- Attention-Deficit / Hyperactivity Disorder (ADHD) SOAP NOTE
Guidelines, Overview, & Resources
There are essentially three main pieces to an Attention-Deficit/Hyperactivity Disorder (ADHD) diagnosis -- the clinical interview, the exam, and the completion/scoring of rating scales (by the parent, teacher/school, other caretakers/coaches, and the child). Below is an example of what these might look like as a SOAP note.
ADVICE / COMMENTS
CC: “TJ has been all over the place and cannot concentrate in class or complete tasks at home”
HPI: 8-year-old male presents with mother, who brought him into clinic after receiving numerous phone calls from the school guidance counselor’s office regarding behavior problems at school. According to these reports, TJ has difficulty sitting in his chair in the classroom, often blurts out answers without raising his hands, cannot concentrate during class assignments and is generally disruptive in the class during lessons. Despite numerous attempts by teacher, TJ refuses to calm down and has difficulty controlling his emotions. This past week he also overturned his classmate’s desk after they got into an argument, for which his parents were called from the guidance counselor’s office. Mother states patient is hyperactive at home too, has difficulty focusing on tasks and often cannot complete simple tasks like dry dishes or choose which clothes he wants to wear for the day. Talks a lot, with and without guests and relatives present at home.
His grades in school have been consistently good. Mother is concerned because she has heard a lot in the media about kids with ADHD and would like him evaluated for his hyperactivity at school and home. She has already filled out a Vanderbilt parent form which screened positive for attention deficit with combined hyperactivity/impulsivity and inattention. Teacher forms are yet to be turned in by teacher.
PMH: No chronic health conditions, no childhood diseases, no overnight hospitalizations or surgeries.
FH: Father has depression, controlled on medications. Mother has a history of anxiety, not on any medications. She is seeing a therapist.
SH: Lives at home with parents and 17yo brother who is about to go to college in the fall. No pets. Self described as “energetic and good at sports and studies.” Plays in the local softball league during summer. Enjoys swimming. Doing well in school, no developmental delays reported by mother. Mother works as a secretary. Father is trying to find employment, previously employed at a machine tool plant which closed down. No smokers at home.
Immunizations: Up to date.
Psych: Positive for difficulty with focus and hyperactivity. No history of anxiety, depression or sleep disorders.
Establish good rapport with the family and child first. Ask the parents if they want the child in the room or out of the room prior to history-taking. Try to gain an understanding of how and why this is impacting the family and also what has been done prior to this snapshot in time. Try to remember that parents, whether accurate or not in their description/reactions, know their child best.
Using a semi-structured interview, ask the parent/child about the symptoms and initial presentation of the behaviors. Be sure not use the word "ADHD," rather keep the focus on the specific description of behaviors and the conditions present when these difficulties arise. This clinical interview is meant to capture the phenomenological data that rating scales cannot capture.
See the DSM 5 for the most up-to-date criteria and conditions you will need to make an ADHD diagnosis.
Complete a thorough developmental history, reviewing domains of gross/fine motor, language, intellectual, academic, emotional, and social functioning. Assess whether other conditions are also present along with ADHD, including any emotional or behavioral (e.g., anxiety, depressive, oppositional defiant, and conduct disorders), developmental, and physical (e.g., tics, sleep apnea) conditions. Behavioral conditions, such as anxiety, are very often hand-in-hand with ADHD due to the distress it can cause. See if you can tease out what might be the primary driver of the pair.
Inquire about family history, specifically in regard to cognitive capacity, attention issues, learning disabilities, organization skills, and other academic concerns. It is always a good question to ask, "Is this child like anyone else in your family, in terms of his behaviors or academic skills?"
VS: T 98.6F, RR 16, HR 92, BP 128/80, Ht 125cm, Wt 55lb
General: Well nourished, well developed. Alert and oriented to time, place and person.
