CASE INFORMATION

Case ID: CCE-2025-010
Case Name: Daniel Carter
Age: 10 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: P20 (Attention Deficit Hyperactivity Disorder), P22 (Child Behaviour Problem)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the parent and child to understand their concerns and expectations. 1.2 Develops a respectful and empathetic doctor-patient relationship. 1.4 Provides appropriate patient-centred explanations.
2. Clinical Information Gathering and Interpretation	2.1 Gathers relevant history, including developmental, behavioural, and educational concerns. 2.2 Selects and interprets appropriate screening tools and assessments.
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis based on clinical findings. 3.5 Identifies red flag symptoms requiring specialist referral.
4. Clinical Management and Therapeutic Reasoning	4.1 Formulates a safe and evidence-based management plan. 4.3 Provides appropriate follow-up and monitoring.
5. Preventive and Population Health	5.2 Addresses modifiable risk factors for learning and behavioural difficulties.
6. Professionalism	6.1 Maintains patient confidentiality and professional integrity.
7. General Practice Systems and Regulatory Requirements	7.1 Orders appropriate assessments and referrals in accordance with MBS guidelines.
9. Managing Uncertainty	9.2 Develops a plan for a patient with an unclear diagnosis.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and acts on neurodevelopmental and behavioural conditions.

CASE FEATURES

10-year-old boy presenting with difficulties with attention, hyperactivity, and impulsivity at home and school.
Parent reports concerns from the teacher about inattention in class, trouble completing tasks, and frequent disruptive behaviour.
Struggles with following instructions, staying seated, and waiting his turn.
At home, forgets homework, loses items, and has trouble finishing chores.
No known significant medical history, seizures, or developmental delays.
Parent is worried about ADHD and whether medication is needed.
Requires clinical reasoning to differentiate between ADHD, anxiety, learning difficulties, and other behavioural concerns.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform a physical examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history.
Discuss your differential diagnosis with the parent.
Explain the assessments and referrals you will request and why.
Provide an initial management plan and follow-up advice.

SCENARIO

Daniel Carter, a 10-year-old boy, is brought in by his mother due to concerns about attention difficulties and disruptive behaviour at school. His teacher has reported that he struggles to stay on task, frequently interrupts, and finds it difficult to complete classwork.

At home, Daniel is described as forgetful, loses things often, and struggles to finish homework and chores. He is always on the move, fidgeting, and talks excessively.

His mother is worried that he might have ADHD and asks whether he needs medication or behavioural therapy.

PATIENT RECORD SUMMARY

Patient Details

Name: Daniel Carter
Age: 10 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

No history of seizures, head injuries, or significant developmental delays.
No previous behavioural or learning assessments.

Social History

Lives with both parents and a younger sister (6 years old).

Family History

No known family history of ADHD, autism, or psychiatric disorders.

Vaccination and Preventative Activities

Up to date with vaccinations.

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, I’m really worried about Daniel. His teacher keeps saying he’s not concentrating in class, and at home, he’s always distracted and forgetful. Do you think he has ADHD?”

General Information

(Freely Shared if Asked Open-Ended Questions)

Daniel is a 10-year-old boy in Year 5 who has been struggling to concentrate in class for the past year.
His teacher has raised concerns about his ability to stay on task, follow instructions, and complete his work.
At home, you have noticed he forgets to do chores, loses things often, and struggles to finish homework.
He is always on the move, fidgeting, and seems restless, even when watching TV or eating dinner.

Specific Information

(Only Revealed if the Candidate Asks Targeted Questions)

Background Information

He often interrupts conversations, blurts out answers before a question is finished, and struggles to wait his turn in games.
He is friendly and social, but sometimes frustrates his classmates by being too impatient or excitable.
You have been getting frequent notes home from the teacher about his behaviour in class.
He isn’t falling behind academically, but the teacher worries he could struggle more as schoolwork gets harder.
There are no concerns about his vision or hearing.

