ADHD Basic Template

I was pleased to review Liam Tremblay with his mother, Sarah Tremblay, on 14/05/2024. He is a 9-year-old M referred because of ongoing concerns regarding inattention, hyperactivity, and declining academic performance.

Liam has a 3-year history of significant difficulty sustaining attention, frequent daydreaming, and physical restlessness. At home, he struggles to follow multi-step instructions, frequently loses personal items, and requires constant redirection to complete homework and daily routines. At school, his teacher notes he is easily distracted by extraneous stimuli, blurts out answers, and has difficulty remaining seated during classroom instruction. Behavioural strategies, including preferential seating at the front of the class, visual schedules, and chunking of assignments, have yielded minimal improvement. Recent baseline bloodwork showed normal CBC, ferritin (42 µg/L), and TSH (1.8 mIU/L).

School: Oakridge Public School

Grade: Grade 4

Evaluation Tools

Parent- and teacher-completed SNAP-IV rating scales demonstrate elevated scores in both inattention (Parent: 2.4/3, Teacher: 2.6/3) and hyperactivity/impulsivity (Parent: 2.1/3, Teacher: 2.2/3) domains, strongly supporting a diagnosis of ADHD, combined presentation. Oppositional Defiant Disorder (ODD) subset scores were within normal limits.

Liam reports that his brain feels "too fast" and admits he often misses instructions in class because he is looking out the window or thinking about video games.

Teacher comments on the Vanderbilt Assessment Scale highlight that Liam is a polite and well-intentioned boy whose executive dysfunction significantly impairs his ability to complete independent seatwork and group tasks on time.

There are secondary concerns regarding emerging low self-esteem and frustration related to his academic struggles compared to his peers.

Report cards indicate Liam is meeting expectations in Mathematics and Physical Education, but is approaching expectations in Language Arts due to incomplete written assignments and poor organizational skills. No Individual Education Plan (IEP) is currently in place.

Formal psychoeducational testing has not yet been completed; he is currently on the school board waitlist.

Screening for Concurrent Issues

Social

Social engagement is typical; he makes eye contact easily, reciprocates conversation, and shows appropriate non-verbal communication.

Sensory Processing and Regulation

Picky eater as a toddler, now eats a varied diet with no texture aversions.

No hypersensitivity or unusual responses to smells.

Covers ears occasionally during fire drills at school, otherwise tolerates ambient noise well.

Prefers tagless shirts and soft athletic pants, though able to wear regular clothes without meltdowns.

Normal response to touch; enjoys hugs from family.

Frequently fidgets with pencils, taps his feet, and chews on shirt collars when required to sit still.

Mild situational anxiety around timed school tests; no generalized worry, panic attacks, or separation anxiety.

Tics

Absent; no history of motor or vocal tics, and no stereotyped movements observed.

Sleep

Prolonged sleep latency (takes 60–90 minutes to fall asleep due to restlessness). Sleeps through the night once asleep, waking at 07:00 feeling rested. No snoring or apneic episodes.

Bowel and Bladder Issues

Daytime and nighttime continence achieved by age 3.5 years; no history of enuresis or encopresis. Regular daily soft bowel movements.

Approximately 2 hours per day on weekdays (video games and tablet) and up to 4 hours per day on weekends. Screens are turned off 1 hour prior to bedtime.

Hearing and Vision

Vision and hearing were tested within the past 6 months and were completely normal.

Generally cheerful, energetic, and affectionate, though easily frustrated when tasks require sustained mental effort.

Past Medical History

Spontaneous singleton conception; uncomplicated antenatal course with routine prenatal care.

No gestational exposures to alcohol, tobacco, recreational drugs, or prescription teratogens.

Born at 39+2 weeks via spontaneous vaginal delivery. Birth weight 3,450 g. APGARs 8 and 9. Discharged home at 36 hours of life with no neonatal intensive care unit (NICU) stay.

Early Developmental Milestones

First words at 12 months; 2-word phrases by 20 months. No speech therapy required.

Sat unsupported at 6 months; walked independently at 13 months.

Appropriate pincer grasp at 10 months; currently has messy handwriting but normal dexterity with buttons and zippers.

Shared attention and imaginative play developed appropriately in early childhood.

Overall developmental milestones were achieved on time across all domains.

Hospitalizations: None.

Surgeries: Bilateral myringotomy tube insertion at age 2 for recurrent acute otitis media.

Allergies: NKDA. No known food or environmental allergies.

Medications: Melatonin 3 mg PO QHS PRN for sleep onset.