Skin: Warm, dry, no rashes
HEENT: Head midline. Ears: Clean canals bilaterally, TMs visualized, +light reflex, no erythema or edema bilaterally. Eyes: PERRLA, EOM intact, 20/20 vision bilaterally without correction. No strabismus, no nystagmus. Fundoscopic exam normal, vessels intact, optic disc with clear margins. Nares patent with no edema or erythema. No thyromegaly.
CV: RRR, S1 and S2 present. No murmurs, clicks, or gallops
Lungs: Clear to auscultation bilaterally, no wheezing, rhonchi or rales
Abdomen: Soft, nontender, nondistended. Bowel sounds present in all 4 quadrants, no hepatosplenomegaly
Neuro: CN II-XII grossly intact.
Musculoskeletal: 5/5 strength and ROM in all extremities. No scoliosis or kyphosis.
Screens/Diagnostics: Positive for ADHD in Vanderbilt parent assessment form (see below for details). No co-morbidities. No previous cardiac assessments or EKG done prior to this visit.
Initial Vanderbilt form from the parent/teacher shows:
Total symptoms score for ADHD symptoms is 15/18
For conduct disorder: 1/14
For anxiety/depression: 3/7
Performance: 2/8, with an average performance score of 2.7
It is important to note the child’s behavior, compliance, attention span, activity level, and impulse control while he/she is in the clinic. Even better, if you can watch the child in the waiting room prior to the appointment, you can gain insight into the child's behaviors in less structured context. Also, check out the child's interactions with the parent. Are they visibly defiant, anxious, inattentive, hyperactive, or have poor eye contact? All these are hints and offer a microcosm of what may be going on at home. Always remember though that children will generally be better behaved at clinic than home, so you cannot overgeneralize... just look for hints!
Per the Vanderbilt forms and other screening tools,
it is very important to get all major caretakers/teachers to weigh in on the severity and presence of ADHD symptoms. Screens are used to provide a snapshot of how the child's other important caretakers/teachers view the behaviors or concerns. Children are generally impacted on 2 or more domains when ADHD is present (home, school, extracurricular).
If the child is only affected in one domain, it is worth spending time with the family to understand what/why the behaviors are continuing. Contact the school/teacher whenever possible to gain an understanding of the teacher's concerns, if any. If there are clear learning issues or school failure, referral for a comprehensive evaluation may be warranted and beneficial.
Vanderbilt scoring guide can be found here. Actual forms can be found here for teacher and parent.
ASSESSMENT: ADHD - Combined Type
Initial management (if missing a domain's input):
Follow up with teacher for completing Vanderbilt assessment form.
RTC in 2 weeks for follow-up.
For children and adolescents who are ≥6 years of age and meet the diagnostic criteria for ADHD, the AAP recommends initial treatment with stimulant medication combined with behavioral therapy, unless contraindicate with the specific med. For kids under 6, the first-line is generally behavioral therapy.
To learn more about stimulants and other agents to treat ADHD, go to DBMH Resource's ADHD page, refer to your local online medication database, or check out tools like CHADD's Medication Chart. Refer parents to a resource like CHADD or something like the APA's Parent's Medication Guide (2013).
Everyone's brain/body metabolizes these drugs differently. You may need to try alternate agents if there are undesirable side effects. If the child has failed multiple drug regimes, refer the child to a psychiatrist or developmental pediatrician.
- American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management, Wolraich, M., Brown, L., Brown, R. T., DuPaul, G., . . . Visser, S. (2011). ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 128, 1007-1022. doi:10.1542/peds.2011-2654
- Visser, S. N., Bitsko, R. H., Danielson, M. L., Gandhour, R., Blumberg, S. J., Schieve, L., Holbrook, J., Wolraich, M., Cuffe, S. (2015). Treatment of attention-deficit/hyperactivity disorder among children with special health care needs. Journal of Pediatrics. Published online April 1, 2015, DOI: http://dx.doi.org/10.1016/j.jpeds.2015.02.018