Cases/Neurodiversity and Neurodevelopment Conditions

Mother Discussing ADHD in Her Young Son — Free SCA Practice Case

Mother discussing possible ADHD in her young son

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Toby Harris

Age

7 years

Consultation Type

Telephone

Age

7 (DOB: 12/05/2018)

Caller

Emma Harris (Mother)

Situation

Telephone Consultation.

Reason for Encounter

"Telephone call requested by mother. She is concerned that Toby is falling behind in Year 3 and suspects he might have ADHD."

Medical Records

●PMH: Uncomplicated term delivery. Met all early developmental milestones. Fully immunized.
●Medications: None.
●Allergies: NKDA.

Recent Notes

●Age 4: Seen for minor hearing concern (glue ear), resolved spontaneously. Recent health visitor records from early years show a "very active" toddler but no formal safeguarding or developmental concerns.

Patient Script

For the friend playing the patient role

Character Overview: You are Emma, Toby's mother. You are exhausted, highly defensive, and feeling like a completely failed parent. Toby is a loving boy but he is constantly on the go, acts as if driven by a motor, interrupts constantly, and forgets instructions within seconds. Homework ends in tears every night. Recently, the school's attitude toward Toby has hardened. He has been put on a "behavior report." Yesterday, his class teacher strongly implied that Toby is "naughty," disruptive, and that you need to take him to the GP to "get him medicated" so he can stay in a mainstream classroom. You are terrified of ADHD medication because you read online that it turns children into "zombies." You feel backed into a corner: you want him to get help so he isn't labeled the "bad kid," but you are firmly against drugging him just to make the school's life easier. You will not volunteer this fear of medication or the school's ultimatum unless the doctor explores the sudden urgency of this call, asks how you are feeling about the situation, or asks what you are worried about.

Consultation Flow & Responses:

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The Opening
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If the doctor asks an open question: "Hi Doctor. I'm calling about Toby. His school says he's falling really far behind and he's disrupting the class. They told me I need to ring you today to get him tested for ADHD. I just don't know what to do with him anymore, he's just constantly bouncing off the walls."
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Data Gathering (The Layers)
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Layer 1: Core ADHD Symptoms (Inattention, Hyperactivity, Impulsivity):
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"He can't sit still to eat his dinner. He fidgets constantly. It's like he has a motor inside him."
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"If I tell him to go upstairs and get his shoes, he'll get distracted by a toy and completely forget what I asked him. He loses his school jumper almost every week."
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"He interrupts adults all the time and blurts out answers before you've finished asking the question."
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Layer 2: Multi-Setting Impact & Timeline:
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"He's always been a busy boy, even as a toddler, but it's gotten much worse since he started Year 3 with the harder schoolwork."
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"It happens at home, at school, and at his swimming lessons. The swimming instructor says he won't wait his turn."
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Layer 3: Differentials (Hearing, Sleep, Home Life):
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"His hearing is fine, he hears me opening a packet of crisps from the other room! He sleeps okay once he finally crashes out at 9 PM."
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"Things at home are fine. My husband and I are happily married, no big changes or trauma."
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Layer 4: ICE & The Core Revelation (The Hidden Conflict) - ONLY REVEAL IF ASKED:
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If the doctor asks: "Why did the school tell you to call today?" or "How are you feeling about the idea of ADHD?"
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Reaction (The Reveal): You sound tearful and defensive. "The teacher practically told me he's just a naughty boy. She said if I don't get him 'medicated', he might face exclusion. Doctor, I feel like a terrible mother. But I don't want to drug my 7-year-old just to make the teacher's day easier! I've read those pills turn kids into zombies. I just want them to help him learn, not drug him. Do I have to put him on medication?"

ICE — Ideas, Concerns, Expectations

(Actor guidance: Do not volunteer any of the below unprompted. These responses surface only if the candidate directly explores Emma's perspective — e.g. "What do you think might be going on?", "What are you worried about?", "What were you hoping we could do today?")

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Ideas: "Honestly, I do think it could be ADHD — he ticks a lot of the boxes from what I've read online. But part of me wonders if the school just isn't handling him well. He's always been energetic, and I keep thinking, is this just him being a boy or is there actually something wrong?"
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Concerns: "I'm scared of two things really. One — that they'll just stick a label on him and drug him, and he won't be my Toby anymore. And two — that if I don't do something, he'll get excluded and that will follow him forever. I feel like whatever I do, I'm failing him."
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Expectations: "I want someone to actually listen and take it seriously — not just tell me he's naughty or hand me a prescription. I want to know what the proper steps are to find out what's going on with him, and I want the school to do their part too, not just dump it all on me."

