Paediatric Review Letter

260329 Lucas Miller

cc: Dr Sarah Jenkins

Problem List

1. Attention-Deficit/Hyperactivity Disorder, Combined Presentation (DSM-5-TR F90.2)
2. Autism Spectrum Disorder, Level 2 (DSM-5-TR F84.0)
3. Functional constipation (ICD-10 K59.0)

Medications

1. lisdexamfetamine (Vyvanse®) 30 mg PO mane
2. melatonin (Circadin®) 2 mg PO nocte
3. macrogol 3350 (Movicol®) 1 sachet PO daily

Ceased Medications

• methylphenidate (Ritalin®) ceased due to severe emotional rebound in the afternoons.

Support Team

• Chloe Davis, Occupational Therapist at Adelaide Paediatrics Allied Health, fortnightly sessions.
• Mark Stevens, Speech Pathologist at TalkTime Speech Pathology, fortnightly sessions.

Parents

• Emma and David (separated; week-on/week-off shared care arrangement).

School: Norwood Primary School

Grade: Year 3, 2026

Teacher: Mrs Clare Thompson

I had the pleasure of reviewing Lucas who is now 8 years and 4 months on the 29/03/2026. They attended with Emma who is their mother. The appointment was in clinic rooms.

School Progress

Emma reported that Lucas has settled well into Year 3 with Mrs Thompson. According to Emma, the morning dose of lisdexamfetamine is effective in maintaining his focus until approximately 14:00, after which he becomes increasingly distractible and restless. Lucas receives 5 hours of School Services Officer (SSO) support per week for literacy tasks and uses a sensory break card to manage classroom overwhelm. There have been no recent behavioural suspensions, though Emma noted he still struggles with peer transitions after lunch.

Home Progress

Emma described the home environment as generally calm during the morning routine, but noted significant challenges in the late afternoon with homework refusal and verbal aggression towards his younger sister. Lucas stated that he gets angry when asked to turn off his tablet before dinner. Emma expressed feeling moderately stressed navigating the week-on/week-off transitions with his father, David, noting that Lucas displays heightened separation anxiety on handover days. There is no reported history of exposure to domestic violence or other adverse childhood experiences.

Allied Therapies and External Supports

Lucas continues to engage well with his NDIS-funded therapy team. He attends fortnightly occupational therapy with Chloe Davis at Adelaide Paediatrics Allied Health, focusing on emotional regulation strategies and interoception awareness. He also sees Mark Stevens at TalkTime Speech Pathology on a fortnightly basis to work on pragmatic language skills and navigating social conflicts in the schoolyard.

Mental Health

Lucas presented with a bright and reactive affect in the clinic, stating that he generally feels happy when playing Lego or Minecraft. Emma reported that while his baseline mood is stable, he experiences brief episodes of situational anxiety when routine changes occur unexpectedly, though he shows no signs of persistent low mood or self-harm ideation.

Sleep

Emma reported that Lucas takes melatonin at 19:30 and consistently falls asleep by 20:15 without significant bedtime resistance. Lucas stated that he sleeps through the night in his own bed, waking refreshed at approximately 06:30 each morning.

Diet

Emma stated that Lucas remains a selective eater with a strong preference for beige, crunchy foods, though he reliably consumes protein at breakfast and dinner. His overall weight trajectory has remained stable on the 25th centile over the past six months.

Toileting

Emma reported that Lucas passes a soft, type 4 stool every second day without pain or straining since establishing a regular bowel regimen. He takes macrogol 3350 (Movicol®) 1 sachet PO daily mixed in juice, which Emma noted he adheres to well on her care weeks. Lucas experiences no day or night wetting.

Side Effects of Medications

Emma noted that Lucas experiences mild midday appetite suppression from his stimulant medication, often leaving his school lunchbox half-eaten, though he compensates with a large afternoon snack. Lucas denied experiencing any headaches, abdominal pain, dizziness, or tics.

Examination

Weight – 25.4 kg

Height – 128.5 cm

BMI – 15.4 kg/m2

BP – 98/62 mmHg

Lucas was cooperative and engaged throughout the physical examination, conversing animatedly about his favourite video games. Heart sounds dual with no murmur, chest clear. Abdomen was soft and non-tender with no palpable faecal loading. Neurological tone, power, and coordination were normal.

Summary

Lucas is an 8-year-old boy with ADHD, ASD Level 2, and functional constipation who is making steady progress at school and in allied therapies. His morning symptom control is good on lisdexamfetamine 30 mg, though he experiences some wear-off in the late afternoon contributing to homework difficulties and emotional dysregulation at home. His sleep and bowel habits are well managed on his current regimen, and his growth parameters remain completely satisfactory.

Plan

• Continue lisdexamfetamine (Vyvanse®) 30 mg PO mane, melatonin (Circadin®) 2 mg PO nocte, and macrogol 3350 (Movicol®) 1 sachet PO daily.
• Trial guanfacine (Intuniv®) 1 mg PO nocte to assist with late afternoon stimulant wear-off, emotional regulation, and evening hyperactivity.
• Provided scripts for current regular medications and the new guanfacine trial.
• Emma to monitor BP at the local pharmacy in 2 weeks following guanfacine commencement.
• Continue fortnightly occupational therapy and speech pathology sessions as per current NDIS goals.
• Review in clinic in 3 months to assess response to guanfacine and monitor growth parameters.