Immunizations: Up to date per the Ontario publicly funded immunization schedule.

Family History

Mother is 38, healthy. Father is 40, diagnosed with hypertension.

Sister is 12, healthy and doing well academically.

Negative for congenital heart disease, arrhythmias, pacemaker requirement, or sudden unexplained cardiac death under age 50.

Father was diagnosed with ADHD in childhood; paternal uncle has generalized anxiety disorder.

Maternal grandmother has hypothyroidism and T2DM.

Social History

Lives in a detached home in Toronto with his mother, father, Sister, and a family dog. Safe and supportive home environment.

Mother is an elementary school teacher; father is an accountant.

Confidential SHADES interview not fully administered due to young age, though privately Liam confirmed he feels safe at home and school.

Creative, empathetic, excels at Lego building and soccer.

Cisgender male; uses he/him pronouns.

Not applicable/not discussed given age.

Has 3–4 close friends at school and participates in recreational soccer. Occasional minor conflicts with peers due to impulsivity during games, but generally well-liked.

No history of physical, emotional, or sexual trauma, or adverse childhood experiences (ACEs).

Denies experiencing or perpetrating bullying at school or online.

None. No second-hand smoke exposure in the home.

No history of restrictive eating, bingeing, or body image concerns.

Euthymic mood overall; no anhedonia, persistent sadness, or self-harm ideation.

Review of Systems

Negative for chest pain, palpitations, syncope, exercise intolerance, shortness of breath, headaches, seizures, abdominal pain, or recent weight loss.

Physical Examination

Well-nourished, well-developed boy appearing stated age, in NAD. Weight: 31.2 kg (55th percentile), Height: 134.5 cm (50th percentile), BP: 102/64 mmHg, HR: 82 bpm.

Friendly and cooperative, though noticeably fidgety in his chair, frequently spinning in the swivel stool and tapping his shoes during the interview.

HEENT: tympanic membranes pearly grey and intact bilaterally with normal light reflex, oropharynx clear and moist with no erythema, tonsils 1+ bilaterally without exudate, no cervical lymphadenopathy

Resp: Good air entry bilaterally, clear to auscultation, no wheezes or crackles.

CVS: Normal S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops. Femoral and peripheral pulses 2+ and symmetric.

Abdo: Soft, non-tender, non-distended, normal bowel sounds, no hepatosplenomegaly.

Neuro: Cranial nerves II–XII intact. Normal muscle bulk, tone, and power (5/5) throughout. Deep tendon reflexes 2+ and symmetric. Normal gait and coordination.

Skin: Warm and dry; no café-au-lait macules, ash-leaf spots, neurofibromas, or bruising.

MSK

Normal spine alignment, full range of motion in all joints, no dysmorphic features noted.

Assessment and Plan

Liam is a 9-year-old male presenting with classic symptoms of inattention, hyperactivity, and impulsivity across both home and school settings, meeting DSM-5-TR criteria for Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Presentation.

Symptoms are not better explained by a primary mood disorder, anxiety disorder, sleep disorder, or hearing/vision impairment. Autism Spectrum Disorder (ASD) is unlikely given his intact social reciprocity and communication skills. Specific Learning Disorder in written expression remains on the differential and warrants monitoring once ADHD symptoms are treated.

1. Pharmacotherapy: Discussed the risks, benefits, and side effects (decreased appetite, insomnia, headaches, stomach aches, mood changes, minor increases in HR/BP) of stimulant medications with his mother. We will initiate methylphenidate hydrochloride extended-release (Concerta®) 18 mg PO QAM.

2. Educational Support: Provided a letter for Oakridge Public School confirming the diagnosis and recommending formal classroom accommodations, including extended time on tests, chunking of assignments, reduced-distraction environment for assessments, and frequent movement breaks.

3. Behavioural Resources: Recommended parent management training resources, specifically the CADDRA toolkit and books by Dr. Russell Barkley.

4. Sleep Onset Insomnia: Likely secondary to ADHD and intrinsic circadian phase delay. Advised strict sleep hygiene, maintaining a consistent wake time, limiting evening screen time, and continuing melatonin 3 mg PO 30–60 minutes before bedtime as needed.

I will review Liam in clinic in 4 weeks to assess treatment efficacy, monitor weight and vital signs, and titrate methylphenidate as needed. Follow-up SNAP-IV forms were provided for his parents and teacher to complete prior to the next visit. His mother was advised to contact the clinic sooner if he develops any concerning side effects, chest pain, syncope, or significant mood changes.