If Asked — Medical History and Medications

(Actor guidance: Respond naturally in parent voice if the candidate asks about Toby's past medical history, birth, development, or medications.)

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If asked about Toby's birth or early development: "He was born on time, normal delivery, no problems at all. He hit all his milestones — walking at about 13 months, talking on time. The health visitor never had any worries."
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If asked about the glue ear / previous hearing concern: "Oh that — yes, when he was about four the nursery thought he wasn't always hearing them properly. The GP had a look and said it was glue ear. It sorted itself out after a few months and his hearing has been fine since. I don't think that's related to this."
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If asked about immunisations: "He's had all his jabs, completely up to date."
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If asked about any current medications: "No, he's not on anything at all. Never has been."
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If asked about allergies: "No allergies that we know of."

Social History and Lifestyle Impact

(Actor guidance: This context can be shared naturally as conversation develops, particularly when the candidate asks about home life, daily routine, or how the situation is affecting the family.)

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Occupation / daily life context: "I work part-time as a teaching assistant at a different school, funnily enough. My husband Dan works full-time in logistics. Toby's our eldest — he's got a younger sister, Maisie, she's four and about to start reception. We're in a normal three-bed semi, nothing fancy. It's a busy household but a happy one — or it was until all this started with the school."
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Lifestyle impact of the condition: "Honestly, it's taken over everything. Homework is a nightmare — it takes two hours to do twenty minutes of work and it always ends with both of us in tears. I dread the walk to school now because I know I'm going to get pulled aside by the teacher again. Last week I cried in the car park after drop-off. My husband tries to help but he thinks I'm overthinking it — he says Toby's just a typical boy. It's causing arguments between us too. And poor Maisie just gets ignored half the time because all the energy goes into managing Toby. I feel like I'm failing all of them."

If Asked — Associated Symptoms

(Actor guidance: Respond only if the candidate directly asks about these specific symptoms. Keep answers brief and natural.)

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If asked about tics or repetitive movements: "No, nothing like that — no funny movements or sounds or anything."
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If asked about mood or sadness in Toby: "He does get upset when he gets told off, and sometimes he says things like 'I'm the worst kid in the class' which breaks my heart. But generally he's a happy boy — he bounces back quickly."
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If asked about anxiety or worrying: "I wouldn't say he's an anxious child, no. He doesn't worry about things the way some kids do. He's pretty fearless actually — sometimes too fearless."
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If asked about appetite or weight: "He eats fine — he's not fussy really. Normal weight for his age I'd say."
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If asked about coordination or clumsiness: "He's actually quite coordinated — he's good at swimming and he rides his bike fine. He's not clumsy."
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If asked about social skills or friendships: "He does have friends, but he finds it hard to keep them because he's so full-on. He'll get overexcited and be too rough in the playground, and then the other kids don't want to play with him. It upsets him but he doesn't really understand why it happens."
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If asked about behaviour that is defiant or oppositional: "He's not a nasty kid at all. He doesn't do things out of spite. It's more that he just can't help himself — he acts before he thinks. He'll say sorry straight away when he realises he's done something wrong."
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If asked about any features of autism (routine, sensory, restricted interests): "No, he's not rigid about routines or anything like that. He doesn't have any sensory things — he'll wear whatever I put out for him, eats everything. He likes lots of different things, not just one obsession."
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If asked about toileting or bedwetting: "No problems there — he's been dry day and night since he was about three."
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If asked about screen time: "He does like his iPad, and to be fair that's the one time he can actually sit still — but I try to limit it to an hour a day during the week."
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If asked about diet or sugar intake: "Normal diet really. He doesn't have loads of sweets or fizzy drinks. I don't think it's a food thing."
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If asked about any family history of ADHD, autism, or learning difficulties: "Now you mention it, my brother was always like Toby as a kid — couldn't sit still, always in trouble at school. He was never diagnosed with anything though. He's done alright for himself, runs his own building company now."

