ℹ️ This is the case information for the doctor.

Name

Ricky White

Age

5 years old

Address

17 Oakridge Crescent

Social history

None

Past history

No history of allergies.
Immunisations up to date; last seen for preschool immunisations 6 months ago.
No previous significant illnesses.

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Investigation results

None to date.

Medication

None.

Booking note

Dad requests appointment about Ricky's behaviour.

ℹ️ This is the information for the person role playing the patient.

Case overview

Name

Ricky White

Age

5 years old

Address

17 Oakridge Crescent

Social history

None

Past history

No history of allergies.
Immunisations up to date; last seen for preschool immunisations 6 months ago.
No previous significant illnesses.

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Medication

None.

Opening statement

"I've come on to talk about my son Ricky – he’s not right, doc. He’s just always so hyper and doesn't listen. I really think something’s going on."

Information freely divulged

Ricky is "always on the go", can't sit still for more than a few seconds – at home, he jumps around on the sofa and climbs furniture constantly.
The behaviour has always been this way, but seemed more manageable before school started; now feels more pronounced.
Ricky only pays attention to TV; otherwise doesn’t seem to listen to instructions.

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Information given on questioning

Background

No problems with speech – Ricky is articulate and talks a lot, sometimes excessively.
One incident of fighting at school, but nothing further reported by teachers; no teacher concerns voiced regarding attention or listening.
No history of abdominal pain, urinary symptoms, or other medical concerns.
Feels “different” to other 5-year-olds when comparing Ricky to his peers or what Ben thinks is “normal”.
Admits some family stress but denies ongoing conflict with Ricky’s mother.

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Psychosocial background information:

Ricky lives mainly with his mother, and Ben (father) has weekend custody.
Parents have been separated for 4 years. No ongoing conflict but minimal communication.
Ricky has a baby (younger half-sister) at his mother’s home—Ben is not involved with her care.
No extended family support nearby. Ben lives alone; Ricky stays with him one/two nights each weekend.
Ricky is in Reception class at primary school since September. No feedback from teachers about concentration problems.
Ben is in full-time employment as a delivery driver, works weekdays.
No concerns raised about child safeguarding at present.

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Ideas (patient’s ideas about the cause):

Ben suspects Ricky might have “ADHD” and has read/watched information about it online. Sees the behaviour fitting this diagnosis.

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Concerns (patient’s worries):

Worried there may be something “medically wrong” with Ricky.
Concerns Ricky’s not getting the support he needs, might get labelled or struggle as he gets older.
Worried the separation and split home life might be affecting Ricky, but thinks both parents are loving and supportive
Ricky wet the bed once recently ("last weekend"), not sure if this has happened with his mum.

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Expectations (patient’s expectations for consultation):

Hoping for medication or a referral to a specialist to confirm ADHD and support behaviour.
Open to school involvement if suggested.
Wants practical support and advice to manage at home, and doesn’t want to be “fobbed off”.

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Family history:

No known family history of ADHD or neurodevelopmental disorders.
Mum has mentioned that her new partner’s son is “quite lively” but no formal diagnosis.

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Behaviour

Initially comes across as worried and a little frustrated at not knowing how to help Ricky but not angry – genuinely seeking help.
A bit anxious; feels let down by not having a clear answer until now.
Will be open and responsive if the doctor listens, acknowledges concerns, and offers a clear plan (even if referral takes time).
If the GP seems dismissive, minimises concerns or refuses to discuss referral/medication, Ben becomes more insistent, upset, and “pushes” for clear action (“I really think you need to do something, I’m not coping anymore”).
Reassured if doctor gives structure, explains the process of referral, and suggests practical support (e.g. school involvement, possible follow-up).
If told symptoms might be related to family change rather than a neurodevelopmental issue, becomes slightly defensive but not hostile (“I suppose so, but I really think it’s more than that”).

ℹ️ To mark data gathering & diagnosis select from the descriptors below.

Positive descriptors

Negative descriptors

Data gathering was systematic and targeted ensuring patient safety.

Uses open questions to explore the father’s main concerns, onset, and progression of Ricky’s behaviours.
Follows up with targeted closed questions about related symptoms (e.g., sleep, aggression, school performance, wetting episodes) and responds to cues from the father.

Data gathering was incomplete, lacking structure and focus.

Misses clarifying the exact nature, duration, or progression of the behavioural concerns.
Does not structure the questioning or neglects to confirm safety issues such as safeguarding, or enquire about the child’s daily routine and school engagement.

Information gathered placed the problem in its psychosocial context.

Explores parental separation, weekend custody, relationships with both parents, and the presence of siblings.
Assesses parental stressors, support network, and the child’s environment, including routine and screen time.

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The social and psychological impact of the problem was not adequately determined.

Fails to clarify the custody arrangements, relationships between the parents, and how separation affects Ricky.
Ignores the broader family dynamics, living setups, or psychosocial stressors impacting Ricky’s behaviour.

The presence or absence of relevant red flags was established.

Checks for safeguarding concerns including any signs of physical punishment, neglect, or emotional distress.
Asks about developmental regression, self-harm, or risk to Ricky or others.

Fails to assess key information necessary to determine risk.

Does not enquire about potential safeguarding issues or other signs of serious underlying problems.
Fails to clarify if there are concerns about harm to Ricky or others in the home or at school.

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A working diagnosis was reached using a structured, evidence-based approach.

Investigates symptoms systematically: sleep pattern, attention, activity level, behaviour in multiple settings, and any learning or speech difficulties.
Integrates the information to consider (but not assume) neurodevelopmental conditions, environmental effects, and normal developmental variability.

The evidence collected was inadequate to support the conclusions reached.

Jumps to diagnostic labels (such as ADHD) without systematically ruling out sleep deprivation, emotional reaction to life changes, or situational factors.
Does not synthesise or reflect on the collected information before forming conclusions.

Uses an understanding of probability based on prevalence, incidence, and natural history to aid decision-making.

Recognises that ADHD and behavioural problems are not uncommon in this age group but carefully weighs contextual, family, and environmental factors.
Notes that sleep deprivation and family factors are common in young children and may present similarly.

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Choice of diagnosis and/or investigations does not reflect disease likelihood.

Overemphasises rare conditions or pathologises behaviour without considering normal developmental variation for a 5-year-old.
Recommends medication or a specialist referral prematurely, without appropriate evidence or reasoning.

Revises hypotheses as necessary in light of additional information.

Adjusts initial impressions upon hearing cues about sleep problems, bedwetting, fighting at school, or family setup, integrating these into the working diagnosis dynamically.
Demonstrates flexibility in questioning style and clinical reasoning as new data emerges.

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Rigid consulting with new information not adequately considered and integrated into the working diagnosis.

Sticks to an early hypothesis (e.g., hyperactivity disorder) without integrating emerging data about family breakdown, sleep disruption, or variability in behaviour.
Does not modify the clinical approach when presented with additional or conflicting information.

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ℹ️ To mark clinical management & medical complexity select from the descriptors below.

Positive descriptors

Negative descriptors

Practises holistically, promoting health, and safeguarding:

Recognises the potential impact of parental separation and step-sibling relationships on Ricky’s behaviour and explores the wider family context.
Checks sensitively for any safeguarding concerns and offers holistic support, including signposting to family or parenting support groups.

Fails to safeguard patient welfare:

Ignores the context of family breakdown or potential domestic issues that could influence behaviour.
Fails to enquire or act upon possible safeguarding or emotional wellbeing issues within the family setting.

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Manages uncertainty, including that experienced by the patient:

Acknowledges that at this stage there is diagnostic uncertainty and explains to dad why formal assessment is not yet indicated, while outlining clear next steps.
Provides clear safety netting around what would prompt expedited review or action.

Struggles with uncertainty, leading to inconsistent decisions:

Appears uncomfortable with diagnostic uncertainty, resulting in inappropriate referral or vague reassurances.
Fails to explain the limitations of assessment at this stage or how uncertainty will be managed going forward.

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Tailors management options responsively according to circumstances, priorities and preferences:

Takes into account that Ricky’s issues are only observed at home and discusses the implications with dad, suggesting contacting mum and school before making further decisions.
Sensitively explains why input from both parents and the school is vital, and seeks agreement on how to share information appropriately.

Management options fail to adequately consider patient preference and circumstance:

Follows a one-size-fits-all approach or pushes referral without tailoring plans to Ricky’s specific family, school, and custody context.
Does not discuss with dad the importance of involving mum or school in a non-judgemental, collaborative way.

Refers appropriately being mindful of resource:

Recognises ADHD referral is not appropriate until there is further information and criteria are met (problems evident in multiple settings, previous school and parental support tried).
Explores other local voluntary and school-based support first, such as the school nursing team or early intervention services.

Sends patients for specialist input unnecessarily:

Inappropriately refers to specialist paediatric services before basic assessment and support steps have been taken.
Omits consideration of community resources (school nurse, parenting support, family support services).

Offers management options that are safe and appropriate:

Explains clearly that behavioural concerns such as hyperactivity can be within normal limits for a 5-year-old and that a diagnosis like ADHD requires evidence of pervasive symptoms across multiple settings.
Suggests gathering more information from school and both parents before considering referral, and discusses non-pharmacological support options first (e.g., parenting support, school nurse, family support services).
Provides reassurance appropriately while maintaining vigilance for emerging concerns.

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Fails to provide appropriate and or safe management choices:

Recommends referral or suggests medication without sufficient evidence or assessment.
Does not reassure the parent that this behaviour may be normal at this age, or fails to explain the process needed for a diagnosis.
Does not mention the need for symptom persistence across different settings.

Empowers self-care and independence:

Provides practical advice to dad on behaviour management strategies at home and signposts to reputable parenting resources.
Encourages dad to keep a diary of behaviours and sleep patterns to support future discussions and self-reflection.

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Management fails to foster self-care and patient involvement:

Relies solely on referral or formal services, not giving any advice or tools for the father to use proactively.
Misses opportunities to encourage the parent’s role in managing and observing the situation.

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ℹ️ To mark relating to others select from the descriptors below.

Positive descriptors

Negative descriptors

Shows understanding of medical-legal principles and regulatory standards:

Clearly explains that information may need to be gathered from both parents and the school, and that mum will be contacted—with sensitivity about consent and family dynamics.
Ensures confidentiality and discusses the rationale for involving both parents in Ricky’s care.

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Fails to give appropriate regard to key legal aspects of consulting:

Does not explain the need for information-sharing between parents, school, and healthcare providers.
Refers or takes action involving the family without proper discussion of consent or sensitivities.

Information gathered placed the problem in its psychosocial context.

Explores parental separation, weekend custody, relationships with both parents, and the presence of siblings.
Assesses parental stressors, support network, and the child’s environment, including routine and screen time.

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Fails to recognise the patient's agenda and impact of the problem:

Does not explore the father’s ideas, concerns, or expectations about Ricky’s behaviour.
Fails to elicit the family’s preferences around assessment or support.

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Recognises what matters to the patient and works collaboratively to enhance patient care:

Involves the father in discussion about steps forward, checking how he feels about contacting mum or school, and encourages him to share observations.
Works towards a plan that the father feels comfortable with, promoting partnership in ongoing care.

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Fails to work with the patient to plan care:

Imposes a solution without involving the father or considering his views on contacting the school or mum.
Does not adjust the plan to the family’s practicalities or preferences.

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Demonstrates flexibility of communication adapting to the patient and scenario:

Adjusts language to suit the father's understanding, explaining medical terms and normal childhood behaviour clearly.
Picks up on cues such as the father's question about bedwetting, explaining sensitively that this can be normal.

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Consults rigidly, providing generic explanations and management plans:

Uses technical or overly rigid language that does not take the father’s emotions or confusion into account.
Does not tailor explanations—for example, fails to reassure about bedwetting or adapt approach when father is concerned about possible diagnosis.

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Demonstrates an empathic approach, and a willingness to help and care for the patient:

Shows warmth and reassurance, acknowledges how worrying parenting concerns can be, and offers practical support options.
Normalises the experience for the father (“many parents feel like this at some stage”) and offers further contact.