Behaviour at Home

You first noticed these behaviours when he was around 5 years old, but they’ve become more problematic as schoolwork has become harder.
He often starts activities but doesn’t finish them.
You have to remind him repeatedly to do simple tasks, such as brushing his teeth or putting his school bag away.
He struggles with time management, frequently running late or getting distracted while getting ready.
He forgets instructions easily, even if you tell him something just a few minutes earlier.

School Performance

His teacher describes him as bright but easily distracted.
He enjoys creative activities and hands-on learning but struggles to focus on longer tasks like reading or writing essays.
He rushes through his work, often making careless mistakes.
He gets out of his seat frequently and struggles to wait his turn in group activities.
He sometimes gets frustrated when he doesn’t understand something quickly.

Sleep, Diet, and Routine

He sleeps around 9-10 hours a night, but you often have to tell him to go to bed multiple times before he actually settles down.
He doesn’t seem excessively tired during the day.
He eats well and doesn’t seem to have any major dietary issues.
No significant screen time overuse, but he does struggle to transition away from games or TV when asked.

Family and Social History

He has no history of major illnesses, seizures, or head trauma.
There is no family history of ADHD, autism, or learning difficulties.
No recent major stressors at home (e.g., divorce, trauma, or loss of a loved one).

Emotional Cues & Concerns

You feel frustrated and exhausted because managing Daniel’s behaviour at home is becoming difficult.
You are worried about how this will affect his future—whether he will struggle in school, make friends, or need medication.
You have read about ADHD online and want to know if Daniel needs an assessment or medication.
You wonder if he will grow out of this or if it will affect him long-term.
You want practical strategies to help him concentrate and manage his behaviour.

Questions for the Candidate

(Drop these in naturally throughout the consultation)

“Do you think Daniel has ADHD? How do you diagnose it?”
“What tests or assessments does he need?”
“Does this mean he’ll struggle in school or need special education?”
“Will he need medication? Are there other treatment options?”
“What can I do at home to help him?”
“Will he grow out of this, or will it affect him as an adult?”

How to Respond Based on the Candidate’s Answers

If the Candidate Provides a Clear Explanation and Plan:

You feel somewhat reassured but still concerned.
You may ask for clarification on the next steps:
- “So, we need to get the school’s input and do some tests before we know for sure?”
- “How long does the diagnosis process take?”
You agree to the suggested assessments and follow-up plan.

If the Candidate is Unclear or Dismissive:

You become more anxious and insistent on immediate answers.
You might push for an urgent diagnosis or specialist referral:
- “I don’t want to wait too long. Can’t we just get him tested straight away?”
- “What if this is something serious and we’re missing it?”

Ending the Consultation

If the Candidate Has Done Well:

You feel more reassured and are willing to follow the plan.
You might still confirm:
- “So, I’ll need to get some feedback from his teacher before we go further?”
- “What can I do in the meantime to help him at home?”
You thank the doctor and leave with a clear plan.

If the Candidate Has Not Addressed Your Concerns Well:

You remain doubtful and uneasy.
You may say:
- “I think I might get a second opinion. I just want to be sure.”
- “I still don’t know if this is serious or not.”
You leave feeling frustrated and uncertain about your next steps.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including developmental and behavioural concerns.

The competent candidate should:

Use open-ended questions to gather information from the parent about concerns with attention, hyperactivity, and impulsivity.
Establish onset, duration, and severity of symptoms, identifying whether they have been present since early childhood and occur in multiple settings (home, school, social interactions).
Assess impact on school performance, including ability to follow instructions, complete tasks, and interact with peers.
Identify associated behaviours, such as emotional dysregulation, aggression, sleep disturbances, or anxiety symptoms.
Ask about developmental history, including speech, motor milestones, and early childhood behaviour.
Assess for family history of ADHD, learning difficulties, or mental health conditions.
Explore psychosocial factors, including home environment, parenting strategies, and any major life stressors (e.g., divorce, trauma, bullying).
Address parental concerns about diagnosis, medication, and future implications.