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Negotiation & Collaborative Management Plan
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If the Doctor agrees to just "prescribe something to calm him down":
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Reaction: Panics. "Wait, you can just do that over the phone? But I said I don't want him to be a zombie!" (Note: Candidate fails for attempting to diagnose and prescribe controlled ADHD medication in primary care).
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If the Doctor dismisses the school's concerns ("He's just an active boy"):
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Reaction: Frustrated. "But he's failing maths and reading! If it's just him being a boy, why is he being threatened with exclusion? I need you to do something."
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If the Doctor explains the diagnostic pathway (Community Paediatrics/CAMHS) and the need for school forms:
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Reaction: "So you don't just test him today? How long does the waiting list take? The school wants answers now." (Doctor must manage expectations regarding the notoriously long NHS waiting lists for neurodevelopmental assessments).
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If the Doctor addresses the medication fear and empowers the mother:
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Reaction: "So the first step isn't medication? It's actually getting the school to change how they teach him? That makes me feel so much better. I'll talk to the Special Educational Needs Co-ordinator (SENDCO) tomorrow."
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Safety Netting / Follow-up
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If the Doctor sets a plan to send the referral forms and review in a few weeks:
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Reaction: "Okay. I will pick up those school questionnaires from reception and give them to his teacher. Thank you for not judging my parenting."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 26 indicators checked+0−0

Positive (0/13)

Negative (0/13)

Domain 2: Clinical Management and Medical Complexity

0 / 28 indicators checked+0−0

Positive (0/14)

Negative (0/14)

Domain 3: Relating to Others

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Clinical Learning Points

Diagnosing ADHD: DSM-5 Criteria and What Specialists Look For

ADHD is a neurodevelopmental disorder diagnosed exclusively by a specialist (Community Paediatrician or CAMHS) after structured assessment. Key criteria:

●Core domains: A persistent pattern of inattention (e.g., losing items, inability to follow sequential instructions, poor sustained attention) and/or hyperactivity-impulsivity (e.g., constant fidgeting, appearing driven by a motor, blurting out answers, inability to wait for a turn).
●Pervasiveness: Symptoms must be present in two or more settings — home, school, and social/extracurricular contexts. Behaviour confined to one setting (typically school) raises the possibility of an environmental or educational mismatch rather than ADHD.
●Timeline and onset: Symptoms must have been present for at least 6 months, with several signs evident before age 12. In this case, Toby's history of being a "very active" toddler supports an early onset.
●Functional impairment: Symptoms must cause clear impairment — academic underachievement, social difficulties (playground rejection), and family strain all count.
●Family history: ADHD has strong heritability (estimated 70–80%). A maternal uncle with an identical childhood presentation increases pre-test probability and is clinically relevant to document in the referral.

The GP's Role: Gatekeeping, Not Diagnosing

●GPs cannot formally diagnose ADHD or initiate stimulant medication — these are controlled drugs and their prescription is a specialist function.
●The GP's role is to: take a structured history across all domains; rule out reversible differentials; and build an evidence base that enables a high-quality referral.
●Differential diagnoses to exclude before referral: hearing impairment (Toby has a documented history of glue ear — always ask), sleep disturbance (inadequate sleep closely mimics ADHD), psychosocial stress or attachment difficulties, absence seizures (brief episodes of apparent inattention), and ASD (ask about rigidity, sensory sensitivities, and restricted interests — ADHD and ASD commonly co-occur).
●A brief ASD screen is important: if features of autism are present, the referral framing changes and the specialist pathway may differ.

Making the Referral: What Gives It the Best Chance of Acceptance

Most Community Paediatrics and CAMHS pathways will not accept a referral letter alone. To avoid rejection at triage:

●Distribute validated rating scales before submitting the referral — commonly the Conners Comprehensive Behaviour Rating Scales, SNAP-IV, or Vanderbilt Assessment Scales.
●Both parents and school must complete their respective versions independently. The school's input is not optional — it provides the multi-setting evidence the specialist needs.
●Instruct the parent clearly: collect the school questionnaire from reception, give it to the class teacher, and return both completed forms to the surgery.
●Document the pervasiveness, timeline, functional impact, and any differentials ruled out in the referral letter itself.

Waiting List Reality: Setting Honest Expectations

●NHS waiting times for neurodevelopmental assessment through Community Paediatrics or CAMHS routinely exceed 12–24 months in most areas, and longer in some.
●Parents must be told this clearly and early — not discovering it when no appointment arrives. Failure to address this is a common candidate omission and leaves families in crisis.
●The waiting period is also the period during which school-based support, parent-training, and behavioural strategies should be actively pursued.
●Right to Choose (England only): Patients in England have a legal right to choose an NHS-funded independent provider for their assessment (e.g. Psychiatry-UK, Clinical Partners). This pathway frequently reduces waiting time to weeks or months while remaining fully NHS-funded. GPs should proactively offer this as an option at the point of referral, particularly where there is an urgent occupational or personal need.

Immediate School Support: SENDCO and the EHCP Pathway

A critical misconception — shared by many parents and some candidates — is that a formal ADHD diagnosis is required before a child can receive school support. This is incorrect.

●Under the SEND Code of Practice 2015, schools are legally obligated to provide support based on a child's identified needs, not their diagnosis.
●Advise parents to request a meeting with the school's SENDCO (Special Educational Needs and Disabilities Co-ordinator) without delay.
●Practical classroom adjustments available immediately: movement breaks, visual timetables, preferential seating near the teacher, chunked tasks, and extended time.
●If needs are substantial, the SENDCO can initiate an Education, Health and Care Plan (EHCP) application — a statutory process independent of the medical referral.
●Empowering parents with this information is one of the highest-yield interventions a GP can make in this consultation.

NICE-Recommended Treatment Hierarchy: Addressing Medication Fears Accurately

Emma's fear that medication will turn Toby into a "zombie" is one of the most commonly held parental concerns in ADHD consultations. It must be addressed with accurate psychoeducation, not avoidance.

●First-line for school-age children (NICE NG87): Environmental modifications and group-based ADHD-focused parent-training programmes — not medication.
●Parent-training programmes (e.g., those based on the Incredible Years or Triple P frameworks, adapted for ADHD) are recommended by NICE before medication is considered for school-age children with moderate presentations. Refer or signpost to these programmes in primary care.
●Medication (methylphenidate [e.g., Concerta, Ritalin] or lisdexamfetamine [Elvanse]) is typically reserved for children with severe ADHD, or moderate ADHD unresponsive to environmental and behavioural interventions. It is a specialist decision, made jointly with the family after full assessment.
●Modern ADHD medications are not sedatives. They work by increasing dopamine and noradrenaline availability in the prefrontal cortex, improving attention regulation. Side effects (appetite suppression, sleep latency) are real but manageable and dose-dependent. Emphasise that medication, if indicated, is carefully titrated and monitored.

Comorbidities: Recognising Toby's Emerging Low Self-Esteem

Children with unrecognised or untreated ADHD are at significantly elevated risk of secondary emotional difficulties.

●Toby's statement — "I'm the worst kid in the class" — is a clinically significant indicator of emerging low self-esteem and possible low mood. It must not be dismissed as a throwaway comment.
●Document this explicitly in the referral. Specialist assessors need to know that emotional and behavioural comorbidities are present, as this affects the assessment scope and potential treatment plan.
●If Toby's mood deteriorates or he expresses hopelessness, worthlessness, or any self-harm ideation, this changes the urgency of the referral and should trigger urgent CAMHS contact.

Safety-Netting: When to Seek Earlier Review

Safety-netting in this case must be specific, not generic:

●Return urgently if Toby expresses hopelessness, talk of self-harm, or there is a significant deterioration in mood beyond what is described today.
●Return promptly if the threat of exclusion becomes immediate — this is an educational safeguarding concern that may require GP advocacy or a formal letter to the school.
●Arrange routine follow-up in 4–6 weeks to review whether questionnaires have been completed, check on the SENDCO engagement, support Emma, and ensure the referral has been submitted and acknowledged.

Emma's Wellbeing: Recognising the Carer's Distress

Emma is not simply a collateral informant — she is a patient in her own right in this consultation.

●She has disclosed crying in the car park after school drop-off, relationship strain with her husband, and feelings of failing all her children. These are clinically significant disclosures.
●Acknowledge this directly and compassionately. Ask how she is coping. Signpost to GP support, local carer support resources, or a follow-up appointment focused on her own wellbeing if warranted.
●Parental mental health directly affects a child's outcomes — supporting Emma is part of the clinical management of this case.

Free MRCGP SCA practice case for GP registrars covering Mother Discussing ADHD in Her Young Son — Neurodiversity and Neurodevelopment Conditions. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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