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Lacks empathy and fails to recognise emotional cues:

Dismisses or minimizes the father’s distress or feelings of being overwhelmed.
Fails to offer reassurance that support or follow-up will be available.

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Respectfully challenges unhelpful health beliefs or behaviours:

Gently addresses assumptions about medicalising behaviour and explains the process for understanding and supporting children’s development.
Offers reassurance that challenges like bedwetting and high energy are not uncommon.

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Fails to maintain a productive therapeutic relationship:

Responds dismissively to the father’s concerns or makes the parent feel at fault for Ricky’s behaviour.
Corrects the parent in a way that feels abrupt or patronising, risking loss of trust.

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ℹ️ Insights from the examiner

Case summary

A parent concerned about a 5-year-old’s hyperactivity and possible ADHD.

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Time Efficient Data Gathering

The most time efficient way to collect data is to take a structured approach starting with open questions. Be curious and purposeful.

“Could you walk me through what concerns you most about Ricky’s behaviour at home and at school?”

Sometimes you will see examiners feedback 'The doctor collected data but didn’t synthesise it, leading to solving the wrong problem.' Solving the wrong problem can lose you a lot of time so it is important to recognise the 'right' agenda. Summaries can help you do that by letting you check in with the patient. For example:

“So just to summarise what I’ve heard so far… Ricky is active and struggles to focus at home, but there’s no similar concern from school or mum. This behaviour started after you and his mum separated, and it seems more prominent when he’s with you. Does that sound right?”

This:

Demonstrates synthesis.
Forces reflection on what problem you’re solving (behavioural reaction vs neurodevelopmental disorder).
Builds rapport by showing you’re listening.
Prevents “kicking the can down the road” by helping you commit to a tailored plan.

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Reference: MRCGP annual reports and research

Reference: NICE NG87: ADHD diagnosis and management

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Language

Clear language will help with time efficiency and ensure explanations are accessible. If the patient uses jargon terms, check they understand them. Using terms the patient can easily understand will help you build rapport and the added clarity will reduced the need for repeated questioning or backtracking.

So how might you explain ADHD and compare it with normal behaviour. Perhaps something like:

“ADHD stands for Attention Deficit Hyperactivity Disorder. It’s something that can affect how a child concentrates, stays still, and manages their impulses."

It's a good idea to pause regularly to invite questions. If no questions are forthcoming you might explain further. Perhaps:

Children with ADHD are often more active than other children their age, they can be more implusive and find it harder to focus on a task.

In ADHD, these behaviours usually need to happen in more than one place—like at home and at school.—and they usually affect things like learning, relationships, or daily routines.

Some children just have lots of energy or are struggling with things going on around them—like big changes at home or not getting enough sleep—and that can look similar to ADHD.

Which means Ricky's behaviour might be a normal part of growing up or reacting to stress, getting more information will help me work out if he has ADHD or not”

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Reference: MRCGP annual reports and research

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Cues

This consultation is full of cues to pick up on. Here are some of the key cues.

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Parental Separation

Cue: “Mum and dad are separated.”

This can significantly impact a child’s behaviour due to stress, inconsistent routines, emotional insecurity, or changes in discipline between homes.
It raises questions like:
- How often does Ricky see each parent?
- Are routines consistent between homes?

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Father’s Concern About Getting a Diagnosis

Cue: “Dad wanted Ricky to be referred or given something.”

Suggests possible:
- Pressure or stress on the father.
- Belief that a medical solution is needed, possibly reflecting his own coping difficulties or frustration.
- Lack of awareness of normal developmental behaviours.

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Dad’s Report That Behaviour Only Happens at Home

Cue: “He only does this at home.”

Very important diagnostically:
- ADHD must cause impairment in multiple settings (NG87).
- Behaviour only at home suggests:
  - Situational triggers (e.g. stress at dad’s house).
  - Possible attachment or behavioural responses to family dynamics.

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Lack of Input from Mum

Cue: Mum wasn’t involved in the consultation.

