's mother
History. you are worried about Justin. He has been suspended from school again because he threw a chair at the wall and it smashed. He is always doing things like this - running around breaking things, you are just so fed up.
It started when he was a toddler, he had so much energy he would never sit still. He has never slept through the night, he just gets up and wanders around, or plays on his nintendo. Even that he cant play for more than about twenty minutes, then he gets bored and does something else. He has never sat down to do his homework and you have had to bribe him, punish him, scold him. It seems he cant concentrate for long periods. School is a nightmare, his teachers say he is way below average because he is always distracted. He stands up during lessons, talks all the time, sometimes he even walks out of the classroom. He was suspended three months ago for swearing at his teacher and running out of the school in the morning. They called you in and told you to get help. He already has extra sessions one to one at school through his SEN (statement of educational needs) that was put in place last year. He doesn't really have any friends at school but equally he doesn't seem bothered by this.
Justin has two younger brothers age 7 and 2, both of whom are fine, but the little one Archie is starting to copy Justin in his ways. Your partner Ian now lives at home again, but the social worker Margaret still has to come once a week. Ian used to hit you in front of the kids so for a while he wasnt allowed to see them, then he had supervised visits, but now things are back to normal. He treats you much better and you are much happier with your relationship. He works as a builder and you as a cleaner.
Justin was a normal delivery at full term. He has not really had any problems except for one bad chest infection and the fact that he wet the bed at night until he was 7. He does not take any tablets and has no allergies. He is fully immunised.
Ideas: you are pretty sure he has ADHD, as he is just like your friend's daughter who has that
Concerns: you have just got your family back in the same house and the last thing you want is for Justin to be taken away if people think you are just a bad mother.
Expectations: cant you give him a sedative to make him calm down?
If you are offered tablets of any sort you will take them. If you are offered a referral, again you will be quite happy to see a specialist, although you have seen someone from CAMHS last year and they weren't very nice to you.
Examination Findings
Throughout the consultation, Justin is walking around the room, opening drawers and picking things up, including your medical equipment. When you ask him to come and sit down, he ignores you, then stands on the examination couch. He will not let you perform any examination on him, and does not listen to his mother when he tells him off. He finally sits down, but swings his legs and fidgets with his hands.
Mark scheme
Data Gathering
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POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Uses an incremental approach using time and accepting uncertainty |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them |
Clinical Management Skills
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POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriately Follow-up arrangements and safety netting are adequate |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Unable to construct a problem list and prioritise Unable to enhance patient’s health perceptions and coping strategies |
Inter Personal Skills
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POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Inappropriately influences patient interaction through own views/values Quick to judge |
Management
Explanation: ADHD is a condition that commonly affects children, in particular their behaviour. We don't know the exact cause, but the main symptoms are difficulty concentrating, and being generally restless and impulsive. The symptoms are there in different settings, for example at home and school. There is no simple test to diagnose ADHD, but a series of assessments made by a children's specialist. The treatment is often a mixture of behavioural therapy, family therapy, and sometimes medication.
These children can be quite difficult to assess, and a good history initially is the key. You need to establish a few things to suspect the diagnosis: the child should have symptoms that started before the age of 12, in more than one setting, and affect their ability to function socially and academically. Assess for inattention - is with everything or do they mainly struggle focussing with academic aspects - e.g. it there when they are watching TV or playing on their xbox (to tell the difference between a child that is simply naughty); are they hyperactive - more than just a lot of energy, constant fidgeting, tapping, or any other movements; are they impulsive - sudden hasty actions done without really thinking.
If you suspect ADHD, the child should ideally have an assessment from CAMHS or a community paediatrician - check your local services for whom to refer to. The management consists of advice and support, along with parenting programmes and behavioural therapy for the child. Any relevant medication, such as atomoxetine and melatonin, should be started by a specialist but continued in primary care. In most areas there is a shared care policy, whereby monitoring can be done in primary care (blood pressure, height and weight) on a 6 monthly basis.
If there is mention of dietary involvement, the evidence is limited. Generally speaking you should not encourage any dietary modifications, unless behaviour is consistently affected by a particular food.
These children can be quite difficult to assess, and a good history initially is the key. You need to establish a few things to suspect the diagnosis: the child should have symptoms that started before the age of 12, in more than one setting, and affect their ability to function socially and academically. Assess for inattention - is with everything or do they mainly struggle focussing with academic aspects - e.g. it there when they are watching TV or playing on their xbox (to tell the difference between a child that is simply naughty); are they hyperactive - more than just a lot of energy, constant fidgeting, tapping, or any other movements; are they impulsive - sudden hasty actions done without really thinking.
If you suspect ADHD, the child should ideally have an assessment from CAMHS or a community paediatrician - check your local services for whom to refer to. The management consists of advice and support, along with parenting programmes and behavioural therapy for the child. Any relevant medication, such as atomoxetine and melatonin, should be started by a specialist but continued in primary care. In most areas there is a shared care policy, whereby monitoring can be done in primary care (blood pressure, height and weight) on a 6 monthly basis.
If there is mention of dietary involvement, the evidence is limited. Generally speaking you should not encourage any dietary modifications, unless behaviour is consistently affected by a particular food.