ADHD Comprehensive Psychiatric Evaluation Example: Sarah Higgins, 11-Year-Old (Training Title 48), Differentials and Reflection

Comprehensive Psychiatric Evaluation: Sarah Higgins, 11-year-old female (Symptom Media Training Title 48)

HPI (video notes): The patient presents with a longstanding history of difficulty sustaining attention, distractibility, forgetfulness and hyperactive behaviors, as reported by her mother, present since kindergarten and persisting throughout her academic years. She has significant difficulty maintaining focus during classroom activities, is frequently distracted by environmental stimuli and shows limited eye contact, often looking around the room. Teachers provide written instructions and checklists, but she often misplaces them and forgets assignments or daily responsibilities. She has difficulty remaining seated and is restless in her chair. When reading independently, she sustains attention for about five minutes. Symptoms interfere with academic performance, organization and completion of school responsibilities.

Data: T 97.4, P 58, R 14, BP 98/62, Ht 4’5″, Wt 65 lb. No history of treatment; developmental milestones met on time; vaccinations up to date. Sleeps 9–10 hours/night; meals are difficult because she has a hard time sitting, but nutrition is adequate per PCP. Has a younger brother; lives with her parents in Washington, D.C. No history of head trauma.

Complete the Comprehensive Psychiatric Evaluation, including:

• Subjective: chief complaint and symptoms, duration and severity, impact on functioning.
• Objective: observations during the assessment.
• Assessment: mental status exam; at least three differential diagnoses in priority order, compared with DSM-5-TR criteria; critical-thinking process; pertinent positives and negatives.
• Reflection notes: what you would do differently; legal/ethical considerations beyond confidentiality and consent; health promotion and disease prevention considering patient factors, PMH and other risk factors.

Original example for study purposes.

Week 10: Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders
Student Name • College of Nursing-PMHNP • NRNP 6635 • Faculty Name • Due Date

Subjective

CC: Mother: “[Mother’s words from the video, e.g., She can’t focus in class and keeps losing her assignments.]”

HPI: Sarah Higgins is an 11-year-old female brought by her mother for evaluation of long-standing problems with attention, organization and hyperactivity. Per her mother, symptoms began in kindergarten and have persisted every school year, so the duration is about six years. At school, Sarah has trouble sustaining attention in class, is easily distracted by noises and activity in the room, loses the written instructions and checklists her teachers provide and forgets assignments and daily responsibilities. She has difficulty staying seated and fidgets in her chair. At home, she can read independently for only about five minutes before becoming distracted, and family meals are difficult because she cannot remain seated. Symptoms are moderate to severe in that they occur daily, across settings, and persist despite teacher accommodations. They impair her academic performance, organizational skills and completion of schoolwork. No current mood symptoms, excessive worry, aggression, tics, or suicidal or homicidal ideation are reported [confirm with video].

Past psychiatric history:

• General statement: no previous psychiatric evaluation or treatment.
• Caregivers: lives with both parents and younger brother; mother is the primary informant.
• Hospitalizations: none.
• Medication trials: none.
• Psychotherapy or previous diagnosis: none. Informal school supports (written instructions, checklists); no documented 504 plan or IEP [confirm].

Substance current use and history: denies alcohol, tobacco, vaping and drug use. Caffeine: [ask about soda and energy drinks]. Prenatal exposures: [ask mother].

Family psychiatric/substance use history: [not reported in the case; ask specifically about ADHD, learning disorders, anxiety, depression, bipolar disorder, tics, substance use and sudden cardiac death or arrhythmias, which matter before stimulant treatment].

Psychosocial history: lives with parents and a younger brother in Washington, D.C. In [grade] at [school type]. Social history, friendships, extracurricular activities, screen time, family stressors and any history of trauma or adverse childhood experiences to be clarified. No legal history.

Medical history: developmental milestones met on time; vaccinations up to date; no head trauma; no known seizures. Current medications: none. Allergies: no known drug allergies [confirm]. Reproductive history: menarche [ask; she is 11].