Task 2: Discuss your differential diagnosis with the parent.

The competent candidate should:

Explain that attention and behavioural difficulties can have multiple causes, and a comprehensive assessment is needed.
Discuss most likely differentials:
- ADHD: Core symptoms of inattention, hyperactivity, and impulsivity affecting multiple settings.
- Learning disorders (e.g., dyslexia): May cause inattention due to difficulty with academic tasks.
- Anxiety disorders: Can present as restlessness, inattention, and avoidance of tasks.
- Autism Spectrum Disorder (ASD): May present with social difficulties and rigidity rather than hyperactivity.
- Sleep disorders (e.g., obstructive sleep apnoea): Can cause daytime inattentiveness and hyperactivity.
Address the parent’s concerns about ADHD, explaining that a diagnosis is not based on a single test but a combination of clinical assessment, teacher input, and validated questionnaires.

Task 3: Explain the assessments and referrals you will request and why.

The competent candidate should:

Justify initial assessments, including:
- ADHD-specific screening tools (Conners Rating Scale, Vanderbilt Assessment Scale)—completed by parents and teachers.
- Observation reports from school to confirm symptoms occur in multiple settings.
- Hearing and vision screening to exclude sensory deficits.
- Full developmental and family history to identify contributing factors.
- Consider referral to a paediatrician or child psychologist for formal assessment.
Explain that diagnosis requires persistent symptoms impacting daily functioning for ≥6 months.
Provide clear timeframes for assessment completion and follow-up.

Task 4: Provide an initial management plan and follow-up advice.

The competent candidate should:

Develop a management plan tailored to the child’s needs:
- Behavioural interventions: Parent education on positive reinforcement, structured routines, and school accommodations.
- School support: Arrange a meeting with teachers to discuss classroom strategies.
- Non-medication strategies: Sleep hygiene, physical activity, and mindfulness techniques.
- Medication options (if appropriate): Discuss potential benefits and side effects of stimulant and non-stimulant medications, if indicated after formal assessment.
Address parental concerns about long-term outcomes, academic performance, and social development.
Provide safety-netting advice, advising review for worsening symptoms, emotional difficulties, or concerns about medication effects.
Arrange a follow-up appointment to review assessment results and discuss next steps.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, covering attention, impulsivity, developmental milestones, and psychosocial factors.
Provides a clear differential diagnosis, considering ADHD, learning disorders, anxiety, ASD, and sleep issues.
Orders appropriate assessments, including teacher reports, screening tools, and medical evaluations.
Develops a safe, patient-centred management plan, including behavioural interventions, school support, and possible medication options.
Uses empathetic and reassuring communication, addressing the parent’s concerns about ADHD, diagnosis, and treatment options.

PITFALLS

Failure to confirm symptoms occur in multiple settings, leading to misdiagnosis.
Over-reliance on parental reports without school input, missing teacher observations of behaviour.
Not considering alternative causes (e.g., anxiety, learning disorders, sensory deficits).
Delaying referral for specialist assessment, missing an opportunity for early intervention.
Lack of clear safety-netting, leaving parents unsure of when to seek further support.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the parent and child to gather information about their symptoms, ideas, concerns, expectations of healthcare, and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets relevant history, including behavioural and developmental concerns.
2.2 Selects and justifies appropriate assessments.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms a logical differential diagnosis based on history and findings.
3.5 Identifies red flag symptoms requiring specialist referral.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based, patient-centred management plan.
4.3 Provides structured follow-up and safety-netting.

5. Preventive and Population Health

5.2 Addresses modifiable risk factors for learning and behavioural difficulties.

6. Professionalism

6.1 Maintains confidentiality and professional integrity.

7. General Practice Systems and Regulatory Requirements

7.1 Orders appropriate assessments and referrals in accordance with MBS guidelines.

9. Managing Uncertainty

9.2 Develops a structured approach to a patient with an unclear diagnosis.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and acts on neurodevelopmental and behavioural conditions.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD