ADHD Assessment and Management Note

Date of Assessment or Review

14/05/2026 at 10:00 SAST – Initial Assessment.

Referral Reason and Informant Context

Learner: Sipho Dlamini (8 yo M, DOB: 12/03/2018, Practice ID: 884-219-ZA). Referred by the School-Based Support Team (SBST) at Boksburg Primary School due to severe academic underachievement in Grade 2 and disruptive classroom behaviour. Attended with mother (Nomsa Dlamini) and maternal grandmother (Gogo Thandi), who served as primary informants alongside written educator feedback.

Developmental and Behavioural History

Attended antenatal clinic at local MOU from 16 weeks; uncomplicated NVD at Tambo Memorial Hospital (birth weight 3.1 kg, Apgars 9/10). Motor and speech milestones WNL. High activity levels noted at local crèche. Significant transition difficulties noted in Grade R and Grade 1 (Foundation Phase), struggling to sit on the mat or await turn. Resides in a 4-room house in Vosloorus with mother, maternal grandmother, and two older siblings. Grandmother provides afternoon care while mother works shifts; father uninvolved.

Current Symptom Profile (Inattention/Hyperactivity)

• Inattention: Short attention span (< 5 mins on structured tasks), easily distracted by ambient classroom noise, frequently loses stationery, and avoids homework requiring sustained mental effort.
• Hyperactivity/Impulsivity: Constantly leaves seat in class, fidgets excessively, blurts out answers before questions are completed, and interrupts peers' games at home and church, leading to frequent peer rejection.

Functional Impacts

Failing to meet CAPS requirements for Grade 2 Home Language (isiZulu) and Mathematics due to incomplete classwork and poor executive functioning. Strained relationship with class educator; peers avoid him on the playground due to rough, impulsive play. Low frustration tolerance and emerging low self-esteem ("says he is stupid"). Maternal shift work and financial constraints limit capacity for 1-on-1 homework supervision and private remedial support.

Screening/Rating Tools Used

• Vanderbilt ADHD Diagnostic Parent and Teacher Rating Scales: Parent and Teacher forms both positive for ≥ 6/9 Inattentive and ≥ 7/9 Hyperactive/Impulsive criteria with significant functional impairment.
• Educator report and Support Needs Assessment (SNA 1 & 2) via the SBST.

Diagnosis and Rationale

Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Presentation (DSM-5-TR: F90.2). Symptoms are pervasive across home and school settings, persisted > 6 months, onset prior to age 7, and directly impair academic and social functioning. Differential diagnoses excluded: Specific Learning Disorder (difficulties secondary to task non-completion rather than comprehension deficit, though requires monitoring once attention stabilises), trauma/environmental stressors (safe, stable home environment despite financial constraints), and hearing/vision impairment (screened NAD at local clinic).

Management Plan

• Medical Referral: Referred to Paediatric Outpatient Department (POPD) at Tambo Memorial Hospital to evaluate for pharmacological initiation (e.g., methylphenidate (Ritalin®) 10 mg PO mane).
• Psychoeducation: Provided to mother and grandmother regarding ADHD neurobiology, externalising behaviours, and behavioural scaffolding (visual routines, chunking tasks, positive reinforcement).
• Caregiver Support: Referred to local NGO (FAMSA East Rand) for positive parenting skills group.
• School Liaison: Report forwarded to SBST to motivate for classroom accommodations (preferential seating near educator, movement breaks, reduced workload volume, extra time).
• Follow-up: Review in 6 weeks (25/06/2026 at 11:00) to monitor behavioural interventions and liaise post-POPD review.