ROS:

• General: no fever, fatigue or weight loss; sleeps 9–10 hours nightly.
• HEENT: no reported vision or hearing problems [confirm date of last school screening].
• Skin: no rashes.
• Cardiovascular: no chest pain, palpitations or fainting with exercise.
• Respiratory: no snoring or breathing pauses during sleep reported.
• Gastrointestinal: adequate nutrition per PCP; no abdominal pain.
• Genitourinary: no enuresis.
• Neurological: no headaches, staring spells, tics or seizures.
• Musculoskeletal: no complaints.
• Hematologic and lymphatics: no easy bruising.
• Endocrinologic: no heat or cold intolerance.

Objective

Vital signs: T 97.4°F, P 58, R 14, BP 98/62, height 4’5″ (53 in), weight 65 lb. Calculated BMI is about 16.3, within the healthy range for her age. Height and weight appear to be at the lower end of the typical range for an 11-year-old girl and should be plotted on CDC growth charts as a baseline. Heart rate of 58 is slightly below the usual resting range for her age; it should be rechecked, and cardiac history reviewed, before medication is considered.

Observations: during the interview, Sarah frequently looked around the room rather than at the speaker, shifted and fidgeted in her chair and [describe any interruptions, leaving her seat or off-task behavior seen in the video]. Her mother answered most history questions.

Diagnostic results: none available. Recommended: Vanderbilt ADHD Diagnostic Rating Scales from parent and at least one teacher, school records and report cards, and vision and hearing screening.

Assessment

Mental status examination: 11-year-old girl who appears her stated age, appropriately dressed and groomed. Restless, fidgeting in her chair; limited eye contact with frequent visual scanning of the room. Cooperative. Speech normal in rate, tone and volume. Mood “[her word]”; affect full range and appropriate. Thought process goal directed but easily diverted; thought content without delusions, obsessions or suicidal or homicidal ideation. No perceptual disturbances. Alert and oriented to person, place and time. Attention and concentration impaired; memory grossly intact. Intelligence appears average. Insight limited, consistent with age; judgment fair.

Differential diagnoses:

1. Attention-deficit/hyperactivity disorder, combined presentation, moderate (F90.2). Pertinent positives: inattentive symptoms, including difficulty sustaining attention in tasks and reading, being easily distracted by external stimuli, losing materials needed for tasks (checklists), forgetfulness in daily activities, failing to finish schoolwork and difficulty organizing tasks, and seeming not to listen (looking around while spoken to); hyperactive symptoms, including fidgeting, leaving or being unable to stay seated during class and meals and restlessness. Symptoms began before age 12 (kindergarten), have lasted more than six months, occur in two or more settings (school and home) and clearly reduce academic functioning, meeting DSM-5-TR Criteria A–D (American Psychiatric Association [APA], 2022). Pertinent negatives: normal development, no head trauma, adequate sleep, no reported mood or anxiety symptoms, so Criterion E (not better explained by another disorder) appears met. Combined presentation is specified because both inattentive and hyperactive-impulsive criteria are met; the number of hyperactive-impulsive symptoms should be confirmed with rating scales.
2. Specific learning disorder with impairment in reading (F81.0) (rule out, possibly co-occurring). Supporting evidence: very short reading endurance and academic difficulty. Why it is lower priority: DSM-5-TR requires persistent difficulty in academic skills, such as inaccurate or slow word reading or poor comprehension, with achievement substantially below age expectations on standardized testing, despite targeted intervention for at least six months (APA, 2022). Sarah’s problem is described as distraction and inability to sustain attention across all tasks, including meals, rather than difficulty decoding or understanding text, and her hyperactivity is not explained by a learning disorder. Because learning disorders co-occur with ADHD frequently, psychoeducational testing is recommended.
3. Autism spectrum disorder (considered and ruled out). Supporting evidence: limited eye contact. Ruled out: DSM-5-TR requires persistent deficits in social communication and interaction across all three areas (social-emotional reciprocity, nonverbal communication and relationships) plus restricted, repetitive patterns of behavior (APA, 2022). Sarah’s reduced eye contact occurs while she is scanning the room, which is consistent with distractibility; no deficits in reciprocity, friendships, restricted interests, sensory sensitivities or insistence on sameness are reported, and milestones, including language, were met on time.
4. Generalized anxiety disorder (considered and ruled out). Anxiety can cause restlessness and poor concentration. However, GAD requires excessive, hard-to-control worry about multiple areas for at least six months (APA, 2022), and neither Sarah nor her mother reports worry, somatic complaints or sleep problems. Her symptoms began in kindergarten and are not tied to worry.

