CCE-CBD-198

CASE INFORMATION

Case ID: CCE-2025-15
Case Name: Ethan Reynolds
Age: 9 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: P20 (Attention Deficit Hyperactivity Disorder)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the parents and child to gather information about symptoms, concerns, and expectations. 1.2 Uses effective communication to explain ADHD in a clear and supportive manner.
2. Clinical Information Gathering and Interpretation2.1 Obtains a thorough history relevant to ADHD, including school and home behaviour. 2.2 Identifies red flag symptoms requiring further assessment (e.g., autism, anxiety, learning difficulties).
3. Diagnosis, Decision-Making and Reasoning3.1 Differentiates ADHD from other developmental, behavioural, or psychological conditions.
4. Clinical Management and Therapeutic Reasoning4.1 Provides appropriate initial management, including behavioural interventions. 4.2 Recognises when medication or specialist referral is required.
5. Preventive and Population Health5.1 Provides education on parenting strategies, school support, and lifestyle modifications.
6. Professionalism6.1 Maintains a supportive and non-judgmental approach when discussing ADHD with the family.
7. General Practice Systems and Regulatory Requirements7.1 Orders appropriate assessments (Conners scale, teacher and parent reports) and refers when necessary.
8. Procedural Skills8.1 Recognises indications for stimulant medication and the need for ongoing monitoring.
9. Managing Uncertainty9.1 Develops a safety-netting plan for children with behavioural and learning difficulties.
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises comorbidities such as anxiety, oppositional defiant disorder (ODD), or learning disabilities requiring additional support.

CASE FEATURES

  • 9-year-old boy brought in by his mother due to concerns about hyperactivity, impulsivity, and inattention at school and home.
  • Teacher reports difficulty staying seated, frequent interruptions, and poor focus.
  • No history of autism, seizures, or developmental delays.

CANDIDATE INFORMATION

INSTRUCTIONS

Review the following patient record summary and scenario.

Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.

The time allocation for each question is roughly as follows:

  • Question 1 – 3 minutes
  • Question 2 – 3 minutes
  • Question 3 – 3 minutes
  • Question 4 – 3 minutes
  • Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Ethan Reynolds
Age: 9 years
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known.

Medications

  • Nil regular medications.

Past History

  • No history of epilepsy, autism, or significant developmental delays.

Social History

  • Lives with mother and father, both working full-time.
  • Attends Year 4 at a local public school.
  • Difficulties with focus and behaviour reported by parents and teacher.

Family History

  • Father diagnosed with ADHD as an adult.
  • No history of autism or intellectual disabilities.

Vaccination and Preventative Activities

  • Up to date with routine vaccinations.

SCENARIO

Ethan Reynolds, a 9-year-old boy, is brought in by his mother due to concerns about persistent inattention, hyperactivity, and impulsivity affecting his school performance and behaviour at home.

His teacher reports that Ethan frequently interrupts, struggles to stay on task, and has difficulty sitting still in class. At home, his parents describe challenges with completing homework, following instructions, and emotional outbursts.

There is no history of developmental delays, seizures, or significant anxiety, but his father was diagnosed with ADHD as an adult.

EXAMINATION FINDINGS

  • General Appearance: Alert, cooperative but fidgety.
  • Developmental Assessment:
    • Age-appropriate language and social skills.
    • No speech delays or motor coordination concerns.
  • Neurological Examination:
    • Normal tone, reflexes, and coordination.
  • Behavioural Observations:
    • Frequently shifting in chair, easily distracted.
    • Difficulty waiting for turns during the consultation.

INVESTIGATION FINDINGS

  • Conners Parent and Teacher Rating Scales: Pending.
  • School report and behavioural assessment: Ordered.

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

  • Prompt: How do you differentiate ADHD from other behavioural or learning disorders?
  • Prompt: What key clinical features support a diagnosis of ADHD?

Q2. What are your initial management steps?

  • Prompt: What assessments are needed before confirming ADHD?
  • Prompt: When would you consider a paediatrician or psychologist referral?

Q3. How would you explain the diagnosis and treatment plan to the parents?

  • Prompt: How would you reassure them about ADHD management?
  • Prompt: What are the benefits and risks of medication vs behavioural therapy?

Q4. What non-pharmacological interventions can help manage Ethan’s symptoms?

  • Prompt: What role does school support and parenting strategies play?
  • Prompt: How does physical activity and sleep affect ADHD symptoms?

Q5. What are the red flags that would necessitate further assessment or specialist referral?

  • Prompt: What signs suggest comorbid conditions such as anxiety, autism, or learning disabilities?
  • Prompt: How would you manage treatment failure or worsening symptoms?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

ADHD is a neurodevelopmental disorder characterised by persistent inattention, hyperactivity, and impulsivity that affect daily functioning.