Not necessarily unusual, but:
- ADHD assessment requires input from both parents and school (per NICE NG87).
- Doctor should explore:
  - Is communication open between parents?
  - Would mum’s view differ?
  - Are there barriers to engaging both?

Reference: MRCGP annual reports and research

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Goals

Aim to agree shared goals:

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Gather More Information

Goal: To reach an understanding about diagnosis we need a clear picture of Ricky’s behaviour in different environments.

Agree to contact Ricky’s school to get their perspective.
Encourage dad to ask mum about Ricky’s behaviour in her home.

“One of our goals should be to understand whether Ricky’s behaviour is happening in more than one setting, because that helps us decide if this could be ADHD or something different.”

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Improve Communication Between Parents and Involve Mum in the Assessment

Goal: Ensure both parents are involved in understanding and supporting Ricky’s behaviour by encouraging open communication and arranging a joint discussion or appointment with mum.

“It sounds like Ricky’s behaviour is mainly happening at home, and to get a full picture we really need input from both parents. How would you feel about us inviting mum to a future appointment so we can all look at this together? Getting her views could really help us work out what’s going on and decide next steps together.”

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Differential

Appropriate differential based on NICE NG87 and case details:

Normal range development/temperament variation (most likely)
Disrupted behaviour secondary to sleep deprivation
Situational reaction to family breakdown/separation
Adjustment disorder
Neurodevelopmental disorder (e.g. ADHD, less likely if not seen in more than one setting)
Anxiety or mood disorder (rare at age 5, but possible if further cues identified)
Other medical or neurological cause (rare, e.g. hearing/vision problem, epilepsy)

Reference: NICE NG87

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Impact

Explore the impact of Ricky's behaviour on him and family functioning.

“Has this behaviour affected Ricky’s school, friendships, or family life?”

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Options

Offer a clear, evidence-based “menu” of options before considering referral, in line with NICE NG87:

Reassurance that many 5-year-olds are very active, and this is often normal.
Gather more information from Ricky’s mum (with consent) and from school/teachers.
Encourage both parents to keep a diary of concerning behaviours and sleep patterns to see if there are triggers or patterns.
Explaining normal sleep patterns and giving practical tips for sleep hygiene (consistent bedtime, no screens before bed, wind-down routine).
Signposting to parenting support programmes or local parenting classes—these are first-line and recommended in NICE NG87.
Suggesting school nurse involvement or Early Help/Family Front Door for parenting or behaviour advice.
Monitoring and follow-up review in a few weeks, to see if the behaviour changes or persists.
Safety-netting for red flags—if Ricky’s behaviour worsens or new concerning features appear.

‍Reference: NICE NG87

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Understanding

Confirm that the father understands and is comfortable with the plan. Invite questions to check this.

“Does that make sense? Is there anything you’re worried we haven’t talked about?”

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Bespoke Solutions

Tailor your plan to the specific family setup:

“I’d like to get your agreement to talk to Ricky’s mum and his teachers so we can understand how he’s doing everywhere and decide together what might help.”
Check if dad is happy to keep a diary and follow up; offer extra support for family changes if needed (e.g., Early Help).
If safeguarding or significant stress, escalate as appropriate.

Reference: NICE NG87

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A few tips

Always clarify custody and communication arrangements to avoid misunderstanding and support co-parenting.
Be curious, not judgmental, about family structure, routines, and stressors—they are often key to understanding child behaviour.
Synthesise findings into a summary before forming a management plan—this acts as a safety net against missing psychological or context factors or “solving the wrong problem”.

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Key NICE NG87 ADHD Diagnostic Points to Remember

Diagnosis of ADHD should not be based on symptoms in a single setting (e.g. only at home).
Symptoms must have been present for at least 6 months, evident before age 12, and cause at least moderate impairment in more than one setting.
Exclusion of other causes (e.g. sleep, anxiety, adjustment, family or social stress, developmental stage) is important before specialist referral.
Parent training programmes should be first-line for children of primary school age showing hyperactivity or behaviour difficulties (NG87 Section 1.7).

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Useful GP and SCA References

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