Critical-thinking process: I began with the pattern and timing of symptoms: a chronic course starting in early childhood points to a neurodevelopmental disorder rather than a disorder that begins later, such as depression or adjustment problems. I then checked each DSM-5-TR criterion for ADHD and confirmed symptoms across settings, which separates ADHD from a problem limited to one classroom or teacher. Next, I considered conditions that mimic or co-occur with ADHD, including learning disorders, autism, anxiety, sleep deprivation, vision or hearing problems, absence seizures and trauma. Adequate sleep, normal development, no head injury and no reported staring spells or worry make these less likely, although screening is still needed. Because ADHD in girls is often recognized later and the inattentive symptoms are easily mistaken for daydreaming, I gave weight to the long history and the teachers’ need for accommodations. ADHD, combined presentation, best explains the full picture.

Reflection notes

What I would do differently: I would spend more time interviewing Sarah directly, using age-appropriate questions about how school feels, what is hard for her and how she gets along with friends, and I would interview her privately for part of the visit to screen for bullying, mood symptoms or safety concerns. I would obtain teacher rating scales and school records before finalizing the diagnosis, because DSM-5-TR requires symptoms in two settings and informants other than a parent strengthen the evaluation. I would also complete a family cardiac history and review the slightly low heart rate before discussing medication.

Legal and ethical considerations: Sarah is a minor, so her parents give consent, but she should give assent and have treatment explained at her level, respecting her developing autonomy. Under Section 504 of the Rehabilitation Act and the Individuals with Disabilities Education Act, she may be entitled to formal school accommodations; the provider has an ethical duty to advocate for these and to coordinate with the school, which requires a signed release before sharing information. Stimulant medications are Schedule II controlled substances, so prescribing involves checking the prescription drug monitoring program, safe storage and discussing the risk of diversion in the home. Clinicians must also avoid both over- and underdiagnosis: girls with ADHD are often missed, while labeling a child based on a single informant can be harmful. Finally, providers should consider access and equity; families may face barriers to evaluation, therapy and medication shortages.

Health promotion and disease prevention: ADHD is common: in 2022, about 11.4% of U.S. children aged 3 to 17 had ever been diagnosed, and most children with current ADHD had at least one co-occurring condition (Danielson et al., 2024). For school-aged children, the American Academy of Pediatrics recommends FDA-approved medication along with parent training in behavior management and/or behavioral classroom interventions, as well as educational supports (Wolraich et al., 2019). For Sarah, health promotion includes consistent routines, a structured homework area, visual schedules, breaking tasks into small steps, physical activity, limiting recreational screen time and keeping her healthy sleep schedule. Because stimulants can suppress appetite and affect growth, baseline and ongoing height, weight, heart rate and blood pressure monitoring are important. Untreated ADHD in girls is associated with low self-esteem, anxiety, depression and later risky behaviors, so early support, monitoring of mood and preventive education about substance use as she approaches adolescence are priorities. Cultural factors, family beliefs about medication and the family’s access to care in Washington, D.C., should be explored to tailor the plan.

References

American Psychiatric Association. (2022). Neurodevelopmental disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787.x01_Neurodevelopmental_Disorders

Boland, R., Verduin, M. L., & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

Danielson, M. L., Claussen, A. H., Bitsko, R. H., Katz, S. M., Newsome, K., Blumberg, S. J., Kogan, M. D., & Ghandour, R. (2024). ADHD prevalence among U.S. children and adolescents in 2022: Diagnosis, severity, co-occurring disorders, and treatment. Journal of Clinical Child & Adolescent Psychology, 53(3), 343–360. https://doi.org/10.1080/15374416.2024.2335625

Symptom Media. (Producer). (2017). Training title 48 [Video]. https://video.alexanderstreet.com/watch/training-title-48

Wolraich, M. L., Hagan, J. F., Jr., Allan, C., Chan, E., Davison, D., Earls, M., Evans, S. W., Flinn, S. K., Froehlich, T., Frost, J., Holbrook, J. R., Lehmann, C. U., Lessin, H. R., Okechukwu, K., Pierce, K. L., Winner, J. D., Zurhellen, W., & Subcommittee on Children and Adolescents With Attention-Deficit/Hyperactivity Disorder. (2019). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4), Article e20192528. https://doi.org/10.1542/peds.2019-2528

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