Differential Diagnoses:

  1. Attention-Deficit/Hyperactivity Disorder (Most Likely Diagnosis)
    • Key features: Hyperactivity, impulsivity, inattention present in multiple settings (home, school).
    • Onset before 12 years, symptoms persist for >6 months.
  2. Autism Spectrum Disorder (ASD)
    • Key features: Social communication difficulties, restricted interests, repetitive behaviours.
    • ADHD often coexists with ASD, requiring differentiation.
  3. Oppositional Defiant Disorder (ODD)
    • Key features: Persistent defiance, anger, argumentative behaviour rather than inattention.
  4. Anxiety Disorders
    • Key features: Restlessness, poor concentration due to anxiety rather than impulsivity.
  5. Learning Disorders (e.g., Dyslexia)
    • Key features: Academic difficulties, struggles with reading or maths.
    • ADHD may coexist, requiring separate assessment.

Most Likely Diagnosis:

  • ADHD, based on persistent inattention, hyperactivity, and impulsivity affecting school and home life.
  • Requires parent and teacher ADHD rating scales for confirmation.

Q2: What are your initial management steps?

Answer:

1. Confirm Diagnosis with Assessments

  • ADHD Rating Scales:
    • Conners Parent and Teacher Rating Scales.
    • Vanderbilt ADHD Diagnostic Scale.
  • School Reports: Teacher feedback on classroom behaviour.
  • Developmental History: Exclude other neurodevelopmental disorders.

2. Multimodal Management Plan

  • Behavioural Interventions:
    • Parenting programs (Triple P, 1-2-3 Magic).
    • School support (Individual Learning Plan, classroom accommodations).
  • Consider Medication (If Severe ADHD):
    • Stimulants (Methylphenidate, Dexamphetamine).
    • Non-stimulants (Atomoxetine) if stimulants are contraindicated.

3. Referral and Follow-Up

  • Paediatrician referral for medication initiation.
  • Psychologist referral if anxiety or ODD coexists.
  • Follow-up in 4 weeks to assess response.

Q3: How would you explain the diagnosis and treatment plan to the parents?

Answer:

Diagnosis Explanation:

  • “Ethan’s symptoms are consistent with ADHD, meaning he has difficulty focusing, managing impulses, and staying still.”
  • “This is not due to laziness or poor parenting—ADHD is a neurological condition.”

Treatment Plan:

  • “Behavioural strategies are first-line, including structured routines, positive reinforcement, and school adjustments.”
  • “If symptoms persist, medication may help improve focus and impulse control.“

Safety-Netting:

  • “If you notice worsening behaviour, aggression, or academic decline, return for review.”
  • “We will review Ethan’s progress in 4 weeks and adjust the plan as needed.”

Q4: What non-pharmacological interventions can help manage Ethan’s symptoms?

Answer:

  • Parenting Strategies:
    • Clear routines, structured schedules, visual cues.
    • Positive reinforcement rather than punishment.
  • School Accommodations:
    • Extra time on tasks, preferential seating, movement breaks.
    • Learning support programs.
  • Diet and Sleep:
    • Limit sugar, preservatives, artificial colourings (e.g., 102, 110).
    • Regular bedtime, screen-free evenings.
  • Exercise:
    • Physical activity improves concentration and impulse control.

Q5: What are the red flags that would necessitate further assessment or specialist referral?

Answer:

  • Comorbid mental health issues (anxiety, depression, self-harm).
  • Severe aggression, conduct disorder traits.
  • Significant academic failure despite interventions.
  • Concerns about autism spectrum disorder (ASD) or intellectual disability.

Referral Pathway:

  • Paediatrician for medication initiation.
  • Psychologist for behavioural therapy.
  • Occupational therapist if sensory issues coexist.

SUMMARY OF A COMPETENT ANSWER

  • Correctly differentiates ADHD from other behavioural disorders.
  • Orders ADHD rating scales, school reports for assessment.
  • Provides behavioural interventions as first-line management.
  • Considers stimulant medication if symptoms significantly impact function.
  • Identifies red flags requiring specialist referral.

PITFALLS

  • Failing to use validated ADHD rating scales.
  • Diagnosing ADHD without evidence from multiple settings.
  • Not considering comorbid conditions (ASD, anxiety, learning disorders).
  • Delaying referral for children with severe functional impairment.

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 parents and child to gather information about symptoms, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to ADHD, including school and home behaviour.
2.2 Identifies red flag symptoms requiring further assessment.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates ADHD from other developmental, behavioural, or psychological conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate initial management, including behavioural interventions.
4.2 Recognises when medication or specialist referral is required.

5. Preventive and Population Health

5.1 Provides education on parenting strategies, school support, and lifestyle modifications.

Competency at Fellowship Level

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